A 34-year-old woman comes to the office to discuss the results of a recent CT scan. The patient was in a motor vehicle collision last week and underwent a CT scan of the abdomen and pelvis for possible intraabdominal trauma. The CT scan showed a markedly enlarged uterus with multiple intramural and pedunculated leiomyomata that did not compress the ureters or surrounding bowel. The patient has a monthly menstrual period with 4 days of light bleeding. She typically has abdominal cramping on the first day of her menstrual period, but usually does not require pain medication. The patient has no urinary frequency, urgency, chronic pelvic pain, or changes in bowel habits. She has no chronic medical conditions and takes no daily medications. The patient is in a monogamous, same-sex relationship and has no pain with intercourse. Vital signs are normal, and BMI is 23 kg/m². An irregularly enlarged mass is palpated in the lower abdomen, consistent with uterine leiomyomata. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d268_e806_bc81_c1008f002dee_MD0003_00 This patient has uterine leiomyomata (ie, fibroids), benign smooth muscle (myometrial) tumors that are relatively common (up to 25%) in adult women. These tumors can increase the surface area of the endometrium and the overall size and bulk of the uterus as well as compress surrounding structures; however, some patients have no symptoms and are diagnosed incidentally on physical examination or imaging (as in this patient's CT scan after a motor vehicle collision). fibroids Indications for treatment of uterine leiomyomata include: Heavy, prolonged menses (particularly if associated with anemia). Chronic pelvic pain (eg, dyspareunia). Bulk symptoms (eg, pelvic pressure, hydronephrosis, constipation). Recurrent pregnancy loss. Patients with these clinical features can be managed medically or surgically (eg, myomectomy). Although this patient has multiple, large intramural and pedunculated leiomyomata, she has light menses and no pelvic pain or bulk symptoms (eg, no ureter compression). In patients with asymptomatic fibroids, no additional management is indicated. They require observation and reassurance only. (Choices A and D) Combination oral contraceptive pills and progestin-containing intrauterine devices can be used in the treatment of symptomatic fibroids, but they are not required in the management of asymptomatic fibroids. In addition, this patient has a low risk for an unintended pregnancy (eg, monogamous, same-sex relationship), and the potential risks of these contraceptives (eg, venous thromboembolism, uterine perforation) outweigh their benefits. (Choice B) GnRH agonist therapy (eg, leuprolide) is a treatment for symptomatic uterine fibroids that acts at the hypothalamus to decrease pulsatile FSH and LH release, thereby decreasing estrogen levels. Low estrogen levels result in transient decreased leiomyoma size, which improves heavy menses and bulk symptoms. GnRH agonists are only used short-term (ie, preoperative) because long-term therapy is associated with an increased risk of osteoporotic fractures. (Choice E) Tranexamic acid is a nonhormonal medical treatment that acts by inhibiting fibrin degradation (ie, antifibrinolytic agent) to decrease heavy menstrual bleeding. This patient has light menses. Educational objective: Uterine leiomyomata (fibroids) are common, benign myometrial tumors that can cause a variety of symptoms but may be diagnosed incidentally. Indications for treatment include heavy menstrual bleeding, pelvic pain, and bulk symptoms. Patients with asymptomatic fibroids require observation and reassurance only. References: Uterine fibroids: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28084714) Prevalence, morbidity, and current medical management of uterine leiomyomas. (http://www.ncbi.nlm.nih.gov/pubmed/26275638)

A 34-Year-Old Woman Comes to the Office to Discuss the Results