What is the treatment for a 36-year-old woman with heavy vaginal bleeding due to a large uterine leiomyoma (fibroid)?

From the Guidelines

Treatment for heavy vaginal bleeding with a large fibroid in a 36-year-old woman should begin with medical management, specifically first-line medical management including NSAIDs and estrogen-progestin oral contraceptive pills, which reduce bleeding symptoms 1.

Medical Management Options

• First-line medical management: NSAIDs and estrogen-progestin oral contraceptive pills to reduce bleeding symptoms 1
• Tranexamic acid as a nonhormonal alternative agent to reduce bleeding symptoms in patients with fibroids 1
• Second-line medical management: parenteral GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, and relugolix) to reduce bleeding symptoms and tumor volume 1

Surgical Options

• Myomectomy (removing just the fibroid while preserving the uterus for future fertility) or uterine artery embolization (UAE) if medical management fails or the fibroid is very large (>10 cm) 1
• Hysterectomy provides definitive treatment but ends fertility

Additional Considerations

• Iron supplementation (e.g., ferrous sulfate 325 mg daily) to address anemia from chronic bleeding
• The choice of treatment depends on the severity of symptoms, fibroid size and location, desire for future pregnancy, and the woman's preferences
• Medical management should be trialed prior to pursuing more invasive therapies 1

From the Research

Treatment Options for Heavy Vaginal Bleeding with Large Fibroid in 36-year-old Woman

• Medical therapy before surgery for uterine fibroids, such as gonadotropin-hormone-releasing analogues (GnRHa) and selective progesterone-receptor modulators (SPRMs), may reduce uterine and fibroid volume, increase preoperative haemoglobin levels, and reduce bleeding before surgery 2
• GnRHa pretreatment may reduce uterine volume and fibroid volume, and probably increases preoperative haemoglobin, but may also increase adverse events such as hot flushes 2
• SPRMs, such as ulipristal acetate, may reduce uterine volume, increase haemoglobin level, and reduce fibroid-related bleeding, but the certainty of the evidence is moderate to low 2
• Initial evaluation of heavy vaginal bleeding should focus on hemodynamic stability, and a thorough history and physical examination should be performed to determine the cause of bleeding 3
• Treatment approach for heavy vaginal bleeding includes acute stabilization and long-term treatment with medical and surgical modalities, such as non-steroidal anti-inflammatory drugs, tranexamic acid, and hormonal intrauterine systems (IUS) 3, 4
• Tranexamic acid may reduce blood loss perioperatively in myomectomies and reduce menorrhagia in patients with fibroids, but more studies are needed to confirm its efficacy 5

Surgical Options

• Hysterectomy is a definitive and effective surgical treatment for leiomyoma, but many patients may benefit from other management options, such as myomectomy or hysteroscopic resection 6
• GnRHa pretreatment may reduce the duration of hysterectomy and the number of blood transfusions, and may also reduce postoperative morbidity 2
• Myomectomy and hysteroscopic resection are alternative surgical options for treating uterine fibroids, but the effects of GnRHa pretreatment on these procedures are uncertain 2

Medical Management

• Medical therapy, such as GnRHa and SPRMs, may be used to reduce uterine and fibroid volume, and to increase preoperative haemoglobin levels before surgery 2
• Non-steroidal anti-inflammatory drugs and tranexamic acid may reduce menstrual blood loss, and hormonal IUS may be effective in reducing menstrual bleeding 4
• Cyclic progestogens do not significantly reduce menstrual bleeding in women who ovulate, and drug treatment should be used and evaluated before surgical interventions are considered 4