What are the treatment options for symptomatic anemia due to uterine fibroids?

Treatment of Symptomatic Anemia Due to Uterine Fibroids

The optimal treatment for symptomatic anemia due to uterine fibroids should follow a stepwise approach, starting with medical management to control bleeding and correct anemia, followed by minimally invasive or surgical interventions based on symptom severity, fibroid characteristics, and fertility desires. 1

Initial Medical Management

First-Line Treatment for Anemia

• Iron supplementation is essential to correct anemia
• Tranexamic acid - first-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation 1
  • Reduces bleeding by 20-40%
  • Contraindicated in women with active thromboembolic disease or history of thrombosis

Hormonal Options

• Levonorgestrel-releasing intrauterine device (IUD) - most effective hormonal option for controlling bleeding 1

  • Significant improvement in pain and bleeding
  • Does not significantly reduce fibroid volume

• GnRH agonists - effective for short-term use (3-6 months) 1

  • Reduces bleeding and fibroid volume by 40-50%
  • Chronic use causes trabecular bone loss
  • Add-back therapy can minimize side effects while maintaining efficacy
  • Useful as preoperative treatment to improve hemoglobin levels (MD 0.88 g/dL increase) 2

• Selective progesterone receptor modulators (SPRMs) 3, 1

  • Ulipristal acetate (UPA) achieves amenorrhea in 70-83% of patients
  • Median fibroid volume reduction of 65-67%
  • Induces amenorrhea within approximately 7 days 4
  • Can be used for 1-2 courses (3 months each) 3
  • Increases preoperative hemoglobin levels (MD 0.93 g/dL) 2

• Other hormonal options

  • Oral contraceptives - effective for controlling bleeding symptoms, especially with small fibroids 1
  • NSAIDs - can reduce bleeding by 20-40% and help with pain 1

Interventional and Surgical Options

Minimally Invasive Procedures

• Uterine Artery Embolization (UAE) 1

  • Improves symptom scores and quality of life for up to 7 years
  • Shorter hospital stay and decreased blood loss compared to hysterectomy
  • 20-25% incidence of symptom recurrence at 5-7 years
  • Risk for permanent amenorrhea: <2-3% for women under 45, up to 20% for women over 45
  • 18% hysterectomy rate for persistent symptoms

• MR-guided Focused Ultrasound (MRgFUS) 1

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

Surgical Interventions

• Myomectomy - preferred for women desiring fertility preservation 1

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

• Hysterectomy - most definitive treatment 1

  • Very high patient satisfaction (90% reporting at least moderate satisfaction 2 years after procedure)
  • Completely eliminates risk of fibroid recurrence
  • Also treats alternative causes of symptoms, such as adenomyosis

Treatment Algorithm Based on Fertility Desires

For Women Desiring Future Fertility

1. Initial medical management

   • Iron supplementation + tranexamic acid during menses
   • Consider short-term GnRH agonists or SPRMs to control bleeding and improve anemia

2. Surgical management if medical therapy fails

   • Myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location and size)
   • Consider preoperative GnRH agonists or SPRMs to reduce fibroid size and correct anemia 2

For Women Not Desiring Future Fertility

1. Initial medical management

   • Iron supplementation + tranexamic acid during menses
   • Levonorgestrel IUD or hormonal contraceptives for ongoing bleeding control

2. Minimally invasive procedures if medical therapy fails

   • UAE or MRgFUS

3. Surgical management if minimally invasive procedures fail

   • Hysterectomy (definitive treatment)

Special Considerations

• Life-threatening anemia (Hb <2.0 g/dL) may require immediate hospitalization, blood transfusion, and urgent surgical intervention 5
• Perimenopausal women may benefit from pulsatile courses of SPRMs to help transition into menopause while avoiding surgery 3
• Preoperative medical therapy with GnRHa or SPRMs can:
  • Increase preoperative hemoglobin levels
  • Reduce fibroid and uterine volume
  • Reduce blood loss during surgery
  • Decrease operation time and complication rates 2

Monitoring and Follow-up

• Monitor hemoglobin levels to ensure anemia is resolving
• Follow fibroid size with imaging (ultrasound) before and after treatment 1
• For women using SPRMs, assess response based on most relevant symptoms (bleeding control, anemia resolution) 3