26year old para 1 ,history of 6 month menorhagia,mass per abdomen

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Clinical Case: 26-Year-Old Para 1, Menorrhagia x 6 Months + Mass Per Abdomen

Most Likely Diagnosis: Uterine Fibroid (Leiomyoma/Myoma)

This is the classic presentation. Fibroids are benign, monoclonal tumors of smooth muscle cells of the myometrium containing large aggregations of extracellular matrix (collagen, elastin, fibronectin, proteoglycan). They are the most common pelvic tumor in women of reproductive age and the most frequent indication for hysterectomy.

Key Pathophysiology

Estrogen-dependent tumors - grow in reproductive years, regress after menopause
Risk factors: obesity (21% increased risk per 10 kg weight gain), low parity (increasing parity actually decreases incidence), first-degree relatives (2.5x increased risk), African American women (2.9x higher risk)
Fibroids are common: by age 35, incidence is 60% in African American women and ~40% in White women

Why Menorrhagia Occurs

Submucous fibroids distort the endometrial cavity - leading to heavy/prolonged bleeding
Intramural fibroids interfere with normal myometrial contraction, impairing the ability to compress endometrial vasculature
Increased endometrial surface area over a submucosal fibroid

FIGO Classification of Fibroid Location

Type	Description
0	Intracavitary (pedunculated submucosal)
1	<50% diameter within myometrium
2	≥50% diameter within myometrium
3	Abuts endometrium, no intracavitary component
4	Intramural, entirely within myometrium
5	Subserosal, ≥50% intramural
6	Subserosal, <50% intramural
7	Pedunculated subserosal
8	Cervical, broad ligament, parasitic

Submucous (Types 0-2) are most responsible for menorrhagia; subserosal/large intramural are most responsible for the palpable abdominal mass.

Diagnosis

Clinical:

Enlarged, irregularly shaped, firm, nontender uterus on bimanual pelvic examination
The uterus is typically bosselated (knobby), non-tender, mobile

Investigations to order:

Investigation	Purpose
Pelvic USG (TVS)	First-line imaging - size, number, location of fibroids
Saline infusion sonography (SIS)	Best for submucous fibroids
MRI pelvis	Precise mapping before surgery, to distinguish from adenomyosis/sarcoma
Hysteroscopy	Direct visualization + biopsy of submucous fibroids
CBC	Assess for iron deficiency anemia (from menorrhagia)
LFT/coagulation profile	Rule out coagulopathy as cause of bleeding
Serum LH, FSH, TSH	Rule out hormonal causes
Endometrial biopsy	Rule out endometrial pathology

Red flags suggesting sarcoma (rare but must exclude):

Rapid growth, especially postmenopausal
Pain + fever (degeneration)
Postmenopausal new/growing mass

Differential Diagnosis

Uterine fibroid (most likely)
Adenomyosis - boggy, tender, symmetrically enlarged uterus; dysmenorrhea more prominent
Ovarian mass (dermoid, endometrioma, ovarian cyst) - arising from adnexa, separate from uterus
Endometrial polyp - smaller, usually intracavitary
Pregnancy - always exclude in reproductive age (urine/serum βhCG)
Uterine sarcoma - rare, rapid growth, more pain, older women

Management

Since this patient is 26 years old, para 1, and likely wants future fertility preserved, management must be conservative (fertility-sparing).

1. Watchful Waiting

Appropriate for asymptomatic or minimally symptomatic fibroids
Not appropriate here given 6 months of menorrhagia and significant abdominal mass

2. Medical Management

Drug	Mechanism	Use
Tranexamic acid 1.3 g TDS for 3-5 days during menses	Antifibrinolytic	Reduces menstrual blood loss
NSAIDs	Inhibit prostaglandins	Reduce bleeding and dysmenorrhea
Combined OCP	Reduces flow; no proven effect on fibroid size	Symptom control
Progesterone/IUS (Mirena)	Endometrial suppression	Reduces bleeding; device expulsion 15% with fibroids >3 cm
GnRH agonists (Leuprolide, Goserelin)	Induce pseudomenopause	Reduce fibroid volume by 30-35% and uterine volume by 35% within 6 months; used preoperatively to reduce size, correct anemia
GnRH antagonists (Ganirelix)	Immediate GnRH suppression	29% reduction in fibroid volume within 3 weeks
Ulipristal acetate	Selective progesterone receptor modulator	Pre-surgical fibroid shrinkage

GnRH agonist caveats:

Side effects in 95% (hot flushes 78%, vaginal dryness 32%)
Significant bone loss after 6 months - use for max 3-6 months
Fibroids regrow to pretreatment size within 4-6 months of stopping
Main use: preoperative to correct anemia and shrink fibroid before myomectomy

3. Surgical Treatment (Preferred in This Patient)

Since she has a mass per abdomen (likely large fibroid) + menorrhagia with no complete family, myomectomy is the procedure of choice.

