A 48-year-old perimenopausal woman with known stable fibroids for 5 years presents with rapid enlargement of her uterus from 12-week to 20-week size over 6 months, with new-onset pelvic pain and postmenopausal bleeding after amenorrhea of 1 year. What is the MOST concerning diagnosis?

• A Hyaline degeneration of fibroid
• B Cellular leiomyoma variant
• C Red degeneration of fibroid
• D Leiomyosarcoma (sarcomatous change) ✓

Explanation

Rapid growth of a fibroid in a perimenopausal or postmenopausal woman is the cardinal red flag for leiomyosarcoma. The incidence of sarcomatous change in rapidly growing fibroids is approximately 0.2-0.5%. Rapid enlargement was traditionally defined as 6-week-size increase in 1 year, but postmenopausal growth warrants urgent evaluation. Hyaline and red degeneration are benign changes.

Reference: Comprehensive Gynecology, 8th ed.

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