In a 32-year-old woman with menorrhagia caused by a 3 cm × 3 cm subserosal uterine fibroid, what is the most appropriate management: myomectomy, hysterectomy, uterine artery embolization, or reassurance?

Management of Menorrhagia in a 32-Year-Old Woman with a 3 cm Subserosal Fibroid

The most appropriate management is reassurance and medical therapy for the menorrhagia, because subserosal fibroids do not cause menorrhagia and are not the source of her bleeding symptoms. 1, 2

Why Subserosal Fibroids Do Not Cause Menorrhagia

• Subserosal fibroids project outward from the uterine surface and are associated with minimal to no menstrual bleeding symptoms, making them an unlikely cause of menorrhagia. 1
• The American College of Radiology explicitly states that the location and type of fibroid determines whether it causes bleeding—submucosal fibroids distort the endometrial cavity and cause menorrhagia, while subserosal fibroids do not. 2
• In this 32-year-old woman, the subserosal fibroid is an incidental finding and the menorrhagia requires a separate diagnostic workup to identify the true cause. 1

First-Line Medical Management for Menorrhagia

Since the subserosal fibroid is not causing the bleeding, medical therapy should be initiated:

• The levonorgestrel intrauterine device (LNG-IUD) is recommended as first-line treatment for menorrhagia, demonstrating high effectiveness for reducing heavy menstrual bleeding and improving quality of life. 2, 3
• Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy to reduce menstrual blood loss by inhibiting prostaglandin synthesis. 1, 2
• Tranexamic acid is an effective non-hormonal antifibrinolytic agent for decreasing menstrual blood loss when NSAIDs alone are insufficient. 1, 2
• Combined oral contraceptives can effectively manage abnormal uterine bleeding in this context. 1, 2

Why Surgical Options Are Inappropriate

Myomectomy (Option A) - Not Indicated

• Myomectomy is indicated only for symptomatic fibroids causing bulk-related complaints (pelvic pressure, pain, urinary or bowel dysfunction) or impairing reproductive function—not for asymptomatic subserosal fibroids. 1
• The American College of Radiology states that myomectomy is not indicated for subserosal fibroids that do not cause menorrhagia and should be reserved for symptomatic fibroids causing bulk symptoms or submucosal fibroids causing bleeding. 2
• At 3 cm, this fibroid is below the threshold where bulk symptoms typically occur. 4

Hysterectomy (Option B) - Contraindicated

• The American College of Radiology states that performing hysterectomy as first-line treatment for a benign, asymptomatic subserosal fibroid in a young woman is inappropriate. 1
• Hysterectomy leads to permanent loss of fertility and is contraindicated in women of reproductive age (32 years old) who may desire future childbearing. 1
• Hysterectomy should be avoided unless all less-invasive therapies have failed, because it results in permanent infertility and carries significant long-term health risks including elevated cardiovascular disease, bone fracture, and dementia. 1
• Hysterectomy is reserved for women who have exhausted all conservative therapies and have completed childbearing. 1, 2

Uterine Artery Embolization (Option C) - Not Indicated

• The American College of Radiology advises that UAE is inappropriate for subserosal fibroids that are not responsible for the patient's bleeding symptoms. 1, 2
• UAE is linked to higher rates of miscarriage (35%), cesarean delivery (66%), and postpartum hemorrhage (~13.9%), and therefore should not be offered to women desiring future pregnancy. 1, 5
• UAE has a 20-25% symptom recurrence rate at 5-7 years, with higher failure rates in patients <40 years of age. 6, 5, 2

Essential Diagnostic Workup

Before treating the menorrhagia, the following evaluations are necessary:

• Endometrial biopsy is recommended to rule out malignancy when risk factors or clinical findings suggest it may be present. 1
• Magnetic resonance imaging (MRI) should be considered when ultrasound findings are inconclusive or when adenomyosis is suspected as the true cause of menorrhagia. 1
• A full gynecologic workup including Pap smear should be performed to exclude other pelvic pathology. 6

Critical Clinical Pitfall to Avoid

• Do not assume that an incidentally discovered subserosal fibroid is the cause of menorrhagia; the bleeding should be addressed with medical therapy first. 1
• Do not proceed to surgery for an asymptomatic fibroid without first attempting guideline-recommended medical management. 1
• The 2024 American College of Radiology guidelines advise that medical therapy should be trialed before any invasive procedure is considered. 1