What is the best medication to decrease heavy menstrual bleeding in a patient with a small uterine leiomyoma (fibroid)?

From the Guidelines

For a patient with a small uterine leiomyoma (fibroid) experiencing heavy menstrual bleeding, the most effective first-line medication is tranexamic acid (Lysteda) 1300 mg three times daily during menstruation, as it promotes blood clotting and reduces bleeding symptoms. This recommendation is based on the most recent and highest quality study available, which suggests that tranexamic acid is a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids 1.

Alternative Options

Other treatment options for heavy menstrual bleeding in patients with small uterine leiomyomas include:

• Hormonal methods, such as combined oral contraceptives taken cyclically or continuously, or a levonorgestrel-releasing intrauterine device (Mirena), which can reduce bleeding by up to 90% over 3-6 months
• Nonsteroidal anti-inflammatory drugs like ibuprofen (600-800 mg every 6 hours during menses), which can reduce bleeding by 20-40% and help with pain
• GnRH agonists like leuprolide acetate, which can temporarily shrink fibroids and stop bleeding but are limited to short-term use due to side effects

Considerations

Treatment choice depends on bleeding severity, desire for contraception, and tolerance of side effects. If medications fail to control symptoms after 3-6 months, surgical options may need consideration. It is essential to weigh the benefits and risks of each treatment option and consider the patient's individual needs and preferences. As noted in a recent study, patient preferences and symptom severity help inform treatment choice, with options ranging from medical therapy to surgery 1.

Additional Considerations

In addition to medical management, it is crucial to consider the economic burden of symptomatic fibroids to society, with total estimated societal costs ranging from $5.9 to $34.4 billion annually 1. Therefore, effective management of heavy menstrual bleeding in patients with small uterine leiomyomas is not only essential for improving patient outcomes but also for reducing the economic burden on society.

From the FDA Drug Label

In patients with primary dysmenorrhea, ibuprofen tablets have been shown to reduce elevated levels of prostaglandin activity in the menstrual fluid and to reduce resting and active intrauterine pressure, as well as the frequency of uterine contractions.

The best medication to decrease heavy menstrual bleeding in a patient with a small uterine leiomyoma (fibroid) is ibuprofen.

• Key benefits: reduction of prostaglandin activity, decrease in uterine pressure and contractions.
• Mechanism of action: inhibition of prostaglandin synthesis. 2

From the Research

Treatment Options for Heavy Menstrual Bleeding with Uterine Leiomyoma (Fibroid)

• Medical therapy is usually considered a first-line treatment for idiopathic heavy menstrual bleeding (HMB) 3, 4
• Tranexamic acid has proven to be an effective treatment for HMB, reducing menstrual blood loss (MBL) by 26%-60% 3, 5
• The recommended oral dosage of tranexamic acid is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 3
• Other treatments used for HMB include oral contraceptives, danazol, and surgical interventions (endometrial ablation and hysterectomy) 3, 4
• For patients with fibroid-related menorrhagia, a levonorgestrel-releasing intrauterine system (LNG-IUS) may be more effective in reducing MBL than a low-dose combined oral contraceptive (COC) 6
• Surgical treatment, such as hysteroscopic resection or laparoscopic myomectomy, may be beneficial for women with submucosal fibroids or those who would like to preserve their uterus and fertility 7

Efficacy and Safety of Tranexamic Acid

• Tranexamic acid significantly improves the quality of life of women treated for HMB, with a 46-83% improvement in patient quality-of-life parameters 5
• Available evidence indicates that tranexamic acid treatment is effective and safe, with no evidence of an increase in the incidence of thrombotic events associated with its use 3, 5
• Adverse effects of tranexamic acid are few and mainly mild, but an active thromboembolic disease is a contraindication 3

Considerations for Patients with Uterine Leiomyoma (Fibroid)

• Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician 4
• Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause 4
• Surgical treatment, such as hysterectomy or myomectomy, may be necessary for patients with symptomatic fibroids or those who do not respond to medical therapy 4, 7