Fibroids

Why they form

Fibroids grow from a single muscle cell in the wall of the womb, and their growth is driven by oestrogen and progesterone. That single fact explains most of their behaviour: they appear during the reproductive years, can grow in pregnancy, and shrink after the menopause when hormone levels fall.

Where they sit — the classification that decides everything

• Submucosal — bulging into the cavity of the womb. The most troublesome by far: even small ones cause heavy bleeding and interfere with fertility, because they distort the lining where a pregnancy would implant
• Intramural — within the muscle wall. The commonest type; causes heavy bleeding and bulk symptoms as they grow
• Subserosal — on the outer surface. Can become very large and cause pressure symptoms while barely affecting periods
• Pedunculated — on a stalk. Can twist, causing sudden severe pain

Who is more likely to have them

• Black women — around three times the risk, with earlier onset, larger and more numerous fibroids, and more severe symptoms. The disparity is well documented and still poorly acted upon
• Family history — a mother or sister with fibroids roughly doubles the risk
• Age — rising through the thirties and forties, peaking before the menopause
• Obesity, which raises circulating oestrogen
• Never having been pregnant
• Early first period
• Vitamin D deficiency — an association, though not proof that supplementing prevents them

What reduces the likelihood

Pregnancy and childbirth, and longer-term hormonal contraception. Neither is a reason to make those decisions, but both are real associations.

What fibroids are not

• They are not cancer, and they do not turn into cancer. The malignant version — leiomyosarcoma — is rare and arises separately rather than developing out of a fibroid. This is a very common fear and the reassurance is genuine
• They are not caused by anything you ate, did or failed to do
• They are not the same as ovarian cysts, endometriosis or PCOS — though fibroids and endometriosis frequently coexist, and untangling which is causing what takes some care

Fibroids are diagnosed by ultrasound. Our role remotely is to recognise the picture, arrange the right scan, test for the anaemia that is often doing the most damage, and make sure the treatment options are properly laid out rather than narrowed to one.

What we assess

• How heavy the bleeding actually is — in practical terms: how often you change protection, whether you flood or double up, how many days, whether you pass clots, whether you have missed work
• Pressure symptoms: urinary frequency, incomplete emptying, constipation, abdominal swelling
• Pain, and whether it is cyclical
• Fatigue, breathlessness, palpitations and brain fog — the anaemia questions, asked deliberately
• Fertility plans, which change the treatment entirely
• Whether you are approaching the menopause
• Family history and ethnicity, both of which are relevant here

Tests we arrange

• Full blood count and ferritin — and ferritin is the important one. You can be significantly iron deficient with a normal haemoglobin, and feel every bit as tired. A full blood count alone regularly misses this
• Thyroid function, since thyroid disease also causes heavy periods
• Clotting studies where heavy periods have been present since your very first one — which can indicate an inherited bleeding disorder, and is under-recognised
• Pelvic ultrasound, ideally transvaginal, which we refer for

What the scan report should tell you

Not just "fibroids present". Ask for, or look for: the number, the size of the largest, and — most importantly — the location of each, and whether any distorts the cavity of the womb. That last detail determines whether a hormonal coil will work, whether fertility is affected, and which procedures are options.

Further imaging

• MRI — for a precise map before embolisation or surgery, and where the picture is unclear
• Hysteroscopy — a camera inside the womb, which both diagnoses submucosal fibroids and can remove them in the same procedure

What always needs referral

Postmenopausal bleeding, a fibroid growing after the menopause, rapid growth, severe pain, urinary retention, or bleeding not controlled by treatment.

Managing heavy periods practically

• Start tranexamic acid and an anti-inflammatory on day one, not day three. Both work far better started before the heavy day arrives — the commonest reason women think they do not work
• Period pants and a menstrual cup alongside conventional protection for the worst days, which reduces the anxiety about leaking as much as the leaking
• Track your cycle so heavy days are not a surprise, and plan around them where you can
• Keep a proper record for a couple of cycles — days, flooding, clots, changes per day. It is far more persuasive at an appointment than "they're heavy", and heavy bleeding is chronically under-treated because it is under-described

