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case 22 A 55-year-old woman presents to the office because of vaginal spotting, abdominal distention and constipation for the past 3 months. She is also having difficulty defecating and often has to put her index and middle finger in her vagina to aid in pushing the stools out. Menopause was at age 48. Past history is significant for breast cancer treated by breast-sparing mastectomy and tamoxifen. Vitals are within normal limits. BMI is 33 kg/m2. Physical examination shows an enlarged irregular uterus and normal rectal tone. Transvaginal doppler ultrasound shows mixed echogenic masses with increased vascularity and central necrosis, bulging into the uterine cavity. Hysterectomy is performed which reveals a poorly-demarcated large yellow soft mass with areas of hemorrhage and necrosis.

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