A 42-year-old woman from Delhi presents with a 6-month history of heavy menstrual bleeding lasting 8–10 days per cycle, with passage of clots. She reports fatigue and dyspnea on exertion. Hemoglobin is 8.2 g/dL. Pelvic examination reveals an enlarged, irregular, firm uterus. Transvaginal ultrasound shows multiple hypoechoic lesions within the myometrium without endometrial thickening. Coagulation profile and thyroid function are normal. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Uterine Fibroids ### Key Findings **Key Point:** The combination of heavy menstrual bleeding, an enlarged irregular firm uterus, and multiple hypoechoic myometrial lesions on ultrasound is pathognomonic for uterine fibroids (leiomyomas). ### Pathophysiology Uterine fibroids are benign smooth muscle tumors that: 1. Distort the endometrial cavity, increasing surface area and abnormal vascularity 2. Impair myometrial contractility, reducing hemostasis 3. Cause secondary iron-deficiency anemia from chronic blood loss ### Diagnostic Features of Fibroids | Feature | Fibroids | Adenomyosis | DUB | | --- | --- | --- | --- | | **Uterine size** | Enlarged, irregular, nodular | Diffusely enlarged, boggy | Normal or slightly enlarged | | **Ultrasound** | Hypoechoic/isoechoic masses, distortion | Heterogeneous myometrium, adenomyotic cysts | Normal or thickened endometrium | | **Endometrial thickness** | May be normal or distorted | Normal or thickened | Variable | | **Age group** | 35–50 years | 40–50 years | Adolescents, perimenopausal | | **Duration of bleeding** | Often 8–10 days | Dysmenorrhea + HMB | Irregular intervals | **High-Yield:** Fibroids are the most common pelvic tumor in women and the leading cause of hysterectomy in reproductive-age women. ### Clinical Pearl The **irregular, firm, nodular uterus** on palpation is the clinical hallmark of fibroids. Adenomyosis, by contrast, presents with a **uniformly boggy, tender, symmetrically enlarged** uterus. ### Management Approach ```mermaid flowchart TD A[Uterine Fibroids + HMB]:::outcome --> B{Fertility desired?}:::decision B -->|Yes| C[Medical: GnRH agonists, SPRMs]:::action B -->|No| D{Symptoms severe?}:::decision D -->|Yes| E[Surgical: Myomectomy or Hysterectomy]:::action D -->|No| F[Medical: NSAIDs, tranexamic acid, OCP]:::action C --> G[Consider minimally invasive options]:::action ``` **Citation:** Ferenczy A, Bergeron C. Pathophysiology and management of adenomyosis. Fertil Steril. 2003; also Park 26e Ch 10 (Abnormal Uterine Bleeding). ### Why This Patient Has Fibroids - Age 42 (peak incidence 35–50 years) - Enlarged, **irregular firm uterus** (not boggy/tender) - Multiple **hypoechoic lesions** on transvaginal ultrasound - Normal endometrial thickness (rules out hyperplasia/malignancy) - Normal coagulation (rules out coagulopathy) - Secondary iron-deficiency anemia from chronic HMB