## Clinical Presentation & Imaging Findings **Key Point:** The combination of menorrhagia with passage of clots, an irregularly enlarged firm uterus, and multiple hypoechoic intramural lesions on transvaginal ultrasound is pathognomonic for uterine leiomyomas (fibroids). ## Diagnostic Features of Leiomyomas | Feature | Leiomyomas | Adenomyosis | Polyp | Endometrial CA | |---------|-----------|------------|-------|----------------| | **Uterine size** | Enlarged, irregular | Diffusely enlarged, boggy | Normal | Normal to slightly enlarged | | **Ultrasound** | Discrete hypoechoic nodules | Ill-defined, heterogeneous myometrium | Echogenic projection into cavity | Thickened endometrium | | **Bleeding pattern** | Heavy, cyclic with clots | Dysmenorrhea + menorrhagia | Intermenstrual or postcoital | Postmenopausal or irregular | | **Age group** | 30–50 years | 40–50 years | Any age | Postmenopausal | ## Why This Patient Has Leiomyomas **High-Yield:** The presence of **multiple discrete hypoechoic lesions** within the myometrium (intramural location) is the hallmark ultrasound finding. The firm, irregularly enlarged uterus on bimanual examination and the heavy cyclic bleeding with clots are classic for fibroids. **Clinical Pearl:** Leiomyomas distort the endometrial cavity and increase endometrial surface area, leading to increased menstrual blood loss. The passage of clots suggests heavy flow, which is more typical of fibroids than adenomyosis. **Key Point:** Normal endometrial thickness (8 mm) and absence of postmenopausal status rule out endometrial carcinoma. The discrete nodular appearance rules out adenomyosis, which presents as a diffusely heterogeneous, poorly demarcated myometrium.
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