Chief Complaint

Uterine fibroids, postmenopausal bleeding, and pelvic pain

HPI
Ms. R is a 57-year-old African American Female, G2P1011, LMP unsure, and irregular. She
presented to the gynecology clinic on 3/19/2024 for ongoing pelvic cramping pain and vaginal
bleeding. Ms. R has a history of fibroids with abnormal uterine bleeding that has occurred 2-3
times a year for the last 4-5 years. However, the bleeding has been heavy and ongoing for over
one month. The heavy bleed requires 2 pads every 2 hours and has been passing large clots
frequently. During this clinical visit she was instructed to come go to the ER due to suspicion of
leiomyosarcoma and was subsequently admitted for perioperative optimization for hysteroscopy
with Dilation and curettage.
Ms. R was last seen in fibroid clinic 8/15/23 during this visit, the attending gynecologist
suspected leiomyosarcoma and ordered a pelvic MRI to evaluate the size changes of fibroid but
was lost to follow up.
Prior to this she was seen in 2021, where she noted improved bleeding, and menses every 6
months, but with chronic pelvic pain since a prior motor vehicle accident (MVA).
OBSTETRIC HISTORY
G2p1011 – Ms. R had one nonspontaneous vaginal delivery with birth weight unknown, and one
termination of pregnancy.
GYNECOLOGICAL HISTORY
Menarche at 14, post-menopausal, with irregular interval Abnormal uterine bleeding and fibroids
Denies history of STIs, sexually active with male partner for 5 years (infrequently). LMP unsure
but has had her bleeding episode since 2/1/24. Pap smear on 05/2021 negative for intraepithelial
lesion of malignancy (NILM) and High Risk
MEDICAL HISTORY
The patient was seen by General surgery 2021 for left inguinal hernia. A decision was made not
to operate due to large fibroid, would likely do this after hysterectomy performed. Was then lost
to follow up.
History of Asthma, schizophrenia, MVA with traumatic brain injury, that required tracheostomy
and gastric tube.
SURGICAL HISTORY
IVC filter placement 06/2023. Hip replacement 10/2023.
SURVEILLANCE
Pap smear: NILM HR HPV negative 05/2021
Mammogram: 3/2021 normal per patient at an outside radiology center, no records available.
Colonoscopy 2020 normal per patient
MEDICATIONS
Ascorbic acid 250 mg, ferrous sulfate 325 mg, multivitamins, folic acid, vitamin D3 1250 mcg
(50,000 intl units), albuterol 90 mcg/inh inhalation aerosol, mirtazapine 15 mg, buspirone 5 mg,
fluticasone-vilanterol 200 mcg-25 mcg/inh inhalation powder, aspirin Enteric Coated 81 mg oral
delayed release tablet, atorvastatin 40 mg oral tablet, Colace 100 mg.
ALLERGIES
Penicillin- Causes Swelling and hives
FAMILY HISTORY
No history of ovarian, breast, endometrial or colon cancer
SOCIAL HISTORY
Ms. R lives alone, her brother is her Home Health Aide who helps her mainly with cleaning,
laundry, and food shopping. She performs other activities daily by herself. She lives in a building
with elevators access and uses walker when mobilizing.
Ms. R denies use of tobacco, alcohol, or other illicit drug use and toxic habits.
REVIEW OF SYSTEMS
Pelvic Pain, feeling faint, and weakness.
PHYSICAL EXAM
BP: 133/88 mmHg, HR: 83 bpm, Temp: 98.1 F (36.7 C), RR: 18 rpm, O2 Sat: 98% on room air,
BMI: 47.8
General: Alert & oriented x4, not currently in acute distress.
HEENT: PERLA, head has scar on the right temple, but otherwise normocephalic. The neck is
supple without thyromegaly, but there is a midline scar from tracheostomy.
Cardiovascular: Normal S1 and S2 sounds no murmurs, no rubs
Respiratory: fields clear to auscultation with normal excursion, no chest wall tenderness, dyspnea
on exertion
Abdomen: soft, non-tender, but distended with a palpable mass, dull to percussion, no
hepatosplenomegaly, irregular centrally located palpable mass of the uterus at approx. 30w size,
