Most Likely Diagnosis: Benign Functional Ovarian Cyst
The most likely diagnosis is a benign functional ovarian cyst (O-RADS 2 category), with the abnormal Pap smear representing either atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion (LSIL) that requires follow-up but is unrelated to the ovarian finding. 1, 2
Understanding the Ovarian Cyst Finding
Simple ovarian cysts in premenopausal women aged 48 years carry an extremely low malignancy risk (<1%) and are classified as O-RADS 2 (almost certainly benign). 1
- In women younger than 50 years, no simple cysts were diagnosed as cancer in a large study of 12,957 cysts over 3 years of follow-up 1
- Simple cysts up to 10 cm in diameter can be safely monitored without surgical intervention, even approaching menopause 1
- For simple cysts ≤5 cm in premenopausal patients, no additional management is required 1
- For simple cysts >5 cm but <10 cm, follow-up ultrasound in 8-12 weeks is reasonable to confirm functional nature 1
Addressing the Abnormal Pap with Negative HPV
The combination of abnormal Pap with negative HPV testing indicates low-risk cervical pathology that requires surveillance but not immediate colposcopy (assuming ASC-US). 2, 3
If the Abnormal Pap is ASC-US:
- Repeat Pap testing in 12 months is the recommended management for ASC-US with negative HPV 3
- The 5-year risk of CIN3+ after HPV-negative ASC-US is 0.48%, which is low but higher than a completely negative cotest 3
- Do not return to routine 3-5 year screening intervals immediately; the shortened 12-month interval is necessary 3
If the Abnormal Pap is LSIL:
- Immediate colposcopy is recommended for LSIL regardless of HPV status, as 80-86% of LSIL cases are HPV-positive, making HPV testing non-discriminatory 2
- However, if truly HPV-negative LSIL, this represents an unusual scenario that may warrant colposcopy to rule out sampling error 2
Clinical Context Integration
The patient's heavy periods and copper IUD are unrelated to both the ovarian cyst and cervical findings.
- Copper IUDs cause heavy menstrual bleeding through inflammatory mechanisms but do not increase cervical dysplasia risk 2
- Nabothian cysts are benign cervical retention cysts with no malignant potential and no relationship to abnormal Pap results 2
- At age 48, the patient is perimenopausal, making functional ovarian cysts still common but requiring slightly more vigilance than in younger women 1
Management Algorithm
Step 1: Clarify the exact Pap smear interpretation
- Determine if result is ASC-US, LSIL, or another category 2
Step 2: Manage cervical findings based on specific cytology
- ASC-US + negative HPV → Repeat Pap in 12 months 3
- LSIL + negative HPV → Consider colposcopy (unusual scenario) 2
- If repeat testing shows ASC or higher → Follow management for that specific abnormality 3
Step 3: Manage ovarian cyst based on size
- If ≤5 cm → No follow-up needed 1
- If >5 cm but <10 cm → Repeat ultrasound in 8-12 weeks 1
- If >10 cm → Consider gynecology referral for further evaluation 1
Critical Pitfalls to Avoid
Do not perform immediate colposcopy for ASC-US with negative HPV, as this leads to unnecessary procedures and the risk of CIN3+ is very low 2, 3
Do not assume the ovarian cyst and abnormal Pap are related, as they represent separate pathologic processes requiring independent management 1, 2
Do not surgically intervene on simple ovarian cysts <10 cm in this age group, as the malignancy risk is negligible and most are functional 1
Do not use HPV testing to triage LSIL if that is the cytology result, as it provides no useful discrimination 2
Do not allow the patient to return to routine 5-year screening after HPV-negative ASC-US, as the risk profile requires a 12-month follow-up interval 3