Case notes
A 37-year-old, G3 P2012 African American female was referred by her rheumatologist for a history of menorrhagia to anemia. Her medical history was significant for serology-positive rheumatoid arthritis. She described onset of heavy menstrual bleeding after the birth of her second child, which was >10 years earlier. She was counseled on management options, and elected for a levonorgestrel (Mirena; Bayer HealthCare Pharmaceuticals, Pittsburgh, PA) intrauterine device. A transvaginal ultrasound scan revealed an echogenic uterine mass that measured 27 × 24 × 18 mm with no central flow. The endometrial echo was normal at 11 mm. Because of the irregular appearing mass, office hysteroscopy with endometrial sampling was performed with an operative 5-mm Bettocchi hysteroscope (Karl Storz Endoscopy-America, Inc, El Secundo, CA) and normal saline solution as the distending medium. A 3 × 3 cm flat, homogeneously porous, free-floating mass was visualized in the endometrial cavity ( Figure 1 ). The mass was manually broken up and partially removed with hysteroscopic graspers. Inspection revealed hard, calcified specimen pieces. After approximately 20 minutes of manual morcellation in the office, the excision was stopped because of patient discomfort. Approximately 60% of the mass remained. Pathologic evidence confirmed the presence of calcified material. After counseling, she agreed to undergo repeat hysteroscopic removal in the operating room. Approximately 2 weeks later, the mass was then completely excised in pieces ( Figure 2 ), and a levonorgestrel intrauterine device was placed for management of her menorrhagia. Pathologic evaluation of the sections revealed trabeculated bone with osteoblastic cells, rare osteoclastic giant cells, and associated scant inflammatory changes ( Figure 3 ). Her postoperative course was uncomplicated, and she had scheduled follow up.