Iron — which is where most of the improvement comes from

• Ask for ferritin, not just a full blood count. Iron stores fall long before haemoglobin does, and you can feel dreadful with a "normal" blood count
• Take iron on alternate days rather than daily — absorption is better and side effects fewer
• Take it with orange juice or vitamin C; avoid tea, coffee, milk and antacids within a couple of hours
• Dietary iron: red meat, pulses, dark leafy greens, fortified cereals. Helpful, but rarely enough on its own against ongoing heavy loss

General measures — honestly framed

• Maintaining a healthy weight may reduce fibroid growth, since fat tissue produces oestrogen
• Regular exercise, and treating high blood pressure, which is associated with fibroids
• Vitamin D is often low and worth checking
• No diet, supplement or herbal remedy has been shown to shrink fibroids, despite an entire market built on the claim. Anything sold on that basis is selling you hope

Questions worth asking about your scan

The most useful thing you can do at your appointment:

• Where exactly are they — and does any of them distort the cavity of the womb?
• How many, and how big is the largest?
• Given that, which treatments are genuinely options for me?
• If I want children in future, which options preserve that?
• What are the alternatives to hysterectomy in my case?

That last question matters. Uterus-preserving options are not offered evenly, and asking for them by name — hysteroscopic resection, embolisation, myomectomy, ablation — changes the conversation.

Worth saying

Heavy bleeding is not something to endure because it is "just periods". Flooding through clothes, planning your life around your cycle and being permanently exhausted are not normal, and every one of them is treatable. Women wait years before raising this, usually because they assume it is what everyone experiences. It is not.

Are fibroids cancer?

No, and they do not turn into cancer. This is the fear most women arrive with and the reassurance is genuine. The malignant tumour of the womb muscle — leiomyosarcoma — is rare and arises separately rather than developing out of an existing fibroid. What does warrant investigation is a fibroid growing after the menopause, because fibroids should shrink then.

Does the size matter?

Less than you would think. Location matters far more. A small submucosal fibroid pressing into the cavity of the womb can cause torrential bleeding and fertility problems; a large one on the outer surface may cause nothing but pressure. When you get your scan result, ask where they are, not just how big — that is what determines your options.

Do I need surgery?

Usually not. Many fibroids need no treatment at all, and medical options often control the symptoms well. Where a procedure is needed, hysterectomy is one option among several, not the default — hysteroscopic resection, uterine artery embolisation, myomectomy and radiofrequency ablation all preserve the womb. Ask for them by name if they are not offered.

Why am I so tired?

Almost certainly iron deficiency from the blood loss, and it is the most under-treated part of this whole condition. Ask for a ferritin level, not just a full blood count — iron stores fall long before haemoglobin does, so you can be told your blood count is fine while feeling exhausted, breathless and foggy. Treating it changes how people feel within weeks.

Will fibroids stop me having children?

Most women with fibroids conceive without difficulty. The ones that matter for fertility are those distorting the cavity of the womb, and removing those — usually hysteroscopically, without any incision — can improve the chances considerably. If you are planning a pregnancy, say so early, because it changes which treatments are appropriate.

Will they go away on their own?

After the menopause, yes — they shrink as oestrogen falls. Before then they tend to stay or slowly grow. If you are within a few years of the menopause and symptoms are manageable, waiting is a perfectly legitimate plan, as long as any anaemia is being treated in the meantime rather than ignored.

Can I have the coil fitted?

Often yes, and it is very effective for heavy bleeding — but only if the cavity of your womb is not distorted. With submucosal fibroids it is more likely to be expelled and less likely to work. This is exactly why the location on your scan report matters before anyone fits one.

Is there anything I can take that isn't hormonal?

Yes — tranexamic acid, taken only during your period, reduces blood loss substantially with no hormones and no effect on fertility. Combined with an anti-inflammatory like mefenamic acid it helps both bleeding and pain. It is underused, and it is often the right place to start. Start it on day one, not once the heavy day has arrived.

Why do I keep reading that fibroids are worse for Black women?

Because they are, and it is well documented. Fibroids are around three times more common in Black women, tend to appear younger, are often larger and more numerous, and cause more severe symptoms — yet diagnosis takes longer and hysterectomy is more likely to be the operation offered. Knowing that is practically useful: it is grounds for asking early, asking specifically about uterus-preserving options, and asking for a second opinion if you are not satisfied.