Myomectomy options:

Approach	Indication
Hysteroscopic myomectomy	Submucous fibroids (Types 0-2) - gold standard
Laparoscopic myomectomy	Smaller fibroids (<5-8 cm), fewer in number
Open (abdominal) myomectomy	Large fibroids, multiple fibroids, palpable abdominal mass
Laparoscopic radiofrequency ablation	Newer technique

Myomectomy relieves symptoms in ~80% of women
Myomectomy should be considered a safe alternative to hysterectomy, even for large fibroids in women wishing to retain fertility - per Berek & Novak's Gynecology
Less intraoperative blood loss than hysterectomy despite longer operating time

Preoperative anemia correction:

IV iron infusion if Hb <9 g/dL
3 months GnRH-a to shrink fibroid and correct anemia before surgery

4. Uterine Artery Embolization (UAE)

Effective for selected patients
NOT recommended if she desires future fertility (effect on fertility and pregnancy unclear)
Used when surgery is not feasible

Complications of Fibroids

Iron deficiency anemia (from chronic menorrhagia)
Degeneration (hyaline, cystic, calcific, red/carneous degeneration in pregnancy)
Torsion of pedunculated fibroid - surgical emergency
Infertility and recurrent miscarriage
Obstructive uropathy (ureteral compression by large fibroid)
Pressure symptoms (bladder - urinary frequency; rectum - constipation)

Summary of Approach for This Patient

Confirm diagnosis: TVS pelvis + CBC
Rule out pregnancy (βhCG)
Endometrial sampling (to rule out endometrial pathology)
MRI pelvis for surgical planning
Correct anemia - IV iron ± GnRH agonist for 3 months
Myomectomy (abdominal or laparoscopic depending on size/number) - fertility-preserving
Counsel about fibroid recurrence (~27% within 10 years after myomectomy) and the need for follow-up

Source: Berek & Novak's Gynecology - Chapter on Uterine Fibroids

Causes,history, examination. Ovarian or uterine,benign or malignant

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Mass Per Abdomen in a 26-Year-Old Para 1 with Menorrhagia

Causes, History, Examination + Ovarian vs Uterine + Benign vs Malignant

CAUSES OF MASS PER ABDOMEN IN A WOMAN OF REPRODUCTIVE AGE

UTERINE CAUSES

Condition	Nature
Fibroid (Leiomyoma)	Benign - most likely here
Adenomyosis	Benign - diffuse uterine enlargement
Pregnancy (incl. hydatidiform mole)	Non-neoplastic
Endometrial carcinoma	Malignant - rare at 26 years
Uterine sarcoma (leiomyosarcoma)	Malignant - rare, rapid growth
Cervical carcinoma (bulky)	Malignant
Pyometra / Haematometra	Benign - outflow obstruction

OVARIAN CAUSES

Condition	Nature
Functional cysts (follicular, corpus luteum)	Benign/physiological
Endometrioma ("chocolate cyst")	Benign
Dermoid cyst (mature cystic teratoma)	Benign
Serous/mucinous cystadenoma	Benign
Polycystic ovaries (PCOS)	Benign
Epithelial ovarian carcinoma	Malignant
Germ cell tumors (dysgerminoma, yolk sac)	Malignant - peak in young women
Sex cord-stromal tumors (granulosa cell)	Malignant
Borderline (low malignant potential) tumors	Borderline
Krukenberg tumor	Malignant (metastatic)

OTHER PELVIC/ABDOMINAL CAUSES

Full bladder
Pelvic kidney
Appendicular mass / abscess
Retroperitoneal sarcoma
Omental cake (malignancy)
Lymphoma / lymph node mass

HISTORY TO TAKE

Presenting Complaint

Duration of abdominal mass - onset, progression, rate of growth (rapid growth = sinister)
Site: lower abdomen, suprapubic, lateral

Menstrual History (MOST important in this case)

Menorrhagia - duration, quantity (pads/day), passage of clots
Cycle regularity - irregular bleeding suggests malignancy or hormonal cause
Dysmenorrhea - secondary dysmenorrhea points to endometriosis/adenomyosis
Intermenstrual or postcoital bleeding - suggests cervical or endometrial pathology
LMP - always establish to rule out pregnancy

