Medications for fibroids answer different questions. Some are used to control bleeding without treating the fibroid itself. Studies of elagolix and relugolix reported reduced menstrual bleeding and smaller leiomyomas while treatment continued [1]. Medication does not remove fibroids, and no available medical treatment permanently stops fibroid growth [1]. Symptoms can return after effective treatment ends [1]. At an appointment, ask whether the proposed medicine is meant to reduce bleeding, change fibroid size, or address both.
What is a uterine fibroid?
A uterine fibroid, also called a leiomyoma, is a growth of muscle and tissue that develops within the wall of the uterus or on its surface [5]. Cleveland Clinic lists excessive or painful bleeding during periods, bleeding between periods, lower-abdominal fullness or bloating, frequent urination, pain during sex, low back pain, constipation or rectal pressure, chronic vaginal discharge, difficulty emptying the bladder, and increased abdominal distention among possible symptoms [5].
Fibroids are nearly always benign [5]. Published estimates of the chance of a cancerous fibroid differ. Cleveland Clinic states that one out of 350 people with fibroids will develop cancer, while the Office on Women’s Health gives a figure below one in 1,000 [5]. The published estimates differ.
Cleveland Clinic lists ultrasonography, magnetic resonance imaging, computed tomography, hysteroscopy, hysterosalpingography, sonohysterography, and laparoscopy as tests used to find or assess fibroids [5].
What does heavy bleeding mean?
Cleveland Clinic describes heavy menstrual bleeding as blood loss above the usual amount. The source gives about two to three tablespoons as typical menstrual blood loss and more than five tablespoons as heavy [6]. Signs include bleeding for longer than seven days, soaking a pad or tampon every hour for several hours, needing more than one pad at a time, changing pads during the night, and passing clots the size of a quarter or larger several times a day [6].
Cleveland Clinic says prompt professional evaluation is needed when bleeding reaches at least two pads or tampons each hour and continues for two to three consecutive hours [6]. Heavy bleeding can cause tiredness or shortness of breath from blood loss, which may lead to anemia [6].
Blood tests are among the tests Cleveland Clinic lists for a heavy-bleeding workup [6]. Blood work for iron-deficiency anemia includes ferritin and total iron-binding capacity [6]. Iron-deficiency anemia is usually caused by bleeding, and people with heavy periods are at increased risk [6].
What does tranexamic acid do?
Tranexamic acid is used for heavy bleeding during menstruation [2]. MedlinePlus places it in a class called antifibrinolytics and says it improves blood clotting [2]. The review of medical treatment for fibroid-associated heavy menstrual bleeding found that tranexamic acid significantly reduced that bleeding [1].
Tranexamic acid does not treat the fibroid directly [1]. The review found no long-term treatment data for tranexamic acid in this setting [1]. Its reported effect is on bleeding, not fibroid size [1].
MedlinePlus says people who have had a blood clot, have a blood-clotting condition, or have been told they are at risk of a blood clot are generally told not to take tranexamic acid [2]. Tell the prescriber about that history before discussing the medication [2].
What do contraceptive hormones do?
Cleveland Clinic lists birth control options and hormone therapy among treatments for heavy menstrual bleeding [6]. The review found limited direct data supporting contraceptive hormone use for fibroid-associated heavy menstrual bleeding [1]. A review of progestogen treatment found a lack of evidence for progestogens in fibroid-associated heavy menstrual bleeding [1].
The cited evidence does not report a fibroid-size reduction for contraceptive hormones [1]. Ask whether the recommendation is based on evidence specific to fibroid-related bleeding.
What does the levonorgestrel intrauterine system do?
The levonorgestrel intrauterine system is discussed as an option for fibroid-related heavy menstrual bleeding [1]. Data are sparse in this setting, although one trial found a greater reduction in menstrual bleeding than with a combined oral contraceptive [1].
The cited review does not report that the levonorgestrel intrauterine system reduces fibroid size [1]. Ask which outcome the clinician is expecting the treatment to change.
What do elagolix, relugolix, and the listed medicines do?
Cleveland Clinic lists medicines used for fibroids, including medicines that shrink fibroids temporarily, elagolix as an oral therapy for up to 24 months, and tranexamic acid [5]. It also lists medicines used for heavy menstrual bleeding, including medicines that shrink fibroids temporarily [6].
The medical-management review reports that several studies found decreased menstrual bleeding, pelvic pain, and leiomyoma size in women treated with elagolix or relugolix [1]. The review states that fibroid-size reduction continues while treatment continues [1].
What is MYFEMBREE used to treat?
MYFEMBREE contains relugolix, estradiol, and norethindrone acetate [3]. Pfizer reports that the FDA approved it on May 26, 2021, as a once-daily treatment for the management of heavy menstrual bleeding associated with uterine fibroids in premenopausal women [3].
Use of MYFEMBREE should be limited to 24 months because continued bone loss may not be reversible [3]. It carries a boxed warning for thromboembolic disorders and vascular events, with risk emphasized in women over 35 who smoke or have uncontrolled high blood pressure [3].
What is ORIAHNN used to treat?
ORIAHNN contains elagolix, estradiol, and norethindrone acetate capsules, along with elagolix capsules [4]. AbbVie describes it as a prescription medicine used to control heavy menstrual bleeding related to uterine fibroids in women before menopause [4].
ORIAHNN should not be taken for more than 24 months because low estrogen levels during treatment can cause bone mineral density loss, and complete recovery may not occur [4]. Its boxed warning covers increased chances of heart attack, stroke, or blood clots. The warning gives particular attention to people over 35 who smoke or have uncontrolled high blood pressure, high cholesterol, diabetes, or obesity [4].
