Primary Impression and Differential Diagnoses
Primary Impression: Symptomatic Uterine Leiomyomas (Fibroids) with Severe Anemia Secondary to Heavy Menstrual Bleeding
This 47-year-old woman presents with a classic triad of heavy menstrual bleeding requiring 2-3 adult diapers daily, a large palpable abdominal mass (17x30cm, firm, nodulated), and severe anemia requiring prior blood transfusion (Hgb 6.6 g/dL in 2022). 1 The documented history of multiple uterine myomas on transvaginal ultrasound in 2022, combined with progressive symptoms over 3 years, strongly supports this diagnosis. 2, 3 Her current presentation with dyspnea on exertion (grade 3, after 10 steps) and pale conjunctivae indicates ongoing severe anemia from chronic blood loss. 3
Differential Diagnoses
1. Adenomyosis with Concurrent Fibroids
- Adenomyosis frequently coexists with uterine fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia—all present in this patient. 4, 1
- The "areas of dullness" on abdominal examination in multiple quadrants could represent a diffusely enlarged uterus from adenomyosis in addition to the discrete fibroid mass. 1
- Adenomyosis is common in women in their 40s and can contribute significantly to menorrhagia and anemia. 4
- Key distinguishing feature: Transvaginal ultrasound or MRI would show myometrial thickening and heterogeneity distinct from discrete fibroid masses. 1
2. Endometrial Hyperplasia or Malignancy
- While her recent Pap smear (October 2025) was negative, this does not exclude endometrial pathology. 5
- At age 47 (perimenopausal), persistent heavy bleeding warrants exclusion of endometrial cancer, especially given the duration and severity of symptoms. 1, 5
- Risk factors present include nulliparity equivalent (G1P1), chronic anovulation patterns (suggested by progressively worsening bleeding), and age. 5
- Critical caveat: The American College of Radiology recommends endometrial sampling in patients with risk factors for endometrial cancer, and persistent abnormal bleeding despite known fibroids requires tissue diagnosis. 1, 5
- Her negative Pap smear does not evaluate the endometrium; endometrial biopsy or hysteroscopy with biopsy is necessary to definitively exclude this diagnosis. 5
3. Degenerating Fibroid with Acute Complications
- The large size of the fibroid mass (17x30cm) places her at risk for degenerative changes, which can cause acute pain, fever, and worsening symptoms. 3
- Red degeneration or torsion of a pedunculated fibroid could explain acute worsening of symptoms, though she is currently afebrile. 3
- Rapid growth or degeneration in a woman approaching menopause raises concern for leiomyosarcoma, though this is rare (occurring in <1% of presumed fibroids). 3
- Key distinguishing feature: Acute degeneration typically presents with fever, leukocytosis, and acute severe pain—not fully present in this case, though her dyspnea and worsening fatigue suggest progressive deterioration. 3
Critical Next Steps
Immediate evaluation must include: 1, 5
- Complete blood count to assess current hemoglobin and need for transfusion
- Endometrial biopsy to exclude hyperplasia or malignancy, given her age, persistent bleeding, and risk factors 5
- Transvaginal ultrasound with measurement of endometrial thickness (if ≥3-4mm, further investigation required) 5
- Consider saline infusion sonohysterography or MRI if ultrasound cannot adequately visualize the endometrium due to the large fibroid burden 1, 5
Definitive management: Given her age (47), completed childbearing (G1P1), severe symptoms requiring prior transfusion, and large fibroid burden, hysterectomy is the most appropriate definitive treatment. 4, 1 Hysterectomy provides complete resolution of fibroid-related symptoms and eliminates risk of recurrence, accounting for three-quarters of fibroid treatment in the United States. 4 The least invasive surgical route should be chosen based on uterine size and surgical expertise. 4