Fibroids are noncancerous growths that appear in the uterus, predominantly during a woman's childbearing years. However, the question arises: Can these fibroids cause bleeding after menopause, a time when menstrual periods have naturally ceased, and the reproductive hormones- oestrogen and progesterone have diminished significantly?
Understanding the nature of fibroids is important. These growths vary greatly in size, from as small as a pea to as large as a melon, and their presence is quite common among women of reproductive age. While many women with fibroids experience no symptoms at all, others may face a range of issues, including heavy menstrual bleeding, pelvic pain, and fertility problems. The symptoms and management of fibroids largely depend on their number, size, location within the uterus and the age of the woman.
Postmenopause brings about significant changes in a woman's body, primarily due to the reduction in oestrogen and progesterone levels. Since fibroids are known to grow in response to oestrogen, one might expect them to shrink and cease causing symptoms after menopause. Indeed, for many women, this is the case. However, the situation isn't so straightforward for everyone.
Bleeding after menopause is considered abnormal and warrants medical attention, as it could be a symptom of various conditions, including the presence of fibroids. Although less common, fibroids can indeed persist or even develop new growth after menopause, leading to postmenopausal bleeding. This scenario is particularly possible in women undergoing hormone replacement therapy (HRT) for the management of menopausal symptoms, as the treatment may stimulate fibroid growth.
Therefore, while not as common as during the reproductive years, fibroids can cause bleeding after menopause and represent a significant health concern. The connection between fibroids and postmenopausal bleeding underscores the importance of monitoring and managing fibroids, even after the cessation of menstruation.
What are fibroids?
Fibroids, also known as uterine leiomyomas or myomas, are benign (noncancerous) tumours that develop in the muscular tissue of the uterus. They are among the most common gynaecological conditions, affecting a significant portion of women at some point in their lives, especially during their reproductive years. Despite their prevalence, the exact cause of fibroid development remains unclear, though factors such as hormones (oestrogen and progesterone), genetic variations, and certain growth factors that promote tissue repair and regeneration are believed to play a role.
The characteristics of fibroids can vary greatly from one woman to another. They range in size from microscopic, barely detectable nodules to large masses that can distort and enlarge the uterus. Some women may have a single fibroid, while others could have multiple growths, leading to a variety of symptoms based on their size, number, and location.
Symptoms associated with fibroids include but are not limited to, heavy and prolonged menstrual bleeding, pelvic pain or pressure symptoms on adjacent organs, leading for example to frequent urination, difficulty emptying the bladder, constipation, backache or leg pains, and, in some cases, infertility or recurrent miscarriages. However, it's noteworthy that many women with fibroids experience no symptoms at all and may only become aware of their condition during a routine pelvic examination or prenatal ultrasound.
Fibroids are classified based on their location within the uterus:
Submucosal fibroids
These tend to grow within the cavity of the uterus and can mainly cause heavy menstrual bleeding and trouble conceiving.
Intramural fibroids
Intramural fibroids are found within the muscular wall of the uterus, the most common type, and can markedly grow and lead to increasing the size of the uterus.
Subserosal fibroids
Subserosal fibroids extend beyond the wall of the uterus into the pelvic cavity, often on a stalk, and can cause pressure on other organs.
The growth of fibroids is highly individual- some may grow quickly, while others remain the same size for years or even shrink on their own. Their growth is influenced by the body's oestrogen and progesterone levels, which is why symptoms often improve after menopause when hormone levels decrease.
Understanding fibroids is the first step in managing their symptoms and impacts. Though characteristically benign growths, their presence in the uterus can lead to significant discomfort and complications, emphasising the importance of regular gynaecological checkups for early detection and management.
Can fibroids cause bleeding after menopause?
The cessation of menstrual periods and the transition into menopause marks a significant change in a woman's reproductive life, typically characterised by a decline in oestrogen and progesterone levels. Given that fibroids are oestrogen sensitive, it's commonly expected that these uterine growths diminish in size and symptoms in the postmenopause. However, one of the pressing concerns for postmenopausal women is whether fibroids can cause bleeding during this phase of their life.