Pain History

Dull aching pressure - fibroids (chronic)
Sudden severe pain - torsion, rupture of cyst
Dyspareunia (deep) - endometriosis, fibroid
Cyclical pain - adenomyosis, endometrioma

Pressure Symptoms

Urinary frequency/urgency (bladder compression by anterior fibroid)
Constipation/tenesmus (posterior fibroid/ovarian mass on rectum)
Leg edema (large pelvic mass)

Associated Symptoms

Weight loss, anorexia, bloating - suggest malignancy
Ascites (abdominal fullness/fluid) - ovarian cancer
Fever - PID, tubo-ovarian abscess
Hirsutism, virilization - sex cord-stromal tumor (granulosa, Sertoli-Leydig)
Postmenopausal bleeding - not applicable here but important flag

Obstetric History

Para 1 - mode of delivery, any complications
Infertility/difficulty conceiving - fibroids (submucous type), endometriosis

Past Medical/Surgical History

Prior pelvic surgery
History of known PCOS
Personal/family history of ovarian, breast, colon cancer (BRCA1/2, Lynch syndrome)

Drug History

Hormonal contraception, hormone therapy
Tamoxifen (increases endometrial pathology)

Family History

BRCA1 mutation: 39% lifetime risk of ovarian cancer
BRCA2: 11-17% lifetime risk
Lynch syndrome (mismatch repair genes): 9-12% ovarian cancer risk

EXAMINATION

General Examination

Pallor (anemia from menorrhagia)
Cachexia, weight loss (malignancy)
Lymphadenopathy - left supraclavicular (Virchow's) in advanced malignancy
Virilization/hirsutism (sex cord-stromal tumor)
Jaundice (Krukenberg/metastatic disease)

Abdominal Examination

Inspection:

Distension - central (uterine/ovarian) or flank (large ovarian cyst with fluid)
Visible mass, visible pulsations
Sister Mary Joseph nodule (periumbilical metastasis)
Striae (rapid expansion)

Palpation:

Feature	Fibroid (Uterine)	Ovarian Mass
Arising from	Pelvis centrally, midline	Can be lateral or midline
Shape	Irregular, bosselated, firm	Round/ovoid, smooth
Consistency	Firm to hard	Cystic (tense), or solid
Mobility	Moves side to side with uterus; restricted upward movement	Moves in all directions
Lower border	Cannot reach below mass (arises from pelvis)	Can get below the mass if pedunculated
Bimanual	Continuous with uterus	Separate from uterus, groove felt

Percussion:

Dull centrally over mass
Shifting dullness / fluid thrill - ascites (suggests malignancy)
Ovarian cyst: tympanic in flanks (bowel pushed to sides); uterine mass: dull in flanks

Auscultation:

Bowel sounds (obstruction if malignant)

Pelvic Examination

Speculum:

Cervical erosion, polyp, contact bleeding
Cervical os - discharge (PID), mass protruding (submucous fibroid, cervical carcinoma)

Bimanual Examination:

Feature	Fibroid	Ovarian
Uterus	Enlarged, irregular, bosselated, non-tender, firm	Normal size (separate from mass)
Fornices	Mass felt in continuity with uterus	Mass felt separate; groove between uterus and mass
Tenderness	Non-tender (unless degeneration/torsion)	Tender if torsion, endometrioma
Mobility	Mobile en masse with uterus	Often mobile, can be fixed in malignancy
Pouch of Douglas	Free	Nodularity in POD = endometriosis or malignant deposits

DIFFERENTIATING UTERINE FROM OVARIAN MASS

Feature	Uterine Mass (Fibroid)	Ovarian Mass
Menorrhagia	Common (especially submucous)	Usually absent or irregular bleeding
Movement with uterus	Yes - moves together	No - separate groove felt
Bimanual findings	Continuous with uterus	Separate from uterus
Percussion	Central dullness, no shifting dullness	Large cysts: flanks tympanic
Ascites	Absent (benign)	Present in malignancy
USG	Heterogeneous solid mass within myometrium	Adnexal, separate from uterus

