What happens to fibroids during the menopause?

This week on the podcast, Dr Louise is joined by Osama Naji, a Consultant Gynaecologist who is an expert in advanced gynaecological scanning at Guy’s and St Thomas’ NHS Foundation Trust.

In this episode Osama shares his vast knowledge on fibroids – common, benign growths that usually develop during a woman’s reproductive years when oestrogen levels are at their highest. He explains the impact menopause can have on fibroids, treatment options and the possibility of HRT.

Finally, Osama advises on things to consider if you’ve recently been diagnosed with fibroids:

1. Find out all the facts about your fibroid – number, location and size – as knowledge is power. You can usually get this from an ultrasound scan. Use that knowledge to get professional guidance about managing your fibroids.
2. HRT is safe. The benefits of it usually outweigh the risks. The only thing to consider is if the fibroid is causing problems before starting HRT but even in this scenario, HRT may worth trying.
3. If you experience rapid growth in the fibroids or accelerated symptoms seek help to determine the right treatment.

Find out more about Osama here and read his feature on balance on fibroids and the menopause here.

Click here to find out more about Newson Health.

Dr Louise: [00:00:11] Hello, I’m Doctor Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast we’re going to talk about fibroids, something that’s very common. And often people have lots of questions both on social media and in my clinic as well. So I’ve got the great privilege of having Osama Naji with me, who has been talking on my podcast before about bleeding when, especially on HRT. So that’s a great podcast to listen to. So I’ve invited him back again. He’s a leading gynaecologist in London. We do a lot of work behind the scenes, including some research together. So welcome back to the podcast today. [00:01:31][80.8]

Osama: [00:01:32] Thank you so much for having me again. It’s always a pleasure to talk to you. [00:01:35][3.2]

Dr Louise: [00:01:36] So fibroids just let’s just get straight into it really. They’re really common. Different people, different papers I’ve read have said different things. Some say two out of three women, which is a lot. So the majority of women have fibroids. They’re more common in certain races and certain ages of women. But just let’s just go for it. What are fibroids? [00:01:55][18.8]

Mr Osama: [00:01:56] Lovely. Thank you very much. Thanks again for having me. I’m delighted to be with you today and hopefully we will find the next few minutes we are going to talk to be useful, informative to your audience and to your team as well. So fibroids are common benign tumors of the genital tract. In particular they belong to the muscle layer originally from the uterus. They are very common like we said. And we will try and we call it mansplain and explain it in very simple terms. [00:02:24][28.4]

Dr Louise: [00:02:25] Perfect. [00:02:25][0.0]

Osama: [00:02:25] So they can make comments about their symptoms, their potential problems, as well as what are the available solutions for them. So fibroids are very common. They are particularly increasingly common recently because we are getting better to notice them. And patients are also more aware of them. So when they report any unusual symptoms, quite often fibroids get picked up during routine examinations, during routine imaging from accidents and emergency department visits. And you know, when a woman presenting for some months specific pelvic pain or abdominal pain related initially probably to a renal tract/abdominal problem and then, oh, by the way, there is a fibroid here. So therefore they manifest not in a very straightforward symptoms unless they are reaching a certain size and a certain number. But to simplify it, these fibroids are affecting approximately maybe 1 in 4 to 2 in 4 women. And they tend to trouble the woman in the spectrum of four main symptoms. So heavy menstrual bleeding. Number two is abdominal pain. Number three is pressure symptoms and pressure symptoms I mean, because the uterus is located in the pelvis surrounded by other pelvic organs, primarily the bladder in the front and the large bowel in the back. So depends on their location, these may exhibit some pressure symptoms. And therefore we call it indirect manifestation of these fibroids. So that’s number three. And number four is infertility. However the woman may struggle with one, two, three or all of them or none of these symptoms. And depending on three factors, the number of the fibroids, the size of these fibroids, and the location of these fibroids. The uterus, very sophisticated pelvic organ has got three layers in particular. So therefore the fibroids could interfere with the outer layer, with the inner layer or the middle layer. So it depends on their location towards the top part of the uterus, towards the lower part or towards the middle part. So therefore location is crucial to understand the symptoms of these fibroids. And therefore we call it fibroid mapping. Based on the fibroid mapping we can tell and connect the dots to which symptoms. I keep saying it to my patients. Every fibroid has got a single bond story. There is no standardised treatment. So and it is unfair or unjust to the patient or to the pathology to standardise a universal approach for them. [00:05:12][166.7]