Bleeding after menopause is deemed abnormal and should always prompt medical evaluation. While fibroids are less likely to be a cause of postmenopausal bleeding compared to during the reproductive years, they remain a possible source. The link between fibroids and postmenopausal bleeding can be understood through a few key perspectives:
Oestrogen production
Although overall oestrogen levels drop after menopause, the body continues to produce oestrogen from other sources, such as adipose (fat) tissue. Women with higher levels of body fat may therefore have slightly elevated oestrogen levels, which can maintain the size of fibroids or potentially encourage their growth, albeit at a slower rate than before menopause.
Hormone replacement therapy (HRT)
Women undergoing HRT to manage menopausal symptoms might experience a resurgence in fibroid growth or symptoms due to the reintroduction of oestrogen, albeit in controlled amounts. This can lead to the recurrence of fibroid-related symptoms, including bleeding.
Existing fibroids
If fibroids were present before menopause, they might not shrink completely and could still cause symptoms, including bleeding. This is particularly true for submucosal fibroids, which are situated beneath the lining of the uterus and have been closely linked to abnormal bleeding.
It's important to note that while fibroids can contribute to postmenopausal bleeding, other conditions, such as endometrial hyperplasia, endometrial polyps, or more serious conditions like endometrial cancer, are also potential causes. Therefore, any incidence of bleeding after menopause warrants a thorough investigation to rule out these conditions.
Diagnostic procedures may include an ultrasound scan to visualise the uterus and fibroids, a hysteroscopy for a closer examination of the uterine cavity, or an endometrial biopsy to assess the cells of the uterine lining. These tests help to determine the cause of bleeding and guide appropriate treatment options.
How common is bleeding with fibroids in postmenopausal women?
There are instances where postmenopausal women experience bleeding related to fibroids, although this is not common.
The prevalence of fibroid-related bleeding in postmenopausal women is difficult to quantify because of the varying nature of fibroids and the influence of external factors such as hormone replacement therapy (HRT), which can affect fibroid behaviour and symptoms. Additionally, the exact incidence of fibroids in postmenopausal women is not well documented, partly because fibroids tend to be less symptomatic and thus may go undiagnosed in this population. Having said that, one study suggests that in postmenopausal women, uterine fibroids are more commonly associated with severe heavy menstrual bleeding, affecting 16.7% compared to 7.7% in other groups (Source).
However, it is known that the risk factors for developing fibroids, such as age, obesity, family history, and ethnicity, do not simply disappear with the onset of menopause. African American women, for example, are at a higher risk of developing fibroids and may continue to experience symptoms, including bleeding, beyond menopause (Source). Obesity can also play a role in maintaining higher levels of postmenopausal oestrogen, potentially contributing to the persistence or growth of fibroids and associated symptoms.
When postmenopausal bleeding occurs (PMB), fibroids are considered alongside a spectrum of possible causes. While fibroids can contribute to PMB, the differential diagnosis includes other conditions such as endometrial hyperplasia, endometrial polyps, and, more concerningly, endometrial cancer. For this reason, any postmenopausal bleeding must be thoroughly investigated to identify the exact cause and to rule out more serious conditions.
What role does hormone therapy play in fibroids and postmenopausal bleeding?
Hormone Replacement Therapy (HRT) is commonly prescribed to alleviate menopausal symptoms such as hot flashes, night sweats, mood swings, and vaginal dryness. HRT aims to replenish oestrogen, alone or in combination with progesterone, to a level that mitigates these symptoms. However, the introduction of hormones can have implications for women with fibroids, particularly concerning the risk of postmenopausal bleeding.
Fibroids are oestrogen-sensitive, meaning their growth is influenced by the presence of oestrogen. During the reproductive years, the fluctuating levels of oestrogen and progesterone can lead to fibroid growth and its associated symptoms. After menopause, the natural decline in hormone levels typically results in a reduction in fibroid size and a decrease in symptoms. However, the administration of HRT may alter this trajectory.
The impact of HRT on fibroids and postmenopausal bleeding is multifaceted. It can potentially stimulate the growth of existing fibroids or the development of new ones due to the increased levels of oestrogen. This growth can lead to the recurrence of symptoms previously experienced during the reproductive years, including bleeding.
