Part 1: Managing Fibroids in Perimenopausal Women: Challenges and Best Practices

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Uterine fibroids occur in women of all ages.

In fact, fibroids are the most common benign or non-cancerous gynecologic tumors in premenopausal women worldwide.1

Fibroids aren’t associated with an increased risk of uterine cancer; almost never develop into cancer; can range in size from seedlings to big enough to distort the uterus; and women can have one or many.2

It’s estimated that nearly 70–80% of women will develop fibroids at some point during their lifetime. 1 Fibroids often appear during childbearing years, but the risk actually increases as women age.2

What about those women who are moving through childbearing years and into perimenopause? The main symptoms for women who have fibroids in perimenopause or menopause is abnormal uterine bleeding. This represents up to 70% of all gynecological consultations in perimenopausal and postmenopausal women.1

Fibroids typically begin to regress in menopause with the change in hormones. But some doctor are concerned about fibroids regrowing because of hormone therapy.1

Those two concerns—continued or new fibroid growth and abnormal uterine bleeding—makes addressing fibroids in perimenopausal women important. Here’s a look at managing fibroids in perimenopausal women, including the challenges faced by obstetricians and gynecologists in fibroid management during this stage.

Understanding Fibroids in Perimenopausal Women

We often hear about fibroids and a possible impact on women’s fertility. But the risk of a woman developing uterine fibroids is at its highest during perimenopause. Fibroids do occur at other times, but the time when menopause is approaching is when women seem to notice symptoms of fibroids.3

Perimenopause means “around menopause,” and is the time when a woman’s body begins a natural transition to menopause. This marks the end of the reproductive years, and women start this phase at different ages. Signs like irregular menstrual cycles may start in the 40s, but some women notice changes as early as their mid-30s.4

The biggest impact is a change in the  level of the main female hormone, estrogen. It rises and falls unevenly during perimenopause, creating side effects like longer or shorter menstrual cycles, hot flashes and sleep problems. Once a woman has gone through 12 consecutive months without a menstrual period, it’s considered the end of perimenopause and instead a woman is in menopause.4

It also means the risk of fibroid growth can vary. For most women it may be highest between the ages of 40 and 58, but perimenopause can begin as soon as 30 for some women and sometimes earlier.3 

There are other factors at play when it comes to developing fibroids, like race, genetics and lifestyle:

  • Fibroids seem to disproportionately affect the African American population, although researchers understand little about what causes this disparity.5 Black women have fibroids at younger ages, and they’re also likely to have more or larger fibroids, along with more severe symptoms.2
  • Heredity has an impact too, because if your mother or sister had fibroids, you’re at increased risk of developing them.2
  • Lifestyle factors like obesity can lead to propensity for fibroids, as can having a diet higher in red meat and lower in green vegetables, fruit and dairy.2 One study found that vegetable and fruit intakes and occupational intensity played positive effects on uterine fibroids.6 

While fibroids are typically not cancerous, they do have an impact on quality of life during perimenopause—like abnormal uterine bleeding. 

Common symptoms associated with fibroids include:3

Challenges in Diagnosing Fibroids in Perimenopause

Doctors have found that fibroids are dependent on the ovarian hormones of estrogen and progesterone. Fibroids have more estrogen receptors and progesterone receptors than normal tissue. Recent findings also show that estrogen increases the expression of progesterone receptors and their sensitivity to tissue like fibroids.1

The prevalence of fibroids seems to peak in the perimenopausal years and declines following menopause—for instance, one study found that over 30% of newly diagnosed UFs were between the ages of 45-49 years. While fibroids are common, their symptoms can have a significant impact on women’s quality of life. The assumption that they will resolve with the onset of menopause is “simplistic and not always valid,” as one study cites.1

Since abnormal uterine bleeding accounts for more than 70% of all gynecological consultations in perimenopause and postmenopause, and that there are a multitude of conditions that may cause this bleeding, it’s important that a thorough evaluation and diagnosis is carried out on women with this symptom.1 Then a treatment plan can be determined in conjunction with the patient. 

Added to that is the fact that women in this stage of life have changes in menstruation like intermittent periods, and it’s hard to differentiate the symptoms of fibroids from typical side effects of perimenopause. 

When it comes to diagnosis of fibroids, there are some limitations with testing such as imaging, and differences between the types of imaging.

