What are the treatment options for menorrhagia (heavy menstrual bleeding) caused by uterine fibroids?

Treatment of Menorrhagia from Uterine Fibroids

For menorrhagia caused by uterine fibroids, a stepwise approach starting with medical management is recommended, with tranexamic acid being the most effective first-line non-hormonal medication for heavy menstrual bleeding, reducing blood loss by up to 54%. 1

Medical Management Options

First-Line Options:

1. Non-hormonal medications:

   • Tranexamic acid: Most effective non-hormonal option, reduces menstrual blood loss by 54% 2, 3
     • Recommended dosage: 1g every 6 hours for 4-5 days starting from first day of menstruation 3
     • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1
   • NSAIDs: Can reduce bleeding by 20-40% and help with pain, but less effective than tranexamic acid 1

2. Hormonal options:

   • Progestin-containing IUDs: Most effective hormonal option with significant improvement in bleeding and pain 1
   • Oral contraceptives: Effective for controlling bleeding symptoms, especially with small fibroids 4
   • GnRH agonists: Reduce bleeding and fibroid volume by 40-50%, effective for short-term use (3-6 months) 4, 1
     • Can be used to temporarily reduce uterine and myoma size before surgical therapy
     • Drawbacks: Fibroids return to previous size after discontinuation; chronic use causes trabecular bone loss 4
   • GnRH antagonists: Similar efficacy to GnRH agonists; can be used with low-dose estrogen and progestin to mitigate side effects 1

Minimally Invasive Procedures

When medical management fails or is contraindicated:

1. Uterine Artery Embolization (UAE):

   • Improves symptom scores and quality of life for up to 7 years
   • Short-term symptom improvement: 94%; Long-term: 85% 1
   • Shorter hospital stay and decreased blood loss compared to hysterectomy 4
   • 18% hysterectomy rate for persistent symptoms 1

2. MR-guided Focused Ultrasound (MRgFUS):

   • Uses high-intensity ultrasound waves to thermally ablate fibroids
   • Results in 18% decrease in fibroid diameter 1

3. Laparoscopic Uterine Artery Occlusion (LUAO):

   • Less effective than UAE for fibroid reduction (39% vs. 53% diameter reduction) 1

Surgical Options

When other treatments fail or for specific indications:

1. Myomectomy (for women desiring fertility preservation):

   • Hysteroscopic myomectomy: Recommended for submucosal fibroids 1
   • Laparoscopic myomectomy: Preferred for intramural/subserosal fibroids when feasible 1
   • Open myomectomy: Preferred for multiple fibroids or very large uteri 1
   • Recurrence rate: 23-33% 4

2. Hysterectomy:

   • Most definitive treatment when fertility preservation is not desired 1
   • Options include vaginal, laparoscopic, or abdominal approaches

Important Considerations

• Fertility concerns: Myomectomy is preferred for women desiring future pregnancy, though less than half achieve pregnancy after the procedure 1
• Monitoring: Follow hemoglobin levels and fibroid size with imaging before and after treatment 1
• Morcellation risks: Not recommended during minimally invasive hysterectomy due to risk of spreading occult malignancy 4

Treatment Algorithm

1. Start with medical management (tranexamic acid or hormonal options)
2. If inadequate response, consider minimally invasive procedures (UAE, MRgFUS)
3. If these fail or are contraindicated, proceed to surgical options based on fertility desires:
   • Desire for fertility: Myomectomy
   • No fertility desired: Consider hysterectomy

Pitfalls to Avoid

• Chronic use of GnRH agonists can cause bone loss; limit to 3-6 months 4
• Morcellation during surgery can spread occult malignancy 4
• Tranexamic acid is contraindicated in women with thromboembolic disease 1, 3
• UAE may impact fertility and should be used cautiously in women planning pregnancy 1