The effect of HRT on fibroids largely depends on the type of therapy. Oestrogen-only therapy may have a greater potential to stimulate fibroid growth compared to combined oestrogen progesterone therapy, where progesterone can counteract some of oestrogen's effects on the uterine lining and fibroids.
The method of hormone delivery (oral, transdermal, vaginal) might also influence the impact on fibroids. Some studies suggest that transdermal (through the skin) oestrogen might have a lesser effect on fibroid growth compared to oral administration, although more research is needed to fully understand these conditions.
Given these considerations, the role of HRT in managing menopausal symptoms for women experiencing bleeding with fibroids requires careful consideration and personalised management. Women with a history of fibroids should discuss the potential risks and benefits of HT with their healthcare provider, considering factors such as the severity of menopausal symptoms, the history of fibroid-related symptoms, and the individual's overall health profile.
In cases where HRT is deemed necessary, healthcare providers may recommend the lowest effective dose for the shortest duration to manage menopausal symptoms while minimising the potential impact on fibroids. Regular monitoring through pelvic exams and imaging studies may be advised to assess any changes in fibroid size or symptoms.
When should you seek medical advice for postmenopausal bleeding?
Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring after a woman has gone 12 consecutive months without a menstrual period, marking the end of her reproductive years. PMB is a symptom that should never be ignored or considered part of the normal ageing process. Instead, it warrants prompt medical evaluation to determine its cause, which can range from benign conditions like atrophy of the vaginal walls or uterine fibroids to more serious concerns such as endometrial hyperplasia or cancer.
Seeking medical advice is important under the following circumstances:
Any occurrence of bleeding: The primary guideline is straightforward- if you experience any bleeding after menopause, it's time to see your doctor. Even spotting or a small amount of bleeding should be evaluated.
Recurrent bleeding: If you experience bleeding more than once after menopause, even if it stops on its own, you should seek medical advice. Recurrent bleeding could be a sign of an underlying condition that needs evaluation and may be treatment.
Symptoms accompanying bleeding: If the bleeding is accompanied by other symptoms, such as pelvic pain, unusual discharge, weight loss, or fatigue, it's particularly important to consult a healthcare provider. These symptoms, in combination with bleeding, could indicate a more serious underlying condition.
After hormone therapy (HRT) initiation: Women who have started hormone therapy and then experience bleeding should report this to their healthcare provider or menopause specialist. Although some women might experience light spotting when they begin HRT, any bleeding should be assessed to ensure it's not indicative of a more serious issue.
Postmenopausal women with a history of fibroids: Those who had fibroids before menopause should be vigilant. While fibroids typically shrink and become asymptomatic after menopause, any postmenopausal bleeding warrants a checkup to rule out fibroid regrowth or other causes.
What to expect during your visit:
Your doctor will ask about the bleeding, any accompanying symptoms, your medical history, and any medications or hormone treatments you're taking. This may include a pelvic exam to check for any abnormalities or changes in the uterus or ovaries. Depending on the initial evaluation, your doctor may order tests such as an ultrasound, endometrial biopsy, or hysteroscopy to further investigate the cause of bleeding. Here at the Rylon Clinic we pride ourselves on being able to offer all these services and more as part of our ‘one-stop gynaecology clinic’ making it easier and faster for patients seeking diagnosis and treatment.
The goal of the evaluation is to identify the source of the bleeding, assess the severity of the underlying condition, and determine the appropriate course of treatment. Early diagnosis and treatment can improve the outcome for conditions associated with postmenopausal bleeding, making it imperative to seek medical advice promptly if you experience any form of bleeding after menopause.
How does the management of fibroids differ before and after menopause?
The management of fibroids, benign tumours that grow in the uterus, necessitates a tailored approach that considers the woman's age, symptom severity, fibroid size and location, and reproductive goals. This approach evolves significantly as a woman transitions from her reproductive years into menopause, primarily due to changes in hormone levels and the shift in focus from fertility preservation to symptom relief.
