Uterine fibroids are noncancerous tumors that can grow in the uterus and can cause a host of painful and often life-impacting symptoms. Statistics show that 80% of all women will experience fibroids before the age of 50, but only 30% of these women will seek treatment for fibroid symptoms.
The most common symptom due to fibroids is heavy menstrual bleeding. The medical term for this condition is menorrhagia. The National Institute for Health and Clinical Excellence defined it as:
Menorrhagia is excessive menstrual blood loss, which interferes with a woman’s physical, social, emotional, and/or material quality of life.
A normal menstrual cycle occurs every 25-31 days and lasts from 3-7 days. Periods are considered heavy if a woman:
- Soaks through one or more sanitary pads or tampons every hour for several consecutive hours.
- Needs to use double sanitary protection to control menstrual flow.
- Needs to wake up to change sanitary protection during the night.
- Bleeds for longer than a week.
- Passes blood clots.
- Experiences signs of anemia like fatigue, brain fog, migraine-like headaches, and chewing/craving ice.
Women can experience breakthrough bleeding in between their periods, (metrorrhagia), or periods that occur closer together than normal (polymenorrhea). Menorrhagia affects around 10 million women in the United States every month and the most common reason is fibroids.
Often women with heavy periods don’t recognize this as being heavy, typically because they have been bleeding this way for some time and consider it normal. This can lead to delays in treatment.
How Do Fibroids Cause Heavy Or Prolonged Bleeding?
Each month, the lining of a woman’s uterus builds up and thickens, and later, if there is no fertilized egg to implant, the lining is discarded. The uterus naturally contracts to assist in removing the lining, and this is why some women experience cramping and discomfort. The shedding lining presents itself as a menstrual period with bleeding that lasts between 3-7 days.
When a woman has fibroids growing on or within the lining of her uterus, they can interfere with the natural functions of the uterus. They can distort the shape of the uterus and cause heavy bleeding because:
- Abnormal pressure exerted on the lining of the uterus causes it to bleed more than normal.
- The ability of the uterus to contract may be interrupted, rendering it unable to stop the bleeding.
- The growing fibroids can spur the growth of blood vessels, which can result in heavy menstrual bleeding, intermittent periods, or breakthrough bleeding.
- Elevated hormone levels can cause abnormally heavy bleeding during menstruation.
In addition to heavy bleeding, fibroids can also cause a host of other unpleasant symptoms, such as pelvic pain and pressure, back and leg pain, nausea, constipation, bloating, enlargement of the uterus and abdomen, and pain during sex. If fibroids are not treated, they will continue to grow larger, new ones may form, and heavy bleeding often becomes worse.
Fibroids that are near the uterine lining, or that affect blood flow to the lining, may be associated with heavy, painful, or prolonged periods and spotting between periods. Fibroids vary in size, number, and location, and some cause no symptoms. The NIH lists heavy bleeding, anemia, bleeding between periods, pelvic pressure, urinary symptoms, pain during sex, and lower-back pain among possible fibroid symptoms.
Heavy Bleeding Does Not Always Mean Fibroids
Fibroids are one possible cause of heavy or irregular bleeding, but symptoms alone cannot confirm the diagnosis. Other possible causes include adenomyosis, uterine polyps, hormone or ovulation changes, thyroid disease, bleeding disorders, infection, pregnancy-related complications, some medications, and, less commonly, cancer. New bleeding between periods, after sex, during pregnancy, or after menopause deserves medical evaluation rather than self-diagnosis.
NICE guidance on heavy menstrual bleeding recommends investigating the cause and choosing treatment in light of the patient’s symptoms, priorities, and preferences. If the main change is spotting outside the usual cycle, the published article Can Fibroids Cause Spotting Between Periods? explains the distinction between spotting, light bleeding, and breakthrough bleeding.
