What is the best management approach for a patient with a history of uterine leiomyoma (Noncancerous growths in the uterus) and anemia (Low red blood cell count)?

Management of Uterine Leiomyoma with Anemia

For patients with uterine leiomyomas causing anemia, correct the anemia preoperatively with iron supplementation combined with either selective progesterone receptor modulators (SPRMs) or GnRH agonists, then proceed with definitive treatment based on fertility desires: hysterectomy for completed childbearing or myomectomy for fertility preservation. 1, 2

Immediate Anemia Management

Anemia correction is mandatory before any elective surgical intervention. 2

• Iron supplementation (ferrous sulfate 325 mg three times daily) is the foundation of anemia treatment and should be initiated immediately 3, 4
• For severe anemia (hemoglobin <7-8 g/dL), consider blood transfusion while initiating medical therapy 5
• GnRH agonists (goserelin 10.8 mg depot or leuprorelin) combined with iron increase hemoglobin by approximately 1.2 g/dL more than iron alone and should be used preoperatively in anemic patients 2, 4
• SPRMs (ulipristal) effectively reduce bleeding and correct anemia while awaiting surgery, though use is limited to 3 months due to endometrial effects 1, 3

Critical Pitfall

Life-threatening anemia (hemoglobin <2 g/dL) can occur when patients delay seeking care due to lack of disease awareness—the most important risk factors are patient mental, social, and personal factors rather than fibroid characteristics alone 5

Definitive Treatment Algorithm

For Women Who Have Completed Childbearing

Hysterectomy is the gold standard definitive treatment with the highest satisfaction rates (up to 90% at 2 years) and eliminates recurrence risk. 6, 1

• Vaginal approach is preferable to abdominal or laparoscopic when feasible, resulting in fewer infections and less bleeding 3
• No advantage exists in preserving the cervix 3
• This is curative and allows estrogen-only hormone replacement therapy at menopause 6

For Women Desiring Fertility Preservation

Myomectomy is the appropriate surgical option but carries a 27% recurrence rate at 10 years, with higher rates in women with multiple fibroids. 1, 2

• Hysteroscopic myomectomy is first-line for intracavitary and submucosal fibroids that protrude significantly into the endometrial cavity 6, 2
• Abdominal myomectomy is required for intramural and subserosal fibroids 6
• Preoperative GnRH agonist therapy for 3-6 months reduces fibroid size and corrects anemia 6, 2
• Intraoperative blood loss reduction techniques should be employed: vasopressin injection, peri-cervical tourniquet, or gelatin-thrombin matrix 2
• Women should wait 2-3 months after myomectomy before attempting pregnancy 1
• Recurrence risk necessitates counseling that this provides only an interval of symptom relief, not cure 6

Minimally Invasive Alternative: Uterine Artery Embolization

UAE is appropriate for women who wish to preserve their uterus but have completed childbearing, with 95% symptomatic relief at 12 months and major complications in <3% of patients. 6, 1, 7

• UAE achieves 42% fibroid volume reduction and controls symptoms in 80% of patients 6, 7
• Symptom improvement includes menorrhagia (83%), dysmenorrhea (77%), and urinary frequency (86%) 6, 7
• Reintervention rates are 28% at 5 years and 35% at 10 years 7
• Higher failure rates occur in women <40 years of age due to increased collateral vessel recruitment 1, 7
• Amenorrhea risk is age-dependent: <3% for women <45 years, up to 20% for women >45 years 7
• The role in women desiring future fertility remains unclear—counsel that pregnancy is possible but outcomes are uncertain 7

Medical Therapy for Symptom Control

When surgery must be delayed or the patient is approaching menopause:

• Levonorgestrel intrauterine system is first-line medical therapy for bleeding control, though expulsion risk is approximately 20% in women with fibroids 3, 2
• GnRH agonists reduce bleeding but cause significant hypoestrogenic side effects including 1% bone loss per month, limiting use to 6 months maximum 6, 1, 2
• Add-back therapy with GnRH agonists mitigates hypoestrogenic effects while maintaining efficacy 1
• Oral contraceptives and progestins may manage bleeding in women with smaller fibroids but have limited effect on fibroid size 1
• Tranexamic acid reduces menorrhagia but has unclear thrombotic risk and uncertain efficacy 3

Key Clinical Considerations

Location of fibroids significantly impacts treatment success:

• Intracavitary and submucosal fibroids are best treated with hysteroscopic resection 6
• Cervical fibroids and multiple submucosal fibroids have higher UAE failure rates 1
• Pedunculated subserosal fibroids were previously considered UAE contraindications but recent data show good outcomes 1

Morcellation warning: When specimen removal requires morcellation, patients must be informed that fibroids may rarely contain unexpected malignancy (approximately 1 in 350 cases) and laparoscopic power morcellation may spread cancer, worsening prognosis 6, 2

Coexisting conditions:

• For adenomyosis with fibroids, UAE shows 65-88% long-term symptomatic relief 1
• When endometriosis coexists, surgical methods addressing both conditions simultaneously may be more appropriate 1