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Fibroids in perimenopause and after menopause

Fibroids are non-cancerous growths in or around the uterus. They mainly affect women before menopause and often cause heavy or painful periods, pelvic pressure, peeing more often or pain during sex. Many cause no symptoms and need no treatment, and they usually stop causing problems after menopause. HRT has variable effects on fibroid size. A fibroid that grows after menopause without HRT needs specialist review.

Fibroids mainly cause problems before menopause and are a common cause of heavy bleeding in perimenopause. Treatment, HRT, and when growth needs checking.

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Fibroids in menopause: expectation vs reality

What people often expect

“You can't take HRT if you have fibroids”

What the evidence shows

Studies of menopausal women with fibroids show variable effects of hormone therapy on fibroid size. Some report growth, and new fibroids, with higher progestogen doses in combined therapy, but in many cases the change wasn't statistically significant. Low blood-flow resistance in the uterine arteries before starting HRT has been linked with more growth. It's a monitored discussion, not a blanket ban.

What happens to fibroids in perimenopause and after menopause

Fibroids depend on estrogen and progesterone

Fibroids respond to estrogen and progesterone, which is why they mainly cause problems before menopause. The NHS notes that you're more likely to get them if you haven't reached menopause. In perimenopause, when estrogen can run high and erratic, fibroids may keep growing or cause heavier bleeding. Once hormone levels fall after menopause, most fibroids stop growing and many shrink, and symptoms ease for many women.

Fibroids and heavy bleeding in perimenopause

Fibroids and endometrial polyps become more common with age, so abnormal bleeding picks up in perimenopause even while cycles are becoming irregular. Fibroids that bulge into the uterine cavity are the most likely to cause heavy bleeding. A transvaginal ultrasound is the usual first test, once pregnancy, infection and cervical causes are ruled out.

Symptoms of fibroids

Many fibroids cause no symptoms, so you may not know you have them. When they do, symptoms include heavy or painful periods, stomach pain, lower back pain, peeing more often or suddenly, not being able to control when you pee, bloating, constipation or pain when pooing, and pain or discomfort during sex. Pressure symptoms depend on where the fibroids are and how big they grow.

Complications of fibroids

Heavy periods from fibroids can lead to iron deficiency anemia, and large fibroids pressing on the bladder can cause UTIs, trouble peeing or incontinence. When bleeding is severe enough to cause anemia, treatment needs to cover both the blood loss and the iron deficit. A full blood count is recommended for every woman with heavy periods.

Who is more likely to get fibroids

The exact cause is unknown, but you're more likely to get fibroids if you haven't reached menopause, have never had a full-term pregnancy, are overweight, have high blood pressure or diabetes, are from a Black or Asian background, or have a close relative with fibroids. Reviews describe fibroids as a major cause of health problems in women of reproductive age, and sometimes after menopause.

Fibroids that grow after menopause

Because fibroids depend on hormones, they rarely grow after menopause unless you take HRT. Leiomyosarcoma, a very rare cancer of the uterine muscle, should be suspected in postmenopausal women whose fibroid grows without hormone therapy. That's why new growth, or bleeding after menopause, always gets a specialist review. Most fibroid growth after menopause turns out to be benign, but the check is still essential.

How common are fibroids around menopause?

3 cm

is the size below which NICE suggests a hormonal IUD first for heavy bleeding with fibroids that don't distort the uterus

Fibroids often cause no symptoms, so many women don't know they have them. They're common before menopause and become less of a problem after it.

Conditions that look like fibroids

Heavy bleeding and pelvic pressure in your 40s point to fibroids, but several other conditions cause the same symptoms. An ultrasound usually tells them apart.

Adenomyosis
Check →
Heavy, very painful periods and a bulky, tender uterus.
Test: Ultrasound or MRI
Polyps
Check →
Bleeding between periods or after sex.
Test: Ultrasound or hysteroscopy
Ovarian problems
Check →
Persistent bloating, feeling full quickly, pelvic pain on 12 or more days a month.
Test: CA125 and ultrasound
Unopposed estrogen bleeding
Check →
Heavy, irregular periods with no growth found on the scan.
Test: Ultrasound; sometimes biopsy