When Is Heavy Bleeding Urgent?
| Situation | Suggested next step |
|---|---|
| You experience a new pattern of heavy, prolonged, painful, or between-period bleeding without severe symptoms. | Set up an evaluation with your doctor to help determine the underlying cause. A cycle and symptom diary can help your doctor decipher the pattern. |
| Repeatedly soaking through protection, passing large or frequent clots, or having fatigue, weakness, dizziness, shortness of breath, or a racing heartbeat. | Contact a healthcare provider promptly because blood loss may be causing anemia. The published article Fibroids and Anemia explains the connection in more detail. |
| Very heavy vaginal bleeding with fainting, severe weakness, lightheadedness, chest pain, trouble breathing, or sudden severe pelvic or abdominal pain | Seek emergency medical care. Do not use a routine appointment form for an emergency. |
Cleveland Clinic advises seeking emergency care when bleeding through two or more pads or tampons each hour continues for two to three hours. Johns Hopkins also advises emergency care for severe vaginal bleeding with signs of anemia or for sudden, severe abdominal pain.
How Fibroid Bleeding Is Evaluated
An evaluation usually begins with the timing and amount of bleeding, associated pain or pressure, pregnancy possibility, medications, contraception, and the effect on daily life. Depending on the situation, your doctor may use a pelvic examination, blood testing, or imaging.
- A complete blood count can check for anemia, and iron testing may help confirm iron deficiency.
- Pelvic ultrasound is commonly used to look for fibroids and other structural causes.
- An MRI can provide more detailed information when needed for determining size, placement, and the number of fibroids that exist to help with a treatment plan.
The right work-up depends on your age, symptoms, medical history, and pregnancy status.
The FDA’s uterine fibroid guide describes ultrasound, saline ultrasound, MRI, and blood tests such as a complete blood count and iron levels as possible parts of a fibroid evaluation.
Your bleeding pattern is worth discussing, even if it has felt “normal” for years.
Start with an evaluation to identify the cause. If fibroids are confirmed and you would like to understand nonsurgical options, request an appointment with Atlanta Fibroid Center.
Anemia: A Dangerous Side Effect Of Heavy Bleeding
Three types of blood cells are continually created by your bone marrow: white blood cells, red blood cells, and platelet blood cells. The red blood cells are the ones that carry oxygen throughout your body and contain hemoglobin. Hemoglobin is a protein that contains iron and is vital as it transports oxygen from the lungs to every part of the body and also assists in expelling carbon dioxide. With heavy periods, the amount of iron and hemoglobin lost in the blood is too much to be able to be replaced by a normal diet or even supplementation. This leads to iron deficiency anemia.
Fibroids are the most common cause of prolonged heavy bleeding that can lead to anemia. The continual loss of blood decreases the level of hemoglobin carrying red blood cells and causes fatigue, headaches, “brain fog,” dizziness, sallow skin, insomnia, hair loss, brittle nails, irregular heartbeat, as well as a condition called “pica” where you experience abnormal cravings for things like ice, corn starch, dirt/clay (kaolin), or chalk. These symptoms of anemia can often affect a woman’s quality of life and in severe cases can become very serious or even life-threatening.
Video: Why Do I Chew Ice? Anemia Due to Fibroid Heavy Bleeding
Treatments For Fibroid Bleeding
Approximately 1 in every 3 women that are diagnosed with fibroids will eventually seek treatment to alleviate their symptoms. Besides heavy bleeding, fibroids can cause pain and pressure in the pelvic area, back and leg pain, bloating, protruding abdomen, constipation, urinary incontinence or frequent urination, pain during intercourse, fertility issues, and more.
Fibroid symptoms can sometimes be so debilitating that they can destroy a woman’s quality of life and adversely impact relationships. For these women, finding a solution becomes imperative. There are non-surgical and surgical treatments available to alleviate the symptoms and heavy bleeding caused by fibroids. Some of these treatments merely lessen the symptoms caused by fibroids but do not address the fibroids directly.