Here are a few examples:

1. One study compared magnetic resonance imaging (MRI) to transvaginal ultrasonography (TU). The mean number of correctly identified fibroids was significantly higher using MRI than TU. Researchers concluded that TU is as efficient as MRI in detecting the presence of fibroids, but not in its ability for exact mapping—in other words, where and how many.7

2. Another study concluded that MRI is the most accurate imaging technique for detection and localization of fibroids, and also plays a role in treatment by assisting in surgical planning and monitoring the response to therapy.8

3. The American Academy of Family Physicians reports that there are several ways to detect fibroids, with varying results: 

  • Transvaginal ultrasonography (TU) has the lowest sensitivity and specificity, but preferred as an initial test because it’s noninvasive and inexpensive. 
  • MRI is preferred when precise myoma mapping is required, typically to prepare for surgery, but it’s also the most expensive. 
  • Other options such as sonohysterography, which is used to evaluate the extent of fibroids but considered somewhat invasive.9

This highlights how important it is that a comprehensive evaluation is conducted, allowing for precise diagnosis of the fibroids. Here are some tests used:10

  • Ultrasound.
  • Lab tests such as a complete blood count, which can check for anemia because of chronic blood loss, as well as other blood tests to rule out bleeding disorders or thyroid problems.
  • Imaging such as MRI, hysterosonography, hysterosalpingography or hysteroscopy. 

Hysteroscopy is a less invasive exam that lets the doctor examine the walls of the uterus as well as the fallopian tubes. To do this, a small, lighted telescope called a hysteroscope is inserted through the cervix into the uterus.10

Caldera Medical’s Benesta Hysteroscope is ideal for visualizing the uterine cavity and diagnosing fibroids. It can also be used in conjunction with the Benesta Tissue Removal Device if fibroids are to be removed.

Hormonal Management of Fibroids in Perimenopausal Women

There is some evidence that shows both hormones and genetics play a large part in fibroid growth. Fibroids do not develop until a woman’s body begins the production of estrogen, which occurs during the onset of menstruation. Hormonal imbalance during the reproductive years can trigger the development of fibroids as well their growth.11

For instance, a study by the Endocrine Society found that women with higher levels of estrogen and testosterone were at increased risk of developing uterine fibroids. This “estrogen dominance” can result in the development and growth of fibroids.11

Fibroids sometimes shrink after menopause, when a woman’s body stops producing as much sex hormone. But women taking birth control pills or undergoing hormone replacement therapy may find that fibroids do not shrink.11 As mentioned earlier, it’s not always correct to assume that fibroids will resolve with the onset of menopause.1

Hormone therapies can be used to temporarily relieve heavy menstrual bleeding and period pain, as well as shrink fibroids—but they can’t make them disappear completely.12

There are positive and negative sides to hormone therapy:12

  • Hormones are usually only used for a limited amount of time because of the risk of side effects. 
  • Therapy only works for as long as it is used, so the fibroids may grow again once it is stopped.

A common use of hormone therapy is to shrink fibroids before surgery; for women just before menopause; or for women who can’t have surgery.

Each hormone therapy comes with side effects:

1. GnRH analogues, artificially produced hormones that inhibit the production of estrogen in the ovaries. Side effects are similar to problems associated with menopause, including hot flashes, sweating and vaginal infections.12

2. Progestins in hormonal intrauterine devices and progestin-only pills. IUDs are inserted into the womb and can remain there for up to five years, containing artificial hormones called progestins which are similar to the female sex hormone progesterone. This prevents the lining of the womb from building up during the menstrual cycle. Side effects include acne, spotting, mood swings and breast tenderness. IUDs are sometimes rejected by the body, and they cause damage to the womb in up to 1 out of 1,000 women.12

3. Progestin and estrogen combination birth control pills, which can reduce the flow of menstrual blood, and with uninterrupted use can cause menstrual periods to stop completely over time. Side effects can include water retention, headaches and breast tenderness, and an increase in the risk of blood clots, especially in older women and women who smoke.  It’s also not clear how effective the pill is in relieving fibroid symptoms, in particular how it compares to other treatments.12

4. Ulipristal acetate, the drug used in the “morning-after pill”, in a lower dose, which blocks the effect of the female sex hormone progesterone that promotes fibroid growth. That’s called a selective progesterone receptor modulator (SPRM). The risk of life-threatening liver damage caused this to be taken off the market throughout the European Union in March 2020 for the treatment of uterine fibroids.12

Any hormonal treatment needs to be carefully considered in consultation with each patient.

Conclusion of Part 1

Uterine fibroids are a common condition, but that doesn’t mean treatment is straightforward. For women in perimenopause, the similarity of symptoms can make management and treatment different than at other times of life. Some women with fibroids have no symptoms, while others find their quality of life impacted enough that they want to seek treatment.

In the second installment of this article, we will look at surgical and non-surgical treatment options, collaborative care and patient education, and follow up and long term management of fibroids.

Women’s Pelvic Health issues are often not talked about due to embarrassment or lack of knowledge, leading women to believe they are alone on this journey. Whether you’re a woman suffering with fibroids or you’re treating someone with this condition, it’s important to remember that you’re not the only one. Don’t go through this journey alone. 

There’s plenty of support, guidance and treatment options, including minimally invasive treatments offered by Caldera Medical, to help women regain confidence and live life to the fullest.

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