FIBROIDS

UNDERSTANDING FIBROIDS AFTER MENOPAUSE: WHAT YOU NEED TO KNOW

Apr 22, 2024

Quick Answer

Fibroids usually shrink after menopause because they depend on estrogen, and your estrogen levels drop sharply once your periods stop. Existing fibroids often shrink or stop growing within a year or two. But some fibroids persist, and a small number grow again, especially if you start hormone therapy. Any fibroid that grows, or shows up for the first time after menopause, needs a closer look.

Key Takeaways

Fibroids are fueled by estrogen, so most shrink within a year or two after menopause
Hormone therapy (HRT) can cause some fibroids to grow again, transdermal estrogen more than oral
A fibroid that grows, or one diagnosed for the first time after menopause, is a red flag worth an urgent evaluation
Postmenopausal bleeding is never “probably the fibroid” until cancer has been ruled out with ultrasound and a biopsy
Treatment ranges from watchful waiting to embolization or hysterectomy depending on your symptoms and findings

If you were told your fibroids would disappear once you hit menopause, you are not alone in being confused now. Most fibroids do shrink once your estrogen drops during this stage of life, but not all of them, and not always in the way you expect. I want to walk you through what actually happens to fibroids after menopause, when a change is normal, and when it is worth a call to your doctor.

What Are Fibroids After Menopause?

Fibroids, also known as uterine fibroids or leiomyomas, are non-cancerous growths that develop in the walls of the uterus. These growths are made up of fibrous tissue and can vary in size from small and barely noticeable to large, causing discomfort. While fibroids are most common during the childbearing years, they can still grow or persist after menopause, although less frequently.

Why Do Fibroids Persist After Menopause?

Fibroids depend on estrogen and progesterone to grow. These are the same hormones that drop sharply once you stop having periods during the menopause transition. That drop is why most fibroids go quiet after menopause, not because the fibroid disappears, but because the hormones fueling it are no longer there in the same amount, according to Cleveland Clinic.

Your estrogen does not disappear completely after menopause, though. Your body still makes a small amount, and in some women that is enough to keep a fibroid from shrinking as much as expected, or to let it grow again later. Genetics, family history, and your weight also play a role in how much a hormone imbalance like this shrinks, since fat tissue produces its own small amount of estrogen.

A study that followed over 600,000 postmenopausal women for an average of 11 years found just over half a percent needed surgery for a fibroid during that time, which tells you persistence after menopause is real but uncommon. When it does happen, hormone therapy is usually the biggest factor, which I cover next.

Does Hormone Therapy Affect Fibroids After Menopause?

If you are on hormone therapy for hot flashes, night sweats, or other menopause symptoms, it is worth knowing this: HRT can cause a fibroid to grow again, since it replaces some of the estrogen your body stopped making.

In a review of 17 studies covering over 1,100 women on hormone therapy, about 28% had a fibroid grow by more than 30%. The type of hormone therapy mattered. Transdermal estrogen, the patch or gel forms, caused enlargement in up to half of patients within the first six months. Oral estrogen was gentler. Close to half of women on oral HRT saw no real change in fibroid size at all. Most of the growth that does happen shows up in that first six months, then levels off.

This does not mean you cannot take hormone therapy if you have a history of fibroids. It means your provider should know about that history before you start, and should recommend monitoring, especially in the first six months. In my practice, I ask about fibroid history before prescribing hormone therapy, and I check in with an ultrasound if a patient reports new pelvic pressure or bleeding after starting.

Symptoms of Fibroids After Menopause

A fibroid causing symptoms after menopause usually shows up as pelvic pressure, not pain that stops you in your tracks. These can overlap with general signs of hormonal imbalance, so it helps to know the specific pattern a fibroid tends to cause. Common symptoms include:

Pelvic pressure or a feeling of fullness in your lower abdomen
Frequent urination, especially if the fibroid is pressing on your bladder
Bloating that does not come and go with your digestion
Lower back pressure if a fibroid sits toward the back of your uterus

Bleeding is different. Any bleeding after menopause, even spotting, needs to be evaluated. It is not automatically the fibroid, and I explain why in the next section. Many women with fibroids after menopause have no symptoms at all, and the fibroid is only found on an imaging scan done for another reason.

When a Postmenopausal Fibroid Could Signal Something More Serious

I want you to know this before anything else: the overwhelming majority of fibroids, including ones found after menopause, are not cancer. But a small number of masses that look like fibroids turn out to be a rare cancer called leiomyosarcoma, and postmenopausal status is one of the factors that raises that risk.