DIFFERENTIATING BENIGN FROM MALIGNANT OVARIAN MASS

Feature	Benign	Malignant
Age	Young (reproductive)	Perimenopausal/postmenopausal (but germ cell in young)
Onset	Slow	Rapid growth
Pain	Mild/absent or acute (torsion)	Dull, persistent
Consistency	Cystic, smooth	Solid or mixed solid-cystic
Surface	Smooth	Irregular, nodular
Mobility	Mobile	Fixed, tethered
Ascites	Absent	Present (shifting dullness)
Bilateral	Usually unilateral	Often bilateral
Cachexia/weight loss	Absent	Present
Lymphadenopathy	Absent	May be present

Risk of Malignancy Index (RMI)

From Bailey & Love's Surgery:

RMI = U × M × CA-125

U = ultrasound features (1 point each): multilocular, solid areas, metastases, ascites, bilateral lesions (score 0, 1, or 3)
M = menopausal status: premenopausal = 1, postmenopausal = 3
CA-125 = serum level in U/mL

RMI >200 = high risk of malignancy → refer to gynaecological oncologist

Classification of Ovarian Tumours (Bailey & Love's Surgery)

Type	Proportion	Key Examples
Surface epithelial	~65% of all; 90% of malignancies	Serous, mucinous, endometrioid, clear cell
Germ cell	~15%	Benign: dermoid cyst (most common in reproductive age); Malignant: dysgerminoma, yolk sac, immature teratoma, choriocarcinoma
Sex cord-stromal	~10%	Granulosa cell (estrogen), Sertoli-Leydig (androgen)
Metastatic	~5%	Krukenberg (from stomach/breast/colon)

In a 26-year-old, the commonest ovarian malignancy is a germ cell tumor (especially dysgerminoma, yolk sac tumor), NOT epithelial carcinoma (which peaks at 65-69 years).

INVESTIGATIONS

Test	Reason
Urine/serum βhCG	Rule out pregnancy first, always
CBC	Anemia from menorrhagia
Pelvic USG (TVS + TAS)	First-line imaging - size, site, echogenicity, vascularity
Saline infusion sonography	Submucous fibroids
MRI pelvis	Best for surgical mapping; differentiates fibroid vs adenomyosis vs sarcoma
CA-125	Ovarian malignancy (>35 U/mL); elevated in endometriosis, PID, menstruation
AFP, βhCG, LDH	Germ cell tumors (essential in young women)
CA-19-9, CEA	Mucinous/other tumors
CT chest-abdomen-pelvis	Staging if malignancy suspected
Endometrial biopsy	Rule out endometrial pathology
Hysteroscopy	Submucous fibroids, endometrial pathology

SUMMARY FOR THIS CASE

Most likely diagnosis: Uterine fibroid (benign), given:

Age 26, reproductive, para 1
6 months of menorrhagia (submucous/intramural fibroid)
Mass per abdomen - large intramural or subserosal fibroid
Firm, irregular, non-tender uterus on bimanual

Must exclude: Ovarian germ cell tumor (especially in this age group), endometriosis with endometrioma, pregnancy

Red flags for malignancy: Rapid growth, ascites, weight loss, fixed mass, bilateral on USG - would necessitate urgent CA-125 + CT staging + oncology referral

Sources: Berek & Novak's Gynecology; Bailey & Love's Short Practice of Surgery, 28th Edition

Types of fibroid

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Types of Uterine Fibroids (Leiomyomas)

Fibroids are classified by two main systems: Location/Site (classical anatomical) and the FIGO Numerical Classification System.

1. CLASSICAL ANATOMICAL CLASSIFICATION

A. Intramural (Most Common - ~70%)

Located entirely within the myometrium
Surrounded by a pseudocapsule of compressed muscle
Enlarges the uterus symmetrically or asymmetrically
Symptoms: Menorrhagia (if large/distorting cavity), bulk symptoms, pelvic heaviness
Palpation: Smooth or bosselated, firm, enlarged uterus

B. Subserosal

Arise from outer myometrium, project outward beneath the serosa
Can become pedunculated (attached by a stalk) - may mimic ovarian mass
Symptoms: Pressure on adjacent organs - urinary frequency (bladder), constipation (rectum), back pain; minimal menorrhagia
Pedunculated subserosal fibroid can undergo torsion - surgical emergency

C. Submucous (Submucosal)

Arise just under the endometrium, bulge into the uterine cavity
Smallest in size but most symptomatic
Most important cause of menorrhagia and infertility
Can become pedunculated and prolapse through the cervical os ("fibroid polyp")
Diagnosed best by: SIS, hysteroscopy, MRI

D. Cervical

Located in the cervical stroma (<1%)
May cause obstructed labor, dyspareunia, urinary symptoms
Technically difficult to remove surgically

