Can uterine fibroids (leiomyomas) cause abnormal bleeding in a 62-year-old postmenopausal woman?

Uterine Fibroids and Abnormal Bleeding in Postmenopausal Women

In a 62-year-old postmenopausal woman, uterine fibroids are unlikely to be the primary cause of abnormal uterine bleeding, and endometrial cancer must be ruled out first through appropriate evaluation. 1, 2

Pathophysiology of Fibroids in Postmenopausal Women

• Uterine fibroids (leiomyomas) are hormone-dependent benign tumors that typically:

  • Respond to estrogen stimulation during reproductive years
  • Naturally regress after menopause due to decreased circulating estrogen levels 2
  • Are not considered precancerous lesions for endometrial cancer 2

• In postmenopausal women:

  • Continued fibroid growth or new-onset bleeding should raise suspicion for malignancy rather than being attributed to the fibroids themselves 2
  • The risk of malignancy in women with presumed fibroids increases with age (from 2.94 per 1,000 overall to 10.1 per 1,000 in women aged 75-79) 2

Diagnostic Algorithm for Abnormal Bleeding in a 62-Year-Old Woman

1. First-line imaging: Transvaginal ultrasound (TVUS) with Doppler

   • Most appropriate initial imaging modality 1
   • Evaluates endometrial thickness and identifies structural abnormalities
   • If endometrium remains <4 mm in a postmenopausal woman, the negative predictive value for cancer is nearly 100% 1

2. Endometrial sampling:

   • Required for postmenopausal women with fibroids and abnormal uterine bleeding to rule out endometrial cancer 2
   • Should be performed regardless of ultrasound findings in this age group

3. Additional imaging if needed:

   • MRI with diffusion-weighted imaging if ultrasound is inconclusive or if there's suspicion of malignancy 1
   • Sonohysterography if focal endometrial abnormality is detected on TVUS 1

Important Considerations and Pitfalls

• Common pitfall: Attributing abnormal bleeding to fibroids in a postmenopausal woman without ruling out endometrial cancer

  • Endometrial cancer is the most serious etiology and the main focus of evaluation in postmenopausal women with abnormal uterine bleeding 1

• Structural causes of abnormal uterine bleeding in postmenopausal women:

  • Endometrial cancer (primary concern)
  • Endometrial polyps
  • Endometrial hyperplasia
  • Fibroids (less common primary cause in this age group) 1, 3

• Risk factors for endometrial cancer that should be assessed:

  • Obesity (relative risk 2.54)
  • Hypertension (relative risk 1.81)
  • Diabetes mellitus (odds ratio 2.1)
  • Unopposed estrogen therapy (10-30 fold increased risk with 5+ years)
  • Tamoxifen use (relative risk 2.53) 2

Management Approach

• If fibroids are confirmed as the cause of bleeding (after ruling out malignancy):

  • Most fibroids decrease in size during menopause and become asymptomatic 4
  • Medical options for persistent symptoms include:
    • Tranexamic acid
    • Non-steroidal anti-inflammatory drugs
    • Selective progesterone receptor modulators 3, 5
  • Surgical options if medical management fails:
    • Hysterectomy (most definitive)
    • Uterine artery embolization
    • Myomectomy (less common in this age group) 4, 6

• Critical warning sign: Any increase in fibroid size or new abnormal bleeding in a postmenopausal woman warrants immediate evaluation for malignancy 2