What is the primary impression and differential diagnoses for a 47-year-old female patient with heavy menstrual bleeding, a history of uterine myoma, and a palpable abdominal mass?

Primary Impression and Differential Diagnoses

Primary Impression: Symptomatic Uterine Leiomyomata (Fibroids) with Severe Anemia

This 47-year-old woman presents with the classic triad of heavy menstrual bleeding requiring 2-3 adult diapers per day, a large palpable abdominal mass (17x30cm, firm, nodulated), and severe anemia requiring previous transfusion, all consistent with symptomatic uterine fibroids 1, 2. The documented history of multiple myomas on transvaginal ultrasound in 2022, progressive worsening of menorrhagia over 3 years, and current dyspnea on exertion (grade 3) secondary to anemia strongly support this diagnosis 3, 4.

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Differential Diagnoses

1. Adenomyosis (with or without coexisting fibroids)

• Adenomyosis frequently coexists with uterine fibroids and can independently cause heavy menstrual bleeding and dysmenorrhea 1
• The patient's dysmenorrhea and dyspareunia are consistent with adenomyosis 3
• Critical distinction: MRI is more sensitive than ultrasound for diagnosing adenomyosis, and this diagnosis affects treatment success rates 1
• The large uterine size and irregular contour could represent adenomyosis rather than or in addition to fibroids 1

2. Endometrial Hyperplasia or Malignancy

• This is a critical consideration that must be ruled out: The patient is perimenopausal (age 47), and endometrial cancer risk increases significantly in this age group 1, 5
• Her recent Pap smear (10/18/2025) was negative, but Pap smears do not screen for endometrial cancer 5
• Endometrial biopsy is essential even with normal imaging in perimenopausal women with heavy menstrual bleeding to rule out endometrial cancer or hyperplasia 1, 5
• Risk factors present: prolonged heavy bleeding (3 years of unopposed estrogen-like exposure from anovulatory cycles is possible), though she has no obesity, diabetes, or nulliparity 5
• The American College of Radiology emphasizes that thorough evaluation is necessary to avoid assuming bleeding is due to perimenopause or fibroids alone 1

3. Submucous Fibroids with Intracavitary Component

• Submucous fibroids are most likely to cause heavy menstrual bleeding compared to other fibroid locations 1, 4, 6
• Fibroids that distort the uterine cavity (either submucous or intramural with submucous component) are associated with increased uterine bleeding 4
• Characterization of fibroid location, size, and number is crucial for treatment planning 1
• The patient's previous TVS showed "4 multiple myoma uteri" but specific locations were not documented—this information is essential 1, 4

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Critical Next Steps Required

Before any surgical intervention, the following must be completed:

• Endometrial biopsy is mandatory despite the recent negative Pap smear, given her age and bleeding pattern 1, 5
• Repeat imaging with combined transabdominal and transvaginal ultrasound with Doppler to reassess current fibroid characteristics (size, number, location—especially submucous vs. intramural) 1
• Consider MRI of pelvis if ultrasound cannot fully visualize the endometrium or if adenomyosis needs to be definitively diagnosed, as this affects surgical outcomes 1
• Current hemoglobin level to assess severity of anemia and need for preoperative transfusion 2

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Common Pitfalls to Avoid

• Do not assume all bleeding is from fibroids: Endometrial pathology must be excluded in perimenopausal women, even with documented fibroids 1, 5
• Do not miss coexisting adenomyosis: This significantly impacts treatment success and should be evaluated with MRI if suspected 1
• Do not proceed to surgery without complete characterization: Fibroid location (submucous vs. intramural vs. subserosal) determines the appropriate surgical approach (hysteroscopic vs. abdominal myomectomy vs. hysterectomy) 4, 6, 7