What's the next step for a 48-year-old woman with heavy menstrual bleeding, uterine polyp, ovarian cyst, dehydration, muscle cramps, and risk of iron deficiency anemia, currently taking naproxen (nonsteroidal anti-inflammatory drug) and iron supplements?

Gynecology Referral for Hysteroscopic Polypectomy and Consideration of Endometrial Ablation

This patient requires urgent gynecology referral for hysteroscopic polypectomy to remove the 7mm endometrial polyp, which is the most likely structural cause of her heavy menstrual bleeding and progressive iron deficiency anemia. 1

Immediate Management Priorities

Stop Naproxen Immediately

• Naproxen is contraindicated in this clinical scenario because NSAIDs can paradoxically worsen menstrual bleeding in some patients and should be avoided when cardiovascular concerns exist with dehydration 1
• While NSAIDs reduce menstrual blood loss compared to placebo, they are significantly less effective than other medical therapies for heavy menstrual bleeding 2
• The patient has been taking naproxen without adequate bleeding control, demonstrating treatment failure 3

Optimize Iron Replacement

• Continue oral iron supplementation with ferrous sulfate 325 mg daily (65 mg elemental iron) taken on an empty stomach with 500 mg vitamin C to enhance absorption 4
• Iron therapy must continue for 3 months after hemoglobin normalization to replenish depleted iron stores 4
• Given the severity of ongoing blood loss (100 mL/day for 3 days monthly), consider transitioning to intravenous iron if oral iron fails to correct anemia within 3 weeks or if oral iron is poorly tolerated 5

Address Dehydration and Electrolytes

• Aggressive oral rehydration with electrolyte-containing fluids to address dehydration and muscle cramps
• Monitor for electrolyte abnormalities, particularly if considering hormonal therapies

Definitive Structural Management

Hysteroscopic Polypectomy is Indicated

• The 7mm endometrial polyp is a structural PALM-COEIN cause of her abnormal uterine bleeding and must be removed 6, 1
• Endometrial polyps are present in approximately 68% of women with abnormal uterine bleeding 7
• Polyp removal is necessary before considering endometrial ablation, as ablation cannot be performed with intracavitary lesions present 6

Endometrial Ablation Consideration

• Endometrial ablation is appropriate for this patient given failed medical management (naproxen ineffective), presence of a structural lesion requiring hysteroscopy, and her age (48 years, likely approaching menopause) 6, 1
• The American College of Obstetricians and Gynecologists recommends surgical options including endometrial ablation when medical treatment fails, is contraindicated, or not tolerated 6
• Ablation can be performed at the same time as polypectomy once the polyp is removed 1

Management of the Ovarian Cyst

• The 42 x 40 x 37 mm simple ovarian cyst is benign and requires expectant management only 8
• Simple cysts in premenopausal women are generally managed conservatively with observation 8
• This cyst is not contributing to her bleeding or symptoms

Bridging Medical Therapy Until Surgery

Hormonal Options to Control Bleeding

• Levonorgestrel intrauterine system (IUD) is the most effective medical therapy for heavy menstrual bleeding and can reduce blood loss by 71-96% 9
• Combined oral contraceptives can reduce menstrual blood loss and provide contraception 6, 9
• Tranexamic acid is more effective than NSAIDs for reducing heavy menstrual bleeding, though it should be used cautiously given her dehydration history 2

Why Not Continue Current Management

• Naproxen monotherapy has clearly failed after "few months" of worsening symptoms 2
• Continuing ineffective therapy while she develops progressive iron deficiency anemia and quality of life impairment is inappropriate 6
• The presence of a structural lesion (polyp) requires surgical intervention regardless of medical therapy 1

Monitoring and Follow-Up

Pre-Operative Assessment

• Obtain complete blood count to quantify degree of anemia before surgery 4
• Check ferritin, iron saturation, and transferrin saturation if not recently done 4
• Pregnancy test (β-hCG) must be performed before any surgical intervention 1

Post-Operative Care

• Continue iron supplementation for 3 months after hemoglobin normalizes 4
• Monitor hemoglobin at 3-week intervals initially, then every 3 months for one year 4
• If ablation is performed, expect significant reduction or cessation of menstrual bleeding 1

Critical Pitfalls to Avoid

• Do not delay gynecology referral for further medical management trials—she has already failed conservative therapy and has a structural lesion requiring removal 1
• Do not perform endometrial ablation without first removing the polyp—intracavitary lesions are a contraindication to ablation 6
• Do not assume the simple ovarian cyst requires intervention—it is benign and unrelated to her bleeding 8
• Do not discontinue iron supplementation prematurely—stores must be repleted even after hemoglobin normalizes 4