What is the treatment for abnormal uterine bleeding (AUB) post coital with uterine fibroids?

Treatment of Abnormal Uterine Bleeding Post-Coital with Uterine Fibroids

For abnormal uterine bleeding (AUB) post-coital associated with uterine fibroids, a stepwise approach beginning with medical management is recommended, with surgical interventions reserved for cases refractory to medical therapy or when fertility preservation is not desired.

First-Line Medical Management

• NSAIDs and estrogen-progestin oral contraceptive pills are the first-line medical treatments for reducing bleeding symptoms associated with uterine fibroids 1
• Tranexamic acid is an effective nonhormonal alternative that can reduce bleeding symptoms in patients with fibroids who cannot use hormonal options 1
• Progestin-containing intrauterine devices (IUDs) can effectively reduce bleeding symptoms and should be considered for long-term management 1, 2

Second-Line Medical Management

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) are effective second-line options 1
• These agents not only reduce bleeding symptoms but also significantly reduce fibroid volume by 18-30% 1
• GnRH agents can be used for short courses to decrease fibroid size in preparation for surgery 1, 3
• Combination treatment with low doses of estrogen and progestin can mitigate hypoestrogenic side effects (headaches, hot flushes, bone mineral density loss) and is FDA-approved for fibroid-related heavy menstrual bleeding 1

Surgical Management Options

For Patients Desiring Fertility Preservation

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal uterine fibroids <5 cm 1
• This procedure offers shorter hospitalization and faster recovery compared to laparoscopic or open myomectomy 1
• Improvement in symptom scores and quality of life is equivalent to more invasive approaches at 2-3 months post-procedure 1

For Patients Not Desiring Fertility Preservation

• Hysterectomy (transvaginal, laparoscopic, or abdominal) provides definitive resolution of all fibroid-related symptoms 1
• It remains the most common treatment for uterine fibroids, accounting for three-quarters of fibroid treatments in the United States 1
• When possible, vaginal or laparoscopic approaches should be preferred over laparotomy 4

Minimally Invasive Alternatives

• Uterine Artery Embolization (UAE) is effective for patients with adenomyosis and fibroids who desire uterus-preserving therapy 1
• UAE improves symptom scores and quality of life for up to 7 years follow-up 1
• Short-term (<12 months) and long-term (>12 months) improvement in symptoms occurs in 94% and 85% of patients, respectively 1
• MR-guided Focused Ultrasound (MRgFUS) can be considered, though it has a higher reintervention rate (30%) compared to UAE (13%) 1

Important Considerations and Caveats

• Fertility is suppressed during GnRH treatment, and cessation of therapy leads to rapid recurrence of symptoms 1, 3
• Progesterone receptor modulators (e.g., ulipristal acetate) show promise but have limited availability in the US due to concerns about hepatotoxicity 1
• For patients with post-coital bleeding specifically, examination should rule out cervical pathology before attributing bleeding solely to fibroids 5
• The reintervention rate after UAE is approximately 7% for persistent symptoms 1
• Treatment selection should consider the size, location, and number of fibroids, as well as the patient's age and reproductive goals 2, 6

Treatment Algorithm

1. Begin with first-line medical management (NSAIDs, hormonal contraceptives, tranexamic acid)
2. If inadequate response, progress to second-line medical therapy (GnRH agonists/antagonists)
3. For persistent symptoms:
   • If fertility preservation desired: Hysteroscopic myomectomy for submucosal fibroids <5cm
   • If no fertility desired: Consider UAE or hysterectomy based on patient preference and desire for uterine preservation