From the Guidelines
Fibroids in the submucosal layer of the uterine lining are at the highest risk for causing significant bleeding in patients with uterine fibroids. This is because submucosal fibroids can distort the uterine cavity and increase the endometrial surface area, leading to abnormal bleeding 1. Management of significant bleeding in patients with uterine fibroids includes both medical and surgical approaches. Medical options start with hormonal treatments such as combined oral contraceptives, progestins like medroxyprogesterone acetate (10-20mg daily), or levonorgestrel-releasing intrauterine systems (Mirena) 1. Tranexamic acid (1000mg three times daily during menstruation) can reduce bleeding by inhibiting fibrinolysis 1. GnRH agonists like leuprolide acetate (3.75mg monthly injection) can be used for short-term treatment (3-6 months) to reduce fibroid size and bleeding, though side effects limit long-term use 1. Newer options include selective progesterone receptor modulators like ulipristal acetate (5mg daily) and GnRH antagonists like elagolix (200mg twice daily) 1.
Some key points to consider in the management of uterine fibroids include:
- The location of the fibroid, with submucosal fibroids being more likely to cause bleeding 1
- The size and number of fibroids, which can impact treatment options 1
- The patient's age, desire for future fertility, and symptom severity, which can influence treatment choices 1
- The potential risks and benefits of different treatment options, including medical and surgical approaches 1
For persistent bleeding, surgical interventions may be necessary, ranging from minimally invasive procedures like uterine artery embolization or focused ultrasound to myomectomy (fibroid removal) or hysterectomy for definitive treatment 1. The choice of management depends on the patient's individual circumstances and preferences. Anemia from chronic bleeding should be addressed with iron supplementation (ferrous sulfate 325mg three times daily) or intravenous iron for severe cases.
From the Research
Uterine Fibroids and Bleeding
- Uterine fibroids are common benign neoplasms that can cause abnormal uterine bleeding, pelvic pressure, and other symptoms 2.
- The location and size of fibroids can affect the severity of symptoms, with submucosal fibroids being more likely to cause heavy menstrual bleeding 3.
- Fibroids in the submucosal layer of the uterine lining are at highest risk for causing significant bleeding, as they can protrude into the uterine cavity and disrupt the normal lining of the uterus 4.
Management of Uterine Fibroids and Bleeding
- Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs 2, 3.
- Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause 2, 5.
- Surgical treatment options include hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery 2, 3.
- The management of iron deficiency and iron deficiency anemia, which can result from chronic bleeding, is also an important consideration in the treatment of uterine fibroids 3, 6.
Factors Affecting Bleeding Risk
- The size and location of fibroids, as well as the presence of multiple fibroids or coexistent adenomyosis, can affect the risk of bleeding 3, 6.
- The patient's age, symptoms, desire to maintain fertility, and access to treatment can also influence the management of uterine fibroids and bleeding 2, 3.
- The experience of the physician and the availability of treatment options can also impact the management of uterine fibroids and bleeding 2, 3.