Introduction to fibroids and menopause

Uterine fibroids are non-cancerous growths in the uterus, common in women of reproductive age, influenced by hormones like estrogen and progesterone. As women enter perimenopause - the transition before menopause - and postmenopause, hormone levels change, affecting fibroid behaviour. This article explores whether fibroids naturally regress or remain a problem, and discusses symptoms, diagnosis, and treatments.

Behaviour during perimenopause

During perimenopause, typically starting in the 40s and lasting for years, hormone levels fluctuate, with estrogen sometimes higher, potentially stimulating fibroid growth. Studies show symptomatic fibroids peak here, with many women experiencing heavy bleeding and pelvic pain. For example, research indicates over 30% of new fibroid diagnoses occur in women aged 45-49.¹

Behaviour during postmenopause

Postmenopause, after 12 months without a period, sees low estrogen and progesterone levels, generally shrinking fibroids. However, some fibroids persist, especially with hormone therapy or obesity, and can cause symptoms like abnormal bleeding, which may need medical attention.²

Background and Prevalence

Uterine fibroids are prevalent, with estimates suggesting 70-80% of women develop them during their lifetime, most commonly between ages 30 and 50.¹ They vary in size, from microscopic to several centimeters, and can be subserosal (on the outer surface), intramural (within the uterine wall), or submucosal (beneath the lining). Many women are asymptomatic, but during reproductive years, fibroids can cause heavy menstrual bleeding, pelvic pain, frequent urination, and reproductive issues. As women approach menopause, hormonal changes can alter fibroid behaviour, making perimenopause and postmenopause critical periods for observation and management.

Perimenopausal Dynamics

Perimenopause, the transitional phase before menopause, typically begins in the early 40s and can last 4-8 years, marked by irregular menstrual cycles due to declining ovarian function and fluctuating estrogen levels.¹ Symptoms often include heavy menstrual bleeding, pelvic pain, and pressure, exacerbated by hormonal fluctuations, which can overlap with perimenopausal symptoms, complicating diagnosis.

The growth rate of fibroids increases during this stage, with abnormal uterine bleeding (AUB) accounting for over 70% of gynaecological consultations, necessitating thorough evaluation to differentiate fibroid-related symptoms from typical perimenopausal changes.³ Treatment during perimenopause may involve watchful waiting if symptoms are mild, anticipating natural regression postmenopause, or medical interventions like hormonal therapies if symptoms impact quality of life.

Postmenopausal Trends

Postmenopause, defined as the period after 12 consecutive months without a menstrual period, typically begins around age 51, with hormone levels stabilising at low levels.¹

Persistent fibroids can cause symptoms like abnormal bleeding, pelvic pain, or pressure, requiring evaluation for conditions like leiomyosarcoma, especially if growth continues postmenopause. Factors such as race, weight, or genetics may also contribute to continued growth, with postmenopausal women sometimes needing interventions if symptoms are severe.⁴

Role of Hormone Therapy

Hormone replacement therapy (HRT) is used to manage menopausal symptoms like hot flashes and vaginal dryness, involving estrogen supplementation, often with progestins for women with an intact uterus. Its effect on fibroids is controversial, with variable outcomes reported. Some studies suggest HRT, particularly with higher progestogen doses, can increase fibroid size, especially within the first two years, with effects declining thereafter.⁵

The choice of HRT regimen is crucial, with recommendations for periodic monitoring and using minimal effective doses, especially in women with fibroids, to balance symptom relief with fibroid management. Transdermal estrogen with high-dose medroxyprogesterone acetate may increase risk, while tibolone shows little effect on fibroid size, offering alternatives.⁶

Symptoms and Diagnosis

Symptoms in perimenopausal and postmenopausal women include abnormal uterine bleeding, often heavy or irregular, pelvic pain, and pressure on the bladder or bowels, potentially affecting quality of life. In perimenopause, these can overlap with menstrual irregularities, while postmenopausal bleeding is abnormal and warrants investigation for fibroids or malignancy.¹

Diagnosis begins with a medical history and pelvic examination to assess uterine size and shape. Imaging is essential, with transvaginal ultrasound as the first-line test, providing detailed views of fibroids. MRI may be used for complex cases, and hysteroscopy can visualise submucosal fibroids, sometimes with biopsy for differential diagnosis. Regular check-ups and imaging are recommended to monitor changes, especially in postmenopausal women with symptoms.

Treatment Strategies

Treatment varies based on symptom severity, fibroid characteristics, and patient preferences. Options include:

• Watchful waiting: Suitable for asymptomatic or mild cases, particularly in postmenopausal women expecting natural shrinkage, with periodic monitoring via pelvic exams and ultrasounds⁷
• Medications: Hormonal therapies like GnRH agonists induce a menopause-like state, shrinking fibroids temporarily, but long-term use is limited by side effects like bone loss. Other options include tranexamic acid for bleeding, NSAIDs for pain, and oral contraceptives or progestins for perimenopausal bleeding control⁸
• Minimally invasive procedures: Uterine artery embolisation (UAE) blocks blood supply to fibroids, causing shrinkage, with high efficacy and shorter recovery, suitable for many women. MRI-guided focused ultrasound surgery (FUS) uses ultrasound waves to destroy fibroid tissue, offering a non-invasive alternative
• Surgery: Myomectomy removes fibroids, preserving the uterus, but is less common postmenopause. Hysterectomy, removing the uterus, is definitive but involves major surgery, typically reserved for severe cases or suspicion⁹

Summary

While fibroids often naturally regress postmenopause due to hormonal decline, they can persist and pose challenges during perimenopause and in some postmenopausal cases, particularly with HRT or risk factors like obesity. The controversy around HRT effects underscores the need for personalised approaches, with careful monitoring and tailored treatments. Symptoms like abnormal bleeding necessitate thorough evaluation, and treatment options range from conservative to surgical, ensuring comprehensive care based on individual needs.