What is the best treatment for acute bleeding due to uterine fibroids?

Best Treatment for Acute Bleeding Due to Uterine Fibroids

For acute bleeding due to uterine fibroids, tranexamic acid is the first-line non-hormonal treatment, with progestin-containing IUDs being the most effective hormonal option for bleeding control. 1

Initial Management of Acute Bleeding

Non-Hormonal Options

• Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, reducing bleeding by 20-40% 1
  • Take only during menstruation
  • Contraindicated in women with active thromboembolic disease or history of thrombosis
• NSAIDs: Can reduce bleeding by 20-40% 1

Hormonal Options

• Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control 1
  • Works through local mechanism with lower systemic hormone levels
  • Significantly improves bleeding compared to oral contraceptives
• Combined oral contraceptives: Effective for controlling bleeding, especially with smaller lesions 1
  • Less effective than progestin IUDs for bleeding control
• GnRH agonists/antagonists: Reduce bleeding and lesion volume by 40-50% 1
  • Limited to short-term use due to bone loss concerns
  • Add-back therapy can minimize side effects while maintaining efficacy
• Selective progesterone receptor modulators (SPRMs): Emerging treatment option 1
  • Ulipristal acetate (UPA) achieves amenorrhea in 70-83% of patients
  • Can rapidly induce amenorrhea in women with acute fibroid-related bleeding 2

Surgical and Interventional Options

For Women Desiring Fertility Preservation

• Hysteroscopic myomectomy: Indicated for submucosal fibroids 3, 1
  • Shorter hospitalization and faster recovery than other surgical approaches
  • Risks include uterine perforation, fluid overload, need for blood transfusion
  • Improvement in symptom scores and quality of life equivalent to other surgical approaches at 2-3 months

For Women Not Concerned with Fertility

• Uterine Artery Embolization (UAE): Effective minimally invasive option 3, 1

  • Improves quality of life and symptom scores
  • Short-term and long-term symptom improvement in 94% and 85% of patients, respectively
  • Requires ruling out uterine sarcoma and endometrial cancer before treatment, especially in postmenopausal women
  • Selective catheterization and embolization of both uterine arteries is the cornerstone of treatment 4

• Hysterectomy: Only definitive treatment with very high patient satisfaction 1

  • Completely eliminates risk of recurrence
  • Should be performed using least invasive route possible (vaginal, laparoscopic, or robotic-assisted)

Treatment Selection Algorithm

1. Assess bleeding severity:

   • If hemodynamically unstable: IV tranexamic acid and possible blood transfusion
   • If stable: Proceed with oral medications

2. Consider patient's fertility desires:

   • If fertility preservation desired: Avoid hysterectomy and consider myomectomy options
   • If fertility not a concern: Consider all treatment options including definitive procedures

3. Evaluate fibroid characteristics (location, size, number):

   • Submucosal fibroids: Hysteroscopic myomectomy is preferred
   • Intramural/subserosal fibroids: Laparoscopic myomectomy or UAE
   • Multiple/large fibroids: Open myomectomy or UAE

Important Caveats

• Before any minimally invasive therapy in postmenopausal women with abnormal uterine bleeding, uterine sarcoma and endometrial cancer must be ruled out 3
• Risk of unexpected uterine sarcoma following surgery for presumed fibroids is estimated at 2.94 per 1,000, with higher risk in older patients 3
• Preoperative medical therapy with GnRH agonists or SPRMs can increase hemoglobin levels, reduce fibroid volume, decrease blood loss during surgery, and reduce operation time 1
• For acute bleeding episodes requiring immediate intervention, ulipristal acetate has been shown to induce amenorrhea rapidly and can be useful in emergency management 2