A 49 year-old, previously healthy woman presented with one day of progressively worsening right-sided body pain and shortness of breath. She noted her pain started while in bed the previous morning, radiating from her right upper quadrant to her chest and worsening with inspiration. She denied fever or leg swelling and denied any recent surgeries, hospitalizations, or traveling. She had no personal or family history of heart disease or blood clots and did not smoke tobacco or take oral contraceptives. The patient had been told she had a fibroid uterus several months prior and reported experiencing heavy menstrual periods for years.
On exam, she was tachycardic and tachypneic, taking shallow breaths. Her abdomen was non-tender to palpation although pain was present in her right upper quadrant with inspiration. She had no lower extremity edema.
Due to high suspicion for venous thromboembolic disease and widespread pain, a CT scan of her chest, abdomen and pelvis was ordered. It revealed bilateral pulmonary emboli and a right-sided pleural effusion. The abdominal and pelvic CT scan revealed a 20.1 x 19.4 x 12.7 cm uterine myoma compressing the inferior vena cava and common iliac veins. A lower extremity venous Doppler ultrasound was negative for deep vein thrombosis. A complete hypercoagulability workup was also negative.
The patient was diagnosed with venous thromboembolism due to mass effect from her large uterine myoma. She was treated with enoxaparin and scheduled for a total hysterectomy.
Venous thromboembolism is a common problem encountered by internists. They are a result of a culmination of Virchow’s triad—venous stasis, vascular endothelial injury, and a hypercoaguable state. Venous thromboembolisms are usually classified as being caused by acquired risk factors, inherited thrombophilias or a combination of the two. Acquired risk factors for VTE include the following: immobility, hospitalization, surgery, oral contraceptive use, antiphospholipid antibody syndrome, and malignancy. Inherited thrombophilias include Factor V Leiden, Prothrombin, Protein C and S gene mutations as well as Antithrombin deficiency.
When exploring the potential causes of a venous thromboembolism, it is important to take a thorough history before reporting an unprovoked venous thromboembolism. The label of “unprovoked” can lead to longer anticoagulation and further unnecessary, diagnostic workup. As uterine myomas are very common in women over the age of 40, it is important to recognize an enlarged uterus as a potential cause for venous thromboembolism. Definitive treatment for a venous thromboembolism in this case is a total hysterectomy.