What is the appropriate management for a 30-year-old patient with leiomyoma (uterine fibroids) and abnormal uterine bleeding, presenting with extreme bleeding during periods and a thickened endometrial layer of 5mm on ultrasound?

From the Guidelines

The most appropriate initial management for a 30-year-old patient with leiomyoma and abnormal uterine bleeding, presenting with extreme bleeding during periods and a thickened endometrial layer of 5mm on ultrasound, is to perform an endometrial biopsy to rule out endometrial hyperplasia or malignancy. This patient's symptoms and ultrasound findings warrant further investigation, particularly given the heavy menstrual bleeding and thickened endometrium, which may indicate an increased risk of endometrial pathology 1. Although the patient's age makes malignancy less likely, the 5mm endometrial thickness is still concerning and requires evaluation.

After excluding malignancy or other endometrial abnormalities through biopsy, medical management options can be considered for the leiomyoma, such as hormonal therapy with oral contraceptive medication or gonadotropin-releasing hormone (GnRH) agonists or antagonists, as these have been shown to effectively manage bleeding symptoms and reduce uterine and myoma volume 1. Surgical options, including uterine artery embolization, would only be pursued if medical management fails or if the biopsy reveals concerning findings 1.

Key considerations in the management of this patient include:

• The need for a thorough gynecologic workup, including a physical examination and imaging studies, to characterize the location, size, and number of fibroids
• The importance of ruling out other causes of heavy menstrual bleeding, such as endometrial hyperplasia or malignancy, through endometrial biopsy
• The potential benefits and drawbacks of medical management options, including hormonal therapy and GnRH agonists or antagonists
• The role of surgical options, including uterine artery embolization, in the management of symptomatic uterine fibroids.

From the Research

Management of Uterine Fibroids and Abnormal Uterine Bleeding

The management of a 30-year-old patient with leiomyoma (uterine fibroids) and abnormal uterine bleeding, presenting with extreme bleeding during periods and a thickened endometrial layer of 5mm on ultrasound, involves various treatment options.

• Medical management includes:
  • Nonsteroidal anti-inflammatory drugs
  • Tranexamic acid
  • Levonorgestrel intrauterine system
  • Gonadotropin-releasing hormone (GnRH) agonists and antagonists
  • Selective progesterone receptor modulators
  • Aromatase inhibitors 2, 3
• Surgical options include:
  • Hysterectomy, which is a definitive solution but not preferred for women who wish to preserve fertility and/or their uterus 4, 5
  • Myomectomy, which is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention 5
  • Hysteroscopic myomectomy for symptomatic intracavitary fibroids 5
• Minimally invasive options include:
  • Uterine artery embolization
  • Magnetic resonance-guided focused ultrasound
  • Endometrial ablation 4, 6
• The choice of treatment depends on the patient's age, fertility plans, and the number, size, and location of the fibroids, as well as the presence and severity of symptoms 4, 3, 5

Considerations for Treatment

• The patient's desire for definitive treatment or fertility preservation should be taken into account when choosing a treatment option 4, 3
• The location, size, and number of fibroids, as well as the presence of coexistent adenomyosis, should guide the choice of treatment 3
• The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities 5
• Anemia should be corrected prior to proceeding with elective surgery, and selective progesterone receptor modulators and gonadotropin-releasing hormone analogues can be effective at correcting anemia 5