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35yr women with heavy menstrual bleeding with clots and severe cramping, usg s/o large,irregularly shaped mass in uterus. Whats is Diagnosis

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"uterine fibroids" AND "heavy menstrual bleeding"

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uterine fibroid leiomyoma ultrasound

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Diagnosis: Uterine Leiomyoma (Fibroid)

This is the most likely diagnosis based on the classic triad:
  • 35-year-old premenopausal woman
  • Heavy menstrual bleeding (menorrhagia) with clots + severe dysmenorrhea
  • Ultrasound showing a large, irregularly shaped uterine mass

What Are Uterine Fibroids?

Uterine leiomyomas are benign monoclonal tumors arising from smooth muscle cells of the myometrium, stimulated by estrogen and progesterone. They are the most common pelvic tumor in women, occurring in up to 70–80% of women by age 50, though most are asymptomatic.

Why This Presentation Fits

FeatureSignificance
Age 35, premenopausalPeak symptomatic age; estrogen-driven growth
Heavy bleeding with clotsSubmucosal/intramural fibroids distort endometrial vasculature, impairing hemostasis
Severe crampingUterine attempts to expel submucosal fibroids; prostaglandin excess
Irregularly enlarged uterus on USGMultiple fibroids create a lobulated, asymmetric contour — classic "lumpy-bumpy" uterus
As stated in Berek & Novak's Gynecology: "Clinically significant subserosal and intramural fibroids can usually be diagnosed by pelvic examination based on findings of an enlarged, irregularly shaped, firm, and nontender uterus."

FIGO Classification of Fibroid Location

Fibroids most likely to cause heavy bleeding are submucosal (Types 0–2):
  • Type 0 — Pedunculated, entirely within the cavity
  • Type 1 — <50% intramural
  • Type 2 — ≥50% intramural
  • Types 3–4 — Intramural (cause bulk symptoms + bleeding)
  • Types 5–7 — Subserosal (mainly bulk/pressure symptoms)

Pathophysiology of Bleeding

  1. Increased endometrial surface area due to cavity distortion
  2. Impaired myometrial contractility around fibroid — uterus can't compress spiral arteries effectively
  3. Increased vascularity and angiogenesis around fibroids
  4. Prostaglandin imbalance → uterine cramping and heavy flow

Ultrasound Findings (Classic)

Uterine fibroid ultrasound — intramural leiomyoma
Transvaginal ultrasound: well-defined, hypoechoic, heterogeneous intramural fibroid (FIGO Type 4)
Submucosal fibroid on saline sonohysterography
Saline sonohysterography showing FIGO Type 0 submucosal leiomyoma — most common cause of heavy bleeding
Typical USG findings:
  • Heterogeneous, hypoechoic solid mass with well-defined margins
  • May show posterior acoustic shadowing (dense fibrous tissue)
  • Enlarged, lobulated uterine contour
  • Multiple lesions possible

Differential Diagnosis to Consider

ConditionDistinguishing Features
AdenomyosisDiffuse uterine enlargement, globular shape, heterogeneous myometrium; no discrete mass
Endometrial polypFocal intracavitary lesion; smaller; best seen on SIS/hysteroscopy
Uterine sarcoma (LMS)Rare at 35; more common postmenopausal; rapid growth, heterogeneous; requires MRI/biopsy
Ovarian massSeparate from uterus on USG; different origin
⚠️ Note: The textbook emphasizes that "rapid growth almost never indicates uterine sarcoma in premenopausal women" — sarcoma mean age is 55–68 years. However, if imaging shows atypical features, MRI is warranted.

Investigations

  1. Transvaginal USG — first-line; confirms size, location, number
  2. Saline infusion sonography (SIS) or hysteroscopy — for submucosal fibroids
  3. MRI pelvis — gold standard for mapping multiple fibroids pre-operatively; distinguishes fibroid from sarcoma
  4. CBC — assess anemia from chronic blood loss
  5. Serum ferritin — iron deficiency
  6. TFTs — rule out hypothyroidism as co-contributor to HMB
  7. Endometrial biopsy — if endometrial pathology suspected (age >40 or irregular bleeding)

Management Overview

Medical (preserve fertility/temporize):
  • GnRH agonists/antagonists (e.g., leuprolide, relugolix) — reduce fibroid volume 30–50%; used preoperatively (recent 2025 Cochrane review [PMID: 40183418] supports preoperative GnRH therapy)
  • Levonorgestrel IUS (Mirena) — reduces bleeding for smaller fibroids not distorting cavity
  • Tranexamic acid / NSAIDs — symptomatic relief of bleeding and cramping
  • Combined OCP — cycle regulation
Surgical:
  • Hysteroscopic myomectomy — for submucosal fibroids (Types 0–2); fertility-preserving
  • Laparoscopic/open myomectomy — for intramural/subserosal fibroids; fertility-preserving
  • Hysterectomy — definitive cure; for completed family or failed conservative management
  • Uterine artery embolization (UAE) — minimally invasive; good for multiple fibroids; reduces fertility potential

Key Points

  • Most common pelvic tumor in women; peak symptoms in reproductive age (30s–40s)
  • Driven by estrogen + progesterone → regress after menopause
  • Submucosal location causes the heaviest bleeding
  • Irregularly enlarged uterus on USG is the hallmark finding
  • Treatment depends on symptom severity, fibroid location, size, and fertility wishes
— Berek & Novak's Gynecology; Robbins & Kumar Basic Pathology
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