Background Vaginal bleeding in the prepubertal child has several etiologies including structural anomalies, endocrinologic dysfunction, infection, trauma, foreign body, and hematologic disorders. While bleeding in this age group is often benign, it can be distressing to both the child and parent so a comprehensive evaluation is important. Case An 8-year-old premenarcheal girl presented with vaginal bleeding. On ultrasound, she was found to have an intramural hyperechogenic mass in the left uterine fundus. This was biopsied and showed smooth muscle. She was subsequently started on a GnRH agonist to suppress bleeding and has since been followed with serial ultrasounds. We have 6 years of follow up imaging showing a presumed adenomyoma versus fibroid stable in size. Comments We present a novel case of a benign uterine neoplasms presenting as prepubertal bleeding. Pelvic imaging is prudent to exclude structural etiologies as the cause of prepubertal vaginal bleeding.