Question

Write the medical management of intramural leiomyoma of size 4cmX4cm in a 50-year-old woman.

Hint:

In perimenopausal women, managing symptoms with hormonal therapy or NSAIDs is often effective, but surgical intervention may be needed for larger fibroids or when symptoms persist.

Answer 1

Step 1: Medical Management Goals.
The medical management of leiomyomas, particularly in a 50-year-old woman, aims to alleviate symptoms, control bleeding, and minimize the impact on fertility (though fertility preservation may be less of a concern in this age group). The focus is typically on managing heavy bleeding, pain, and other symptoms.
Step 2: Medical Treatment Options.
(1) Hormonal Therapy:
- Progestins (oral or IU: Progestins can help control abnormal bleeding associated with fibroids. A levonorgestrel intrauterine device (IU can be particularly helpful for controlling heavy menstrual bleeding and improving symptoms.
- Combined Oral Contraceptives (COCs): These can help regulate menstrual cycles and reduce bleeding, though they are generally not used long-term in perimenopausal women.
- GnRH Agonists: Gonadotropin-releasing hormone (GnRH) agonists, like leuprolide, can shrink fibroids temporarily by inducing a hypoestrogenic state. These are used for short-term management, especially before surgery, but should be used cautiously due to potential side effects like bone loss.
(2) Tranexamic Acid:
- A non-hormonal treatment option that can help reduce heavy menstrual bleeding associated with fibroids. It works by preventing fibrinolysis (clot breakdown) and is used during periods of heavy bleeding.
(3) Non-steroidal Anti-inflammatory Drugs (NSAIDs):
- NSAIDs such as ibuprofen can help manage pain and reduce inflammation. They are useful for managing the discomfort caused by fibroids, particularly in smaller fibroids.
(4) Aromatase Inhibitors:
- Letrozole is an aromatase inhibitor that reduces estrogen production, which may help in shrinking fibroids. However, this is generally not a first-line treatment and is used in specific cases.
Step 3: Management of Symptoms.
In a 50-year-old woman, especially one approaching menopause, the symptoms of fibroids may decrease naturally as estrogen levels decline. For persistent symptoms, a more aggressive treatment, such as surgery, may be considered if medical management is not effective.
Step 4: Surgery Considerations.
If medical management is insufficient or if there is significant discomfort, myomectomy (removal of the fibroids) or hysterectomy (removal of the uterus) may be considered, especially if the woman has completed her family planning.