I am a pre‑menopausal woman with a recent pelvic ultrasound showing a normal‑sized uterus, small nabothian cyst, mild endometrial thickening, non‑visualized ovaries and no adnexal mass, and a thyroid ultrasound showing an atrophic left lobe and several sub‑5 mm benign‑appearing nodules; what is the appropriate next step in management?

Management of Mildly Thickened Endometrium and Benign Cervical Findings in a Premenopausal Woman

For your mildly thickened endometrium as a premenopausal woman, no immediate intervention is required since endometrial thickness varies throughout the menstrual cycle and there is no validated upper limit cutoff in premenopausal women; however, if you develop abnormal uterine bleeding, endometrial sampling would be indicated. 1

Pelvic Ultrasound Findings – Management Algorithm

Endometrial Thickening

• In premenopausal women, endometrial thickness is not a reliable indicator of pathology because it varies with menstrual cycle phase, and even thin endometrium (<5 mm) can harbor polyps or other pathology. 1
• Endometrial thickness measurement alone does not determine the need for biopsy in premenopausal women; instead, abnormal echogenicity and texture correlate better with underlying pathology. 1
• No action is needed unless you develop abnormal uterine bleeding, at which point transvaginal ultrasound with possible sonohysterography or endometrial sampling would be appropriate. 1

Nabothian Cyst

• Small nabothian cysts are benign mucinous retention cysts that require no treatment or intervention in asymptomatic women. 2
• These are common, non-neoplastic cervical findings in reproductive-age women that form when cervical crypts become blocked. 2, 3
• No follow-up imaging or intervention is indicated for small nabothian cysts. 2

Cervical Calcifications

• Tiny cervical calcifications are typically benign findings that require no specific management in the absence of suspicious features.

Non-Visualized Ovaries

• Non-visualization of ovaries on transvaginal ultrasound can be a normal finding, particularly in women with body habitus limitations or bowel gas interference. 1
• Since there are no adnexal masses, free fluid, or concerning features, no additional imaging is required. 1
• If clinical concern for ovarian pathology develops (pelvic pain, palpable mass, elevated tumor markers), repeat ultrasound or MRI would be appropriate. 1

Thyroid Ultrasound Findings – Management Algorithm

Atrophic Left Thyroid Lobe

• Document this finding for future reference, as it may represent chronic thyroiditis or other benign atrophy.
• Correlate with thyroid function tests (TSH, free T4) to assess for hypothyroidism.

Sub-5 mm Benign-Appearing Nodules

• Nodules ≤5 mm with benign sonographic features do not require biopsy regardless of appearance. 1
• Routine clinical monitoring is appropriate, which typically means:
  • Repeat thyroid ultrasound in 12–24 months to assess stability
  • Annual thyroid function testing
  • No fine-needle aspiration indicated at this size threshold

Summary Action Plan

Immediate actions:

• None required for pelvic findings
• Check thyroid function tests (TSH, free T4) if not recently done
• Document findings in your medical record

Follow-up schedule:

• Thyroid ultrasound in 12–24 months to confirm nodule stability 1
• Pelvic imaging only if abnormal uterine bleeding develops 1
• Annual clinical examination

Red flags requiring urgent re-evaluation:

• Development of abnormal uterine bleeding (would prompt endometrial sampling) 1
• Pelvic pain or palpable adnexal mass (would prompt repeat pelvic ultrasound) 1
• Rapid thyroid nodule growth or compressive symptoms (would prompt earlier thyroid imaging)

Key Pitfalls to Avoid

• Do not pursue endometrial biopsy based solely on thickness measurement in premenopausal women without abnormal bleeding, as this leads to unnecessary procedures. 1
• Do not assume non-visualized ovaries indicate pathology—this is often a technical limitation rather than a clinical concern when no masses are present. 1
• Do not biopsy thyroid nodules ≤5 mm, as the yield is extremely low and management would not change. 1