A 32-year-old woman from Mumbai presents with menorrhagia for the past 8 months. Pelvic ultrasound shows a 4 cm intramural fibroid. Hemoglobin is 9.2 g/dL. She is counseled about medical and surgical options. All of the following are evidence-based first-line or adjunctive medical treatments for fibroid-related menorrhagia EXCEPT:

Explanation

## Medical Management of Fibroid-Related Menorrhagia ### Treatment Hierarchy & Evidence | Treatment | Role | Duration | Efficacy | |-----------|------|----------|----------| | **Tranexamic acid** | First-line, reduces bleeding 40–50% | During menses only | High; antifibrinolytic | | **NSAIDs** | First-line, reduces bleeding 20–30% | During menses | Moderate; anti-inflammatory | | **Combined OCP/POP** | First-line, adjunctive | Continuous or cyclic | Moderate; hormonal suppression | | **LNG-IUD** | First-line, excellent for AUB | 3–6 months trial | High; local endometrial effect | | **GnRH agonists** | Bridge therapy *before* surgery | 3–6 months maximum | Very high; but not definitive long-term | | **Progestins (oral/IM)** | Adjunctive | Variable | Moderate | ### Key Point: **GnRH agonists are NOT definitive long-term therapy for fibroids.** They are used as *bridge therapy* for 3–6 months to: - Shrink fibroids temporarily (20–40% volume reduction) - Improve anemia before surgery - Reduce intraoperative bleeding - Allow time for surgical planning After stopping GnRH agonists, fibroids regrow within 3–6 months, and menorrhagia recurs. They are not suitable for indefinite use due to: - Hypoestrogenia side effects (hot flushes, vaginal dryness, bone loss) - Cost - Lack of sustained benefit ### High-Yield: **First-line medical options for fibroid-related AUB:** 1. Tranexamic acid (antifibrinolytic) 2. NSAIDs (mefenamic acid, ibuprofen) 3. LNG-IUD (most effective; 80% reduction in bleeding) 4. Combined hormonal contraceptives ### Clinical Pearl: The LNG-IUD is often the best medical option for fibroid-related menorrhagia because it delivers high local progestin concentration to the endometrium, reducing bleeding by 80–90% regardless of fibroid size (as long as the uterine cavity is not severely distorted). ### Warning: Do NOT use GnRH agonists as long-term definitive therapy. They are bridge therapy only. Add-back hormone replacement (estrogen + progestin) may be needed if side effects are intolerable, but this reduces efficacy.