What is the appropriate management for a patient with fibroids and symptoms, who is being discharged from the hospital with a follow-up appointment with an obstetrician/gynecologist (OB/GYN)?

Management of Uterine Fibroids in Patients Being Discharged

For patients with symptomatic uterine fibroids being discharged from the hospital, pain medication should be provided along with a scheduled outpatient OB/GYN follow-up appointment to determine the most appropriate long-term management strategy based on symptom severity, fibroid characteristics, and fertility desires. 1

Initial Pain Management

• NSAIDs are recommended as first-line pain management for fibroid-related pain

  • Can reduce bleeding by 20-40% in addition to providing pain relief 1
  • Should be prescribed at discharge with clear dosing instructions

• For patients with more severe pain:

  • Consider stronger analgesics for short-term use until OB/GYN follow-up
  • Ensure adequate pain control before discharge

Medical Management Options for Follow-up

The American College of Radiology recommends a stepwise approach to fibroid management, starting with medical options 1:

1. For heavy bleeding symptoms:

   • Tranexamic acid: First-line non-hormonal medication, taken only during menstruation (reduces bleeding by 20-40%) 1
   • Hormonal contraceptives: Effective for controlling bleeding with small fibroids 1
   • Progestin-containing IUDs: Most effective hormonal option for significant improvement in pain and bleeding 1

2. For fibroid volume reduction:

   • GnRH agonists: Reduce bleeding and fibroid volume by 40-50%, effective for short-term use (3-6 months) 1
   • Selective progesterone receptor modulators: Can achieve amenorrhea in 70-83% of patients with median fibroid volume reduction of 65-67% 1

Procedural/Surgical Options to Discuss at Follow-up

Based on symptom severity, fibroid characteristics, and fertility desires, the OB/GYN may recommend:

1. For patients desiring fertility preservation:

   • Myomectomy (preferred surgical option) 1
     • Hysteroscopic approach for submucosal fibroids
     • Laparoscopic approach for intramural/subserosal fibroids when feasible
     • Open approach for multiple or very large fibroids

2. For patients not concerned with fertility:

   • Uterine Artery Embolization (UAE): Improves symptoms for up to 7 years with shorter hospital stay than hysterectomy 1
   • MR-guided Focused Ultrasound (MRgFUS): Minimally invasive option that can decrease fibroid diameter by 18% 1
   • Hysterectomy: Most definitive treatment with 90% patient satisfaction at 2 years 1

Follow-up Recommendations

• Schedule follow-up appointment with OB/GYN within 2-4 weeks
• Monitor hemoglobin levels to ensure anemia is resolving
• Follow fibroid size with imaging (ultrasound) before and after treatment 1

Important Considerations

• Treatment should be tailored based on:

  • Size and location of fibroids
  • Patient's age and symptoms
  • Desire to maintain fertility
  • Access to treatment options 2

• Hysterectomy should be avoided if a less invasive procedure is available, as randomized studies have demonstrated increased rate of severe complications with hysterectomy despite similar symptom relief 3

• If hysterectomy is eventually indicated, the least invasive route should be performed to minimize recovery time and complications 3