What is the appropriate assessment and management plan for a reproductive‑age woman with known uterine fibroids presenting to the emergency department with active heavy uterine bleeding and symptomatic anemia?

Emergency Management of Active Uterine Bleeding from Fibroids with Symptomatic Anemia

For a reproductive-age woman presenting to the ED with active heavy bleeding from known fibroids and symptomatic anemia, immediately stabilize with IV fluids, transfuse packed red blood cells to correct symptomatic anemia (target hemoglobin >7 g/dL), initiate high-dose tranexamic acid (1-1.5g IV every 6-8 hours) to control acute bleeding, and consult gynecology emergently for consideration of urgent surgical intervention if bleeding is life-threatening or medical management fails. 1, 2, 3

Immediate ED Assessment and Stabilization

Hemodynamic Status and Severity Assessment

• Assess vital signs for hemodynamic instability (tachycardia, hypotension, orthostatic changes) which indicates severe blood loss requiring aggressive resuscitation. 2
• Obtain immediate hemoglobin/hematocrit to quantify anemia severity—hemoglobin <7 g/dL represents severe anemia requiring transfusion, while levels <2 g/dL constitute life-threatening anemia documented in fibroid cases. 2
• Evaluate for symptoms of severe anemia including altered mental status, dyspnea, chest pain, or syncope, which mandate immediate transfusion regardless of absolute hemoglobin value. 2
• Quantify active bleeding by assessing pad saturation frequency, presence of clots, and duration of current bleeding episode to guide urgency of intervention. 1, 3

Initial Laboratory Workup

• Complete blood count with differential to assess hemoglobin, hematocrit, and platelet count. 2, 3
• Type and crossmatch for potential blood transfusion—order 2-4 units initially based on severity. 2
• Coagulation studies (PT/INR, aPTT) to exclude underlying coagulopathy contributing to bleeding. 1
• Iron studies (ferritin, serum iron, TIBC) to assess for iron deficiency anemia from chronic blood loss. 1, 4
• Beta-hCG to exclude pregnancy-related bleeding in reproductive-age women. 3

Acute Medical Management in the ED

Hemostatic Therapy

• Tranexamic acid 1-1.5g IV every 6-8 hours is the first-line hemostatic agent for acute heavy uterine bleeding, reducing bleeding by inhibiting fibrinolysis. 5, 1, 3
• High-dose oral contraceptives (combined estrogen-progestin pills, one pill every 6-8 hours for 5-7 days, then taper) can be used to stabilize the endometrium and control acute bleeding if tranexamic acid is insufficient. 5, 6
• IV conjugated estrogens (25mg IV every 4-6 hours for up to 24 hours) may be considered for severe refractory bleeding, though evidence is limited specifically for fibroid-related bleeding. 1

Blood Product Replacement

• Transfuse packed red blood cells for hemoglobin <7 g/dL or symptomatic anemia at any level (dyspnea, chest pain, altered mental status, hemodynamic instability). 2
• Target hemoglobin >7-8 g/dL for hemodynamically stable patients; higher targets (>8-9 g/dL) may be appropriate for patients with cardiovascular disease or ongoing bleeding. 2
• IV iron supplementation should be initiated once acute bleeding is controlled to replenish iron stores, particularly if oral iron is not tolerated. 1, 4

Gynecology Consultation and Disposition

Indications for Emergent Gynecology Consultation

• Life-threatening bleeding (hemodynamic instability despite resuscitation, hemoglobin <4 g/dL, altered mental status from anemia) requires immediate gynecology evaluation for urgent surgical intervention. 2
• Failure of medical management after 12-24 hours of tranexamic acid and hormonal therapy necessitates surgical consultation. 1, 2
• Recurrent severe anemia (hemoglobin <7 g/dL) despite prior medical management indicates need for definitive treatment planning. 2

Surgical Options for Acute Control

• Dilation and curettage (D&C) can provide temporary bleeding control and exclude endometrial pathology, though it is less effective for fibroid-related bleeding than other causes of AUB. 1, 3
• Hysteroscopic myomectomy is appropriate for pedunculated submucosal fibroids causing acute bleeding and can be performed urgently if expertise is available. 5, 6
• Emergency hysterectomy is definitive treatment for life-threatening bleeding unresponsive to medical management, particularly in women who have completed childbearing. 7, 5, 6
• Uterine artery embolization (UAE) can be performed emergently for acute bleeding control with 73-98% immediate symptom control, though this requires interventional radiology availability. 7, 5

Hospital Admission Criteria

Mandatory Admission Indications

• Hemoglobin <7 g/dL or symptomatic anemia requiring transfusion. 2
• Active heavy bleeding requiring IV hemostatic therapy or ongoing transfusion. 2
• Hemodynamic instability or orthostatic vital sign changes. 2
• Failed outpatient medical management with recurrent severe anemia. 2

Inpatient Management Plan

• Continue tranexamic acid 1-1.5g IV/PO every 6-8 hours until bleeding controlled. 1, 3
• Initiate or continue high-dose hormonal therapy (combined oral contraceptives or progestin) to suppress endometrium. 5, 6
• Correct anemia with blood transfusion to hemoglobin >7-8 g/dL and initiate iron replacement. 1, 2
• Plan definitive management with gynecology—options include GnRH agonist/antagonist therapy to shrink fibroids and control bleeding, followed by interval myomectomy or hysterectomy based on fertility desires. 7, 5, 6

Definitive Treatment Planning (Post-Stabilization)

For Women Desiring Future Fertility

• GnRH agonists (leuprolide) or antagonists (elagolix, relugolix) for 3-6 months preoperatively to shrink fibroids, correct anemia, and facilitate surgical resection—use with add-back estrogen-progestin therapy to prevent bone loss. 7, 5, 6
• Interval myomectomy (hysteroscopic for submucosal, laparoscopic/open for intramural) after medical optimization is the fertility-sparing surgical option. 5, 6
• UAE may be considered but has controversial fertility outcomes and higher reintervention rates (28% at 5 years, 35% at 10 years). 7, 5

For Women Not Desiring Future Fertility

• Hysterectomy provides definitive cure with 90% patient satisfaction and eliminates recurrence risk—this is the most effective long-term option. 7, 5, 6
• UAE is an alternative for women wishing to preserve the uterus, with 72-73% sustained symptom relief at 5 years and mean fibroid volume reduction of 42-53%. 7, 5
• Medical management with levonorgestrel IUD, combined oral contraceptives, or GnRH agonists/antagonists can bridge perimenopausal women to menopause, avoiding surgery. 7, 5, 6

Critical Pitfalls to Avoid

• Delaying transfusion in symptomatic anemia—case reports document hemoglobin levels as low as 1.1 g/dL from fibroid bleeding, emphasizing the life-threatening potential. 2
• Discharging patients with hemoglobin <7 g/dL or active heavy bleeding without definitive plan—these patients require admission and gynecology consultation. 2
• Failing to exclude pregnancy in reproductive-age women before initiating hormonal therapy or planning surgical intervention. 3
• Underestimating patient's bleeding severity due to chronic adaptation—patients may appear relatively stable despite profound anemia due to gradual onset. 2
• Not addressing iron deficiency after acute stabilization—oral or IV iron replacement is essential to prevent recurrent anemia. 1, 4
• Assuming medical management alone will suffice in patients with prior treatment failures or severe anemia—these patients need definitive surgical planning. 2