3-4 finger-width above navel, normoactive bowel sounds, no rebound or guarding.
Genitourinary: No unusual dysuria, hematuria, urgency, or frequency; + vaginal bleeding and no
incontinence.
Extremities: ROM preserved, peripheral edema +1, pain.
Neuro: no facial deviation or droop. Strength 5/5 in all extremities. Slow, muffled speech but
intelligible.
Pad check: Soaked pad.
External genital: no visible lesions, blood on the pad.
Vagina: smooth, and very long.
Urethra: no masses or discharge or prolapse
Internal Genital: Cervix is very high out of the pelvis, Uterus, though extremely large is out of
the pelvis and not fixed; no cervical fibroids; Adnexa not palpable.
Rectal: not involved
Lymph node Survey: no palpably enlarged Axillary, Inguinal or Groin lymph node enlargement.
LABS
CBC: WBC count 7.1, HGB 9.9 (low), hematocrit 31.7 (low), MCV 92.9, platelet 473 (high)
BMP: Sodium 142, potassium 5.2 (high), Chloride 104, Calcium 9.1, BUN 12, Creatinine 0.9,
Glucose 114
Iron 34 ug/dl (low), folate >20.0ng/ml (high), CA125 20.2 (normal limits), Hemoglobin A1C
5.6% (normal), TSH 1.14 (normal)
IMAGING
Echo 10/2023 EF 74%
Pelvic ultrasound 3/9/24: Enlarged leiomyomatous uterus. The endometrium is effaced by
leiomyomata and poorly evaluated. A discrete thickened endometrium is not identified. Consider
evaluating the endometrium clinically or repeat pelvic MRI.
EMB 3/10/24: fragments of blood clots and acute inflammatory exudates, no endometrial glands
are seen.
MRI Pelvis w/wo Contrast 3/10/24: Large and increasing (since 2021) fibroid uterus. Multiple
fibroids show suspected degeneration. Moderate new endometrial cavity dilatation with new
complex material potentially representing blood clots and/or necrotic debris from degenerating
fibroid. Hysteroscopy may be informative. Note that underlying leiomyosarcoma cannot be
reliably excluded on an imaging basis. The size and heterogeneity of the dominant 15 cm fundal
fibroid places the patient at a higher risk category. Consider tissue sampling/resection as
indicated clinically.
PATHOLOGY
EMB 7/27/21 endometrium curettage: benign inactive endometrium without hyperplasia or
atypia.
EMB 3/10/2024: fragments of blood clots and acute inflammatory exudates, no endometrial
glands are seen.
BRIEF ASSESSMENT OF PATIENT
The patient is a 57year-old G2P1011 presenting to the GYN clinic and subsequently admitted to
the hospital for ongoing pelvic cramping pain and vaginal bleeding for over a month. She
previously had a history of fibroids with abnormal uterine bleeding that has occurred 2-3 times a
year for the last 4-5 years. However, the bleeding is currently heavy and ongoing for over one
month. The heavy bleed requires 2 pads every 2 hours and has been passing large clots
frequently. During this clinical visit she was instructed to come go to the ER due to suspicion of
leiomyosarcoma and was subsequently admitted due to concern for perioperative optimization
for hysteroscopy with Dilation and curettage.
DIFFERENTIAL DIAGNOSIS
Uterine sarcoma vs endometrial cancer vs benign uterine fibroid.
Benign uterine fibroid (Uterine Leiomyoma): Given the patient's history of fibroids and the
presence of a large fibroid uterus on imaging, benign fibroids are a likely differential diagnosis.
Fibroids can cause symptoms such as heavy menstrual bleeding, pelvic pain, and pelvic pressure,
consistent with the patient's clinical presentation. The enlarged, firm and irregular uterus during
pelvic examinations also support this differential. The MRI findings of multiple fibroids with
suspected degeneration and endometrial cavity dilatation further uphold this differential. The
presence of complex material within the endometrial cavity may indicate degenerative changes
in fibroids.

