What is the most appropriate management for a 32-year-old single woman with menorrhagia caused by a 4 × 4 cm subserosal uterine fibroid?

Management of a 32-Year-Old Woman with Menorrhagia and a 4 cm Subserosal Fibroid

The most appropriate management is nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic control, as subserosal fibroids do not cause menorrhagia and surgical intervention is not indicated for this fibroid location. 1, 2

Critical Clinical Reasoning: The Fibroid is NOT the Cause

The 4 cm subserosal fibroid identified on ultrasound is almost certainly NOT causing her menorrhagia. This is the most important clinical insight that changes the entire management approach:

• Subserosal fibroids project outward from the uterus and typically cause minimal to no bleeding symptoms 3
• Subserosal fibroids do not appear to have any impact on fertility or menstrual bleeding 2
• Removal of subserosal fibroids is not recommended 2

The menorrhagia in this patient requires investigation for other causes (adenomyosis, endometrial pathology, coagulation disorders, etc.), but the subserosal fibroid itself does not require treatment.

First-Line Management: Medical Therapy

Since the subserosal fibroid is not causing symptoms, medical management of the menorrhagia is appropriate:

NSAIDs (Answer D - Correct)

• NSAIDs are recommended as first-line therapy for pain control and bleeding reduction in women with fibroids 1
• NSAIDs are effective symptomatic agents for UF-related abnormal uterine bleeding 4
• This addresses the menorrhagia without unnecessary surgical intervention 5

Additional Medical Options to Consider

• Tranexamic acid is an effective nonhormonal alternative for reducing menstrual blood loss 1, 4
• Levonorgestrel intrauterine device (IUD) provides long-term bleeding control 1, 5
• Combined oral contraceptives can manage bleeding symptoms 1, 4

Why Surgical Options Are Inappropriate

Myomectomy (Answer A - Incorrect)

• There is fair evidence to recommend AGAINST myomectomy for subserosal fibroids 2
• Myomectomy carries surgical risks (adhesions, uterine rupture in future pregnancy, bleeding) without benefit when the fibroid is not causing symptoms 2
• In a 32-year-old woman who may desire future fertility, unnecessary myomectomy introduces risks of adhesion formation that could impair fertility 2

Hysterectomy (Answer B - Incorrect)

• Hysterectomy should be avoided unless less invasive options fail 1
• This causes permanent infertility in a 32-year-old single woman 3
• Hysterectomy is associated with significant long-term complications including increased cardiovascular disease, bone fracture risk, and dementia 1
• This is grossly inappropriate as first-line management in a young woman with a benign, asymptomatic subserosal fibroid 6

Uterine Artery Embolization (Answer C - Incorrect)

• Women seeking future pregnancy should not generally be offered UAE as a treatment option 2
• UAE is associated with increased miscarriage rates, cesarean sections, and postpartum hemorrhage 3
• UAE is associated with loss of ovarian reserve, especially problematic in a 32-year-old woman 2
• UAE would be inappropriate for a subserosal fibroid that is not causing the bleeding symptoms 6

Essential Diagnostic Workup

Before attributing menorrhagia to any cause, complete evaluation is mandatory:

• Rule out malignancy with endometrial biopsy if indicated by risk factors or examination findings 3
• Evaluate for other causes of menorrhagia: adenomyosis, endometrial polyps, coagulation disorders, thyroid dysfunction 4
• Consider MRI if ultrasound findings are unclear or if adenomyosis is suspected 6

Common Pitfall to Avoid

The critical error would be performing surgery (myomectomy, UAE, or hysterectomy) on a subserosal fibroid that is not causing the patient's symptoms. 2 The menorrhagia requires separate investigation and management, but the subserosal fibroid should be observed without intervention. 1, 2