A 33-year-old nulligravid woman comes to the office for evaluation of heavy menstrual bleeding. The patient has menses every 28 days with 7-8 days of heavy bleeding. She also has associated cramping, bloating, and pelvic fullness. The patient has episodic migraines with aura and takes preventive therapy. Family history is negative for ovarian, breast, and endometrial cancer. The patient recently started taking prenatal vitamins because she is getting married and planning on pregnancy in the next few months. BMI is 24 kg/m². Vital signs are normal. On pelvic examination, the uterus is enlarged with an irregular contour. Transvaginal ultrasound shows multiple intramural uterine fibroids and a homogeneous endometrial stripe. Hemoglobin is 10 g/dL. Which of the following is the best next step in management for this patient?

Question

A 33-year-old nulligravid woman comes to the office for evaluation of heavy menstrual bleeding.  The patient has menses every 28 days with 7-8 days of heavy bleeding.  She also has associated cramping, bloating, and pelvic fullness.  The patient has episodic migraines with aura and takes preventive therapy.  Family history is negative for ovarian, breast, and endometrial cancer.  The patient recently started taking prenatal vitamins because she is getting married and planning on pregnancy in the next few months.  BMI is 24 kg/m².  Vital signs are normal.  On pelvic examination, the uterus is enlarged with an irregular contour.  Transvaginal ultrasound shows multiple intramural uterine fibroids and a homogeneous endometrial stripe.  Hemoglobin is 10 g/dL.  Which of the following is the best next step in management for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9f0_3e59_bc81_dbbe82b1bbf4_MD0003_00 This patient has uterine leiomyomata (ie, fibroids), benign tumors of the uterine myometrium. Women with symptomatic fibroids have prolonged, heavy menstrual bleeding (eg, 7-8 days every month, anemia). The volume and duration of menses are dependent upon the following factors: Surface area of the endometrial cavity (ie, increased endometrial glands) Platelet aggregation and thrombi formation (ie, clotting and tamponade of the denuded spiral arterioles) Uterine spiral arteriole constriction (ie, menstrual cessation) in response to vasoconstrictive factors Uterine fibroids cause heavy menstrual bleeding by enlarging the uterus (increasing the surface area of the endometrial cavity) and decreasing responsiveness to vasoactive factors (limiting spiral arteriole vasoconstriction). Treatment of heavy menstrual bleeding is aimed at improving the factors involved in the bleeding. Tranexamic acid (TXA) is used in heavy menstrual bleeding because it can reduce blood loss during menses by up to 50%. TXA stabilizes thrombi/clots by preventing plasmin formation, which is responsible for degrading fibrin and dissolving blood clots. This allows time for vasoconstriction of the spiral arterioles. Additionally, it is safe to take while attempting pregnancy. (Choice A) An endometrial ablation cauterizes the endometrial lining to decrease menstrual bleeding; however, it is contraindicated in people desiring future fertility due to the increased risk of future obstetric complications (eg, spontaneous abortion). (Choice B) An endometrial biopsy (EMB) is performed in patients with abnormal bleeding who are at risk for malignancy (eg, postmenopausal bleeding, abnormal bleeding, obesity). This patient has regular ovulatory menses and a normal BMI; therefore, an EMB is not indicated. endometrial biopsy (EMB) (Choice C) Estrogen/progestin oral contraceptives (OCPs) are often used for fibroid-induced heavy bleeding. This patient's migraine with aura is a contraindication to OCPs due to the increased risk of stroke. Educational objective: Treatment of symptomatic uterine fibroids depends on both the patient's age and desire for fertility. Tranexamic acid is used to treat heavy menstrual bleeding by preventing the formation of plasmin and stabilizing thrombi within the endometrium to regulate blood loss.

A 33-Year-Old Nulligravid Woman Comes to the Office for Evaluation