What is the best treatment approach for a patient with heavy menstrual bleeding due to a single uterine fibroid and concurrent iron deficiency anemia (IDA) who declines contraceptive management?

Treatment for Heavy Menstrual Bleeding with Uterine Fibroid and Iron Deficiency Anemia

For a patient with heavy menstrual bleeding due to a single uterine fibroid and iron deficiency anemia who declines contraceptive management, uterine artery embolization (UAE) is the recommended first-line treatment as it provides effective symptom relief while preserving the uterus. 1, 2

Non-Hormonal Medical Management Options

Since contraceptive management has been declined, the following non-hormonal options should be considered:

1. Tranexamic acid:

   • First-line non-hormonal medication for reducing heavy menstrual bleeding
   • Take only during menstruation
   • Effectively reduces blood loss in patients with fibroids 2, 3

2. NSAIDs:

   • Can reduce bleeding by 20-40%
   • Take during menstruation
   • Less effective than tranexamic acid but may help with pain 2, 4

3. Iron supplementation:

   • Essential for treating the iron deficiency anemia
   • Should be administered alongside any chosen treatment 3

Procedural Interventions

If medical management fails to control symptoms, the following interventions should be considered:

1. Uterine Artery Embolization (UAE)

• Recommended first-line procedural intervention
• Minimally invasive procedure using transfemoral/transradial approach
• Causes ischemic necrosis and involution of fibroids
• Benefits:
  • 85-94% symptom improvement in short and long-term 1, 2
  • Average >50% decrease in fibroid size at 5 years
  • Shorter hospital stays compared to surgical options
  • Lower risk of blood transfusion than myomectomy
  • Preserves the uterus 1
• Considerations:
  • Post-embolization syndrome (pain, nausea, fevers)
  • 7-18% may require hysterectomy for persistent symptoms 1

2. Hysteroscopic Myomectomy

• Procedure of choice for pedunculated submucosal fibroids <5 cm
• Benefits:
  • Shorter hospitalization and faster recovery than open procedures
  • Equivalent symptom improvement to more invasive approaches 1
• Best suited for fibroids that protrude into the uterine cavity

3. Hysterectomy

• Definitive treatment providing permanent resolution of symptoms
• Consider only if less invasive options fail
• If performed, choose least invasive approach:
  • Vaginal or laparoscopic preferred over abdominal
  • Associated with shorter recovery and fewer complications 1
• Drawbacks:
  • Increased risk of severe complications
  • Longer hospitalization and recovery than UAE
  • Long-term risks including cardiovascular disease, osteoporosis, and dementia 1

GnRH Modulators

If the patient is willing to consider hormonal options that aren't contraceptives:

• GnRH agonists/antagonists with add-back therapy:
  • Effectively reduce bleeding and fibroid size
  • Add-back therapy (low-dose estrogen/progestin) mitigates hypoestrogenic side effects
  • Can be used as bridge to definitive treatment 1, 2
  • Not contraceptive in purpose, though will prevent pregnancy during use

Treatment Algorithm

1. Start with iron supplementation and tranexamic acid during menstruation
2. If inadequate response after 2-3 cycles, consider UAE
3. For submucosal fibroids <5 cm, consider hysteroscopic myomectomy as an alternative
4. Reserve hysterectomy for treatment failures when fertility preservation is not desired

Important Considerations

• The location, size, and characteristics of the fibroid should guide treatment selection
• Concurrent treatment of iron deficiency anemia is essential
• UAE provides better long-term outcomes than myomectomy for most fibroid types
• Hysterectomy should be avoided if less invasive procedures are suitable due to associated long-term risks 1
• MRI may be helpful to better characterize the fibroid and guide treatment selection