Uterine Leiomyosarcoma: Leiomyosarcoma is a rare malignant tumor arising from smooth

muscle cells of the uterus. It presents with symptoms similar to fibroids but tends to progress
rapidly and may cause more severe symptoms. The patient's presentation of ongoing pelvic
cramping pain, heavy vaginal bleeding requiring frequent pad changes, and passage of large clots
raises concern for leiomyosarcoma, especially considering the size and heterogeneity of the
dominant fundal fibroid on imaging. The palpable mass in the abdomen, distension, and
laboratory findings including low hemoglobin, high platelet count, and high potassium may also
raise suspicion for leiomyosarcoma. However, further evaluation, including tissue sampling or
resection, is warranted to confirm the diagnosis and guide appropriate management.

Endometrial hyperplasia/cancer is another consideration given the patient's age, prolonged heavy
vaginal bleeding with clots, and dilated endometrial cavity with complex material on imaging.
The patient has a BMI of 47.8, indicating that she is obese which is a risk factor for endometrial
hyperplasia due to the increased estrogen production due to adipose aromatase activity. While
fibroids and leiomyosarcoma are common causes of abnormal uterine bleeding, endometrial
hyperplasia and cancer should be ruled out, especially in postmenopausal women with persistent
or worsening bleeding. When endometrial cancer has regional extension, it can present with
pelvic pain. However, the endometrial biopsies, thus far have been benign, and imaging showing
dilation rather than marked thickening making endometrial hyperplasia and cancer unlikely.

PLAN WITH RATIONALE FOR TREATMENT

The patient was initially admitted to be optimized and medically cleared for urgent hysteroscopy
with possible D and C to be done 3/21/24. The patient had to first be optimized because she was
suspected to have anemia which was confirmed with CBC and high BMI put patient at and
increased risk for adverse event during the hysteroscopy. Preoperative anemia is associated with
increased perioperative mortality. It is also a significant predictor for perioprative blood
transfusion, which itself is associated with post operative mortality. The patient BMI of 47.8 puts
her at risk for obstructive sleep apnea, due to which she is at an increased risk of developing
systemic and pulmonary hypertension with left and right ventricular hypertrophy respectively,
that increases the risk of peri-operative arrythmias, myocardial infarction and stroke.

The patient was first stabilized, and supportive measures were initiated. The patient had
intravenous fluid resuscitation to address volume depletion due to heavy vaginal bleeding. Ms. R
was then transfused with packed red blood cells to correct anemia and stabilize hemoglobin
levels, considering the patient's difficult venous access and BMI. The patient was provided
analgesia to manage pelvic cramping pain, ensuring appropriate pain control. The supportive
measures are crucial to address the patient's acute symptoms of heavy vaginal bleeding, pelvic
pain, and anemia, ensuring hemodynamic stability and adequate tissue perfusion.

The patient then proceeded with hysteroscopy with dilation and curettage (D&C) to obtain tissue
samples for histopathological examination. This was important for accurate diagnosis and
guiding subsequent treatment decisions. The hysteroscopy revealed that the patient had normal
external genitalia, vaginal purulent discharge, uterus that was about 30-week size, and
endometrial tissue with suspicions of malignancy. Noting this, gynecologic oncology was
consulted.
After the patient was informed about this, the plan is in place for a total abdominal hysterectomy
with bilateral oophorectomy and salpingectomy, staging lymphadenectomy, omentectomy other
indicated procedures on 03/25/24. The patient expressed that she “just needs for the bleeding to
be stopped, just take out everything, I have no use for it.” This surgical intervention aims to
achieve complete tumor resection.
The patient was also administered Lupron (a leuprolide) gonadotropin-releasing hormone
(GnRH) agonists preoperatively to reduce fibroid size and vascularity, potentially facilitating
surgical resection. Adjunctive therapy, such as GnRH agonists can optimize disease control and
improve long-term outcomes.
HOSPITAL COURSE
The patient is a 57year-old G2P1011 presenting to the GYN clinic and subsequently admitted to
the hospital for ongoing pelvic cramping pain and vaginal bleeding for over a month. She
previously had a history of fibroids with abnormal uterine bleeding that has occurred 2-3 times a
year for the last 4-5 years. However, the bleeding is currently heavy and ongoing for over one
month. The heavy bleed requires 2 pads every 2 hours and has been passing large clots
frequently. During this clinical visit she was instructed to come go to the ER due to suspicion of
leiomyosarcoma and was subsequently admitted for perioperative optimization for hysteroscopy
with Dilation and curettage.

The patient was stabilized and transfused ttransfused with packed red blood cells to correct
anemia and stabilize hemoglobin levels. She was provided analgesia to manage pelvic cramping
pain, ensuring appropriate pain control.

The patient then proceeded with hysteroscopy with dilation and curettage (D&C) to obtain tissue
samples for histopathological examination. The hysteroscopy revealed the patient had normal
external genitalia, vaginal purulent discharge, uterus that was about 30-week size, and
endometrial tissue with suspicions of malignancy. Since the uterine cavity was likely infected,
the diagnostic hysteroscopy was aborted. The curettage was not performed either. Noting this,
gynecologic oncology was consulted. The patient was prescribed antibiotics for the infection.
After the patient was informed about this, the plan is in place for a total abdominal hysterectomy
with bilateral oophorectomy and salpingectomy, staging lymphadenectomy, omentectomy other
indicated procedures on 03/25. The patient continues to have 1-2pad/1 hour with large blood
clots. IV access obtained by IV on call nurse, and the patient continues to be optimized before
the surgery.

