What is the appropriate next step in management for a premenopausal woman with two small uterine fibroids (≈1.5–2.5 cm), a simple right ovarian cyst (<3 cm), subcentimeter nabothian cysts, trace endocervical fluid, and an endometrial thickness of 8 mm?

Management of Small Uterine Fibroids and Simple Ovarian Cyst in Premenopausal Woman

For a premenopausal woman with small uterine fibroids (1.5–2.5 cm) and a simple right ovarian cyst (2.4 cm), no further imaging or intervention is required—these findings are benign and require only clinical correlation with symptoms. 1

Uterine Fibroid Management

Assessment of Current Findings

• The two intramural fibroids measuring 1.6 cm and 2.4 cm are small and typically asymptomatic, requiring no intervention unless the patient experiences menorrhagia, pelvic pressure, or pain 2
• The endometrial thickness of 8 mm is within normal limits for a premenopausal woman and does not require further evaluation 2
• The inhomogeneous myometrial parenchyma is consistent with the presence of fibroids and does not indicate additional pathology 2

When to Intervene

• Medical management (GnRH agonists, levonorgestrel IUD, hormonal contraceptives, or tranexamic acid) should be considered only if the patient develops heavy menstrual bleeding or iron deficiency anemia 2
• Surgical options (myomectomy or hysterectomy) are reserved for patients with severe bulk symptoms, failed medical management, or fertility concerns 2
• Uterine artery embolization (UAE) is appropriate for symptomatic patients who wish to avoid surgery, though myomectomy remains first-line for women desiring future pregnancy 2

No Routine Imaging Follow-Up Needed

• Small asymptomatic fibroids do not require serial imaging surveillance 2
• Repeat imaging should only be obtained if symptoms develop or worsen 2

Ovarian Cyst Management

Risk Stratification

• The 2.4 cm anechoic right ovarian cyst is a simple cyst and falls into O-RADS 2 category (almost certainly benign, <1% malignancy risk) 1, 3
• Simple cysts ≤3 cm in premenopausal women are considered physiologic and require no additional management 1
• Even though this cyst is 2.4 cm, it meets all criteria for a benign simple cyst: anechoic, thin smooth walls, no septations, no solid components, and no vascularity 1, 3

No Follow-Up Required

• No imaging follow-up is necessary for simple cysts <5 cm in premenopausal women, as these are functional cysts that typically resolve spontaneously 1, 3
• The malignancy risk for simple cysts in premenopausal women is only 0.5–0.6%, with zero malignancies reported among simple cysts in women <50 years in large cohort studies 1

When Follow-Up Would Be Indicated

• Follow-up ultrasound at 8–12 weeks (during proliferative phase) would only be warranted if the cyst were >5 cm but <10 cm 1, 3
• Immediate gynecology referral would be needed if the cyst showed complex features: thick septations (≥3 mm), solid components, papillary projections, or high vascularity on Doppler 3, 4

Incidental Findings—No Action Required

Nabothian Cysts

• Subcentimeter nabothian cysts are benign retention cysts of the cervix and are extremely common normal variants requiring no evaluation or follow-up 5

Trace Endocervical Fluid

• A trace amount of fluid in the endocervical canal is a normal finding in premenopausal women and does not indicate pathology 5
• This finding does not require further investigation unless the patient has symptoms of infection (fever, purulent discharge, pelvic pain) 3

Clinical Correlation and Symptom Assessment

Key Symptoms to Assess

• For fibroids: Inquire about heavy menstrual bleeding (number of pads/tampons per day, clots, duration), dysmenorrhea, pelvic pressure, urinary frequency, constipation, and fertility concerns 2, 5
• For ovarian cyst: Ask about acute pelvic pain (which could indicate torsion or rupture, though risk is only 0.2–0.4% for benign cysts), though most simple cysts are asymptomatic 1, 5

When to Initiate Treatment

• Symptomatic fibroids: Start medical management if menorrhagia causes anemia or significantly impacts quality of life 2
• Asymptomatic fibroids: Reassure the patient and provide return precautions for development of symptoms 2
• Simple ovarian cyst: Reassure the patient that this is a normal functional cyst requiring no treatment 1, 3

Critical Pitfalls to Avoid

• Do not order routine follow-up imaging for small asymptomatic fibroids or simple cysts <5 cm in premenopausal women—this leads to unnecessary healthcare costs and patient anxiety 1, 3
• Do not recommend surgical intervention for small fibroids unless the patient has failed medical management or has severe symptoms affecting quality of life 2
• Do not misinterpret the simple ovarian cyst as requiring intervention—the risk of malignancy is essentially zero, and the risk of complications (torsion, rupture) is <0.5% 1
• Do not obtain MRI or CT for further characterization of these clearly benign findings—ultrasound has already provided definitive diagnosis 2, 1
• Do not assume all pelvic masses require gynecology referral—these findings are within normal limits and can be managed in primary care with symptom-based treatment if needed 1, 3

Summary Algorithm

1. Confirm patient is premenopausal (these findings have different implications in postmenopausal women) 1
2. Assess for symptoms: heavy bleeding, pelvic pain, pressure symptoms, fertility concerns 2, 5
3. If asymptomatic: Reassure patient, no further imaging, return if symptoms develop 2, 1
4. If symptomatic from fibroids: Initiate medical management (hormonal therapy, tranexamic acid, NSAIDs) 2
5. If medical management fails: Refer to gynecology for consideration of myomectomy, UAE, or hysterectomy 2
6. For the ovarian cyst: No action required regardless of symptoms, as simple cysts <5 cm are physiologic 1, 3