What is the most appropriate management for a 32‑year‑old woman with menorrhagia caused by a 3 × 3 cm subserosal uterine fibroid?

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

The correct answer is D) Reassure and initiate medical management with NSAIDs or tranexamic acid, because subserosal fibroids do not cause menorrhagia and the bleeding requires medical therapy, not surgery. 1

Why Subserosal Fibroids Are Not the Culprit

• Subserosal fibroids project outward from the uterine surface and are associated with minimal to no menstrual bleeding symptoms, making them an unlikely cause of this patient's menorrhagia. 1
• These fibroids produce bulk-related symptoms (pelvic pressure, urinary frequency) but do not impair fertility or cause abnormal uterine bleeding. 2
• The menorrhagia in this case requires a separate diagnostic workup—the fibroid is an incidental finding. 1

First-Line Medical Management for Menorrhagia

Since the subserosal fibroid is not causing the bleeding, treat the menorrhagia medically:

• NSAIDs are the first-line option for reducing menstrual blood loss by inhibiting prostaglandin synthesis. 1, 3
• Tranexamic acid is an effective non-hormonal alternative if NSAIDs are insufficient or contraindicated. 1, 2
• Levonorgestrel-releasing IUD provides long-term control of abnormal uterine bleeding. 1, 4
• Combined oral contraceptives can manage bleeding symptoms effectively. 1, 2

Why Surgery Is Inappropriate

A) Myomectomy is NOT indicated:

• Myomectomy is reserved only for symptomatic fibroids causing bulk-related complaints (pelvic pressure, urinary/bowel dysfunction) or reproductive impairment—not for asymptomatic subserosal fibroids. 1
• The American College of Radiology explicitly states that myomectomy should not be performed for asymptomatic subserosal fibroids. 1
• Myomectomy carries operative risks including uterine perforation, transfusion requirements, and potential adverse pregnancy outcomes. 2

B) Hysterectomy is contraindicated:

• Hysterectomy results in permanent infertility and is contraindicated in a 32-year-old woman of reproductive age who may desire future childbearing. 1, 2
• The American College of Radiology advises that performing hysterectomy as first-line treatment for a benign, asymptomatic subserosal fibroid in a young woman is inappropriate. 1
• Hysterectomy carries significant long-term health risks including elevated cardiovascular disease, bone fracture, and dementia. 1, 3

C) Uterine Artery Embolization is NOT indicated:

• UAE is inappropriate for subserosal fibroids that are not responsible for bleeding symptoms. 1, 2
• UAE is associated with higher rates of miscarriage (35%), cesarean delivery (66%), and postpartum hemorrhage (~13.9%), making it unsuitable for women desiring future pregnancy. 1
• In women younger than 40 years, UAE has a 20–25% symptom recurrence rate at 5–7 years and a 23% treatment failure rate at 10 years. 1, 2

Essential Diagnostic Workup

Before treating the menorrhagia, complete the following:

• Endometrial biopsy to rule out malignancy when risk factors or clinical findings suggest it may be present. 1
• Complete gynecologic assessment including Pap smear to exclude other pelvic pathology. 1
• MRI should be considered if ultrasound findings are inconclusive or adenomyosis is suspected. 1

Critical Clinical Pitfall

Do not assume that an incidentally discovered subserosal fibroid is the cause of menorrhagia—the bleeding should be addressed with medical therapy first, and the fibroid requires no intervention unless it becomes symptomatic with bulk effects. 1