What are the initial lab tests and management steps for a female patient with heavy menses and a history of uterine fibroids?

Initial Laboratory Workup for Heavy Menses with Fibroids

Order a complete blood count (CBC) to assess for anemia, which is the most critical initial lab test for patients with heavy menstrual bleeding and fibroids. 1, 2

Essential Laboratory Tests

First-Line Labs

• CBC with differential to evaluate hemoglobin, hematocrit, and mean corpuscular volume (MCV) to identify iron deficiency anemia, which occurs in approximately 30% of symptomatic fibroid patients 1
• Serum ferritin to assess iron stores, as chronic blood loss depletes iron reserves even before anemia develops 1
• Iron studies (serum iron, total iron-binding capacity, transferrin saturation) if anemia is present to confirm iron deficiency 1

Additional Considerations

• Thyroid-stimulating hormone (TSH) to exclude thyroid dysfunction as a contributing cause of heavy bleeding 2
• Pregnancy test (β-hCG) in reproductive-age women to rule out pregnancy-related bleeding 2

Immediate Management Algorithm

Step 1: Address Anemia

• Initiate iron replacement therapy immediately if iron deficiency or iron deficiency anemia is documented, both during medical treatment and before any surgical procedure 1

Step 2: First-Line Medical Management for Bleeding Control

Start with hormonal contraceptives or levonorgestrel-releasing IUD (52-mg) as these provide the strongest evidence for bleeding control. 3, 4

• Combined oral contraceptive pills effectively reduce menstrual blood loss and are recommended as first-line therapy 4
• Levonorgestrel-releasing IUD (52-mg) represents an equally effective first-line option with local hormone delivery and minimal systemic effects 3, 4
• Tranexamic acid as a nonhormonal alternative for patients who cannot tolerate or prefer to avoid hormonal therapy, achieving significant reduction in menstrual blood loss 5, 3, 4
• NSAIDs provide dual benefit for both bleeding reduction and pain control during menstrual periods 5, 4

Step 3: Second-Line Medical Management

If first-line options fail to adequately control symptoms, escalate to GnRH antagonists with combination hormone add-back therapy. 3, 4

• GnRH antagonists (elagolix, linzagolix, relugolix) significantly reduce both bleeding symptoms and fibroid volume with rapid onset 5, 3, 4
• Always prescribe combination hormone add-back therapy (low-dose estrogen plus progestin) when using GnRH antagonists to mitigate hypoestrogenic side effects while maintaining efficacy—this is FDA-approved for fibroid-related heavy menstrual bleeding 5, 3, 4
• Monitor bone mineral density if treatment extends beyond 2 years due to risk of bone loss 4

Critical Pitfalls to Avoid

• Do not use GnRH agonists or antagonists in patients actively trying to conceive, as fertility is suppressed during treatment 4
• Never use long-term GnRH therapy without add-back therapy due to significant bone mineral density loss 3, 4
• Recognize that most medical treatments provide only temporary symptom relief, with recurrence after discontinuation 4
• Do not delay iron replacement therapy while initiating bleeding control measures, as anemia management should occur concurrently 1

When to Escalate Care

If anemia persists despite medical therapy, escalation to interventional or surgical options is necessary. 3

• Hysteroscopic myomectomy for pedunculated submucosal fibroids <5 cm 5
• Uterine artery embolization for properly selected patients who wish to preserve their uterus but have not improved with medical treatment 3
• Hysterectomy for definitive resolution in patients with completed childbearing who have failed medical management 5, 3