In a 32-year-old nulliparous woman with menorrhagia due to a 4 × 4 cm subserosal uterine fibroid, what is the most appropriate management?

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

The most appropriate management is non-steroidal anti-inflammatory drugs (NSAIDs), as subserosal fibroids do not cause menorrhagia and the bleeding must be addressed with medical therapy while avoiding unnecessary invasive procedures for an asymptomatic fibroid. 1

Understanding the Clinical Disconnect

Subserosal fibroids are not the cause of menorrhagia. This is the critical insight that guides management:

• Subserosal fibroids project outward from the uterine surface and are associated with minimal to no menstrual bleeding symptoms 1
• The menorrhagia in this patient must have another etiology (dysfunctional uterine bleeding, adenomyosis, endometrial pathology, coagulopathy) 1
• Performing invasive procedures targeting the fibroid would be treating the wrong problem 1

Why Each Invasive Option Is Inappropriate

Myomectomy (Option A) - Not Indicated

• Myomectomy is reserved for symptomatic fibroids causing bulk symptoms (pressure, pain, bladder/bowel dysfunction) or reproductive dysfunction 2
• This 4 × 4 cm subserosal fibroid is asymptomatic and not causing the menorrhagia 1
• Subjecting a young nulliparous woman to surgery with risks of adhesion formation, uterine rupture in future pregnancy, and need for reintervention would be inappropriate 2, 3

Hysterectomy (Option B) - Completely Inappropriate

• The American College of Radiology explicitly states that hysterectomy as first-line treatment for a benign, asymptomatic subserosal fibroid in a young woman is inappropriate 1
• Hysterectomy causes permanent infertility and carries significant long-term health risks including elevated cardiovascular disease, bone fracture, and dementia 1
• This is reserved for postmenopausal patients or those who have failed all conservative therapies and completed childbearing 2

Uterine Artery Embolization (Option C) - Contraindicated

• UAE is inappropriate for subserosal fibroids that are not responsible for bleeding symptoms 1
• UAE is linked to higher rates of miscarriage, cesarean delivery, and postpartum hemorrhage, and should not be offered to women desiring future pregnancy 1
• This nulliparous 32-year-old woman must preserve her fertility options 1

The Correct Approach: Medical Management with NSAIDs

First-line medical therapy should be initiated to address the menorrhagia:

• NSAIDs are recommended as first-line therapy for reducing menstrual blood loss in women with uterine fibroids 2, 1
• Medical management should be trialed prior to pursuing invasive therapies according to 2024 ACR guidelines 2
• NSAIDs work by reducing prostaglandin synthesis, thereby decreasing menstrual flow 2

Additional Medical Options to Consider

If NSAIDs alone are insufficient:

• Tranexamic acid is an effective non-hormonal alternative for decreasing menstrual blood loss 2, 1
• Levonorgestrel-releasing IUD provides long-term control of abnormal uterine bleeding 1
• Combined oral contraceptives can manage bleeding symptoms effectively 2, 1

Essential Diagnostic Work-Up

Before finalizing treatment, ensure appropriate evaluation:

• Endometrial biopsy is recommended to rule out malignancy, especially given persistent menorrhagia 1
• MRI should be considered if ultrasound findings are inconclusive or adenomyosis is suspected as the true cause of bleeding 1
• Rule out coagulopathy and thyroid dysfunction as alternative causes of menorrhagia

Critical Pitfalls to Avoid

• Do not assume the fibroid is causing the menorrhagia simply because it is present on imaging 1
• Do not perform surgery on asymptomatic fibroids discovered incidentally 4, 5
• Do not compromise future fertility with inappropriate invasive procedures in a young nulliparous woman 1
• Do not skip medical management as the ACR guidelines emphasize medical therapy should be trialed first 2