What is the best course of action for managing abnormal uterine bleeding with a 2 cm subserosal uterine fibroid in a patient currently on Noriday (Norethisterone)?

Management of Abnormal Uterine Bleeding with a Small Subserosal Fibroid

For a patient with abnormal uterine bleeding and a small (2 cm) subserosal fibroid who is currently on Noriday (norethisterone) with improved regularity, continued medical management with progestin therapy is the most appropriate first-line approach, as subserosal fibroids are rarely the cause of bleeding symptoms and surgical intervention is not warranted for this type of fibroid. 1, 2

Understanding the Clinical Picture

• The patient presents with:
  • Abnormal uterine bleeding (AUB)
  • 2 cm subserosal fibroid (right lateral)
  • Currently on Noriday (norethisterone) with improved bleeding regularity
  • Normal endometrial thickness (3 mm)
  • Normal ovaries bilaterally

Treatment Algorithm Based on Fibroid Location

Subserosal Fibroids and Bleeding

• Subserosal fibroids (those projecting outside the uterus) rarely cause abnormal bleeding
• The 2 cm size is relatively small and unlikely to be the primary cause of symptoms
• The improvement in bleeding regularity with Noriday suggests hormonal therapy is effective

First-Line Approach: Continue Medical Management

1. Continue progestin therapy (Noriday) since it's already showing effectiveness in regulating bleeding 2

   • Progestin-containing medications are effective for controlling bleeding symptoms
   • Consider increasing dose if bleeding is not fully controlled

2. Alternative medical options if needed:

   • Levonorgestrel intrauterine system (LNG-IUS) - most effective hormonal option for heavy menstrual bleeding 2
   • Tranexamic acid - effective non-hormonal option, taken only during menstruation 2
   • Combined oral contraceptives - effective for controlling bleeding with small fibroids 1, 2

When to Consider Intervention

Indications for Intervention

• Persistent abnormal bleeding despite medical therapy
• Growth of the fibroid on follow-up imaging
• Development of pressure symptoms

Intervention Options (if medical management fails)

1. Uterine Artery Embolization (UAE)

   • Previously considered contraindicated for pedunculated subserosal fibroids
   • Recent studies show no instances of fibroid detachment with good clinical outcomes 1
   • Provides symptom improvement similar to patients without pedunculated leiomyomas 1

2. Myomectomy

   • Consider only if the fibroid becomes symptomatic (which is unlikely given its subserosal location)
   • Laparoscopic approach preferred for small subserosal fibroids 2
   • Recurrence rate ranges from 23-33% 1, 2

Monitoring and Follow-up

• Ultrasound follow-up in 6-12 months to assess fibroid size
• Monitor hemoglobin levels if anemia is present
• Reassess symptom control at 3-month intervals

Important Considerations

• The ultrasound found no alternative cause for the abnormal bleeding, suggesting the bleeding may be related to hormonal factors rather than the fibroid
• The subserosal location of the fibroid makes it an unlikely cause of bleeding symptoms
• The normal endometrial thickness (3 mm) is reassuring and suggests no endometrial pathology

Caution

• If bleeding patterns change or worsen despite medical therapy, further evaluation is warranted
• Growth of the fibroid on follow-up imaging may necessitate reconsideration of treatment approach
• Persistent symptoms despite medical management should prompt consideration of alternative diagnoses

The patient's current improvement with Noriday suggests that continuing this therapy is reasonable, with close monitoring for symptom control and fibroid growth.