What is the best management approach for a 39-year-old woman with multiple large (greater than 10 cm) uterine fibroids, severe anemia (low hemoglobin), and a desire to preserve fertility without surgery?

Management of Large Uterine Fibroids in a 39-Year-Old Woman with Anemia and Desire for Fertility

For a 39-year-old woman with multiple large fibroids (>10 cm), anemia (hemoglobin 9 g/dL), and desire for fertility who refuses surgery, the most appropriate management approach is medical therapy with GnRH antagonists (such as relugolix) combined with iron supplementation to correct anemia, followed by reassessment for minimally invasive procedures if needed.

Initial Medical Management

• First priority: Correct anemia with iron supplementation while simultaneously initiating medical therapy to control bleeding and reduce fibroid size 1
• GnRH antagonists (relugolix, elagolix, or linzagolix) are effective for reducing both bleeding symptoms and fibroid volume, making them appropriate first-line options for this patient 1, 2
  • These medications can significantly reduce tumor volume and are commonly used to decrease fibroid size 1
  • Consider combination treatment with low doses of estrogen and progestin to mitigate hypoestrogenic side effects 1
• Tranexamic acid can be used as a non-hormonal alternative to reduce bleeding symptoms during acute episodes 1, 3

Considerations for Fertility Preservation

• While the patient is on medical therapy, perform appropriate imaging (ultrasound or MRI) to characterize fibroid location, size, and number 1, 4
• If the uterine cavity is restored to normal after medical treatment, the patient may attempt natural or assisted conception without surgery 1
• If the cavity remains distorted after medical therapy, surgical intervention may eventually be necessary for fertility optimization 1, 5
• Be aware that fertility is temporarily suppressed during GnRH antagonist treatment, and symptoms typically recur after cessation of therapy 1

Alternative Non-Surgical Options if Medical Therapy Fails

• Uterine Artery Embolization (UAE) can be considered if medical management fails and the patient continues to refuse surgery 1, 2

  • UAE causes an average decrease in uterine fibroid size of >50% at 5 years 1
  • Pregnancy is possible after UAE, with reported live birth rates of approximately 50% 1
  • Consider the combined approach of UAE followed by GnRH antagonist therapy, which has shown effectiveness in reducing fibroid size and symptoms in patients not immediately suitable for surgery 2

• MR-Guided Focused Ultrasound (MRgFUS) is another non-surgical option that uses high-intensity ultrasound waves to thermally ablate fibroids 1

  • This procedure has shown significant improvement in quality of life and decrease in fibroid diameter (18%) compared to placebo 1
  • MRgFUS is associated with decreased post-procedural pain and faster recovery compared to surgical options 1

Special Considerations

• Monitor for rapid fibroid growth during treatment, as this may rarely indicate malignant transformation 4
• Reassess periodically for changes in the patient's symptoms, fibroid size, and fertility goals 4, 3
• If the patient becomes perimenopausal during treatment, consider continuing medical management while awaiting natural regression of fibroids during menopause 4
• Caution regarding ulipristal acetate: While effective for reducing both bleeding and bulk symptoms, reports of hepatotoxicity are a barrier to its approval in the United States 1

When to Consider Surgical Options Despite Patient Preference

• If severe anemia persists despite medical management 5, 6
• If fibroids continue to grow rapidly despite treatment 4
• If the uterine cavity remains significantly distorted, compromising fertility potential 1, 5
• In these cases, hysteroscopic myomectomy for submucosal fibroids or laparoscopic/open myomectomy for intramural or subserosal fibroids may eventually need to be reconsidered 1