A 38-year-old woman presents to the gynaecology clinic with a 2-year history of heavy menstrual bleeding and dysmenorrhoea. She reports soaking 8–10 pads per day during menses, lasting 7 days. On examination, the uterus is firm, irregularly enlarged, and non-tender. Transvaginal ultrasound shows multiple hypoechoic lesions within the myometrium, the largest measuring 4 cm, with normal endometrial thickness. Haemoglobin is 9.2 g/dL. What is the most appropriate initial management?

Explanation

## Clinical Diagnosis **Key Point:** This patient has symptomatic uterine fibroids (leiomyomas) presenting with menorrhagia and dysmenorrhoea. The ultrasound findings (hypoechoic myometrial lesions) and clinical presentation are pathognomonic. ## Management Algorithm ```mermaid flowchart TD A[Symptomatic fibroid uterus]:::outcome --> B{Fertility desired?}:::decision B -->|No| C{Severe symptoms/<br/>large fibroid?}:::decision B -->|Yes| D[Myomectomy]:::action C -->|Mild-moderate| E[Medical management:<br/>OCP/LNG-IUS/NSAIDs]:::action C -->|Severe/large| F[GnRH agonist preop<br/>+ surgery]:::action E --> G[Reassess at 3-6 months]:::action F --> H[Hysterectomy or<br/>myomectomy]:::action ``` ## Rationale for Initial Medical Management This patient is **not seeking fertility** (no mention of pregnancy planning), has **moderate-to-severe symptoms** (Hb 9.2 g/dL indicates significant blood loss), and the fibroid is **4 cm (not massive)**. Medical management is first-line for symptom control. ### Efficacy of Options | Intervention | Indication | Efficacy | Notes | | --- | --- | --- | --- | | **OCP / LNG-IUS** | Heavy menses, dysmenorrhoea, no fertility desire | 40–50% reduction in bleeding | First-line; reversible; improves Hb over 3–6 months | | **Myomectomy** | Fertility preservation, intracavitary/submucosal fibroids | Symptom relief + fertility | Invasive; reserved for specific morphologies or failed medical therapy | | **GnRH agonist** | Preoperative fibroid shrinkage, severe anaemia | 40–60% size reduction | Used 3–6 months before surgery to reduce operative blood loss; not monotherapy | | **Hysterectomy** | Completed family, intractable symptoms | Definitive | Not first-line for a 38-year-old with moderate disease | **High-Yield:** Levonorgestrel intrauterine system (LNG-IUS) is superior to OCP in fibroid-related menorrhagia because it delivers high local progestin concentration and reduces endometrial proliferation. ## Clinical Pearl **Key Point:** In a woman with fibroid uterus and menorrhagia but **no fertility desire** and **no contraindications to hormonal therapy**, medical management (OCP or LNG-IUS) is the standard first step. Surgery (myomectomy or hysterectomy) is reserved for: - Failure of medical therapy after 3–6 months - Fertility preservation (myomectomy only) - Intracavitary or submucosal fibroids distorting the cavity - Severe anaemia requiring rapid intervention (GnRH agonist preop) **Warning:** Do not jump to hysterectomy in a 38-year-old without exhausting medical options first — it is irreversible and carries surgical morbidity. ## Why LNG-IUS over OCP? - Reduces menstrual blood loss by **50–70%** (vs. 40–50% with OCP) - Avoids systemic hormone exposure - Lasts 5 years - Can be used in patients with contraindications to oestrogen [cite:Jeffcoate's Principles of Gynaecology Ch 14]