A 32-Year-Old Nulliparous Woman Comes to the Office for Evaluation

A 32-year-old nulliparous woman comes to the office for evaluation of heavy menstrual bleeding.  The patient has had progressively heavier menstrual periods for the past few years; she now has a menstrual period every month that consists of 6 days of heavy bleeding and often bleeds through her clothes.  The patient is sexually active and uses condoms for contraception.  She is planning on becoming pregnant in the next year and has started taking a daily prenatal vitamin.  The patient has occasional migraines with aura that cause her to miss work a few days a year; she otherwise is healthy and has had no surgeries.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/74 mm Hg, pulse is 78/min, and BMI is 29 kg/m².  Pelvic examination shows an enlarged, 10-week-sized uterus.  Urine pregnancy test is negative.  Transvaginal ultrasound reveals an anteverted uterus with multiple submucosal fibroids.  The endometrium is thickened and has multiple areas impinged by the fibroids.  Which of the following is the best next step in management of this patient's heavy menstrual bleeding?

A) Combination oral contraceptive pills
B) Copper-containing intrauterine device
C) Endometrial ablation
D) Hysteroscopic myomectomy
E) Uterine artery embolization