From the Guidelines
The best next step in management for this patient is to prescribe oral tranexamic acid during her menstrual periods to control the heavy bleeding. Tranexamic acid is an antifibrinolytic agent that can reduce menstrual blood loss by approximately 40-60% without affecting her fertility plans, as noted in the most recent guidelines 1. The typical dosage is 1300 mg three times daily for up to 5 days during menstruation. This medication is particularly appropriate for this patient because she has uterine fibroids causing heavy menstrual bleeding, is planning pregnancy in the near future, and has contraindications to hormonal therapy due to her history of migraines with aura. Additionally, continuing her prenatal vitamins and possibly adding iron supplementation would be beneficial to address her anemia (hemoglobin 10 g/dL) 1. Tranexamic acid works by inhibiting plasminogen activation, which reduces fibrinolysis and helps preserve blood clots in the uterine vasculature. This approach allows for immediate symptom management while preserving her fertility and avoiding interventions that would delay conception, such as surgical management of the fibroids or hormonal treatments that would prevent ovulation. Some studies have also discussed the use of other medical management options, including anti-inflammatory medications and medications that suppress the reproductive axis to decrease symptoms associated with fibroids, such as bleeding and pain 1. However, given the patient's specific situation and the need to prioritize fertility and avoid hormonal therapies due to her migraines with aura, tranexamic acid is the most suitable choice. It's also worth noting that the patient's symptoms, including heavy menstrual bleeding, cramping, bloating, and pelvic fullness, are common presentations of uterine fibroids, and managing these symptoms effectively is crucial for improving her quality of life 1.
From the Research
Patient Management
The patient presents with heavy menstrual bleeding, iron deficiency anemia, and multiple intramural uterine fibroids. The best next step in management for this patient would be to address the iron deficiency anemia and heavy menstrual bleeding.
- The patient's hemoglobin level is 10 g/dL, which is below the normal range, indicating iron deficiency anemia.
- Studies have shown that tranexamic acid can increase hemoglobin and ferritin levels in women with heavy menstrual bleeding 2.
- Oral iron therapy is also effective in improving hemoglobin concentration and other hematological parameters in patients with iron deficiency anemia 3, 4, 5, 6.
- Ferrous sulfate is a commonly prescribed oral iron supplement that has been shown to be effective in treating iron deficiency anemia 3, 4, 5, 6.
- The patient is planning to become pregnant, and iron deficiency anemia should be treated before pregnancy to prevent complications.
Treatment Options
The patient can be treated with:
- Tranexamic acid to reduce heavy menstrual bleeding and improve hemoglobin and ferritin levels 2.
- Oral iron supplements, such as ferrous sulfate, to improve hemoglobin concentration and other hematological parameters 3, 4, 5, 6.
- The patient should also be counseled on the importance of iron deficiency anemia treatment before pregnancy and the potential benefits and risks of different treatment options.