What is the best treatment approach for a female patient of reproductive age with abnormal uterine bleeding (AUB) and myoma uterii (uterine fibroids)?

Treatment of Abnormal Uterine Bleeding in Reproductive-Age Women with Uterine Fibroids

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment for abnormal uterine bleeding caused by uterine fibroids in reproductive-age women, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1

Initial Diagnostic Workup

Before initiating treatment, specific diagnostic steps are essential:

• Perform pregnancy testing with β-hCG in all reproductive-age women to exclude pregnancy as the cause 1, 2
• Order combined transabdominal and transvaginal ultrasound with Doppler as the first-line imaging to confirm fibroids and exclude other structural pathology 3, 1, 2
• Obtain complete blood count with platelets to assess for anemia from chronic bleeding 1
• Measure thyroid-stimulating hormone and prolactin levels to exclude endocrine causes of bleeding 1, 2
• Consider MRI pelvis without and with IV contrast when ultrasound is inconclusive or further characterization of fibroid location and size is needed 3
• Perform endometrial biopsy if age >45 years or risk factors for endometrial cancer (obesity, diabetes, hypertension, unopposed estrogen exposure) are present 2

Medical Management Algorithm

First-Line Treatment

The LNG-IUD should be initiated as first-line therapy for most reproductive-age women with fibroid-related abnormal uterine bleeding who desire uterine preservation 1. This recommendation is based on:

• 71-95% reduction in menstrual blood loss 1
• Efficacy equivalent to endometrial ablation without surgical risks 1
• Minimal systemic absorption, making it appropriate even for women with cardiovascular disease or those on antiplatelet therapy 1

Alternative Medical Options

When LNG-IUD is contraindicated or declined:

• Combined hormonal contraceptives (CHCs) are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs to further reduce bleeding volume 1
• Oral progestins administered for 21 days per month reduce menstrual blood loss in women with cyclic heavy bleeding 1
• Tranexamic acid is a highly effective non-hormonal alternative with significant bleeding reduction 1, 2, 4
• NSAIDs reduce bleeding by 20-50% and are most effective for ovulatory menorrhagia 2, 4

Critical caveat: In women with cardiovascular disease or post-SCAD, avoid NSAIDs and tranexamic acid due to MI and thrombosis risk; LNG-IUD becomes the mandatory preferred option 1

Short-Term Preoperative Medical Management

• GnRH agonists or antagonists (elagolix, linzagolix, relugolix) effectively reduce bleeding symptoms and significantly reduce fibroid volume when preparing for surgical intervention 5, 4, 6
• These agents induce medical menopause temporarily, with symptoms returning after discontinuation 5

Surgical Management

Indications for Surgery

Proceed to surgical intervention when:

• Medical management fails after adequate trial 1, 5
• Medical therapy is contraindicated 1, 5
• Patient has completed childbearing and desires permanent resolution 1
• Bleeding persists despite initial medical therapy, requiring further investigation with hysteroscopy to diagnose focal lesions potentially missed by endometrial sampling 1, 2

Surgical Options Based on Fertility Desires

For women desiring future fertility:

• Myomectomy (hysteroscopic, laparoscopic, or open approach depending on fibroid location, size, and number) is the fertility-sparing surgical option 4, 6
• Uterine artery embolization (UAE) demonstrates significantly greater short-term benefits compared to hysterectomy but has increased percentage of long-term reintervention 5
• UAE requires full gynecologic workup including Pap smear and endometrial biopsy if menometrorrhagia is present, with cross-sectional imaging (preferably MRI) to confirm diagnosis 3
• UAE achieves clinical success rates of 81-100% with median uterine and dominant fibroid volume reduction 3

For women who have completed childbearing:

• Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to LNG-IUD 1
• Important caveat: Endometrial ablation has long-term complications including postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis; thorough informed consent is mandatory 1
• Hysterectomy is the definitive treatment when medical management fails or is contraindicated, providing complete resolution of all fibroid-related symptoms and eliminating recurrence risk 1, 5
• Hysterectomy provides significantly better health-related quality-of-life advantage compared to other therapies 5, 2
• Choose the least invasive surgical route (vaginal, laparoscopic, or abdominal) based on uterine size and surgical expertise 5, 2

Special Clinical Considerations

Coexistent Adenomyosis

• Adenomyosis frequently coexists with fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia, commonly affecting women in their 40s 1, 5
• This coexistence contributes significantly to menorrhagia and anemia, potentially affecting treatment response 5

Iron Deficiency Management

• Initiate iron replacement therapy for iron deficiency and iron deficiency anemia resulting from acute and chronic bleeding, both during medical treatment and before/after surgical procedures 4

Treatment Failure Protocol

If bleeding persists despite initial medical therapy:

1. Perform hysteroscopy to visualize the endometrial cavity and endocervix, diagnosing focal lesions possibly missed by endometrial sampling 1, 2
2. Consider saline infusion sonohysterography, which has 96-100% sensitivity and 97% accuracy in distinguishing leiomyomas from polyps 2
3. Do not rely on endometrial biopsy alone to rule out focal lesions, as it has variable sensitivity 1
4. Reassess for structural pathology requiring surgical intervention 1