Dr Louise: [00:05:13] And it’s very similar as, you know, to menopause and perimenopause, everyone’s individual and have individual symptoms. But certainly a lot of women I see have had a scan for another reason, or maybe because they’ve had bleeding and then the fibroids found. And sometimes people will say, well, the bleeding is because you’ve got a fibroid and it might not be or they might have urinary symptoms and it might be because they’ve got some genitourinary syndrome of the menopause related to low hormones. And it’s not the fibroid, because you do look at the scan report and the fibroid is very small and it’s nowhere near the bladder, and you think, well, how can that be pressing on the bladder? So it’s really important, isn’t it, to if you have fibroids, actually know exactly whether you’ve got one or more or where they are it’s crucially important, isn’t it? [00:05:59][45.2]

Osama: [00:05:59] 100%. So it is a that’s a very useful good point you highlighted Louise. So abnormal uterine bleeding is one of the very commonest gynaecological presentation. And to reassure your audience and the patients in general, the vast majority, 60 to 70% of the causes of abnormal uterine bleeding, it’s called functional. It’s due to an element of the hormonal imbalance between the two guardian angels of the reproductive system, which is oestrogen and progesterone. And this mechanism could be disrupted to a variety of reasons. But we call it functional. And the remaining 20, 30%, we call it organic. And the fibroid comes on top of this. So but other causes could be ovarian cyst, could be polyps, it could be fibroid and could be endometriosis. So therefore the picture often correlates. You have a mixture of functional bleed as well as organic bleed. But the sensible approach before we blame it on the functional part, it is prudent to exclude organic parts to make sure today, well there’s nothing going on, this is probably a little bit of hormonal imbalance and can always be adjusted, self resolved once we remove the root cause for it. Whether it is stress, whether it’s travel, whether bereavement, whether exams, these are the common triggers for transit hormonal imbalance. And once we exclude that, then we can safely blame it on that part. But if it is from a fibroid, then we will probably need to talk about the mapping of these fibroids. And like you said, very right. But the fibroids are too small, they are unfair to be blamed for whatever symptoms are presenting at the time. [00:07:46][106.8]

Dr Louise: [00:07:47] Yeah, and do most people have one fibroid or is it more common to have more than one? [00:07:50][3.7]

Osama: [00:07:52] Again, also a very good point. So fibroids generally tend to come like a solitary and they tend to grow or multiple small scattered ones. And it is very difficult to expect which type. It depends on environmental factors. It’s also a lot of research highlighting the ethnicity, for example, of the patient. For example, a woman with the black Asian ethnicity, they tend to have a little bit on the larger size of the fibroids. And while white Caucasian women, they tend to have probably smaller but multiple fibroids. So it’s not easy to predict how many fibroids will be. It’s just generally they are common but on different type, on location. But it’s most of the times it’s individualised. [00:08:39][47.2]

Dr Louise: [00:08:41] And do fibroids get bigger or smaller or do they change in size when people become menopausal? [00:08:46][5.2]

Osama: [00:08:47] So now this is important, simply because fibroids they love oestrogen. They have oestrogen affinity. They depend, they strive, survive and start to cause more problems when there is a lot of oestrogen and the woman during a productive lifespan, there is a lot of oestrogen in the circulation. And these fibroids, they take advantage of that and therefore they start to exhibit more problems. So naturally, when you reach the age of the menopause, it is reasonable to predict that fibroids will start to behave themselves. They will not cause many problems. In the vast majority of cases. There remain to be because every single tissue in the body there are precursors to turn cancerous. But it depends on various aspects of various risk factors. Fibroids, reassuringly, so far they are benign tumours. But in a very small tiny minority from born about 1 in 5,000, particularly after the age of 50, they could turn into sarcoma and sarcoma because we are on a privilege to working in a cancer centre, we see maybe a little bit more of these sarcomas because we are probably a tertiary referral centre. And I can say a couple of warning signs when suspected fibroids to exhibit sarcomatous behaviour. Number one, generally towards the mid-forties plus and above. And when you notice a very rapid exponential growth in the pattern of this fibroid. So you can tell the woman that I’ve noticed my thumb is getting increasingly bigger within a very short period of time. And you will notice also a very sudden onset behaviour and the change of the menstrual bleeding or pain or the pressure symptoms. Because these fibroids, when they grow, they grow the problem with it. So therefore everything will be exaggerated over a relatively short period of time. So therefore this is a warning sign. Please be advised that this is warrants a little bit further checks by certain form of imaging. So to answer your question towards the menopause they tend to settle more or less. [00:10:58][130.7]