Over The Counter Solutions
Over-the-counter medications can help alleviate the pain, bloating, and discomfort that fibroids can cause. Medications like Naproxen and Ibuprofen are pain relievers and anti-inflammatories that can be used. A medication that is helpful for heavy bleeding is a relative of ibuprofen and acts directly at the uterine lining to lighten flow. This medication is only available as a prescription and is called tranexamic acid.
Hormone Therapies To Treat Heavy Bleeding
Many doctors will prescribe hormone therapy before recommending surgery for the relief of fibroid symptoms. Some of these may be:
Birth control pills or IUDs are sometimes prescribed with the intention of regulating hormones and controlling bleeding. However, hormones (particularly estrogen) will cause the fibroids to grow, and, eventually, this type of therapy will cease to work because of this.
SPRMs: Selective Progesterone Receptor Modulators block progesterone receptors, which results in decreased thickness of the uterine lining, and were first used as an emergency contraceptive. Studies to treat uterine fibroids were performed, but a number of women experienced liver damage, resulting in liver failure, and some required liver transplants. This medication lost its license and was removed for use in fibroids in March of 2020.
GnRH agonists: Gonadotropin-releasing hormone agonists suppress ovulation by blocking the production of estrogen and progesterone. The most common of this class is leuprolide acetate, or Lupron. Women receive Lupron as an injection monthly for 3-6 months or a larger dose every 3 months for up to 6 months. The most common indication is used in patients who are too anemic to operate safely on.
Lupron typically puts a woman into immediate menopause, and this will buy time for the surgeon to build up the patient’s iron and hemoglobin to be able to undergo surgery. There will be about a 30% reduction in the size of the fibroids while on this medication. It can make myomectomy surgery more difficult in women on Lupron due to a change in the interface between the fibroids and the rest of the uterus while on this drug. Once this medication is stopped, the fibroids will grow and return to their original size. There are significant side effects for women taking Lupron, most notably significant are hot flashes.
GnRH antagonists are hormone therapies that are only used for a short-term solution to inhibit the growth of fibroids. In addition to bringing on early menopause, they have other known negative side effects, and when the patient stops using GnRH therapy, the fibroids begin to grow again. These medications were developed to try to address the negative side effects of Lupron, most notably the severe hot flashes, significant bone loss, and injection-only formulation.
Elagolix and Oriahnn (Elagolix plus birth control pill) are examples of this class of medicines. There are Lupron-like side effects, and with Oriahnn there is the added risk of blood clots and stroke. There are also no long-term studies on these medications when used for fibroids. Given the history of the SPRMs (see earlier) and the availability of treatment options that have over 25 years of safety and efficacy (Uterine Fibroid Embolization), caution should be used in this class of medications until more independent research is performed.
SERMs: Selective Estrogen Receptor Modulators block the effects of estrogen in specific targeted areas. SERMS are used to treat estrogen-receptor-positive breast cancer, tamoxifen being the best known, but there has not been sufficient research done to prove that fibroids shrink in response to these agents. They are known to cause serious side effects including blood clots, possibly uterine cancer, and stroke. Other side effects that can occur are abnormal vaginal bleeding/discharge, pelvic pain, chest pain, shortness of breath, dizziness, headaches, fatigue, night sweats, hot flashes, mood swings, etc.
Endometrial Ablation To Treat Heavy Bleeding
Endometrial ablation is a procedure that strips the outermost layer of the uterine lining to stop or reduce the flow of heavy or continual menstruation and is best used for patients who do not have fibroid-related bleeding. This is due to the fact that ablation only affects the lining, but does not do anything to the fibroids which are causing the heavy bleeding.
In addition, these patients often have bulk-related symptoms, like pelvic pain and pressure, bloating, back and leg pain, increased urinary frequency, which are completely unaffected by ablating the uterine lining. These patients may be better treated with Uterine Fibroid Embolization (UFE). UFE is not surgery but treats all of the fibroids, bleeding, and bulk-related symptoms. It can also be performed in women interested in fertility, whereas women interested in future fertility cannot undergo endometrial ablation because it permanently destroys the uterine lining.
