Reproductive · Year 2 · from Reproductive
Case 3: Uterine Fibroids
Clinical Image
Source: Wikipedia - Uterine fibroid - CC BY-SA 3.0
Case Presentation
A 42-year-old G2P2 African American woman presents with a 3-year history of progressively heavy menstrual bleeding. She soaks through a super tampon and pad every 1-2 hours during the first 3 days of her period and passes large clots. Her periods last 8-9 days. She has developed fatigue and exertional dyspnea. She also reports pelvic pressure, urinary frequency, and a visibly enlarged lower abdomen. Physical examination reveals a firm, irregular, enlarged uterus palpable at the umbilicus (approximately 20-week size). Hemoglobin is 8.2 g/dL with microcytic indices consistent with iron deficiency anemia. Pelvic ultrasound demonstrates a 14 cm intramural fibroid distorting the uterine cavity, multiple smaller intramural fibroids, and a 3 cm submucosal fibroid. Endometrial biopsy shows secretory endometrium without hyperplasia. Given her completed childbearing, severe symptoms, anemia, and bulk symptoms, surgical options are discussed. She elects to proceed with hysterectomy. Pathology confirms multiple benign leiomyomas, with the largest measuring 15 cm. Post-operatively, her symptoms resolve and her hemoglobin normalizes with iron supplementation.
Key Learning Points
- Uterine fibroids (leiomyomas) are the most common pelvic tumors in women; Black women have higher prevalence and more severe disease than other racial groups
- Fibroids are classified by location: submucosal fibroids disproportionately cause heavy bleeding and infertility; intramural and subserosal fibroids cause bulk symptoms
- Treatment options range from medical management (tranexamic acid, GnRH agonists, hormonal contraception) to procedures (uterine artery embolization, myomectomy) to hysterectomy
- Fibroids are estrogen-dependent and typically regress after menopause; GnRH agonists cause temporary regression but are limited by hypoestrogenic side effects