Dr Louise: [00:11:01] That’s interesting because often, as you know, we see a lot of people who have been found to have fibroids, they may or may not have symptoms with them, but they’re told they can’t have HRT because of fibroids. And obviously, if someone’s got a womb, we always give progesterone. And I have read some information that, you know, progesterone can be very beneficial at reducing the growth of fibroids as well. So I know that you’re in agreement. I presume you still are with me, that people who have fibroids can still usually have combination, when I say combination, I mean oestrogen with progesterone and testosterone if they need it, HRT. There isn’t good quality evidence that having the right dose and type of HRT will be detrimental to fibroids. [00:11:46][44.9]

Osama: [00:11:46] 100%. Please, this is a fact to reassure your audience and your team. Fibroids are not contraindication to prescribe HRT. This is fact there is no harm from prescribing. The only fact is for asymptomatic fibroid. This is more applicable. For symptomatic fibroids. It is probably useful to warn or to advise the patient that although it’s not contraindicated. But beware because you are giving oestrogen and progesterone this is a balance though. Not unbalance. However, I really do not like it. So the only way is to start and see what difference that would make based on that. After that, because the HRT has several other benefits. So therefore we need to balance if you are experiencing some side effects. That the fibroids started to wake up because of this HRT. What is the balance of continuing controlling vasomotor symptoms, improving cognitive function? Increasing the energy? Are these the benefits worth to me to continue on the HRT while I deal the side effect of these fibroids. And that’s where the lack of very consolidated counselling advice. It’s open discussion between the clinician and the patient. [00:13:05][78.4]

Dr Louise: [00:13:06] Absolutely. Yeah, and I think, I mean, this is this goes back to anything in medicine. We can never say everybody can or everybody can’t. And everyone is the same pattern because everybody is different. And like, you know, a lot of women, when they start taking HRT or their dose of HRT has changed for the first 3 to 6 months, they can have bleeding. And then if they have an investigation and found a fibroid, it’s very easy to blame the fibroid. So it’s really important in anything in medicine that we make sure we know what the cause is. But also I do see a lot of women who have had fibroids. They know they’ve had fibroids. They might or might not have caused problems in the past. They might have settled down when they’re menopausal and they might have had a resurgence of symptoms. But I’m surprised that there is still quite a few women I see who’ve been told that they can’t have treatment, but there is treatment for fibroids. Do you mind explaining what different treatments are available for fibroids? [00:13:59][53.7]

Osama: [00:14:00] Yes, absolutely. So if we stick back to the original equation, we discussed fibroids four potential symptoms – bleeding, pressure, pain, and maybe infertility, although maybe some applicable less applicable to some patients. And the other factor is number, size and location. So we have to connect the dots with the current symptoms of the patient to tailor the treatment and the treatment in general by do nothing and approach and just monitor or medical or surgical. And it’s always you have to display the entire clinical picture to the patient, explain the risks, benefits, advantages. So that can be discussed before. It’s difficult to standardise like fibroids surgery, fibroids medicine, tablets. It doesn’t work like this. Every single patient is its own story. Every single fibroid, own story. So therefore the idea is we have to first get the fibroid mapping and match it with the symptoms so that you can tailor the treatment taking the patient, which is taking the patient’s preferences on board. And then we can always tailor a treatment. [00:15:12][71.6]

