Introduction: 

This case analyzes a middle-aged woman presenting with abnormal bleeding and pelvic pain. This case study will help you understand the consequences of intramural fibroids and the options available for their management. This case emphasizes the importance of understanding the clinical manifestations, diagnostic techniques, and treatment options for uterine leiomyomas. It also highlights the need to counsel the patient about the benefits and drawbacks of different therapeutic choices, keeping in mind the patient's symptom severity, quality of life, and fertility wishes.

Case Profile: 

A 44-year-old G3P3 woman presents with a history of abnormal bleeding and pelvic pain. Her health was good until she turned 37 when she began experiencing dysmenorrhea and increasing menorrhagia, unrelieved by NSAIDs. Over a few years, her dysmenorrhea and menorrhagia worsened. She then began experiencing intermenstrual bleeding and pelvic pain, described as persistent pressure. She also complains of frequent urination.

Her past gynecological history is non-contributory, with three children delivered via Caesarean delivery, the last one with a tubal ligation at age 32. Her past medical history is unremarkable. A physical examination shows a well-developed woman in no distress. Abdominal examination reveals an irregularly-sized mass extending halfway between the pubic symphysis and umbilicus and to the left of the midline. A pelvic exam reveals a normal vagina and cervix. The uterus is significantly enlarged and irregular, mainly on the left side, reaching the pelvic sidewalls. The adnexae are not palpable due to the mass size. 

Beta HCG is negative. CBC reveals a hemoglobin of 10.1 and a hematocrit of 30.7%. Indices are hypochromic and microcytic. Serum ferritin confirms mild iron deficiency anemia. Pap test is reported as negative for malignancy and adequate for evaluation. Ultrasound shows multiple large intramural fibroids filling the pelvis and extending into the lower abdomen. The mass extends into the left side of the pelvis. There is mild hydronephrosis on that side. The ovaries are not visualized. An endometrial biopsy reveals proliferative endometrium.

Activity Questions:

• What are the likely causes of the mass prior to imaging? 
  Hint: Reflect on the differential diagnosis for a pelvic mass.
  

• What is the prevalence of leiomyoma in different populations of women? 
  Hint: Discuss the frequency of uterine leiomyomas and any variations among different racial or ethnic groups.
  

• Describe the pathological changes of leiomyomata. 
  Hint: Discuss the typical characteristics and histological features of leiomyomata.
  

• Discuss the appropriate management of women with fibroids. 
  Hint: Explain various management options, including expectant management, medical therapies, and surgical interventions.
  

• What are the indications for hysterectomy in women with fibroids? 
  Hint: Discuss the factors that might lead to considering a hysterectomy in the management of fibroids.
  

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