A 42-year-old woman from Delhi presents with heavy menstrual bleeding for the past 8 months. She reports soaking 8–10 pads per day during menses, with clots the size of a coin. Her cycles are regular (28 days), lasting 7 days. She denies intermenstrual bleeding, pelvic pain, or dyspareunia. On examination, the uterus is uniformly enlarged to 12–14 weeks size, firm, and mobile. Pelvic ultrasound shows a heterogeneous mass within the myometrium measuring 4 cm, with preserved endometrial echo. Hemoglobin is 9.2 g/dL. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Uterine Fibroid ### Key Presentation Features **Key Point:** Heavy menstrual bleeding with regular cycle intervals and a discrete myometrial mass on ultrasound is classic for uterine fibroid (leiomyoma). The patient presents with: - **Menorrhagia** (heavy, prolonged menses with clots) - **Regular cycle pattern** (28-day cycles, 7-day duration) - **Discrete myometrial mass** on ultrasound (4 cm, heterogeneous) - **Uniform uterine enlargement** (firm, mobile uterus) - **Preserved endometrial echo** (rules out endometrial pathology) ### Pathophysiology of Bleeding in Fibroids 1. Submucosal fibroids distort the endometrial surface → increased surface area for menstruation 2. Impaired myometrial contractility → prolonged bleeding 3. Abnormal angiogenesis and increased vascularity within the fibroid 4. Altered prostaglandin and cytokine production ### Differential Diagnosis Table | Feature | Fibroid | Adenomyosis | Polyp | Endometrial CA | |---------|---------|-------------|-------|----------------| | **Cycle regularity** | Regular | Often irregular | Regular | Irregular/postmenopausal | | **Ultrasound finding** | Discrete mass, heterogeneous | Diffuse thickening (>12 mm), globular uterus | Echogenic projection into cavity | Irregular endometrial thickening | | **Uterine size** | Enlarged, firm | Mildly enlarged, boggy | Normal | Normal or slightly enlarged | | **Endometrial echo** | Preserved | Disrupted/indistinct | Focal projection | Irregular/thickened | | **Age group** | Reproductive/perimenopausal | Reproductive/perimenopausal | Any age | Postmenopausal | ### High-Yield Points **High-Yield:** Fibroids are the most common benign pelvic tumor in women of reproductive age. The **combination of regular cycles + discrete myometrial mass + preserved endometrial echo** is pathognomonic for fibroid. **Clinical Pearl:** The degree of menorrhagia correlates with fibroid size and submucosal extension, not total fibroid burden. A small submucosal fibroid can cause severe bleeding, while a large intramural fibroid may be asymptomatic. ### Management Implications - **Medical:** NSAIDs, tranexamic acid, combined oral contraceptives, levonorgestrel-releasing IUD - **Surgical:** Myomectomy (fertility-sparing) or hysterectomy (definitive) - **Interventional:** Uterine artery embolization for symptom relief without surgery [cite:Jeffcoate's Principles of Gynaecology Ch 11]