A 42-year-old woman from Delhi presents with a 6-month history of heavy menstrual bleeding with passage of clots, occurring every 21 days and lasting 8–10 days. She reports fatigue and dyspnea on exertion. On examination, the uterus is firm, irregularly enlarged, and mobile. Hemoglobin is 8.2 g/dL. Transvaginal ultrasound shows a heterogeneous mass within the myometrium, 4 cm in diameter, with preserved endometrial-myometrial interface. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Uterine Leiomyoma (Fibroid) **Key Point:** Uterine leiomyomas are the most common benign pelvic tumors in reproductive-age and perimenopausal women, presenting with heavy menstrual bleeding (menorrhagia), dysmenorrhea, and pelvic mass sensation. ### Diagnostic Features in This Case | Feature | Finding | Significance | |---------|---------|---------------| | **Age** | 42 years | Peak incidence 40–50 years | | **Bleeding pattern** | Heavy, cyclic, with clots | Typical of submucosal/intramural fibroids | | **Uterine findings** | Firm, irregularly enlarged, mobile | Characteristic of fibroid uterus | | **Ultrasound** | Heterogeneous mass, 4 cm, preserved interface | Intramural/submucosal fibroid; preserved interface excludes adenomyosis | | **Hemoglobin** | 8.2 g/dL | Iron-deficiency anemia from chronic blood loss | **High-Yield:** The **preserved endometrial-myometrial interface** on transvaginal ultrasound is the key discriminator — adenomyosis causes **loss or irregularity** of this interface. ### Pathophysiology 1. Benign smooth muscle proliferation in myometrium 2. Submucosal fibroids distort endometrial cavity → ↑ surface area for menstruation 3. Abnormal angiogenesis and impaired hemostasis → heavy bleeding 4. Iron-deficiency anemia develops over months to years **Clinical Pearl:** Fibroids are **estrogen and progesterone-dependent**; they regress postmenopausally and may enlarge during pregnancy. ### Management Approach ```mermaid flowchart TD A[Fibroid confirmed on imaging]:::outcome --> B{Symptoms & fertility goals?}:::decision B -->|Mild symptoms, no fertility desire| C[Observation + iron supplementation]:::action B -->|Heavy bleeding, anemia| D[Medical or surgical management?]:::decision D -->|Medical| E[Levonorgestrel IUD, tranexamic acid, NSAIDs]:::action D -->|Surgical| F{Fertility desired?}:::decision F -->|Yes| G[Myomectomy]:::action F -->|No| H[Hysterectomy or myomectomy]:::action ``` **Mnemonic: FIBROID BLEEDING — Features** - **F**irm uterus, **I**rregularly enlarged, **B**enign smooth muscle - **R**eproductive age/perimenopausal, **O**bstructive (submucosal), **I**ntramural/submucosal location - **D**ysmenorrhea, **B**leeding (heavy, cyclic) - **L**evonorgestrel IUD (first-line medical), **E**strogen-dependent, **E**ndometrial interface preserved - **D**iagnosis by ultrasound/MRI [cite:Jeffcoate's Principles of Gynaecology Ch 14]