What treatment options are available for heavy periods caused by uterine fibroids and uterine wall thickening, accompanied by iron deficiency anemia?

Treatment for Heavy Periods from Uterine Fibroids with Iron Deficiency Anemia

Start with first-line medical management using NSAIDs, tranexamic acid, or hormonal contraceptives (combined oral contraceptives or levonorgestrel IUD) while simultaneously correcting your anemia with oral iron supplementation. 1, 2

Immediate Priority: Correct Your Anemia

• Take ferrous sulfate 200 mg three times daily to restore hemoglobin levels and replenish iron stores 1, 3
• Continue iron supplementation for three months after your hemoglobin normalizes to fully replenish body stores 1
• Your hemoglobin should rise by 2 g/dL within 3-4 weeks; if it doesn't, this indicates continued blood loss requiring more aggressive fibroid treatment 1

First-Line Medical Management for Bleeding Control

Begin with one of these options immediately:

• Tranexamic acid (nonhormonal option that significantly reduces menstrual bleeding) 1, 2
• Combined oral contraceptives (reduce bleeding symptoms effectively) 1, 2
• Levonorgestrel IUD (highly effective for long-term bleeding control with high-quality evidence) 1, 2, 4
• NSAIDs during menstruation (reduce bleeding and pain) 1

Second-Line Medical Options If First-Line Fails

If bleeding persists after 3 months, escalate to:

• GnRH antagonists (relugolix, elagolix, or linzagolix) with add-back estrogen/progestin therapy - this is FDA-approved specifically for fibroid-related heavy bleeding and reduces fibroid volume by 18-30% 1, 2
• This combination mitigates the hypoestrogenic side effects (hot flashes, bone loss, headaches) that occur with GnRH therapy alone 1
• Critical caveat: Symptoms return rapidly after stopping these medications, so this is not a permanent solution 1

When to Consider Surgical or Interventional Treatment

Move to definitive treatment if:

• Medical management fails to control bleeding after 3-6 months
• You cannot maintain normal hemoglobin despite iron supplementation
• You develop severe bulk symptoms (pelvic pressure, urinary frequency, bowel dysfunction)

Surgical Options Based on Your Goals:

If you want to preserve your uterus and potentially maintain fertility:

• Hysteroscopic myomectomy for submucosal fibroids <5 cm (shortest recovery, equivalent symptom relief to more invasive approaches at 2-3 months) 1
• Laparoscopic or open myomectomy for intramural or subserosal fibroids (preserves fertility but carries 30-50% risk of fibroid recurrence requiring reintervention) 1, 4

If you want to preserve your uterus but don't need fertility:

• Uterine artery embolization (UAE) - reduces fibroid diameter by 53% with 7% reintervention rate at long-term follow-up, improves quality of life for up to 7 years 1, 2
• UAE has lower reintervention rates (13%) compared to MR-guided focused ultrasound (30%) 1

If you have completed childbearing:

• Hysterectomy via the least invasive route possible (vaginal or laparoscopic preferred over abdominal) provides definitive cure with high satisfaction rates 1, 2, 4
• Hysterectomy eliminates risk of recurrence and allows treatment of concurrent adenomyosis if present 1

Critical Pitfalls to Avoid

• Do not delay iron supplementation - start immediately regardless of which fibroid treatment you choose, as anemia correction takes months 1, 4
• Do not use GnRH therapy without add-back hormones for more than 3-6 months due to bone density loss 1, 5
• Do not assume fibroids will resolve - only 20-50% of women with fibroids develop symptoms, but once symptomatic, treatment is necessary as natural resolution is unlikely before menopause 1, 6
• Ensure endometrial biopsy is performed if you have risk factors for endometrial pathology (age >45, prolonged bleeding, obesity) to rule out other causes of bleeding 1

Specific Algorithm for Your Situation

Given your oligomenorrhea (only 4 periods in 11 months) with heavy bleeding when periods occur:

1. Start oral iron 200 mg three times daily today 1, 3
2. Begin tranexamic acid or levonorgestrel IUD (most effective for intermittent heavy bleeding pattern) 1, 2, 4
3. Recheck hemoglobin in 3-4 weeks - if not rising by 2 g/dL, escalate to GnRH antagonist with add-back therapy 1
4. If medical management fails at 6 months, proceed to UAE or myomectomy depending on fertility desires 1, 2, 4