Accurate segmentation annotations are critical for disease monitoring, yet manual labeling remains a major bottleneck due to the time and expertise required. Active learning (AL) alleviates this burden by prioritizing informative samples for annotation, typically through a diversity-based cold-start phase followed by uncertainty-driven selection. We propose a novel cold-start sampling strategy that combines foundation-model embeddings with clustering, including automatic selection of the number of clusters and proportional sampling across clusters, to construct a diverse and representative initial training. This is followed by an uncertainty-based AL framework that integrates spatial diversity to guide sample selection. The proposed method is intuitive and interpretable, enabling visualization of the feature-space distribution of candidate samples. We evaluate our approach on three datasets spanning X-ray and MRI modalities. On the CheXmask dataset, the cold-start strategy outperforms random selection, improving Dice from 0.918 to 0.929 and reducing the Hausdorff distance from 32.41 to 27.66 mm. In the AL setting, combined entropy and diversity selection improves Dice from 0.919 to 0.939 and reduces the Hausdorff distance from 30.10 to 19.16 mm. On the Montgomery dataset, cold-start gains are substantial, with Dice improving from 0.928 to 0.950 and Hausdorff distance decreasing from 14.22 to 9.38 mm. On the SynthStrip dataset, cold-start selection slightly affects Dice but reduces the Hausdorff distance from 9.43 to 8.69 mm, while active learning improves Dice from 0.816 to 0.826 and reduces the Hausdorff distance from 7.76 to 6.38 mm. Overall, the proposed framework consistently outperforms baseline methods in low-data regimes, improving segmentation accuracy.