Uterine leiomyomas, commonly called fibroids, are benign smooth muscle tumors of monoclonal origin containing varying amounts of connective tissue [
4,
5]. They are common in the reproductive age group and are extremely rare after menopause. Although rare, anecdotal cases of huge fibroids in postmenopausal women have been reported in the literature previously [
6,
7]. Their occurrence after menopause could be due to stimulation of the growth by estrone, insulin-like growth factor, or epidermal growth factor [
8]. In postmenopausal women with obesity, peripheral aromatization of adrenal-derived androstenedione into estrone might be responsible for the increase in size. As the fibroids enlarge, they outgrow their blood supply or cause mechanical compression of feeder arteries and undergo degenerative changes [
9]. Hyaline degeneration (63%) is the most common, followed by myxomatous (13%), calcareous (8%), mucoid (6%), cystic (4%), carneous (3%), and fatty changes (3%). The exact pathogenesis for degeneration of fibroids in postmenopausal women remains unclear, however, increased production of growth factors (epidermal or insulin like) from the fibroid might explain this condition [
9]. Rarely, it may undergo malignant degeneration to become leiomyosarcoma in less than 1% of cases [
7]. Sadly, the clinical profile of benign leiomyoma and uterine leiomyosarcoma is identical. The definitive diagnosis of a uterine sarcoma can only be made histopathologically after removing the tumor via myomectomy or hysterectomy [
6]. Ultrasound is the first line investigation for diagnosing these fibroids, especially in resource-constrained health centers, as it is the least invasive and most economical. MRI must be considered in cases with a large fibroid or a rapidly growing fibroid in a non-acute setting [
1].
The patient may be asymptomatic or present with varied symptomatology, such as pelvic pain, irregular vaginal bleeding, acute abdomen, lump in the abdomen, pressure-related symptoms, or rapid increase in size, which was seen in our case. Ghaffar reported a case of a 56-year-old postmenopausal woman who presented with polycythaemia associated with rapid enlargement of the uterus due to a huge fibroid weighing 5.05 kg [
3]. Osegi
et al. reported a case of 58-year-old menopausal female with huge fibroid measuring 22 × 16 × 25 cm deriving its blood supply from the omental vessels. They performed total abdominal hysterectomy with bilateral salpingo-oophorectomy and partial omentectomy. Histopathology revealed it to be benign leiomyoma with cystic changes [
4]. Seet
et al. also reported a 55-year-old menopausal woman with a large degenerating fibroid [
1]. Shrestha
et al. published a case of a menopausal woman who presented with acute abdomen due to fibroid degeneration [
9]. Another case of a calcified fibroid was reported in a postmenopausal woman, managed with hysterectomy [
8]. Myomectomy or hysterectomy must be planned depending on the patient’s age, type and size of the fibroid, severity of symptoms, desire to conceive in the future, suspicion of malignancy, and proximity to menopause [
6]. Since our patient was an elderly postmenopausal woman with rapidly enlarging fibroid raising the suspicion of malignancy, TAH with BSO was the treatment of choice. Histopathology remains the gold standard to rule out the possibility of sarcomatous changes.