Can fibroids (uterine leiomyomas) cause postmenopausal bleeding?

Fibroids and Postmenopausal Bleeding

Yes, fibroids can cause postmenopausal bleeding, but uterine sarcoma and endometrial cancer must be ruled out first as the underlying cause, especially in postmenopausal women. 1, 2

Diagnostic Approach for Postmenopausal Bleeding with Fibroids

1. Initial Evaluation:

   • Transvaginal ultrasound with Doppler is the first-line imaging modality to:
     • Evaluate endometrial thickness (critical in postmenopausal women)
     • Identify fibroid location, size, and number
     • Assess for features of malignancy 2

2. Endometrial Assessment:

   • Mandatory endometrial biopsy to rule out endometrial hyperplasia or cancer 2
   • If endometrium remains <4 mm in a postmenopausal woman, the negative predictive value for cancer is nearly 100% 2

3. Further Imaging:

   • MRI with gadolinium and diffusion-weighted imaging if ultrasound is inconclusive 2
   • Sonohysterography for better characterization of submucosal fibroids 2

Important Considerations

• Fibroids typically regress after menopause due to decreased estrogen levels 2, 3

• Red flags that suggest malignancy rather than benign fibroids:

  • Continued fibroid growth after menopause
  • Persistent bleeding despite treatment
  • Rapidly enlarging fibroids 1, 2

• Risk of unexpected uterine sarcoma is higher in older patients (up to 10.1 per 1,000 in patients 75-79 years) 1

Management Options for Postmenopausal Bleeding from Fibroids

1. For Submucosal Fibroids Causing Bleeding:

   • Hysteroscopic myomectomy is the first-line conservative surgical therapy for symptomatic intracavitary fibroids after ruling out malignancy 1, 4
   • Benefits include shorter hospitalization and faster return to usual activities compared to other surgical approaches 1

2. For Fibroids Causing Bulk Symptoms:

   • Uterine artery embolization (UAE) has been shown to be safe and effective in postmenopausal patients, with complete fibroid necrosis and symptom resolution in 89% of cases 1
   • Laparoscopic or open myomectomy may be considered 1

3. Definitive Treatment:

   • Hysterectomy offers definitive resolution of all fibroid-related symptoms 1
   • Consider the least invasive route (vaginal or laparoscopic preferred over abdominal) 1

4. Medical Management:

   • Limited evidence for medical management in postmenopausal women with fibroids 1
   • Aromatase inhibitors may be considered in select cases to reduce fibroid size and stop bleeding 5

Important Caveats

• Never assume fibroids are the cause of postmenopausal bleeding without ruling out malignancy
• The risk of endometrial cancer is significantly higher in postmenopausal women with bleeding
• Hormone replacement therapy may cause fibroid growth in postmenopausal women but rarely causes clinical symptoms 4
• Obesity, hypertension, diabetes, and tamoxifen use increase the risk of endometrial cancer and should be considered when evaluating postmenopausal bleeding 2

Treatment Algorithm

1. Rule out malignancy with endometrial biopsy and imaging
2. If malignancy excluded and fibroids confirmed as cause:
   • For submucosal fibroids: Consider hysteroscopic myomectomy
   • For intramural/subserosal fibroids causing bulk symptoms: Consider UAE or myomectomy
   • For persistent symptoms or if definitive treatment desired: Consider hysterectomy

Remember that fibroids are hormone-dependent tumors that typically regress after menopause, so any growth or new bleeding warrants thorough investigation for malignancy.