What is the recommended treatment for a 32-year-old woman with menorrhagia, 2 large intramural uterine leiomyomas (fibroids), and iron deficiency anemia?

Management of Uterine Leiomyomas with Heavy Menstrual Bleeding and Anemia

For a 32-year-old woman with heavy menstrual bleeding, two large intramural uterine leiomyomas, and anemia, the recommended first-line treatment is medical management with a selective progesterone receptor modulator (SPRM) such as ulipristal acetate (UPA) along with iron supplementation to correct anemia before considering surgical options. 1

Initial Medical Management

Anemia Correction

1. Iron supplementation:

   • Oral iron supplementation (ferrous sulfate 324 mg once daily) as first-line treatment 2
   • Continue for 3 months after hemoglobin normalizes to replenish iron stores
   • Take on an empty stomach with vitamin C (500 mg) to enhance absorption
   • Avoid calcium-containing foods, tea, coffee, and antacids during administration

2. Monitoring response:

   • Check hemoglobin after 2-4 weeks of therapy
   • Consider IV iron if hemoglobin increase is <1.0 g/dL after 2 weeks 2

Fibroid and Bleeding Management

1. Selective Progesterone Receptor Modulators (SPRMs):

   • Ulipristal acetate (UPA) 5-10 mg daily for 3-month courses 1
   • Benefits:
     • Controls bleeding in 90% of women with 35-55% achieving amenorrhea 1
     • Reduces fibroid volume by approximately 30% after a single course and up to 70% after multiple courses 1
     • Improves quality of life by 48-57% 1
     • Can be used as bridge to surgery or as intermittent therapy for symptom control

2. Alternative medical options if SPRMs unavailable:

   • Levonorgestrel intrauterine system (LNG-IUS) 3, 4
   • Tranexamic acid during menstruation 4
   • Combined oral contraceptives 3, 4
   • GnRH analogues (limited to short-term use due to side effects) 3

Surgical Options (After Anemia Correction)

For Women Desiring Fertility Preservation

1. Myomectomy:
   • Hysteroscopic myomectomy for submucosal components 1, 3
   • Laparoscopic or open myomectomy for intramural fibroids 3
   • Preoperative considerations:
     • UPA can be used preoperatively to shrink fibroids and correct anemia 1, 3
     • Surgical planning should include appropriate imaging to map location, size, and number of fibroids 3
     • Use of vasopressin, bupivacaine and epinephrine, or other hemostatic agents to reduce blood loss 3

For Women Not Desiring Future Fertility

1. Uterine Artery Embolization (UAE):

   • Clinical success rates of 81-100% 1
   • Median uterine and fibroid volume reductions of 35% and 42%, respectively 1
   • Significant improvement for patients with menorrhagia (83%) 1
   • Low major complication rate (<3%) 1

2. Hysterectomy:

   • Definitive treatment with high satisfaction rates 3
   • Should be performed by least invasive approach possible 3
   • Consider only after failure of medical management or if patient desires definitive treatment

Treatment Algorithm

1. Initial phase:

   • Begin UPA (5-10 mg daily) for 3 months AND
   • Start iron supplementation to correct anemia

2. Reassessment after 3 months:

   • If symptoms controlled and anemia resolved:

     • Suspend treatment until symptoms recur
     • Restart UPA when symptoms return (pulsatile treatment) 1

   • If inadequate response:

     • Consider additional 1-2 courses of UPA 1 OR
     • Proceed to surgical management

3. Surgical decision-making:

   • For fertility preservation: Myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location)
   • For no fertility desire: UAE or hysterectomy

Important Considerations and Pitfalls

• Fertility implications: Discuss impact of treatments on future fertility. Myomectomy is the preferred surgical option for women desiring future pregnancy 3

• Monitoring: Regular imaging is necessary to assess fibroid response to medical therapy 1

• Risk of malignancy: The risk of unsuspected uterine sarcoma in women undergoing surgery for fibroids is low but should be discussed 1

• Treatment durability: Medical management may require repeated courses for long-term control 1

• Premature discontinuation: Stopping iron supplementation before stores are replenished can lead to recurrence of anemia 2

• Anemia workup: In women with heavy menstrual bleeding, the cause of anemia is usually apparent, but other sources of blood loss should be considered if response to treatment is inadequate 2