DISCUSSION TOPIC UTERINE LEIOMYOMA VS LEIOSARCOMA

Uterine leiomyoma colloquially known as fibroids are benign, hormone sensitive, smooth muscle
uterine neoplasms within the uterine wall. They are classified as either submucosal (beneath the
endometrium), intramural (within the muscular uterine wall of the uterus), or sub serosal
(beneath the peritoneum) and can occur within the uterine corpus or the cervix. Uterine
leiomyosarcoma is a rare malignant tumor arising from the smooth muscle cells of the
myometrium [11]. Leiomyomas and leiomyosarcomas, both originating from smooth muscle
cells of the uterus, exhibit significant differences in clinical behavior, histopathological features,
and treatment approaches. Drawing upon recent research and guidelines from the American
College of Obstetricians and Gynecologists (ACOG), this discussion aims to provide a
comparison between these entities.
Most women experiencing uterine leiomyomas are typically asymptomatic. However, it
frequently manifest with clinical features such as; abnormal uterine bleeding possibly associated
with anemia, hypermenorrhea, heavy menstrual bleeding, metrorrhagia, dysmenorrhea. Uterine
leiomyoma can also present with features of mass effect like enlarged, firm and irregular uterus
during bimanual pelvic examination, back or pelvic pain/discomfort Urinary tract or bowel
symptoms (like, urinary frequency/retention/incontinence, constipation, features of
hydronephrosis). The also presents as reproductive abnormalities; infertility (difficulty
conceiving and increased risk of pregnancy loss), and dyspareunia [1, 6, 7]. In contrast to uterine
leiomyoma, uterine leiomyosarcomas are rare malignant tumors characterized by rapid growth,
often presenting with similar symptoms but potentially exhibiting features of aggressive disease,
including necrosis and distant metastases [1].
Histologically, leiomyomas are composed of well-defined bundles of smooth muscle cells in a
whorled pattern with varying degrees of fibrosis and hyalinization. These tumors typically
demonstrate low mitotic activity and lack cytologic atypia. In contrast, leiomyosarcomas are
single lesions with areas of coagulative necrosis and/or hemorrhage. They have cords of
polygonal cells with eosinophilic cytoplasm, abundant mitoses, and cellular atypia with
infiltrative growth patterns are common [2, 3, 9].
Uterine leiomyomas generally carry a favorable prognosis, with minimal risk of recurrence
following surgical removal. However, factors such as advanced age, prior pelvic radiation
therapy, and certain genetic syndromes like, hereditary leiomyomatosis and renal cell carcinoma
syndrome may predispose individuals to leiomyosarcoma development, which is associated with
a poorer prognosis and higher risk of metastasis [3].
Diagnostic tools used to differentiate between uterine leiomyoma and leiomyosarcoma include
ultrasound pelvis, Sono hysterography, MRI, CT scans and laboratory studies play a crucial role
in evaluating uterine masses. Leiomyosarcomas often demonstrate rapid growth, irregular
margins, and heterogeneous enhancement on imaging compared to leiomyomas. However,
definitive diagnosis requires histopathological examination of tissue samples obtained via biopsy
or surgical resection [4, 10]. The ultrasound pelvis typically is the most appropriate initial test, in
fibroids it shows a well-circumscribed hypoechoic solid mass.
Management of leiomyomas typically involves conservative measures, medical therapy, or
surgical options based on symptoms and patient preferences. ACOG guidelines emphasize the
role of minimally invasive procedures and hormonal therapies, such as gonadotropin-releasing
hormone agonists or selective progesterone receptor modulators, in selected cases. Surgical
options, including myomectomy or hysterectomy, may be considered for symptomatic or
refractory cases. In contrast, leiomyosarcomas require aggressive surgical resection with
consideration for adjuvant chemotherapy or radiation therapy. However, the optimal management
of leiomyosarcoma remains controversial, and prognosis is generally poor, particularly in
advanced or metastatic disease [3, 5].
Leiomyomas and leiomyosarcomas represent distinct entities within the spectrum of uterine
smooth muscle tumors, characterized by differences in clinical behavior, histopathological
features, and treatment strategies. Accurate diagnosis and appropriate management are essential
for optimizing patient outcomes. By integrating recent research findings and ACOG guidelines,
healthcare providers can effectively navigate the complexities of uterine smooth muscle tumors
and provide individualized care to their patients.

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