Research following over 2,000 women having surgery for a presumed fibroid found the overall risk of it actually being a sarcoma was about 1 in 340. That risk is not the same at every age. For women in their 30s, it was under 1 in 500. For women between 75 and 79, it rose to about 1 in 98. Age is not the only factor, but it is one your provider will weigh carefully.

A few things push a fibroid from routine to something that needs a closer look:

A fibroid diagnosed for the first time after menopause. New growth without a prior history is treated differently than a fibroid you have had for years that is simply shrinking slowly.
Rapid growth, especially growth confirmed on two imaging scans a few months apart, rather than a single measurement.
A solitary mass, one large fibroid on its own, rather than the more typical pattern of several smaller ones.
Any bleeding after menopause. This is the one I want you to take most seriously. Postmenopausal bleeding is never assumed to be “just the fibroid.” Updated guidance now recommends both a transvaginal ultrasound and an endometrial biopsy for most women with postmenopausal bleeding, not ultrasound alone, since ultrasound can miss some cancers on its own.

If your provider recommends an MRI or a biopsy after a fibroid is found post-menopause, that is not an overreaction. It is the standard, careful way to rule out the rare case before treating it like the common one.

Treatment Options for Fibroids After Menopause

Treatment depends on your symptoms, not just the fibroid’s size. If a fibroid is small and not causing problems, watchful waiting with a follow-up ultrasound is often the right call. Fibroids often shrink further on their own within a year or two of menopause, so waiting is not the same as ignoring it.

If you are having symptoms, options include:

Watchful waiting with imaging follow-up: appropriate for a stable, asymptomatic fibroid with no red-flag features.
Uterine artery embolization (UAE): a minimally invasive procedure that cuts off blood supply to the fibroid, causing it to shrink. In one study of postmenopausal women who had UAE, over half saw their uterine volume shrink by 50% or more within two months, and about half reported their symptoms resolved completely.
MRI-guided focused ultrasound: a newer, non-surgical option that uses focused sound waves to destroy fibroid tissue. It is used less often after menopause but is worth asking your provider about if you want to avoid surgery.
Hysterectomy: removal of the uterus, usually reserved for larger fibroids, significant symptoms, or when there is any concern about the mass that imaging alone cannot resolve.

Hormone therapy is not typically used to treat fibroid symptoms after menopause. Since fibroid growth is estrogen-dependent, adding hormones back can work against the goal of shrinking it. If you are already on hormone therapy and develop new fibroid symptoms, your provider may adjust your dose or switch you to a different form before considering a procedure. For a deeper look at fibroid treatment options in general, read our guide to treatment options for uterine fibroids.

Dealing with fibroids after menopause is not what most women expect, and that is okay. Most fibroids quiet down on their own, and the ones that do not have clear, effective treatment options. If you notice new pelvic pressure, growth, or any bleeding, do not wait it out. Bring it to your provider and get the imaging that answers the question instead of guessing. Give yourself a little bit of time, a little bit of grace, and the right care plan will follow.

Frequently Asked Questions

If I have fibroids and start bleeding after menopause, is it the fibroid?

Not automatically, and it should never be assumed to be the fibroid without a workup. Any bleeding after menopause needs an evaluation with a transvaginal ultrasound and, in most cases, an endometrial biopsy, since fibroids and endometrial cancer can both cause postmenopausal bleeding and only testing can tell them apart.

Can a new fibroid appear for the first time after menopause?

It is uncommon, but it happens. A fibroid diagnosed for the first time after menopause, rather than one you already knew about, gets extra scrutiny from your provider, since new growth without a prior history is one of the features that raises the index of suspicion for something other than a routine fibroid.

Is hormone therapy safe if I have a history of fibroids?

A history of fibroids is not usually a reason to avoid hormone therapy, but your provider needs to know about it first. It changes the plan to closer monitoring, especially in the first six months, when most fibroid growth on hormone therapy happens.

Do fibroids need to be removed before starting hormone therapy?

Not usually. Most women start hormone therapy with an existing fibroid without any procedure first. The exception is unexplained bleeding, since hormone therapy should never be started until bleeding has been fully evaluated and cancer has been ruled out.

How fast is "rapid growth" for a fibroid, and when should I be concerned?

There is not one universal number, and this is a conversation to have directly with your provider. What matters more than a single measurement is growth confirmed across two separate imaging scans a few months apart, especially if it is happening after menopause, when fibroids are expected to be shrinking, not growing.

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