Uterine Fibroids with Abnormal Uterine Bleeding: When Medical Management Has Not Achieved Adequate Control

Clinical Scenario

This protocol applies to symptomatic uterine fibroids presenting with abnormal uterine bleeding in patients for whom prior medical management did not achieve adequate reduction of heavy menstrual bleeding, uterine volume, or hemoglobin improvement.

Patients presenting with fibroids and abnormal uterine bleeding remain at risk of other causes of abnormal uterine bleeding, and this should be taken into account in clinical evaluation.

Previous Line — Goals Not Met

Prior medical management of fibroid-associated abnormal uterine bleeding — including hematologic treatment (tranexamic acid, iron supplementation), menstrual suppression agents (oral contraceptives, levonorgestrel intrauterine system, progestogens, danazol, GnRH agonists, elagolix, or relugolix combination therapy) — did not achieve the expected reduction in heavy menstrual bleeding, reduction in uterine volume, and improvement in hemoglobin levels.

Clinical Goals

Reduction in uterine volume and improvement in fibroid-related symptoms. With certain uterine-sparing interventions, outcomes include meaningful reductions in leiomyoma and uterine volume, and elimination of abnormal uterine bleeding in over 90% of patients.

Approach (Partial Overview)

Management escalates to surgical or uterine-sparing procedural options. The specific pathway depends on the patient’s fertility goals and preferences, and preoperative optimisation is part of the sequence before elective intervention. The complete decision algorithm, specific procedural indications, and perioperative considerations are in the full structured protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jogc.2025.102970

Fibroid patients with abnormal uterine bleeding may be offered menstrual suppression with oral contraceptives, progestins (including the levonorgestrel intrauterine system), gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists, and danazol.

Patients presenting with fibroids and abnormal uterine bleeding (AUB) remain at risk of other causes of AUB.

Definitive treatment for uterine fibroids is hysterectomy.

In symptomatic patients wishing to preserve their fertility and/or their uterus, myomectomy may be offered.

Preoperative treatment with GnRH agonists is effective in correcting anemia, reducing fibroid size, and reducing intra-operative bleeding.

Uterine artery embolization may be offered as a minimally invasive technique that can reduce fibroid symptoms in patients wishing to preserve their uterus.

Clinical outcomes following UAE include 50–60% reduction in leiomyoma volume, 40–50% in uterine volume, elimination of abnormal uterine bleeding (>90%), and high patient satisfaction rates (80–90%).

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