Dr Louise: [00:15:13] And it’s interesting isn’t it, lots of women and men actually know their bodies really well. And I’ve had some patients over the years who have always had a fibroid and they aware that it’s there, and then when it’s removed, they just feel so much better. And it’s almost like, especially when they’ve got bigger fibroids and they can cause some dragging sensations or like, you say, some bladder problems and they’ve sort of put up with it and it’s like anything really. It’s like having a toothache. It’s not until you’ve seen the dentist you realise how bad that toothache is. And so for some people, they’re not causing any bleeding, they’re not causing any pain, but they might just be causing some discomfort because fibroids can get quite big for some people can’t they. [00:15:53][40.3]

Osama: [00:15:53] Yeah, absolutely. Yeah. That’s why they could be reaching like we compare the size of the uterus when there’s a fibroid by the size of the pregnancy. So when we do the clinical examination equivalent to 16 weeks size uterus, a 20 week size uterus. We see patients we call it full term sized uterus because of the fibroid. But another narrative, for example, I have a special interest in fibroids. That’s why it’s a dear subject to me. So patient I saw recently troubled with fibroids. It is deemed suitable for surgery for some form of surgical intervention. No, what we explained again, we put the mapping, we put the clinical symptoms, we marry them, we form a clinical judgement. And therefore she said OK, what’s the treatment now? I told her based on these factors, surgery, however, are these symptoms to you troubling enough to justify surgery? Surgery doesn’t come easy. Although surgical gynaecology these days now is reached a very, very advanced safe levels with enhanced operating with lots of skills, experience, equipments to make it a sophisticated type of surgery. However, still a risk, you’re going to general anesthesia or you are going under local anesthesia is a surgical intervention. So the question is now having known the problem, now having known the treatment, this is your decision you need to make. Is the problem enough troublesome to me to go for surgery? Quite often, they said now I know. Now I am reassured I can put up with it. Let’s see how I go. Let’s see how much I can cope with to avoid surgery or vice versa. [00:17:33][99.2]

Dr Louise: [00:17:33] Yeah, and it is weighing up that individual risks and benefits that we do for any treatment. And sometimes people have what we call surveillance, where, like you say, you might monitor and do the scan, you know, every 6 to 12 months and see if it changes at all or if symptoms change and even like for, you have mentioned about it could affect fertility. A lot of them don’t affect fertility depending on where they are. But if someone did get pregnant with a fibroid, if the position is OK, it’s not going to affect the pregnancy detrimentally is it? [00:18:04][31.3]

Osama: [00:18:05] At all, absolutely. Which is this is hugely important. When it comes to fibroids and infertility, not every fibroid cause infertility. Fertility is multifactorial, multifaceted approach. There is in the female, which I often explain very sophisticated system. We are very shallow compared to you guys. So they’ve got an ovarian factor, there is age related factor, there is ovarian in reserve. There is tubal factor, there is uterine factor. So the fibroid belongs to the uterine factor, which is not the most common type of the factors of the fertility compromising factors. So only the fibroids that of reasonable size, of reasonable proximity to the in the material cavity, to the uterine cavity, they could potentially interfere with fertility. On the other hand, if the conception happens spontaneously when there is fibroid onboard, then this will trigger probably consultant led obstetric care because these fibroids, trouble the baby. They may trouble the embryo. They may cause a miscarriage. They may cause early labour. They may cause, antepartum haemorrhage, postpartum hemorrhage. So that’s why, again, depends on the number, on the location and on the effect, or some fibroids that are way away from the action point and therefore they can just simply be ignored. [00:19:26][80.7]

Dr Louise: [00:19:27] Yeah. So the important thing is being monitored and assessed and certainly by someone who understands fibroids is crucially important. And there are some clinics that do this embolisation don’t they, this uterine artery embolisation. Can you explain what that is. [00:19:43][15.4]

