What is the best management approach for a 48-year-old female with suspected uterine fibroids and adenomyosis, presenting with abnormal uterine bleeding, and suspected perimenopausal status?

Management of Abnormal Uterine Bleeding in a 48-Year-Old with Fibroid and Adenomyosis

Start with a levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) as first-line therapy, which reduces menstrual blood loss by 71-95% and provides superior symptom control compared to other medical options in patients with concurrent fibroids and adenomyosis. 1

Initial Medical Management Algorithm

First-Line Therapy: LNG-IUD

• The LNG-IUD is the preferred initial treatment due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence. 2, 1
• A recent randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with LNG-IUD versus combined oral contraceptives. 2
• The presence of concomitant adenomyosis does not decrease effectiveness of hormonal therapies. 2
• Critical caveat: Medical therapies will NOT treat bulk symptoms associated with fibroids. 2, 1

Second-Line Medical Options if LNG-IUD Fails or Is Refused

For patients who decline hormonal therapy:

• Tranexamic acid provides significant reduction in menstrual blood loss as a nonhormonal alternative. 1, 3, 4
• NSAIDs reduce menstrual blood loss and bleeding symptoms, but avoid in women with cardiovascular disease. 1, 3, 4

For patients accepting hormonal therapy:

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD. 2, 1
• Oral GnRH antagonists (relugolix, elagolix, linzagolix) are highly effective for heavy menstrual bleeding with 18-30% reduction in fibroid volume. 1, 5
• Mandatory requirement: Combination treatment with low-dose estrogen and progestin add-back therapy must be used with GnRH antagonists to mitigate hypoestrogenic effects and prevent bone loss. 1, 5

When to Escalate Beyond Medical Management

Indications for Interventional or Surgical Therapy

• Failure of medical management after 3-6 months trial
• Presence of significant bulk symptoms (pelvic pressure, urinary frequency, constipation)
• Patient preference for definitive therapy
• Severe anemia not responding to medical therapy

Interventional Options for Uterus-Preserving Therapy

Uterine Artery Embolization (UAE)

UAE is the preferred interventional option for this 48-year-old perimenopausal patient with combined fibroids and adenomyosis who fails medical management. 2

Evidence supporting UAE in this specific population:

• Prospective cohort studies demonstrate improvement in quality of life and symptom scores in women with adenomyosis and fibroids, especially when fibroids predominate. 2
• Short-term (<12 months) symptom improvement in 94% and long-term (>12 months) improvement in 85% of patients. 2
• Symptom control and quality of life improvement maintained up to 7 years follow-up. 2
• Only 7-18% of patients require subsequent hysterectomy for persistent symptoms. 2

Important considerations:

• UAE has shorter hospitalization stays and shorter recovery times compared to surgery. 2
• At 48 years old (perimenopausal), fertility preservation is not a concern, making UAE more appropriate than in younger women. 2
• Recurrence rates for adenomyosis symptoms range from 40-50% at 2 years, but more recent data shows 73-88% symptomatic control at median follow-up of 24-65 months. 2

Endometrial Ablation

• Endometrial ablation is used for treating abnormal uterine bleeding and can treat symptomatic submucosal myomas. 2
• Overall patient satisfaction >95% in studies of 438 women. 2
• Critical limitation: 23% failure rate in treating patients with submucosal fibroids, compared with 4% failure rate in patients with normal uterine cavities. 2
• Uterine cavity size limitations exist, with most devices treating cavities up to 10 cm. 2
• Adenomyosis is unlikely to be effectively addressed with endometrial ablation alone. 2

Surgical Management

Hysterectomy: Definitive Therapy

Hysterectomy should be offered when medical and interventional therapies fail, providing definitive resolution with up to 90% patient satisfaction at 2 years. 2, 1, 5

Advantages specific to this patient:

• At 48 years old with no fertility concerns, hysterectomy eliminates both fibroid and adenomyosis symptoms definitively. 2
• Alternative causes of symptoms, such as adenomyosis, will be effectively treated (unlike myomectomy). 2
• Little potential for recurrence. 2

Route selection:

• The least invasive route for hysterectomy should be performed. 2
• Vaginal hysterectomy is associated with shorter operating times, faster return to normal activities, and better quality of life compared to abdominal hysterectomy. 2
• Laparoscopic hysterectomy is associated with faster return to normal activities, shorter hospital stays, and lower rates of wound infection compared to abdominal hysterectomy. 2
• Robotic-assisted hysterectomy outcomes appear similar to traditional laparoscopy. 2

Important long-term risks to counsel:

• Increased risk of cardiovascular disease. 2, 5
• Increased risk of osteoporosis and bone fracture. 2, 5
• Increased risk of dementia. 2
• Nearly twofold increased risk for ovarian failure even with ovarian preservation. 2

Myomectomy

Myomectomy is NOT recommended for this patient because adenomyosis is unlikely to be effectively addressed with this technique. 2

• There is no relevant literature regarding the use of myomectomy alone in the treatment of uterine fibroids in patients with concurrent adenomyosis. 2

Critical Pitfalls and Caveats

Medical Therapy Limitations

• No medical therapy eradicates adenomyosis lesions; all provide only temporary symptom relief with rapid recurrence after discontinuation. 1, 6
• Medical therapies will not treat bulk symptoms associated with fibroids. 2, 1

Preoperative Optimization

• Anemia should be corrected prior to proceeding with elective surgery. 7
• Selective progesterone receptor modulators and GnRH analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. 7

Age-Specific Considerations

• At 48 years old, this patient is approaching menopause, which may result in natural fibroid shrinkage. 4
• However, adenomyosis symptoms may persist or worsen until menopause. 2
• Given symptomatic presentation, expectant management is not appropriate despite perimenopausal status. 4