38 yrs complaining of heavy menstrual bleeding since 3 months Scan shown fibroids What to do next
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"uterine fibroids" AND "heavy menstrual bleeding" AND management
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Management of a 38-Year-Old with Heavy Menstrual Bleeding and Uterine Fibroids
Step 1 - Complete Initial Assessment
Before deciding on treatment, you need a fuller clinical picture:
History to gather:
- Duration, severity, and pattern of bleeding (number of pads/day, clots, flooding)
- Pelvic pain, pressure, urinary symptoms, or dyspareunia
- Desire for future fertility (this is the single most important decision driver)
- LMP, cycle regularity, contraceptive use
- Past medical/surgical history, medications
Examination:
- Bimanual pelvic exam - uterine size, consistency, mobility, tenderness
- Speculum exam - exclude cervical pathology
Step 2 - Investigations
| Investigation | Purpose |
|---|---|
| Full blood count (FBC) | Assess for iron-deficiency anaemia |
| Serum ferritin + iron studies | Quantify iron stores |
| Thyroid function (TSH) | Exclude thyroid cause of HMB |
| Coagulation screen | Especially if HMB since menarche |
| Endometrial biopsy / pipelle | Rule out endometrial hyperplasia or carcinoma (age 38, HMB) |
| Pelvic USS (already done) | Note fibroid number, size, location (FIGO classification) |
| Saline infusion sonography (SIS) or MRI | Better characterise submucosal vs intramural vs subserosal fibroids if surgery is planned |
| Serum beta-hCG | Rule out pregnancy |
Endometrial sampling is important in a 38-year-old with HMB - do not skip it.
Step 3 - Management Decision Framework
The management depends heavily on fibroid location/size, fertility wishes, severity of anaemia, and patient preference.
A. Treat Anaemia First (if present)
- Oral or IV iron supplementation
- If severe anaemia with haemodynamic compromise: consider blood transfusion
B. Medical Management (first-line for most patients)
1. Tranexamic Acid (antifibrinolytic)
- 1.3 g three times daily for 3-5 days during menstruation
- Reduces menstrual blood loss significantly vs placebo in fibroid-related HMB
- Good short-term option; does not affect fibroid size
- (Berek & Novak's Gynecology)
2. LNG-IUS (Mirena/Levonorgestrel IUD)
- Significantly reduces menstrual blood loss and raises Hb/ferritin
- Does NOT shrink fibroids
- Expulsion risk is higher with fibroids >3 cm (15.4%) vs <3 cm (6.3%)
- Suitable if uterine cavity not significantly distorted
- (Berek & Novak's Gynecology)
3. GnRH Agonists (e.g., leuprolide, triptorelin)
- Reduces fibroid volume by ~30% and uterine volume by ~35% within 3 months
- 97% of women achieve amenorrhoea by 6 months
- Limited to 3-6 months due to hypoestrogenic side effects (hot flushes, bone loss)
- Used as a bridge to surgery to shrink fibroids and correct anaemia pre-operatively
- (Berek & Novak's Gynecology)
4. GnRH Antagonists + Add-back therapy (newer agents)
- Elagolix (300 mg BD) or Relugolix (40 mg OD) combined with estradiol 1 mg + norethindrone acetate 0.5 mg daily
- Reduces HMB while preserving bone density
- Oral, once-daily dosing - better tolerated than GnRH agonists
- (Goldman-Cecil Medicine; FIGO Best Practice Guidance 2025 - PMID 40927887)
5. Ulipristal Acetate (selective progesterone receptor modulator)
- 5 mg daily x 13 weeks; can be repeated for up to 4 treatment courses
- ~80% achieve >25% fibroid volume reduction by 4th course
- Note: use with caution due to hepatotoxicity concerns (regulatory restrictions vary by country)
6. NSAIDs (e.g., mefenamic acid, naproxen)
- Useful for pain/dysmenorrhoea
- NOT effective for fibroid-related HMB specifically (unlike idiopathic HMB)
- (Berek & Novak's Gynecology)
C. Surgical Management
When to consider surgery:
- Failed or contraindicated medical therapy
- Severe anaemia not responding to medical treatment
- Ureteric obstruction / significant mass symptoms
- Fertility impairment (submucosal fibroid distorting cavity)
- Patient preference
| Procedure | Indication | Notes |
|---|---|---|
| Hysteroscopic myomectomy | Submucosal fibroids (FIGO type 0, 1, 2) | Preserves fertility; best for cavity-distorting fibroids |
| Laparoscopic myomectomy | Intramural/subserosal, <10 cm, <3-4 fibroids | Minimally invasive; fertility preserving |
| Open (abdominal) myomectomy | Large/multiple fibroids | Fertility preserving; higher morbidity |
| Endometrial ablation | HMB without desire for fertility; smaller fibroids | Not suitable if large uterus; not for fertility |
| UAE (Uterine Artery Embolisation) | Symptomatic fibroids, no fertility desire | Less invasive; myomectomy has better outcomes |
| Laparoscopic radiofrequency ablation | Selected intramural fibroids | Newer technique |
| Hysterectomy | Definitive; completed family; failed other Rx | Open, vaginal, or laparoscopic |
Myomectomy outcomes are superior to UAE for symptom relief and particularly if fertility is desired. Power morcellation is now avoided due to risk of spreading occult uterine malignancy.
Step 4 - Key Decision Point: Fertility
| Scenario | Preferred Approach |
|---|---|
| Wants future pregnancy | Myomectomy (hysteroscopic if submucosal; laparoscopic/open if intramural) |
| No fertility desire, wants uterus | Medical (LNG-IUS, GnRH agonist/antagonist), UAE, endometrial ablation |
| No fertility desire, completed family | Hysterectomy (definitive), or less invasive options if preferred |
Summary Algorithm
38F with HMB + Fibroids
↓
1. Assess Hb → treat anaemia
2. Endometrial biopsy → exclude hyperplasia/malignancy
3. Characterise fibroids (size, FIGO type, location)
4. Establish fertility wishes
↓
Fertility desired?
YES → Myomectomy (type depends on fibroid location)
GnRH agonist pre-op if large/anaemic
NO → Medical first (LNG-IUS or GnRH antagonist + add-back)
Surgical if failed: UAE, ablation, or hysterectomy
Recent Evidence: A 2025 FIGO Best Practice Guideline (PMID 40927887) and a 2025 Cochrane review on preoperative medical therapy (PMID 40183418) both confirm GnRH analogues as effective pre-operative agents to reduce fibroid bulk and correct anaemia before surgery.
Sources: Berek & Novak's Gynecology; Goldman-Cecil Medicine; FIGO Best Practice Guidance 2025
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