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