Fibroid-Associated Heavy Menstrual Bleeding

Fibroid associated heavy menstrual bleeding is menstrual blood loss above 80 mL per cycle, or a loss that interferes with life, caused mainly by submucosal and large intramural fibroids.

• Fibroids increase endometrial surface area, alter blood vessels and reduce uterine contractility.
• It is a common cause of iron deficiency anaemia in reproductive-age women with fibroids.
• Medical therapy is tried first.

Soaking a pad every 1 to 2 hours, clots larger than 2 cm, flooding, bleeding longer than 7 days, fatigue, pallor, breathlessness and dizziness.

• Enlarged irregular uterus; pale conjunctivae.
• Differential diagnosis: adenomyosis, endometrial polyp, endometrial hyperplasia, endometrial cancer, coagulopathy, ovulatory dysfunction, thyroid disease, hormonal contraceptive effect.
• Complications: iron deficiency anaemia, fatigue, social disruption, hysterectomy, infertility.

Diagnosis is by menstrual history, blood tests and ultrasound, with hysteroscopy for cavity distortion.

• Menstrual history and pictorial blood loss chart.
• Full blood count, ferritin, thyroid function, pregnancy test, and clotting screen in adolescents or when bleeding began at menarche.
• Transvaginal ultrasound; saline infusion sonography or hysteroscopy to show cavity distortion.
• Endometrial sampling for women aged 45 or over, or with risk factors for hyperplasia.
• Pelvic MRI for planning surgery.

Try medical treatment first, correct anaemia, and offer surgery when drugs fail or fertility is complete.

• Supportive: menstrual diary; iron-rich diet; counselling on options and fertility plans.
• Pharmacological: tranexamic acid 1 g oral 8-hourly for up to 4 days during heavy bleeding (maximum 4 g in 24 hours; reduce the dose in renal impairment; avoid in thromboembolism). Mefenamic acid 500 mg oral 8-hourly with food during menses (maximum 3 days). Levonorgestrel 52 mg intrauterine system if the cavity is not distorted. Combined oral contraceptive with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms daily. Norethisterone 5 mg oral 8-hourly from day 5 to day 26. Leuprorelin 3.75 mg IM every 4 weeks for up to 3 months before surgery. Ferrous sulphate 200 mg oral 8-hourly, continued for 3 months after haemoglobin normalises; iron sucrose 200 mg IV per dose for severe anaemia. Transfuse when haemoglobin is below 7 g/dL or there is shock.
• Procedures: hysteroscopic resection of submucosal fibroids; myomectomy; uterine artery embolisation; hysterectomy when fertility is complete. Endometrial ablation only if the cavity is normal.
• Special groups: avoid oestrogen-containing pills in women with migraine with aura, smoking above age 35, hypertension or venous thromboembolism. In renal impairment, reduce tranexamic acid to 15 mg/kg (usually 1 g) oral 12-hourly when creatinine is 120 to 249 micromol/L.
• Red flags: haemoglobin below 7 g/dL, bleeding with dizziness or fainting, postmenopausal bleeding, rapid growth.
• Follow-up: review at 3 months with haemoglobin and ferritin; reassess after 6 months of treatment.