What are the treatment options for heavy menstrual bleeding due to uterine fibroids and polyps?

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Treatment of Heavy Menstrual Bleeding Due to Fibroids and Polyps

For heavy menstrual bleeding due to uterine fibroids and polyps, treatment should begin with medical management using a levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line therapy, followed by minimally invasive procedures if medical management fails, with hysterectomy reserved as definitive treatment when other options are unsuccessful or contraindicated. 1

Medical Management Options

First-Line Treatments

  • Levonorgestrel-releasing IUD (Mirena): Most effective hormonal option for bleeding control, significantly improving both pain and bleeding compared to other options 1
  • Tranexamic acid: Reduces bleeding by 20-60%, taken only during menstruation 1, 2
    • Contraindication: Active thromboembolic disease or history/risk of thrombosis 1
  • NSAIDs: Can reduce bleeding by 20-40% 1, 2
  • Combined oral contraceptives: Effective for controlling bleeding, especially with smaller lesions, but less effective than LNG-IUS 1

Second-Line Treatments

  • GnRH agonists/antagonists: Reduce bleeding and lesion volume by 40-50% 1
    • Limited to short-term use due to bone loss
    • Add-back therapy can minimize side effects while maintaining efficacy
  • Selective progesterone receptor modulators (SPRMs):
    • Ulipristal acetate achieves amenorrhea in 70-83% of patients 1
    • Effective for preoperative treatment to reduce fibroid volume (65-67% reduction) 1

Surgical Management Options

For Polyps

  • Hysteroscopic polypectomy: First-line surgical approach for endometrial polyps 3
    • Simple, safe procedure with excellent outcomes
    • Can be performed as outpatient procedure

For Fibroids

  • Hysteroscopic myomectomy: Indicated for submucosal fibroids 1, 4

    • Offers shorter hospitalization and faster recovery
    • Preferred for women desiring fertility preservation

  • Laparoscopic myomectomy: Beneficial for subserosal or intramural fibroids 1, 4

    • Shorter hospital stays and faster recovery than open myomectomy
    • Appropriate for women desiring fertility preservation

  • Open myomectomy: Preferred for multiple fibroids or very large uteri 1

    • Associated with improved quality of life for up to 10 years
    • Risk of uterine rupture during subsequent pregnancy

Minimally Invasive Procedures

  • Uterine Artery Embolization (UAE): Improves quality of life and symptom scores 1

    • Short-term and long-term symptom improvement in 94% and 85% of patients, respectively
    • Alternative to surgery for women who wish to preserve their uterus

  • Endometrial ablation: Effective for heavy bleeding with success rates comparable to hormonal IUS 2, 3

    • Low operative morbidity
    • Can be performed as outpatient procedure

Definitive Treatment

  • Hysterectomy: Only definitive treatment with very high patient satisfaction 1, 5
    • Completely eliminates risk of recurrence
    • Should be performed using least invasive route possible (vaginal, laparoscopic, or robotic-assisted)
    • Consider when other treatments have failed or are contraindicated

Treatment Selection Algorithm

  1. Initial Assessment:

    • Confirm diagnosis with pelvic examination and vaginal sonography
    • Sonohysterography or hysteroscopy for reliable diagnosis of polyps and fibroids 2

  2. First-line approach: Medical management

    • LNG-IUS for most patients (especially if contraception also desired)
    • Tranexamic acid or NSAIDs if hormonal methods contraindicated

  3. If first-line fails or is contraindicated:

    • For polyps: Proceed to hysteroscopic polypectomy
    • For fibroids: Consider location and size
      • Submucosal: Hysteroscopic myomectomy
      • Subserosal/intramural: Laparoscopic myomectomy
      • Multiple/large: Consider UAE or open myomectomy

  4. If minimally invasive approaches fail or are contraindicated:

    • Consider hysterectomy, especially for women who have completed childbearing

Important Considerations

  • Up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder requiring additional investigation 3
  • Preoperative medical therapy with GnRH agonists or SPRMs can increase hemoglobin levels, reduce fibroid volume, and decrease surgical blood loss 1
  • Treatment selection should consider symptom severity, patient's age, fertility desires, and uterine size 1
  • Regular monitoring of hemoglobin levels and lesion size with imaging is recommended before and after treatment 1

References

1
Guideline

Adenomyosis Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Research

Diagnosis and treatment of menorrhagia.

Acta obstetricia et gynecologica Scandinavica, 2007

4
Research

Surgical treatment of fibroids in heavy menstrual bleeding.

Women's health (London, England), 2016

5
Research

Uterine Fibroids: Diagnosis and Treatment.

American family physician, 2017

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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