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for marking please Posted by narmin B.
Evaluate the options of treatment in a 30-year-old woman with menorrhagia and fibroid uterus.

The available options are medical treatment, surgery,insertion of a Mirena coil and uterine artery embolisation. However the choice of treatment will depend on the size of the fibroid and the patient’s wishes for the future fertility.

The first option is medical treatment, which is the administration of the following medications. Non steroidal anti-inflammatory drugs (NSAIDs) which can reduce the amount of bleeding but they have no effect on the size of the fibroid. Their side effects are mainly gastrointestinal which is acceptable in majority of patients. Similarly antifibrinolytics such as tranexamic acid is helpful in reducing the menstrual loss but again has no effect on the size of the fibroid. As these drugs can rarely cause thrombosis, therefore if the above woman is in the high-risk group for developing a thromboembolic disease, another alternative should be considered. Another medication is gonadotrophin releasing hormone analogues (GnRha), which is effective treatment in reducing blood loss and the size of the fibroid. It can be used before surgery for shrinking of the fibroid and reducing intraoperative blood loss. GnRha have side effects such as hot flushes, dry skin and osteoporosis. Therefore the recommended duration of therapy is six months and after that an oestrogen compound should be added. Contraceptive pill also can reduce the blood loss. Theoritically oestrogen can increase the size of the fibroid, therefore their use should be limited to small fibroids.
The second option of treatment is insertion of a progesterone releasing intrauterine device (Mirena coil). This method is effective in controlling the blood loss and has no effect on the fibroid. At the same time it is a contraceptive method. Also, Mirena coil is effective for 5 years.

The third option is the surgical treatment, which includes hysteroscopy and resection of the fibroid, myomectomy and hysterectomy. If the fibroid was submucousal and small(less than 4 cm), hysteroscopy and resection of the fibroid can be performed. Although patient may have mutiple fibroids, which in that case will need another form of treatment. Myomectomy is the removal of the fibroid with preservation of the uterus. However hysterectomy may be required during the operation, as myomectomy can cause severe intraoperative bleeding. Although hysterectomy is the definite treatment, but of course this is not an option if the woman wishes to preserve her fertility. Both operations are associated with the risks of anaesthetic and surgical complications.

Finally, uterine artery embolisation is another option. This option will result in the shrinkage of the fibroid and the uterus will be preserved. However the method is available in certain centres and has side effects like severe pain and infection. Also there is not adequate evidence about its effects on future pregnancies.

In summary although there are different options available, but each option have its own characteristics which should be considered when offering to the patient.