Osama: [00:19:44] Yes. Thank you. Embolisation is now it’s been in clinical practice in excess of 20 years. It is improving as well. It’s a noninvasive method. It’s offered by interventional radiologist. And luckily there are several of them who are very skilled. And this procedure is basically a procedure without a general anaesthesia and aiming to block the blood supply supplying the uterus internally. And the aim with it is to attract the reduction in the blood supply to the fibroid. And therefore you would expect the fibroid to shrink in size. And the idea is to achieve a satisfactory reduction by at least 30 to 40% of these fibroids. They are not designed to make the fibroid disappear at all, but they work in certain criteria. There are certain indications for it. For example, ideally you need the fibroid to be sizable enough so the shrinkage can be noticeable enough. Fibroid who are two-three centimeters there is little value from this intervention and there is little value from any intervention for that. While fibroids that are ten centimeters and above these are the fibroids that could potentially respond satisfactorily and reduction in size. But the other parameters is fertility wishes as well of the women is desiring fertility so maybe embolisation needs to be counselled thoroughly, although now there are reported cases for successful pregnancy after embolisation. These need to be to be counselled very, very carefully with the risks and benefits of a future implantation, future ongoing pregnancy and childbirth. And finally, again, women who are deemed for any reason at higher risk for surgical intervention or not safe to have surgical intervention, or they don’t prefer to have a surgical intervention, this could be a happy medium. They have a large fibroid that is troublesome enough to require some form of removal, but the surgery is not desired or not advised. Then the embolisation will come as a reasonable option with it and obviously as an intervention, it comes with its own consequences, side effects. The fibroids may not respond to it. Most of the times they do, it is a small proportion they may not. They may probably need more than one embolisation session in the future, although a very small minority. And there is also a sequalae we call it post embolisation syndrome, which is the fibroid undergo exaggerated level of necrosis and ischemia. And they could cause variety of symptoms, including bad infection, including requiring emergency surgical intervention. But these will be counselled thoroughly, adequately reasonable by the specialist radiologist who’s performing them. [00:22:35][171.7]

Dr Louise: [00:22:37] So there’s lots of options. And it’s great talking things through because there has been so much confusion. And I often get a lot of messages from people asking about fibroids, but it’s particularly reassuring about the whole HRT question and fibroids, because that is really good for people to listen from a leading expert. And we have written an article together that’s on the website, but also it’s on the balance app as well that we’ve written so that people can understand more. So it’s great going through everything. Before we finish, I always ask for three take-home tips. So three things that if a woman has just recently been diagnosed with fibroids, what are the three things that she should find out which will help her to lead and have a shared decision making regarding her treatment going forwards? [00:23:24][47.5]

Osama: [00:23:25] Thank you very much. So let me summarise it in three points. Number one, be assured fibroids are benign conditions. So without attracting anxiety, panic about it, they are very common. Most of the times are treatable and most of the times can be harmless. Just being aware of them is what we need, but therefore seek the right fact about it. Fibroid generally needs to be marked by an ultrasound scan. If they are of substantial size, they may need other forms of imaging modality. So understanding all the facts. Knowledge is power. When you understand the fact, your judgement will be better, your clinical decision will be better and the patient decision will be better. So establish the facts of these fibroids: number, location, size and this is often available by ultrasound scan. And seek professional guidance and advice about managing of these fibroids. Most of the time do nothing approach is all what you need to do. And this is fact number one. Fact number two, HRT are safe and fibroid. The benefits of it way more the risks and fibroids are not interfering with this equation. Only in very small minority when the baseline before starting HRT fibroids are diagnosed to be causing problems. And even in that scenario, HRT may worth trying because they may not disrupt this problem at all, they may make it a little worse. And fact number three about sarcoma, please be aware that if you experience rapid growth in the fibroids accelerated exhibition of the symptoms of the problem of the fibroid, just be aware that could be a small, teeny tiny risk of abnormalities in there. [00:25:21][115.6]

Dr Louise: [00:25:23] Excellent. So know your body, know your symptoms. Make sure you know when to receive help and make sure that you are part of this shared decision making process so you can choose the right treatment or there might not be any treatment that’s needed. So thank you so much for your time. It’s been really informative and I’m hoping very enlightening and reassuring for a lot of people listening. So thank you. [00:25:43][20.7]

Osama: [00:25:44] Thank you so much Louise, pleasure. [00:25:45][1.0]

Dr Louise: [00:25:50] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk, and you can download the free balance app on the App Store or Google Play.

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