What is the best next step in management for a woman of childbearing age with chronic pelvic pain, heavy menstrual bleeding, and a uterine fibroid (leiomyoma) shown on CT scan?

Best Next Step: Medical Management with Oral Contraceptive Pills

For a woman of childbearing age with symptomatic uterine fibroids causing chronic pelvic pain and heavy menstrual bleeding, medical management should be trialed first before pursuing invasive therapies, with oral contraceptive pills being an appropriate first-line option. 1

Rationale for Medical Management First

The 2024 ACR Appropriateness Criteria explicitly states that "in most cases, medical management should be trialed prior to pursuing more invasive therapies" for reproductive age patients with symptomatic fibroids experiencing heavy uterine bleeding or bulk symptoms. 1 This recommendation prioritizes:

• Avoiding surgical morbidity in a woman of childbearing age
• Preserving fertility potential without surgical intervention
• Managing symptoms effectively while maintaining quality of life

First-Line Medical Options

Oral contraceptive pills are specifically recommended as first-line medical management for fibroid-related heavy menstrual bleeding, along with NSAIDs. 1 These agents:

• Reduce bleeding symptoms effectively 1
• Are minimally invasive with low risk profiles
• Allow for symptom control while preserving all future treatment options
• Can be discontinued if pregnancy is desired

Additional first-line options include tranexamic acid (a nonhormonal alternative) and NSAIDs for pain control. 1, 2

When to Consider Invasive Therapies

Myomectomy and uterine artery embolization should be reserved for patients who fail medical management or have specific indications. 1 The 2024 ACR guidelines list these as "usually appropriate" but equivalent alternatives that come after medical management has been attempted. 1

Myomectomy Considerations:

• Reserved for women desiring fertility who fail medical therapy 1, 3
• Carries 23-33% recurrence rates 1
• Associated with surgical risks including blood loss and need for repeat intervention 3
• Pregnancy rates after myomectomy are less than 50% in 3-year follow-ups 2

Uterine Artery Embolization Considerations:

• Should NOT be first-line in women seeking pregnancy 1
• Associated with increased miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) 1
• Reintervention rate of approximately 7% due to persistent symptoms 2
• May impact fertility and should be discussed thoroughly if future pregnancy desired 3

Clinical Algorithm

1. Start with medical management (OCP, tranexamic acid, or NSAIDs) 1
2. Assess response after 3-6 months of therapy
3. If symptoms persist despite medical therapy, consider:
   • Myomectomy if fertility preservation is critical 1, 3
   • UAE if uterine preservation desired but not necessarily fertility 1
   • MRgFUS as alternative minimally invasive option 1

Important Caveats

• Correct anemia before any surgical intervention if it develops 3
• Document fibroid characteristics with appropriate imaging (ultrasound or MRI) to guide future decisions if medical management fails 3
• Counsel about fertility implications of all treatment options, particularly UAE 1, 3
• Rule out malignancy if there are concerning features, though leiomyosarcoma is extremely rare (<1 in 1000) 4

Answer: C. Oral contraceptive pills (OCP) - as the appropriate first-line medical management before considering invasive procedures.