Heavy bleeding, pressure, exhaustion. Not just perimenopause.

Fibroids (leiomyomas, myomas) are made of the same smooth muscle as the uterus itself. They grow in response to estrogen and progesterone, which is why they typically appear from the 30s onward, peak in the 40s, and shrink after menopause when estrogen drops. Some women have one; some have a dozen; sizes range from a pea to a grapefruit. They are almost never cancerous — malignant leiomyosarcoma is rare (~1 in 1,000 presumed-fibroid masses).

Submucosal fibroids (bulging into the uterine cavity) cause the heaviest bleeding, even when small. Intramural (inside the wall) cause bulk and pressure. Subserosal (on the outside) can press on bladder or bowel. Pedunculated fibroids hang on a stalk and can twist. A single submucosal fibroid can cause more bleeding than a uterus full of subserosal ones — this is why the imaging report matters, not just the words 'you have fibroids'.

By age 50, roughly 80% of Black women vs 70% of white women have fibroids. Onset is earlier (frequently in the 20s and 30s), tumours are typically larger, symptoms more severe, and hysterectomy rates are 2–3× higher. Almost none of this shows up in the trial evidence because Black women are systematically under-recruited in fibroid research. If you are Black and your bleeding is being dismissed as 'normal for your age', name the evidence gap in the appointment — the answer is imaging, not reassurance.

The estrogen swings of your 40s often feed a growth spurt: heavier bleeds, more pressure, faster fatigue. This is when many long-tolerated fibroids finally get named. After the final period they typically shrink over 6–24 months as estrogen drops. HRT — especially systemic estrogen — can slow that shrinkage or keep symptoms going; it doesn't have to rule HRT out, but the plan should acknowledge the fibroids explicitly.

Years of heavy bleeding drop your iron stores long before hemoglobin looks abnormal. Breathless on stairs, exhausted, foggy, dizzy on standing, restless legs at night, hair shedding — that is often not perimenopause, that is ferritin. Ask specifically for ferritin (iron stores), not just a hemoglobin check. Ferritin under 30 warrants treatment even with a 'normal' hemoglobin.

Transvaginal ultrasound is the first-line scan and picks up the majority of fibroids. If a uterine-sparing procedure is on the table (myomectomy, uterine artery embolization) an MRI is often needed to map size, number, position, and blood supply. A vague 'bulky uterus' on a generic pelvic scan is not enough to plan treatment from — ask for the detail.

Pad/tampon changes per day; nights you have to get up to change; any flooding through clothes or sheets; days you couldn't leave the house. Clinical heavy menstrual bleeding = soaking one pad/tampon per hour for several hours, OR a bleed that interferes with normal life. Either threshold warrants investigation.

Clots bigger than a 50p coin (UK) or a US quarter / 2.5cm are clinically significant. Note how many days per bleed you're passing them, and roughly how many per day. Repeated large clots in your 40s should trigger imaging, not reassurance.

Bleeds lasting 8+ days, or cycles consistently shorter than 24 days, are both red flags. Track first day to last day of every bleed and days between cycle starts. Even rough numbers, kept consistently, matter.

Urinary frequency and urgency, needing to pee two or three times overnight, constipation or feeling of incomplete emptying, bloating that doesn't shift with diet, low-back or hip ache, waistbands not fitting when weight hasn't changed. These are the classic bulk-fibroid symptoms and often the most under-reported.

Cramp severity (1–10), when it starts, what it stops you doing. Whether sex has become painful and in what position (deep dyspareunia is common with larger fibroids). Low-back pain that maps to the cycle.

Breathless on stairs, exhausted regardless of sleep, dizzy on standing, brain fog, restless legs at night, unusual hair shedding, palpitations, pica (craving ice, chalk, dirt). These are ferritin symptoms. Ask specifically for a ferritin test — not just hemoglobin — at your next bloods.