A 36-year-old woman comes to the office due to worsening pelvic pressure over the last year. The patient has had increasing pelvic pressure associated with a dull, aching pain. She has also noticed increasing abdominal girth but has had no changes in appetite or bloody stool. The patient is sexually active and has had deep pelvic pain with intercourse for the past few months. She does not use contraception and has regular monthly menses with 7-8 days of bleeding with each cycle; she has no intermenstrual bleeding or spotting. Family history is significant for 2 maternal aunts with ovarian cancer in their 50s but is otherwise noncontributory. Vital signs are normal. BMI is 26 kg/m². Examination shows an enlarged midline pelvic mass that extends to the umbilicus. The mass is mobile and has several palpable anterior protuberances. There is no fluid wave or tenderness to palpation. Bowel sounds are normal. Urine pregnancy test is negative. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d267_fda5_bc81_8d7524b45ec5_MD0003_00 This patient with an enlarged pelvic mass likely has leiomyomata uteri (ie, uterine fibroids). Fibroids are benign, monoclonal tumors of the uterine myometrium. They are common in reproductive-age women and are usually asymptomatic. However, depending on their size and location, fibroids can cause bleeding symptoms (eg, heavy menses), bulk symptoms (eg, pelvic pressure), or both. This patient likely has multiple, extremely large fibroids causing significant uterine enlargement (eg, mass extending to the umbilicus) and an irregular uterine contour (eg, palpable protuberances). Large fibroids commonly cause mass effect (bulk symptoms) on neighboring structures; therefore, patients may have increasing abdominal girth, pelvic pressure, and impaired urinary, gastrointestinal, and sexual function (eg, urinary frequency, constipation, deep pelvic pain with intercourse). Treatment for bulk symptoms involves reducing fibroid size and number with either medication (ie, GnRH agonist) or surgery (eg, myomectomy). (Choice A) Adenomyosis, or endometrial proliferation within the myometrium, can present with a tender, enlarged uterus and dyspareunia. In contrast to this patient's protuberant, 20-week-sized uterus (ie, reaches the umbilicus), patients with adenomyosis typically have a uniformly globular uterus ≤12 weeks in size. In addition, because of the relatively smaller uterine size compared to that of fibroids, patients with adenomyosis typically do not have constant pelvic pressure. Adenomyosis (Choice B) Endometrial polyps are small growths of endometrial glands and stroma within the uterine cavity. They do not present with a palpable abdominal mass or pelvic pressure, and patients classically have intermenstrual spotting. Endometrial polyps (Choice C) Unlike fibroids, which cause pelvic pressure due to mass effect, endometriosis can cause dyspareunia and pressure by inducing pelvic inflammation and the formation of pelvic adhesions (eg, fixed, immobile uterus). However, endometriosis does not cause an enlarged or irregularly shaped uterus. endometriosis (Choice D) Gestational trophoblastic disease (GTD), caused by overproliferation of abnormal trophoblasts, can present with uterine enlargement. Because trophoblasts secrete β-hCG, patients with GTD typically have elevated β-hCG levels. This patient has a negative pregnancy test, making this diagnosis unlikely. (Choice F) Although ovarian cancer can cause pelvic pressure, increasing abdominal girth, and a large pelvic mass, it typically presents as a fixed mass (due to invasive spread into nearby structures) with ascites (ie, fluid wave on examination), findings not seen in this patient. Educational objective: Leiomyomata uteri (fibroids) are benign uterine tumors common in reproductive-age women. Extremely large fibroids cause an irregular uterine contour and bulk symptoms (eg, pelvic pressure, deep pelvic pain with intercourse). References: Uterine fibroids: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28084714)

A 36-Year-Old Woman Comes to the Office Due to Worsening