What is the diagnosis for a patient with heavy menstrual bleeding, low hemoglobin (Hb) levels, and an ultrasound picture of the uterus showing a mass?

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Diagnosis: Uterine Leiomyoma (Fibroids)

The diagnosis is D - uterine leiomyoma (fibroids), which are the most common benign tumors in women of reproductive age and the leading cause of heavy menstrual bleeding with resultant anemia. 1

Clinical Presentation Matches Fibroid Pathology

The 2-year history of heavy menstrual bleeding with low hemoglobin is the classic presentation of symptomatic uterine fibroids:

  • Uterine fibroids are clinically apparent in up to 25% of women and cause prolonged or heavy menstrual bleeding as their primary symptom, leading to iron deficiency anemia. 2
  • Heavy menstrual bleeding from fibroids can cause life-threatening anemia, with documented cases showing hemoglobin levels dropping below 2.0 g/dl in patients who delay treatment. 3
  • Approximately 30% of women with fibroids experience symptoms that affect quality of life, with abnormal uterine bleeding and heavy menstrual bleeding being the most common complaints, along with iron deficiency anemia. 4

Why Other Diagnoses Are Excluded

Pregnancy (Option A) is excluded because:

  • The 2-year duration of symptoms is incompatible with pregnancy 5
  • β-hCG testing should be performed in all reproductive-age women with abnormal bleeding to exclude pregnancy before proceeding with further evaluation 5

Ovarian cyst (Option B) is excluded because:

  • Ovarian cysts do not typically cause heavy menstrual bleeding or chronic anemia 1
  • The ultrasound shows a uterine mass, not an adnexal/ovarian mass 1

Endometrial/uterine cancer (Option C) is less likely because:

  • The 2-year stable duration without progression suggests benign pathology rather than malignancy 1
  • While endometrial sampling is mandatory in high-risk patients (age >45 years, postmenopausal status, obesity, diabetes, unopposed estrogen exposure), the chronic stable course over 2 years favors fibroids 5
  • Fibroids are far more common than malignancy in reproductive-age women, affecting >60% of women aged 30-44 years 4

Diagnostic Confirmation

Transvaginal ultrasound is the first-line imaging modality for identifying structural causes of abnormal uterine bleeding, with fibroids appearing as hypoechoic, round masses that may develop cystic spaces with degeneration. 1, 5

  • If the ultrasound shows focal endometrial abnormality, saline infusion sonohysterography has 96-100% sensitivity and 97% accuracy in distinguishing leiomyomas from polyps. 5
  • MRI with gadolinium-based contrast is indicated when the uterus is incompletely visualized by ultrasound or findings are indeterminate. 5

Management Implications

The diagnosis of uterine leiomyoma requires:

  • Medical therapy as first-line treatment unless contraindicated or structural pathology requires surgery, including combined oral contraceptives, cyclic progestins, levonorgestrel-releasing intrauterine system, NSAIDs, and tranexamic acid. 5
  • Iron replacement therapy to address the iron deficiency anemia resulting from chronic blood loss. 4
  • Surgical options (myomectomy for fertility preservation or hysterectomy for definitive treatment) if medical management fails. 1, 6

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Uterine fibroids.

Lancet (London, England), 2001

Research

Life-threatening anemia due to uterine fibroids: A case series.

Experimental and therapeutic medicine, 2022

Guideline

Diagnostic Approach to Abnormal Uterine Bleeding - Endometrial Causes

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Abnormal Uterine Bleeding Definition and Classification

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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