What is the recommended management for abnormal uterine bleeding secondary to uterine leiomyoma?

Management of Abnormal Uterine Bleeding Secondary to Leiomyoma

For abnormal uterine bleeding caused by leiomyomas, start with the levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line therapy, which reduces menstrual blood loss by 71-95% with efficacy comparable to surgical options. 1

Initial Medical Management Algorithm

First-Line Therapy

• The LNG-IUD is the most effective medical treatment and should be strongly considered before any surgical intervention, achieving menstrual blood loss reduction of 71-95% 2, 1
• The LNG-IUD works through local endometrial suppression with minimal systemic absorption, making it particularly suitable for patients with cardiovascular contraindications to systemic hormones 1
• Efficacy is equivalent to endometrial ablation, providing a reversible alternative to surgery 1

Alternative Medical Options

• Combined oral contraceptives effectively reduce bleeding symptoms, particularly in younger women with small fibroids who also desire contraception 2, 3
• Tranexamic acid (non-hormonal) reduces menstrual blood loss by 20-60% and serves as an effective alternative when hormonal therapy is contraindicated 1, 3
• Oral progestins administered for 21 days per month reduce menstrual blood loss by approximately 87% in women with heavy cyclic bleeding 1
• NSAIDs can be combined with hormonal contraceptives to further reduce bleeding volume 1

Temporary Pre-Surgical Medical Therapy

• GnRH agonists or antagonists (elagolix, linzagolix, relugolix) effectively reduce both bleeding symptoms and fibroid volume but should only be used temporarily due to bone loss with chronic use 2, 3
• These agents are best utilized to reduce uterine and myoma size before planned surgical therapy, as symptoms rapidly recur after discontinuation 2, 3
• Chronic GnRH agonist use causes trabecular bone loss, limiting long-term application 2

Surgical Management When Medical Therapy Fails

Uterus-Preserving Options

Myomectomy (for fertility preservation):

• Indicated when uterine conservation is desired, with clinical success rates similar to UAE 2
• Recurrence rates range from 23-33% regardless of surgical approach (abdominal or laparoscopic) 2
• Laparoscopic myomectomy carries 2% major and 9% minor complication rates 2
• Avoid morcellation due to risk of spreading occult malignancy and worsening disease-free survival 2

Uterine Artery Embolization (UAE):

• Achieves 94% short-term and 85% long-term symptom improvement 3
• Offers shorter hospital stays, decreased blood loss, and fewer adverse events compared to myomectomy 2
• Critical caveat: UAE has higher reintervention rates (36%) compared to myomectomy (5%), particularly with fibroids >5 cm 2
• Approximately 7% require subsequent hysterectomy for persistent symptoms 3

Endometrial ablation:

• Efficacy comparable to LNG-IUD for bleeding control 1
• Never perform in women desiring future fertility due to high risk of pregnancy complications 1
• Long-term complications include postablation Asherman syndrome, synechiae, cervical stenosis, and potential delayed endometrial cancer diagnosis 1

Definitive Surgical Management

Hysterectomy:

• Hysterectomy is the most appropriate definitive treatment when medical management fails or is contraindicated, providing complete resolution of fibroid-related symptoms with no recurrence risk 3, 4
• Accounts for three-quarters of fibroid treatment in the United States 3
• Studies demonstrate significantly better health-related quality-of-life advantage compared to other therapies 3
• Choose the least invasive surgical route (vaginal > laparoscopic/robotic > abdominal) based on uterine size and surgical expertise 3, 4
• Meta-analysis comparing UAE versus hysterectomy shows similar long-term quality-of-life but UAE requires more reinterventions 2

Special Population Considerations

Cardiovascular Disease Patients

• In patients with cardiovascular disease or post-SCAD, avoid NSAIDs and tranexamic acid due to MI and thrombosis risk 1, 3
• The LNG-IUD becomes the strongly preferred option due to minimal systemic absorption 1, 3
• Systemic hormonal therapy is relatively contraindicated and requires careful clinical judgment 1

Patients on Anticoagulation

• Women on NOACs (particularly rivaroxaban) have 27% risk of abnormal uterine bleeding versus 8.3% with warfarin 3
• Reassess indication for ongoing antiplatelet therapy and discontinue if appropriate before initiating treatment 1
• Progestin-eluting IUDs are preferred due to minimal systemic absorption 1

Perimenopausal Women

• Can be managed expectantly or with GnRH agonists until menopause if symptoms are tolerable 5
• Hysterectomy remains most effective for postmenopausal women with symptomatic fibroids and heavy bleeding 3

Common Pitfalls to Avoid

• Do not rely on endometrial biopsy alone to rule out focal lesions—it has variable sensitivity; use saline infusion sonohysterography or hysteroscopy for intracavitary pathology assessment 1
• When prescribing progestogen therapy, assess need for non-hormonal contraception as ovulation may still occur in up to 20% of patients 1
• If bleeding persists despite initial medical therapy, perform further investigation with imaging or hysteroscopy to diagnose focal lesions potentially missed by sampling 1
• Remember that adenomyosis frequently coexists with fibroids (common in women in their 40s) and presents with heavy bleeding, dysmenorrhea, and dyspareunia 1, 4
• Tranexamic acid use in fibroid patients may cause fibroid necrosis with adverse effects including pelvic pain and fever 2