Total Abdominal Hysterectomy in a Young Woman With Refractory Abnormal Uterine Bleeding of Multifactorial Etiology: A Case Report of an Incidental Hemorrhagic Ovarian Cyst in a Single Ovary

Uterine fibroids are the most common benign tumors of the female reproductive system and a frequent cause of abnormal uterine bleeding, pelvic pain, and reproductive morbidity in women of reproductive age. Their clinical management should be individualized according to symptoms, fibroid characteristics, comorbidities, and reproductive goals. A 33-year-old woman, gravida 5 para 4 with one prior abortion, with chronic hypertension controlled with candesartan and a history of multiple prior abdominal surgeries, including three cesarean sections and right oophorectomy, presented with persistent abnormal uterine bleeding refractory to medical therapy. Clinical and imaging evaluation revealed a solitary uterine fibroid and the absence of the right ovary. Endometrial biopsy showed secretory endometrium with focal irregular maturation and a minute fragment of squamous epithelium with koilocytic atypia, interpreted as likely cervical or vaginal contamination. After multidisciplinary assessment, total abdominal hysterectomy with wedge resection of a hemorrhagic cyst in the left ovary and uterosacral ligament suspension following the principles of McCall culdoplasty was performed. The procedure was completed without complications, with minimal blood loss. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. Histopathological analysis confirmed intramural leiomyomas, benign hemorrhagic cyst, chronic nonspecific cervicitis, and irregular endometrial maturation without malignancy. This case illustrates the complexity of managing persistent abnormal uterine bleeding in a young woman with multiple prior abdominal surgeries, unilateral oophorectomy, and chronic hypertension. Although conservative options may be considered in selected patients, the combination of refractory symptoms, surgical history, and the need to preserve ovarian function supported a definitive surgical approach. Open abdominal hysterectomy allowed safe and controlled management, while partial preservation of the remaining ovary helped maintain endocrine function and reduce the risk of premature menopause. Total abdominal hysterectomy with partial ovarian preservation can be a safe and definitive option in young women with persistent abnormal uterine bleeding, uterine fibroids, prior abdominal surgeries, and associated risk factors. This case underscores the value of individualized surgical planning and multidisciplinary decision-making to achieve favorable outcomes.