A 42-year-old woman from Delhi presents with 3 months of heavy menstrual bleeding occurring every 21 days, with passage of clots and soaking 8–10 pads per day. She reports no intermenstrual bleeding, dysmenorrhea, or pelvic pain. Pelvic examination reveals an enlarged, irregularly nodular uterus. Hemoglobin is 9.2 g/dL. Transvaginal ultrasound shows multiple hypoechoic lesions within the myometrium with preserved endometrial thickness. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Uterine Leiomyomas (Fibroids) ### Key Findings in This Case **Key Point:** The combination of heavy menstrual bleeding (menorrhagia), regular cycle (every 21 days), enlarged irregularly nodular uterus on palpation, and multiple hypoechoic myometrial lesions on ultrasound is pathognomonic for uterine leiomyomas. ### Pathophysiology of Menorrhagia in Fibroids 1. Increased endometrial surface area (submucosal fibroids distort the cavity) 2. Abnormal angiogenesis and increased vascular permeability 3. Impaired uterine contractility → prolonged bleeding 4. Elevated local prostaglandins and growth factors ### Distinguishing Features: Leiomyomas vs. Adenomyosis | Feature | Leiomyomas | Adenomyosis | |---------|-----------|-------------| | **Uterine size** | Irregular, nodular, asymmetric | Uniformly enlarged, boggy | | **Bleeding pattern** | Heavy, regular cycles (if submucosal) | Heavy + dysmenorrhea common | | **Ultrasound** | Discrete hypoechoic masses with whorled pattern | Heterogeneous myometrium, no discrete mass | | **MRI findings** | Well-defined fibroids with junctional zone intact | Disrupted junctional zone, diffuse involvement | | **Age of presentation** | 30–50 years (reproductive age) | 40–50 years (perimenopausal) | **High-Yield:** Leiomyomas are the most common pelvic tumor in women; menorrhagia is the most common presenting symptom. ### Why This Patient Has Leiomyomas, Not Adenomyosis - **Adenomyosis** presents with dysmenorrhea (which this patient lacks) and a uniformly enlarged, boggy uterus; ultrasound shows heterogeneous myometrium without discrete masses. - The **irregular nodular** uterus and **discrete hypoechoic lesions** point to fibroids. - Regular 21-day cycles (not prolonged or irregular) favor fibroids over adenomyosis. ### Clinical Management Approach **Tip:** In reproductive-age women with menorrhagia and fibroids, first-line medical options include: - Combined oral contraceptives (COCs) - Levonorgestrel intrauterine device (LNG-IUD) — most effective for menorrhagia - NSAIDs (mefenamic acid 500 mg TDS during menses) - Tranexamic acid (1.3 g TDS for 4 days during menses) Surgical options (myomectomy, hysterectomy) are considered if medical therapy fails or fertility is desired. **Clinical Pearl:** Fibroids regress after menopause due to loss of estrogen and progesterone stimulation; therefore, expectant management is reasonable in perimenopausal women with tolerable symptoms. [cite:Ferenczy & Bergeron, 2011; ACOG Practice Bulletin 228]