A 34-year-old woman is brought to the emergency department after a syncopal episode. The patient was at work when she became lightheaded, started sweating, and then fell to the floor. Now, she feels better and has no chest pain, dyspnea, or palpitations. The patient is currently on day 10 of her menstrual cycle. She reports that her menstrual periods still occur monthly but have become progressively heavier and longer over the past year, despite being on combination oral contraceptives. Temperature is 36.7 C (98.1 F), blood pressure is 100/60 mm Hg, and pulse is 112/min. BMI is 27 kg/m². On speculum examination, multiple blood clots are removed from the vaginal vault. The cervix has no lesions, but there is active bleeding from the cervical os. Bimanual examination shows a 12-week-size, irregularly shaped, enlarged uterus. Hemoglobin is 4.9 g/dL. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?

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11ec25c8_d9ed_0a05_bc81_4da3521dd6c9_MD0003_00 This patient with heavy, prolonged menstrual bleeding likely has uterine leiomyomas (fibroids), which are common, benign tumors formed by proliferation of smooth muscle within the myometrium. fibroids Symptoms depend on fibroid size and location. Large fibroids, particularly subserosal fibroids, typically cause an irregularly shaped, enlarged uterus and bulk symptoms (eg, pelvic pressure). In contrast, submucosal fibroids are more likely to cause heavy, regular (eg, monthly) menses that may be prolonged because their protrusion into the endometrial cavity increases endometrial surface area. First-line therapy for heavy menses due to fibroids is combined oral contraceptives (COCs), which can decrease bleeding by shortening the duration of menses and regulating endometrial proliferation. However, in patients with enlarging fibroids (likely in this patient with a 12-week-size uterus), the continued increase in endometrial surface area can increase the volume of monthly endometrial shedding to the point where COCs are no longer effective at controlling menstrual bleeding. Persistent heavy menstrual bleeding (eg, blood clots in the vaginal vault, active bleeding from the cervical os) can lead to symptomatic anemia, which may present with syncope. In these patients, more definitive fibroid treatment (eg, uterine artery embolization, myomectomy) is recommended. (Choice A) Cyclic bleeding of ectopic (extrauterine) endometrial glands occurs in endometriosis. Endometriosis implants are intraperitoneal; therefore, cyclic shedding causes dysmenorrhea but not increased vaginal bleeding (ie, no anemia). In addition, endometriosis is not associated with irregular uterine enlargement. endometriosis (Choice B) Adenomyosis can cause heavy menstrual bleeding and uterine enlargement. However, patients typically have a uniformly enlarged, globular uterus and diffuse uterine tenderness due to shedding of endometrial glands and stroma within the myometrium. Adenomyosis (Choice C) In contrast to this patient with heavy but monthly menses, those with endometrial hyperplasia typically have irregular bleeding, often having months of amenorrhea followed by heavy bleeding because of an abnormally thickened endometrium. Endometrial hyperplasia is unlikely in this patient with regular, monthly menses and COC use, which regulates endometrial proliferation. (Choice D) Patients with von Willebrand factor deficiency have impaired platelet adhesion that can lead to heavy menstrual bleeding due to coagulopathy. However, this condition is not associated with irregular uterine enlargement. Educational objective: Uterine leiomyomas (fibroids) are benign tumors formed by proliferation of smooth muscle within the myometrium. Fibroids are a common cause of an irregularly shaped, enlarged uterus and heavy menstrual bleeding that can lead to symptomatic anemia. References: Submucosal fibroids and the relation to heavy menstrual bleeding and anemia. (http://www.ncbi.nlm.nih.gov/pubmed/24080304)

A 34-Year-Old Woman Is Brought to the Emergency Department After