3.  Combined OC with 20 ug EE  Combined OC with 50 ug EE  Oral iron  Intramuscular iron  NSAID  Tranexamic acid (Cyklokapron)  Ethamsylate  Primolut with each menstrual period  Primolut before each menstrual period  Depot Provera  Copper IUCD  Mirena IUS  D&C  Endometrial ablation  Myomectomy  Abdominal hysterectomy  Vaginal hysterectomy

4.  Combined OC with 20 ug EE  Combined OC with 50 ug EE Relatively contraindicated in this patient who is >35 years of age and smoking However, may be a good option if she wants another baby soon, will stop smoking and has no other risk factors for thrombo- embolism Use the lowest dose of oestrogen possible and Avoid 3 rd generation Progestins

5.  Oral iron  Intramuscular iron  Iron dextran infusion  If the patient’s menorrhagia is mild then iron may be all that she needs  Haematologists say that there is no place for IM Iron  Iron by infusion with appropriate precautions against anaphylaxis can be a good alternative to blood transfusion

6.  Tranexamic acid (Cyklokapron)  Ethamsylate  NSAIDs  85% of patients with menorrhagia will have reduced menstrual flow using menstrual phase Cyklokapron in adequate doses  There is no risk of thromboembolism  Tranexamic acid is more effective than the other anti- fibrinolytic agent Ethamsylate and NSAIDs  NSAIDs may be useful if there is also dysmenorrhoea

7.  Primolut with each menstrual period  Primolut before each menstrual period  Depot Provera  Progestins have a limited role in the management of menorrhagia  Luteal progestin for at least 7 days has some effecr  Depot Provera is unpredictable in its onset, control of the endometrium and duration of action

8.  Copper IUCD  Mirena Intra Uterine System  In general menstrual flow is increased for patients who use inert or copper- containing IUD’s  The Mirena IUS may be a good option for this patient. Reduces menstrual loss by a mean of 95% and up to 20% of patients become amenorrhoic  The fibroid, even if impinging on the uetrine cavity, does not preclude a trial of Mirena

9.  D&C  Endometrial ablation  Myomectomy  D&C reduces menstrual flow for no more than 2 – 3 cycles in most patients.  It may be of use in assessing suitability for vaginal hysterectomy and placing a Mirena  Up to 50% of patients who undergo endometrial ablation require further therapy. The Mirena is a better option in the long term.  Myomectomy if the fibroid is solitary my be an option but up to 50% of patients require further treatment

10.  Abdominal hysterectomy  Vaginal hysterectomy  Is 100% effective in the management of menorrhagia  But carries a 10 – 40% risk of minor morbidity and 1 – 2% risk of major morbidity  The vaginal route is associated with lower morbidity and quicker recovery (RCT data)  And a fibroid of this size should be no problem to an experienced operator