How do these medications compare?
| Medication | What it is approved or used for | Effect on bleeding | Effect on fibroid size | Stated limits or warnings | Strength of the evidence |
|---|---|---|---|---|---|
| Tranexamic acid | Used for heavy bleeding during the menstrual cycle [2] | Significantly reduced fibroid-associated heavy menstrual bleeding in the reviewed evidence [1] | Does not treat the fibroid directly [1] | People with a blood clot, clotting condition, or stated clot risk are generally told not to take it [2] | Bleeding benefit reported, with no long-term treatment data [1] |
| Contraceptive hormones | Listed for heavy menstrual bleeding [6] | Direct fibroid-specific data are limited [1] | The cited evidence does not report a size reduction [1] | The review reports a lack of evidence for progestogens in this setting [1] | Limited direct evidence [1] |
| Levonorgestrel intrauterine system | Used for fibroid-related heavy menstrual bleeding [1] | One trial found a greater reduction than with a combined oral contraceptive [1] | The cited review does not report a size reduction [1] | Data are sparse for fibroid-related bleeding [1] | Sparse data [1] |
| Medicines that shrink fibroids temporarily | Used for fibroids and heavy menstrual bleeding [5][6] | Listed for heavy menstrual bleeding [6] | Cleveland Clinic says they shrink fibroids temporarily [5] | Fibroid-size reduction continues while treatment continues [1] | The cited sources report temporary size reduction [1][5] |
| MYFEMBREE | FDA-approved to manage fibroid-related heavy bleeding in premenopausal women [3] | Approved for heavy menstrual bleeding [3] | Relugolix studies reported decreased leiomyoma size [1] | Limit of 24 months because bone loss may not be reversible; boxed warning for thromboembolic and vascular events [3] | FDA-approved use, with the review reporting bleeding and size outcomes for relugolix [1][3] |
| ORIAHNN | Used to control fibroid-related heavy bleeding before menopause [4] | Used to control heavy menstrual bleeding [4] | Elagolix studies reported decreased leiomyoma size [1] | Limit of 24 months because complete bone-density recovery may not occur; boxed warning for heart attack, stroke, and blood clots [4] | The cited source describes its use, and the review reports bleeding and size outcomes for elagolix [1][4] |
What should you ask about the evidence?
Ask whether the proposed medicine is intended to reduce bleeding, reduce fibroid size, or both. Ask whether the evidence is specific to fibroid-related heavy menstrual bleeding.
The review reports limited direct data for contraceptive hormones and a lack of evidence for progestogens in fibroid-associated heavy menstrual bleeding [1]. It reports sparse data for the levonorgestrel intrauterine system, despite one trial finding a greater reduction in menstrual bleeding than with a combined oral contraceptive [1].
Tranexamic acid reduced bleeding in the reviewed evidence, but long-term treatment data were not available [1]. Elagolix and relugolix have reported reductions in bleeding, pelvic pain, and leiomyoma size [1]. Symptoms return after effective therapy stops [1].
What should you write down before the appointment?
Record the number of pads or tampons used during the heaviest hour, whether bleeding lasts longer than seven days, whether you bleed between periods, and whether you pass clots the size of a quarter or larger several times a day [6]. Write down whether you have tiredness or shortness of breath during heavy bleeding [6].
Bring your history of blood clots, clotting conditions, or being told that you are at risk of a blood clot before discussing tranexamic acid [2]. Bring blood-work results if iron-deficiency anemia is being assessed, including ferritin and total iron-binding capacity [6].
If MYFEMBREE or ORIAHNN is discussed, write down the 24-month limit, the bone-density warning, and the boxed warning described for that product [3][4].
What to do next
- Write down your heaviest bleeding hour, the number of pads or tampons used, how long the bleeding lasts, and whether you pass quarter-sized clots.
- Open the appointment with: “I want to separate bleeding control from fibroid treatment. Which outcome is this medication meant to change?”
- Ask whether your evaluation should include blood tests, including ferritin and total iron-binding capacity, when heavy bleeding occurs with tiredness or shortness of breath [6].
- Ask which test is needed to find or assess the fibroids [5].
- If tranexamic acid is discussed, say whether you have had a blood clot, a clotting condition, or been told you are at risk of a blood clot [2].
- If a hormonal option is discussed, ask whether the evidence is specific to fibroid-related heavy menstrual bleeding [1].
- If MYFEMBREE or ORIAHNN is discussed, ask how the 24-month limit and bone-density warning apply to that medication [3][4].
- If you are bleeding through at least two pads or tampons each hour for two to three consecutive hours, seek prompt professional evaluation [6].
Related on Ruby: fibroid treatment options and how to shrink fibroids.
Sources
- Barseghyan 2023, The efficacy of medical management of leiomyoma-associated heavy menstrual bleeding, F&S Reports, PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10958631/
- MedlinePlus, Tranexamic acid. https://medlineplus.gov/druginfo/meds/a612021.html
- Pfizer, Myovant Sciences and Pfizer receive FDA approval for MYFEMBREE. https://www.pfizer.com/news/press-release/press-release-detail/myovant-sciences-and-pfizer-receive-fda-approval-myfembreer
- AbbVie, ORIAHNN patient site. https://www.oriahnn.com/
- Cleveland Clinic, Uterine fibroids. https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids
- Cleveland Clinic, Menorrhagia (heavy menstrual bleeding). https://my.clevelandclinic.org/health/diseases/17734-menorrhagia-heavy-menstrual-bleeding