What is the best course of action for a 32-year-old female with Uterine Myoma, Type 2 Diabetes Mellitus, Bronchial Asthma, REM-related sleep apnea, Major Depressive Disorder, and Mild Anemia, presenting with prolonged vaginal bleeding of eleven months duration, currently taking Mefenamic acid for pain and Tranexamic acid for bleeding, and scheduled for operative hysteroscopic myomectomy?

Assessment and Differential Diagnosis

This is a 32-year-old woman with symptomatic uterine myoma presenting with prolonged menorrhagia (11 months) complicated by anemia, now with bleeding controlled on tranexamic acid and scheduled for hysteroscopic myomectomy—proceed with the planned surgery after optimizing her anemia and ensuring adequate preoperative preparation. 1

Primary Assessment

The patient's clinical picture is consistent with symptomatic uterine leiomyoma (fibroid) causing chronic menorrhagia with secondary anemia. The transrectal ultrasound confirming myoma enlargement, combined with the pattern of heavy bleeding (1-5 pads/day with soaked menstrual pants) and hypogastric pain, establishes this as the primary diagnosis. 2

Key Clinical Features Supporting This Diagnosis:

• Prolonged menorrhagia (11 months): Classic presentation of submucosal or intramural fibroids causing abnormal uterine bleeding 3
• Documented myoma enlargement: Confirmed on imaging, explaining symptom progression 1
• Mild anemia secondary to chronic blood loss: Direct consequence of prolonged menorrhagia 3
• Response to tranexamic acid: Reduction from 1-5 pads to 1-3 pads daily confirms hyperfibrinolytic component of fibroid-related bleeding 4, 5
• Hypogastric pain (7-8/10): Consistent with fibroid bulk symptoms or possible early infarction 2, 6

Differential Diagnoses to Consider

1. Tranexamic Acid-Induced Fibroid Necrosis/Infarction

• Critical consideration: The patient has been taking tranexamic acid 1000mg every 8 hours, which is associated with infarct-type necrosis and intralesional thrombosis in 15% of fibroid cases 6
• Clinical significance: This can cause severe pelvic pain and fever, which may complicate the perioperative period 6
• Her hypogastric pain (PS 7-8/10) could represent early fibroid infarction rather than simple bulk symptoms 6
• Pitfall to avoid: Early infarcts may resemble coagulative necrosis on pathology and be misdiagnosed as smooth muscle tumor of uncertain malignant potential 6

2. Endometrial Pathology (Hyperplasia or Malignancy)

• Must be excluded: Prolonged menorrhagia in a patient with Type 2 Diabetes (increased endometrial cancer risk) requires endometrial sampling 1
• The evidence does not indicate whether endometrial biopsy has been performed—this is a critical gap that must be addressed before proceeding with myomectomy 1
• Recommendation: Perform endometrial biopsy if not already done, especially given 11 months of bleeding 1

3. Adenomyosis

• Can coexist with fibroids and cause similar bleeding patterns and pelvic pain 3
• Transrectal ultrasound should have evaluated for this, but if not clearly documented, consider MRI for definitive characterization 2, 1

4. Coagulopathy or Platelet Dysfunction

• Less likely given response to tranexamic acid, but chronic NSAID use (mefenamic acid) could theoretically affect platelet function 4
• Her anemia is documented as secondary to chronic blood loss, not a primary hematologic disorder 3

5. Leiomyosarcoma (Rare but Important)

• Extremely rare in reproductive age women (benign in this age group per guidelines) 2
• Rapid fibroid growth can occasionally indicate malignant transformation, though this is uncommon 1
• The documented enlargement warrants attention, but in a 32-year-old, benign growth is far more likely 2

Recommended Preoperative Management

Immediate Priorities Before Surgery:

1. Correct anemia aggressively 3, 1:

   • Iron supplementation is mandatory before elective surgery 1, 3
   • Consider GnRH antagonists (relugolix, elagolix, or linzagolix) or selective progesterone receptor modulators to further reduce bleeding and correct anemia preoperatively 1, 3
   • These agents are effective at correcting anemia and should be considered in anemic patients 3

2. Perform endometrial biopsy if not already done 1:

   • Endometrial thickening or prolonged bleeding requires evaluation to rule out hyperplasia or malignancy 1
   • This is especially critical given her Type 2 Diabetes and 11-month bleeding history 1

3. Optimize comorbidities 3:

   • Ensure Type 2 Diabetes is well-controlled (reduces surgical complications)
   • Assess asthma control and ensure appropriate perioperative bronchodilator management
   • Address sleep apnea with anesthesia team (increased perioperative risk)
   • Optimize depression management (may affect postoperative recovery)

4. Continue tranexamic acid until surgery 4, 7:

   • Tranexamic acid 2-4.5g/day reduces menstrual blood loss by 34-59% and is effective for fibroid-related bleeding 4
   • However, be aware of potential fibroid necrosis complications (pain, fever) that may require urgent intervention 6
   • If severe pain develops, consider imaging to assess for fibroid infarction 6

Surgical Planning:

Hysteroscopic myomectomy is the appropriate first-line conservative surgical therapy for symptomatic intracavitary (submucosal) fibroids 3. The surgical plan should include:

• Mapping fibroid location, size, and number with appropriate imaging (ultrasound or MRI) 3, 1
• Counseling regarding morcellation risks: If morcellation is necessary, inform patient about rare possibility of occult malignancy and potential for cancer spread 3, 2
• Intraoperative hemostasis measures: Consider vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss 3
• Tranexamic acid perioperatively: Reduces intraoperative blood loss by mean 213.1 mL and postoperative blood loss by 56.3 mL in abdominal myomectomy 7

Common Pitfalls to Avoid:

1. Do not proceed with surgery without correcting anemia—this increases perioperative morbidity 3
2. Do not ignore the possibility of tranexamic acid-induced fibroid necrosis if pain worsens 6
3. Do not skip endometrial sampling in a patient with prolonged bleeding and diabetes 1
4. Do not underestimate perioperative risks from her multiple comorbidities (diabetes, asthma, sleep apnea) 3

Postoperative Considerations:

• Recurrence risk: Myomectomy has a 23-33% recurrence rate, and she should understand this is not a definitive cure 2, 3
• Fertility preservation: If she desires future pregnancy, wait 2-3 months after myomectomy before attempting conception to allow uterine healing 2
• Long-term surveillance: Monitor for fibroid recurrence and manage any persistent symptoms 2, 3