When retrograde menstruation becomes dangerous: A case of hemodynamic instability from a necrotic leiomyoma

Retrograde menstruation is a common gynecologic occurrence that is typically associated with development of extrauterine endometriosis. However, in rare cases, it may result in life-threatening complications, particularly when compounded by underlying pathology. Case Report: We report a rare and severe presentation of retrograde menstruation due to a necrotic submucosal leiomyoma, resulting in profound anemia and hemoperitoneum in a 29-year-old female. The patient presented with vaginal bleeding, persistent suprapubic and left lower quadrant abdominal tenderness, and an episode of syncope in the emergency department (ED). Imaging results revealed hemoperitoneum and a necrotic intracavitary fibroid. Laboratory findings showed a rapidly declining hematocrit from vaginal and intra abdominal bleeding, that ultimately necessitated emergent surgical intervention. Initial stabilization included blood transfusions, tranexamic acid administration, and pain control. Then, a laparoscopy and hysteroscopic myomectomy was performed that showed retrograde menstruation with copious amounts of old and fresh blood in the anterior and posterior cul de sacs. Blood was seen in the upper abdomen where the blood had tracked around the liver. Why Should an Emergency Physician Be Aware of This?: This case underscores the diagnostic challenge when retrograde menstruation occurs in atypical presentations involving necrotic fibroids and hemorrhagic complications. The unusual severity of this case, marked by active paradoxical abdominal bleeding and hemodynamic instability highlights the importance of timely, multidisciplinary intervention to prevent life-threatening complications. This report contributes to the limited literature on complications involving retrograde menstruation and emphasizes the importance of a high suspicion in similar clinical scenarios.