Video: UFE Vs. Endometrial Ablation
Surgery For Fibroid Removal To Stop Heavy Bleeding
There are a few procedures for surgical removal of fibroids, and each surgery can be performed using several techniques.
Myomectomy is the surgery to remove fibroids one at a time by basically dissecting them out of the uterus. The surgeon will then stitch the uterus back together, but the uterus is often weakened. Different surgical techniques used to perform a myomectomy are open myomectomy, laparoscopic myomectomy , and hysteroscopic myomectomy (like MyoSure). The recurrence rate of fibroids is about 62% within 5 years, and patients usually undergo additional surgeries.
Hysterectomy is a surgery that removes a woman’s uterus and sometimes, the cervix, ovaries, and fallopian tubes. There are different methods to perform a hysterectomy as well. After a hysterectomy, a woman can not become pregnant, and there are side effects and risks associated with a hysterectomy including organ damage, hemorrhage, blood clots, sexual dysfunction issues, incontinence, bone density loss, early menopause, and increased risk for heart disease.
Non-Surgical Fibroid Treatment To Stop Heavy Bleeding
Uterine Fibroid Embolization (UFE) is an outpatient procedure that does not involve surgery. It works by cutting off the blood supply to the uterine fibroids and shrinks or eliminates them entirely. The blood supply is blocked to the fibroids and they immediately begin to die off. As this occurs, the fibroids soften and shrink, and within 3 months, fibroid bleeding and other symptoms are significantly better or gone entirely for most patients.
This procedure does not require a hospital stay and the results are permanent. The recovery time is typically 5-7 days and one of the best things about UFE is that it allows women to keep their uterus and many have children afterward!
Where To Get Help With Fibroid Bleeding
John C. Lipman, MD, FSIR , is a board-certified Interventional Radiologist, with over 25 years of experience in performing UFE. He is one of the world’s leading fibroid experts with extensive experience in the UFE procedure and over 10,000 women treated. Despite what a woman might hear from her Gynecologist, almost every woman that is a surgical candidate will be a candidate for UFE.
If you are experiencing fibroid bleeding and other symptoms related to fibroids, call today to set up a consultation or request a second opinion if you have received a surgical diagnosis. The mission of the Atlanta Fibroid Center is to help you get your life back without any surgery and without sacrificing your uterus.
Frequently Asked Questions About Fibroids And Bleeding
Can fibroids cause spotting between periods?
Yes. Fibroids can be associated with spotting or bleeding between periods, especially when they affect the uterine cavity or lining. Because infections, contraception, pregnancy-related conditions, polyps, and other causes can also produce this symptom, new or persistent spotting should be evaluated.
Does heavy bleeding always mean I have fibroids?
No. Fibroids are one possible cause, but heavy bleeding can also be related to adenomyosis, polyps, hormone or ovulation changes, thyroid disease, bleeding disorders, medications, pregnancy complications, infection, and other conditions. An evaluation is needed to identify the cause.
What tests may be used when fibroids and anemia are suspected?
Your doctor may order a complete blood count and iron testing and may use pelvic ultrasound to look for fibroids or other structural causes. MRI or other tests may be added when the clinical situation or treatment planning requires more detail.
Can keeping track of pads, tampons, clots, and bleeding days help?
Yes. Recording how often you change protection, whether you need double protection, the number of bleeding days, the presence and approximate size of clots, bleeding between periods, and symptoms such as dizziness or shortness of breath can give your healthcare provider useful information. It does not replace an examination or testing.
Can UFE help with heavy bleeding caused by fibroids?
UFE is a minimally invasive treatment that blocks the blood supply to fibroids so they shrink. It may reduce fibroid-related bleeding and other symptoms for appropriate candidates, but it is not the right option for every person or every cause of bleeding. A clinician should first confirm the diagnosis and discuss benefits, risks, alternatives, and fertility goals.
