Introduction: The synchronous association of a Complete Hydatidiform Mole (CHM) and an Exaggerated Placental Site (EPS) is a rare clinical entity. Although benign, EPS can histologically mimic malignant lesions such as Placental Site Trophoblastic Tumor (PSTT), posing a major diagnostic challenge. We report a case illustrating the value of primary surgery in a 50-year-old multiparous patient (G4P4) who presented with persistent metrorrhagia. Presentation of case: Clinical examination revealed an enlarged uterus (corresponding to 12 weeks of gestation), and ultrasonography demonstrated a typical "snowstorm" pattern associated with serum beta-hCG levels > 400,000 mIU/mL. Given the advanced maternal age and hemorrhagic risk, a total abdominal hysterectomy with ovarian conservation was performed as the primary intervention. Clinical discussion: Histopathological examination of the surgical specimen confirmed a CHM associated with a florid proliferation of intermediate trophoblasts infiltrating the superficial myometrium (EPS). The global architectural analysis provided by the hysterectomy specimen allowed for the exclusion of deep invasion and neoplasia (PSTT) without the systematic need for complex immunohistochemistry. The postoperative course was favorable, with beta-hCG negativization within 8 weeks and no need for adjuvant chemotherapy. Conclusion: In perimenopausal patients, primary hysterectomy constitutes a safe and effective therapeutic option for high-risk hydatidiform moles. It enables a precise histological diagnosis of EPS by offering a complete architectural view, thereby avoiding diagnostic errors and unnecessary adjuvant treatments.