Treatment for fibroids in perimenopause and after menopause

No treatment for fibroids without symptoms
First step
Fibroids that don't cause symptoms usually don't need treating, and many women never know they have them. Watchful waiting is reasonable when bleeding and pain stay mild, especially close to menopause, when fibroids tend to settle on their own as hormone levels fall. If you are unsure, a repeat ultrasound can show whether fibroids are growing or stable.
Medicines for heavy bleeding from fibroids
Strong evidence
Tranexamic acid, anti-inflammatory painkillers such as ibuprofen or naproxen, and the combined pill reduce heavy bleeding. NICE suggests a hormonal IUD first if fibroids are smaller than 3 cm and don't distort the uterus. For fibroids of 3 cm or more, NICE advises specialist referral, with tranexamic acid or anti-inflammatories in the meantime.
Related guide →
Procedures and surgery for fibroids
Strong evidence
Options include myomectomy to remove fibroids, uterine artery embolization to block their blood supply so they shrink, endometrial ablation to remove the uterine lining, and hysterectomy. Newer options include focused ultrasound and radiofrequency ablation. The choice depends on size, number, location, symptoms and whether you want to become pregnant.
HRT with fibroids
If this is the cause
HRT is often possible with fibroids. Effects on size vary, and growth has been seen mainly with higher progestogen doses in combined HRT. Your doctor may monitor with ultrasound. Reviews suggest newer tissue-selective drugs may suit some women with fibroids better. If you have had fibroids, tell your prescriber before starting HRT so they can plan the safest regimen.
Related guide →

When fibroids need a doctor

Symptoms affecting your daily life, or painkillers not helping
See a doctor. You'll usually be referred for an ultrasound.
A fibroid that grows after menopause without HRT
Needs specialist review. It's rare, but a cancerous growth has to be ruled out.
Urgent: Any bleeding after menopause
Always needs checking. You should see a specialist within 2 weeks.
More →
Urgent: Very heavy bleeding with dizziness or breathlessness
Get urgent care. You may have lost a lot of blood or become anemic.

Fibroids and menopause: questions women ask

Do fibroids go away after menopause?

They usually stop causing problems and often shrink, because they depend on estrogen and progesterone. They don't always disappear completely. A fibroid that grows after menopause without HRT needs checking. If fibroids caused heavy periods before menopause, those symptoms usually settle once periods stop, which is why doctors often suggest waiting if menopause is close.

Can I take HRT with fibroids?

Often yes. Effects on fibroid size vary, with growth seen mainly at higher progestogen doses in combined therapy, and many changes weren't significant. Your doctor may monitor with ultrasound. If fibroids caused problems before, your doctor may choose a lower progestogen dose or a hormonal IUD for the progestogen part, and check with an ultrasound if symptoms return.

Can fibroids cause heavy bleeding in perimenopause?

Yes. They're a common cause, along with polyps, which also become more frequent with age. NICE suggests a hormonal IUD first for heavy bleeding when fibroids are smaller than 3 cm and don't distort the uterus.

What's the best treatment for fibroids after menopause?

Often none: fibroids that don't cause symptoms don't need treating, and they usually settle after menopause. If they do cause problems, options range from medicines to uterine artery embolization or surgery. Keep in mind that fibroid symptoms after menopause are less common, so new pain or bleeding should be checked for other causes too.

Can fibroids cause bleeding after menopause?

They can, especially if you take HRT, but bleeding after menopause always needs checking, because a thickened lining or, rarely, cancer are other possible causes. You should see a specialist within 2 weeks. If a scan shows fibroids, you may still need a biopsy or hysteroscopy to check the lining.

What are the symptoms of fibroids in menopause?

Often none. When they cause symptoms: heavy or painful periods before menopause, pelvic pressure, lower back pain, needing to pee often, bloating, constipation and pain during sex. After menopause, symptoms usually ease. If you have symptoms that are new after menopause, get them checked rather than assuming they are from old fibroids.

What causes fibroids to grow after menopause?

Mostly HRT, since fibroids respond to estrogen and progestogen, especially higher progestogen doses. Growth without HRT is unusual and needs specialist review to rule out a rare cancer called leiomyosarcoma. If you are on HRT and your fibroids grow, your doctor may adjust the dose or type.

Can you get fibroids after menopause?

New fibroids after menopause are uncommon, because they depend on hormones. Some studies found new fibroids forming on combined HRT with higher progestogen doses. Any new growth found after menopause should be checked. Fibroids found for the first time after menopause may have been there for years without symptoms.

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