E. Broad Ligament / Intraligamentous

Arise in the broad ligament between the leaves of the peritoneum
Can compress the ureter, cause hydronephrosis
Difficult surgical access

F. Parasitic Fibroid

Becomes detached from the uterus and derives blood supply from adjacent organs (omentum, bowel)
Rare; found incidentally

2. FIGO NUMERICAL CLASSIFICATION SYSTEM

(Berek & Novak's Gynecology - Table 11-1)

Fibroids are divided into Submucosal (SM) and Other (O) groups:

Type	Category	Description
0	Submucosal	Pedunculated - entirely intracavitary, no intramural component
1	Submucosal	<50% of diameter within myometrium
2	Submucosal	≥50% of diameter within myometrium
3	Other	Abuts endometrium - 100% intramural, no intracavitary extension
4	Other	Intramural - entirely within myometrium, no extension to serosa or endometrium
5	Other	Subserosal - ≥50% intramural
6	Other	Subserosal - <50% intramural
7	Other	Subserosal pedunculated
8	Other	Special locations - cervical, broad ligament, parasitic (no myometrial involvement)

Hybrid (Transmural) Fibroids

Impact both endometrium and serosa
Described by two numbers (endometrial first, then serosal)
Example: Type 2-5 = submucosal and subserosal, each <50% in their respective cavities

3. HISTOLOGICAL VARIANTS (WHO Classification)

(Berek & Novak's Gynecology)

Variant	Key Feature	Clinical Note
Ordinary leiomyoma	<5 mitoses/10 hpf, no atypia	Benign, standard fibroid
Mitotically active leiomyoma	10-15 mitoses/10 hpf	Seen in pregnancy or with exogenous hormones; benign
Cellular leiomyoma	Higher cellularity than adjacent myometrium	2% recurrence; rare chromosome 1p deletion variants may be aggressive
Atypical/Symplastic/Bizarre leiomyoma	Scattered large atypical cells	12% recurrence after hysterectomy
STUMP (Smooth Muscle Tumor of Uncertain Malignant Potential)	Between leiomyoma and LMS; uncertain necrosis, focal atypia, mitoses <10/hpf	~7.3% recurrence; can rarely develop into low-grade LMS
Leiomyosarcoma (LMS)	≥10 mitoses/10 hpf, diffuse atypia, tumor cell necrosis	Malignant; 5-year survival Stage I = 61%, Stages III-IV = ~30%; prevalence 1 in 1,429 surgeries for "fibroids"

Key point: There is no reliable method to preoperatively distinguish LMS from benign fibroid. Rapid growth, especially postmenopausal, raises suspicion.

4. DEGENERATION TYPES (Secondary Changes)

Fibroids outgrow their blood supply and undergo degeneration:

Type	Appearance	Key Features
Hyaline (most common, ~65%)	White, homogeneous	Replacement by fibrous tissue; benign
Cystic	Fluid-filled spaces	Following hyaline degeneration
Calcific	"Womb stone"	Postmenopausal; seen on X-ray as calcified mass
Red/Carneous	Red, raw-meat appearance	Classic in pregnancy - intense pain, fever, local tenderness; venous thrombosis in fibroid
Myxomatous	Jelly-like
Fatty (rare)	Lipomatous change
Sarcomatous	Rapid growth, soft	Malignant transformation - rare (0.1-0.5%)

CLINICAL CORRELATION: WHICH TYPE CAUSES WHAT?

Symptom	Responsible Type
Menorrhagia	Submucous (Types 0, 1, 2) - most important
Infertility / miscarriage	Submucous > Intramural
Palpable abdominal mass	Large intramural + subserosal
Urinary frequency	Anterior subserosal/intramural
Constipation / tenesmus	Posterior subserosal
Acute pain	Pedunculated (torsion), red degeneration (pregnancy)
Obstructed labor	Cervical, lower segment fibroid
Hydronephrosis	Broad ligament / intraligamentous

DIAGRAM - FIGO Classification

The FIGO system is best remembered visually:

CAVITY ← [0] [1] [2] | WALL: [3][4] | SEROSA → [5] [6] [7]
                        ↑
                   Endometrium

Types 0-2 = Submucous (closest to cavity = most menorrhagia) Types 3-4 = Intramural (within wall) Types 5-7 = Subserosal (closest to serosa = pressure symptoms) Type 8 = Special sites (cervix, ligaments, parasitic)

Source: Berek & Novak's Gynecology, Chapter 11 - Uterine Fibroids

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