What are the treatment options for a patient of reproductive age with menorrhagia and dysmenorrhea, who has two uterine fibroids, one of which is calcified, as shown on ultrasound?

Treatment Options for Reproductive-Age Women with Symptomatic Fibroids

For a reproductive-age woman with menorrhagia and dysmenorrhea from uterine fibroids, start with first-line medical therapy using combined oral contraceptives, levonorgestrel IUD, or tranexamic acid while correcting anemia with iron supplementation. 1

Initial Medical Management

The most effective first-line treatment for reducing menstrual blood loss is the levonorgestrel-releasing IUD 1. This should be your primary recommendation for this patient given the severity of menorrhagia and the need for long-term symptom control.

Alternative first-line options include:

• Combined hormonal contraceptives are particularly effective for women with small fibroids and provide both bleeding control and contraception 1. Standard formulations containing 20-30 μg ethinyl estradiol with progestin are appropriate, though 30 μg formulations may provide more consistent ovulation suppression 2.

• Tranexamic acid is the most important nonhormonal alternative that significantly reduces menstrual blood loss, especially when hormonal options are contraindicated or not desired 1. However, note that tranexamic acid should not be used concomitantly with hormonal contraceptives due to increased thromboembolic risk 3.

• NSAIDs are effective for pain control (addressing the dysmenorrhea) and provide modest reduction in bleeding 1.

Critical caveat: If using tranexamic acid, advise the patient to use nonhormonal contraceptive methods, as concomitant use with hormonal contraceptives increases thromboembolic risk 3.

When First-Line Therapy Fails

If first-line medical management fails to adequately control symptoms after 3-6 months, escalate to second-line medical therapy:

• GnRH antagonists with hormone add-back therapy reduce both bleeding symptoms and fibroid volume more effectively than first-line options 1. Combination low-dose estrogen/progestin add-back therapy mitigates hypoestrogenic side effects while maintaining efficacy 1.

• GnRH agonists are effective for reducing bleeding and fibroid volume but require add-back therapy to prevent bone mineral density loss with prolonged use 1.

• Preoperative use for 3 months can reduce fibroid size and correct anemia before surgery if surgical intervention is planned 1.

Surgical and Interventional Options

The choice between uterine-sparing procedures depends on fibroid location and future fertility desires:

For Fertility Preservation:

• Myomectomy (laparoscopic or open) is appropriate for the two pedunculated fibroids described in this case 1. However, recurrence rates range 23-33% 1, which is a significant limitation for long-term symptom control.

• Uterine artery embolization (UAE) achieves >50% reduction in fibroid size at 5 years with shorter hospital stay and decreased blood loss compared to surgery 1. Clinical success rates range from 81-100%, with significant improvement in menorrhagia (83%) and dysmenorrhea (77%) at 3 months 4.

Important UAE considerations:

• Major complications occur in <3% of patients 4
• Risk of permanent amenorrhea is <2-3% for women younger than 45 years 4
• 20-25% incidence of symptom recurrence at 5-7 years 4
• 14.4% of patients undergo additional procedures within 3 years (9.8% repeat UAE, 2.8% myomectomy, 1.8% hysterectomy) 4
• Follow-up MRI after UAE is recommended to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma 4

Special note on the calcified fibroid: The fundal calcified fibroid may respond less predictably to UAE, as calcification can indicate chronic ischemia. Cross-sectional imaging with MRI is recommended before UAE to better characterize both fibroids and plan treatment 4.

For Definitive Treatment:

Hysterectomy is the most definitive treatment with significantly better long-term quality of life compared to other options 1. This should be offered if the patient has completed childbearing and desires permanent symptom resolution.

Clinical Algorithm for This Patient

1. Start with levonorgestrel IUD as first-line therapy given its superior efficacy for menorrhagia 1
2. Add iron supplementation concurrently to correct anemia 1
3. If IUD fails or is not tolerated after 3-6 months, consider:
   • Tranexamic acid (nonhormonal option) 1
   • Combined oral contraceptives (if no contraindications) 2, 1
4. If medical management fails and fertility preservation is desired, proceed to:
   • UAE (preferred for multiple fibroids with shorter recovery) 4, 1
   • Myomectomy (if UAE contraindicated or patient preference) 1
5. If childbearing is complete, offer hysterectomy for definitive cure 1

Additional Diagnostic Considerations

Before initiating treatment, ensure:

• Pregnancy test to exclude pregnancy-related bleeding 1
• Endometrial biopsy is not routinely needed in this reproductive-age patient unless she has risk factors for endometrial cancer or persistent intermenstrual bleeding 1
• MRI may be considered before UAE to better characterize the calcified fibroid and plan intervention 4