Before menopause:
Hormonal treatments: For women in their reproductive years, hormonal treatments that regulate or lower oestrogen and progesterone levels are often used to manage fibroid symptoms. These can include birth control pills, gonadotropin-releasing hormone (GnRH) agonists, and progestin-releasing intrauterine devices (IUDs), which aim to reduce menstrual bleeding and shrink fibroids.
Fertility considerations: In women who wish to preserve their fertility, management strategies may include myomectomy (surgical removal of fibroids), which spares the uterus, or less invasive procedures like uterine artery embolisation and MRI-guided focused ultrasound surgery, which aims to reduce fibroid size while minimising impact on fertility.
Symptom management: Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage pain associated with fibroids, and iron supplements may be prescribed to address anaemia from heavy menstrual bleeding.
After menopause:
Observation: Given that fibroids tend to shrink and become asymptomatic after menopause due to the natural decline in oestrogen and progesterone levels, observation or "watchful waiting" is often the first line of management for postmenopausal women with fibroids, especially in the absence of symptoms.
Hormone therapy considerations: For women on HRT who have fibroids, careful monitoring is essential. The type of HRT, dose, and route of administration may need to be adjusted to mitigate the risk of fibroid growth or the recurrence of symptoms.
Surgical options: In cases where fibroids cause significant postmenopausal bleeding or other severe symptoms, surgical options may be considered. A hysterectomy, the surgical removal of the uterus, is a definitive treatment for fibroids and is more commonly performed in postmenopausal women who are not concerned with preserving their uterus for fertility reasons.
Non-hormonal treatments: For symptom management, nonhormonal options such as tranexamic acid (to reduce heavy bleeding) and noninvasive procedures like endometrial ablation (destruction of the uterine lining) may be appropriate for some postmenopausal women.
Personalised approach: It's important to note that the management of fibroids is highly individualised. The choice of treatment depends on a variety of factors, including the woman's symptoms, the size and location of the fibroids, her age, overall health, and personal preferences regarding treatment outcomes and potential side effects.
What are the treatment options for fibroids in postmenopausal women?
For postmenopausal women, the landscape of fibroid treatment shifts focus from fertility preservation to primarily addressing symptoms and improving quality of life. Although fibroids typically decrease in size and become less symptomatic after menopause due to the decline in oestrogen levels, some postmenopausal women may still require treatment for fibroids that cause discomfort or health concerns. Here’s an overview of the treatment options available:
Observation or "watchful waiting"
Since fibroids often shrink and cause fewer symptoms after menopause, one common approach is simply to monitor them, especially if they're not causing significant discomfort or health issues. This method avoids the risks and side effects associated with more invasive treatments.
Medication for symptom management
While the use of hormone-based medications to shrink fibroids is less common in postmenopausal women, non-hormonal medications can be employed to manage symptoms. For example, pain relief medication can be used to manage any discomfort associated with fibroids. Tranexamic acid may be prescribed to manage heavy bleeding episodes if they occur, despite the rarity of such symptoms postmenopause.
Hormone replacement therapy (HRT) adjustment:
For women taking hormone replacement therapy (HRT) who experience fibroid growth or symptoms, adjusting the HRT regimen can sometimes mitigate these issues. This might involve changing the dosage, the type of hormones, or the method of delivery, under close medical supervision.
Uterine artery embolisation (UAE)
UAE is a minimally invasive procedure where the blood supply to the fibroids is blocked, causing them to shrink. This treatment can be particularly appealing for postmenopausal women seeking relief from fibroids without undergoing surgery.
MRI guided focused ultrasound surgery (MRgFUS)
This noninvasive treatment uses high-intensity ultrasound waves to heat and destroy fibroid tissue. It's a suitable option for women looking for a nonsurgical approach to manage fibroid symptoms.
Endometrial ablation
This procedure destroys the lining of the uterus (endometrium) and is effective in reducing menstrual bleeding. However, it's typically only recommended for women who are not planning to have children, making it a viable option for postmenopausal women experiencing bleeding related to fibroids.
