A 32-year-old woman comes to the office due to heavy vaginal bleeding. For the past 6 months, the patient has had regular menses every 30 days, with 7 days of painful cramping, heavy vaginal bleeding, and passage of large clots. She uses both a tampon and a sanitary napkin simultaneously to prevent blood from staining her underwear and soaking through her clothes. The patient has had no intermenstrual bleeding or abnormal vaginal discharge. Her last menstrual period ended a week ago. Her menses previously consisted of 5 days of mild cramping with moderate bleeding. Past medical history is significant for recurrent migraines with aura, for which she takes daily prophylaxis. The patient is sexually active and uses condoms and spermicide for contraception. She would like to attempt to conceive in the next few years. Blood pressure is 100/70 mm Hg and pulse is 84/min. BMI is 23 kg/m². Pelvic examination reveals a 14-week-sized, irregularly shaped uterus with no cervical motion tenderness or adnexal masses. Hemoglobin is 9.8 g/dL. A urine pregnancy test is negative. Pelvic ultrasound shows a large uterus with several intramural leiomyomas and a normal endometrial stripe. The patient asks what can be done to treat her condition. Which of the following is the most appropriate management at this time?

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Explanation: 11ec2b69_bf17_04cd_8f63_9d1f28193caf_MD0005_00 Leiomyomas (fibroids) are benign, smooth muscle tumors of the uterus that can present with heavy, regular vaginal bleeding; painful menses; and an enlarged, irregularly shaped uterus. Depending on their size and location, symptomatic leiomyomas can also cause pelvic pressure, urinary symptoms, and constipation. leiomyomas Treatment is tailored to the patient's symptoms and desire for future fertility, as well as the size, number, and location of the leiomyomas. The initial treatment of symptomatic leiomyomas is typically with medical management. Options include combined estrogen/progestin contraceptives (eg, pill, patch, vaginal ring), progestin-only contraceptives (eg, progestin-only pills, progestin-releasing intrauterine device [IUD]), and GnRH agonists. The progestin-releasing IUD decreases uterine bleeding by inducing endometrial atrophy and reducing leiomyoma size. An IUD may be less efficacious in patients with intracavitary and submucosal leiomyomas due to distortion of the endometrial cavity. However, this patient's ultrasound shows a normal endometrial stripe and an intramural leiomyoma. When this patient is ready to conceive, the IUD can be removed with no long-term effects on fertility. submucosal leiomyomas (Choice A) Combined estrogen/progestin contraceptives are effective in decreasing menstrual bleeding. However, because of an increased risk for ischemic stroke, they are contraindicated in patients who have migraines with aura. (Choices B and E) Surgical management of fibroids via hysterectomy or uterine artery embolization is indicated for patients who have leiomyomas unresponsive to medical management and who do not desire future fertility. Pregnancy after uterine artery embolization is not recommended because it is associated with an increased risk for spontaneous abortion, cesarean delivery, and postpartum hemorrhage. (Choice C) In patients with symptomatic leiomyomas, GnRH agonists temporarily induce amenorrhea and shrink leiomyoma size. However, their usefulness is limited due to decreased bone mineral density with prolonged use and symptom recurrence after treatment completion. Therefore, GnRH agonists are used primarily for preoperative management. Educational objective: First-line management for patients with symptomatic leiomyomas who wish to preserve fertility includes combined estrogen/progestin contraceptives and progestin-releasing intrauterine devices. Migraine with aura is a contraindication to estrogen-containing contraceptives. References: The role of levonorgestrel intrauterine systems in the treatment of symptomatic fibroids. (http://www.ncbi.nlm.nih.gov/pubmed/29483855)

A 32-Year-Old Woman Comes to the Office Due to Heavy