A 38-year-old nulliparous woman is found to have multiple uterine fibroids on routine pelvic ultrasound. She is asymptomatic. Which of the following is the most common presenting symptom in women with symptomatic uterine fibroids?

Explanation

## Most Common Presenting Symptom of Uterine Fibroids **Key Point:** Menorrhagia (heavy menstrual bleeding) is the single most common presenting symptom of symptomatic uterine fibroids, occurring in 30–40% of women with fibroids. ### Symptom Frequency and Etiology | Symptom | Frequency | Mechanism | | --- | --- | --- | | **Menorrhagia** | 30–40% | Increased endometrial surface area; abnormal angiogenesis; altered prostaglandin metabolism; submucosal location | | **Dysmenorrhea** | 20–30% | Uterine contractions; distortion of uterine cavity; intramural location | | **Infertility** | 5–10% | Cavity distortion; impaired embryo implantation; abnormal uterine contractions | | **Pelvic pressure/pain** | 20–25% | Large intramural or subserosal fibroids; compression of adjacent organs | | **Asymptomatic** | 50% | Many fibroids remain clinically silent and are discovered incidentally | **High-Yield:** Approximately 50% of women with fibroids are asymptomatic. Among symptomatic women, menorrhagia is the most frequent complaint and is the primary reason for seeking treatment. **Clinical Pearl:** The severity of bleeding does not correlate with fibroid size or number. A small submucosal fibroid may cause severe menorrhagia, while large intramural fibroids may cause minimal bleeding. This is because menorrhagia is driven by endometrial surface area distortion and abnormal angiogenesis, not fibroid volume. ### Pathophysiology of Menorrhagia in Fibroids 1. **Increased endometrial surface area** — submucosal fibroids project into the cavity, enlarging the bleeding surface 2. **Abnormal angiogenesis** — fibroids trigger formation of dilated, fragile vessels in overlying endometrium 3. **Altered prostaglandin and cytokine metabolism** — increased PGE~2~ and PGF~2α~, leading to increased bleeding and dysmenorrhea 4. **Impaired hemostasis** — fibroid-induced changes in endometrial hemostatic factors **Mnemonic:** **FIBROID bleeding = Fibroids Increase Bleeding Rate Over Increased Distension** — Remember that surface area and vascular changes, not size alone, drive menorrhagia. [cite:Telinde's Operative Gynecology 12e Ch 20; Novak's Gynecology 16e Ch 16]