Surgical options:
Myomectomy: Although less commonly performed on postmenopausal women, myomectomy involves the surgical removal of fibroids while leaving the uterus intact. This option might be considered if fibroid symptoms are severe and other treatments have been ineffective.
Hysterectomy: The surgical removal of the uterus (hysterectomy) is a definitive treatment for fibroids, eliminating the possibility of fibroid recurrence. This option is often considered for postmenopausal women who have significant symptoms and are not concerned about preserving their uterus.
Choosing the right treatment involves a detailed discussion between the woman and her healthcare provider, considering factors such as the severity of symptoms, the size and location of the fibroids, overall health, and personal preferences. The goal is to select a treatment that effectively addresses the symptoms while aligning with the woman's lifestyle and health priorities.
Are there any risks associated with fibroids after menopause?
While fibroids typically become less problematic after menopause due to the natural decline in oestrogen levels, which contributes to their growth during a woman's reproductive years, they do not completely exempt postmenopausal women from potential risks. Understanding these risks is important for managing health proactively after menopause, especially for women with a history of fibroids or those experiencing symptoms indicative of their persistence or growth. Here are some risks associated with fibroids in the postmenopausal period:
Continued growth:
In some cases, especially among women undergoing hormone replacement therapy (HRT) to manage menopausal symptoms, fibroids may continue to grow. This can lead to discomfort, pressure symptoms, or even pain, mirroring the experiences of women before menopause.
Postmenopausal bleeding:
As mentioned above, any vaginal bleeding after menopause is considered abnormal and warrants immediate medical evaluation. While fibroids are a less common cause of postmenopausal bleeding compared to conditions like endometrial hyperplasia or cancer, they remain a potential source of such bleeding, especially if they continue to grow.
Pressure symptoms:
Large fibroids can exert pressure on adjacent pelvic organs, including the bladder and rectum, leading to urinary frequency, urgency, or difficulty emptying the bladder, as well as constipation. These symptoms can affect a woman's quality of life, even after the cessation of menstrual periods.
Pain:
Though less common after menopause, fibroids can still cause pain or discomfort, especially if they undergo a degeneration process (accelerated shutdown of their blood supply) where the fibroid starts to break down, leading to acute pain and sometimes fever.
Rare transformation to sarcoma
There is a very low risk of fibroids undergoing malignant transformation into leiomyosarcoma, a type of uterine cancer. This risk is extremely rare, but any rapid growth of fibroids, especially after menopause, should be evaluated promptly to rule out malignancy.
Conclusion
In conclusion, navigating the complexities of fibroid management before and after menopause underscores the need for personalised, patient-centric care, a hallmark of our newly established private gynaecology clinic in the heart of central London. Our clinic is dedicated to empowering women to understand and actively participate in their treatment plans.
Fibroids, while commonly associated with the reproductive years, can persist or emerge as a health concern even after menopause. This article has explored various aspects of fibroids in postmenopausal women, from the potential for continued growth and the array of symptoms they may cause to the importance of seeking medical advice and the spectrum of treatment options available. Our aim is to offer both educational insights and clinical excellence in addressing these concerns, ensuring our patients are informed and receive the highest standard of care.
Not only do we offer advanced gynaecology scanning, a critical component in diagnosing and managing conditions like fibroids, but our capabilities are further enhanced by our NHS base at the prestigious Guy's and St Thomas' Hospital. Our expertise in advanced diagnostic techniques, combined with a comprehensive approach to gynaecological health, positions us as a one-stop clinic for women seeking thorough, compassionate care.
Feel free to contact us via our booking form or call us today to schedule your consultation.
Author: Mr Osama Naji
Mr Naji offers a “one-stop” gynaecology clinic for instant detection of various gynaecological cancers as well as providing all the diagnostic and treatment services needed under one roof.
Mr Naji provides advanced gynaecology scanning which is essential when conducting any gynaecology consultation, he is bilingual in English and Arabic and has an NHS base at the highly reputable Guy's and St Thomas' Hospital in London.
He is passionate about raising awareness of various subtle signs and symptoms of gynaecological conditions that are often overlooked by patients.
You can read more about Mr Naji on his about page here.