What is the management for bleeding in a patient with a uterine mass?

Management of Bleeding in Patients with Uterine Mass

Start with first-line medical therapy using combined hormonal contraceptives, levonorgestrel IUD, or tranexamic acid to control bleeding while simultaneously correcting anemia with iron supplementation. 1, 2

Immediate Assessment Requirements

Before initiating treatment, you must:

• Perform endometrial biopsy if the patient is ≥35 years old, has risk factors for endometrial cancer, or has endometrial thickening >1.5 cm to rule out hyperplasia or malignancy 3, 2
• Obtain complete blood count to assess degree of anemia and platelet count 4, 5
• Perform pregnancy test (beta-hCG) to exclude pregnancy-related bleeding 3, 6
• Check thyroid function and prolactin levels as thyroid dysfunction and hyperprolactinemia commonly cause abnormal bleeding 3, 6
• Obtain pelvic ultrasound (transvaginal preferred) to characterize fibroid size, number, and location 2, 5

First-Line Medical Management for Bleeding Control

The most effective medical options, ranked by efficacy:

1. Levonorgestrel-releasing IUD - Most effective first-line treatment for reducing menstrual blood loss 1, 5
2. Combined hormonal contraceptives (oral contraceptive pills) - Particularly effective for women with small fibroids 3, 1
3. Tranexamic acid - Important nonhormonal alternative that significantly reduces menstrual blood loss, especially when hormonal options are contraindicated or not desired 3, 1, 5
4. NSAIDs - Effective for pain control and modest reduction in bleeding 1, 6

Critical caveat: Tranexamic acid may cause fibroid necrosis leading to pelvic pain and fever, though it effectively reduces menorrhagia 3

Second-Line Medical Management

If first-line therapy fails or is inadequate:

• GnRH antagonists (relugolix, elagolix, linzagolix) with hormone add-back therapy - These reduce both bleeding symptoms and fibroid volume more effectively than first-line options 1, 2
• Combination low-dose estrogen/progestin add-back therapy mitigates hypoestrogenic side effects while maintaining efficacy 1, 2
• GnRH agonists - Effective for reducing bleeding and fibroid volume but require add-back therapy to prevent bone mineral density loss with prolonged use 3, 1

Important limitation: Fertility is suppressed during GnRH therapy, and symptoms typically recur rapidly after cessation 1

Surgical and Interventional Options

When medical management fails, is contraindicated, or patient has concomitant significant intracavitary lesions:

For Fertility Preservation:

• Hysteroscopic myomectomy for submucosal fibroids 2
• Laparoscopic or open myomectomy for intramural or subserosal fibroids, though recurrence rates range 23-33% 3, 2

For Non-Fertility Candidates:

• Uterine artery embolization (UAE) - Achieves >50% reduction in fibroid size at 5 years with shorter hospital stay and decreased blood loss compared to surgery, but has higher reintervention rates (up to 36%) 3, 2
• Endometrial ablation - For women with completed childbearing and no structural abnormalities 3, 5
• Hysterectomy - Most definitive treatment with significantly better long-term quality of life compared to other options, though UAE shows similar quality of life at 5 years 3

Critical warning: Avoid morcellation in minimally invasive procedures due to risk of spreading occult malignancy and worsening disease-free survival 3

Special Clinical Scenarios

Large or Multiple Fibroids:

• Preoperative GnRH agonists/antagonists for 3 months to reduce fibroid size and correct anemia before surgery 1, 2
• Concurrent iron supplementation during medical therapy 2, 5

Vascular Malformations:

If imaging shows dilated vessels within myometrial mass with profuse bleeding, consider uterine artery embolization as this may represent arteriovenous malformation rather than typical fibroid 7

Failed Medical Therapy:

• Perform hysteroscopy to visualize endometrial cavity and diagnose focal lesions possibly missed by endometrial sampling 3
• Consider saline infusion sonohysterography (96-100% sensitivity) for assessing intracavitary pathology 3, 5

Treatment Algorithm

Step 1: Correct anemia with iron + initiate first-line medical therapy (levonorgestrel IUD, combined hormonal contraceptives, or tranexamic acid) 1, 2, 5

Step 2: If inadequate response after 3 months, escalate to GnRH antagonists with hormone add-back therapy 1

Step 3: If medical management fails or structural lesions identified, proceed to:

• UAE for non-fertility candidates (shorter recovery, less invasive) 3
• Myomectomy for fertility preservation 2
• Hysterectomy for definitive cure when childbearing complete 3