Lupita Nyong’o and fibroids: what Brazil’s SUS incorporated for heavy bleeding and what health plans cover

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

On 26 February 2026, in an interview with TODAY, on the American network NBC, republished by NBC Washington, Lupita Nyong’o said that the uterine fibroids diagnosed in 2014 had returned. At the time of the diagnosis, according to the report, there were about thirty; today there are more than fifty, and she described them as “a ticking bomb”. Before 2014, she reported fatigue, pre-anemia, pelvic pain every month and heavy bleeding, and explained why none of it alarmed her: “They taught me that once my period started, that I should expect to be in pain every month”. The routine examination and the ultrasound ordered after repeated complaints of pain revealed the fibroids; the doctor, she said, presented two ways out, living with the pain or having them surgically removed, and she had a myomectomy. The sentence that organizes this article is also hers: if fibroids are this common, “that doesn’t make it normal, right?”.

On 15 July 2025, the actress was in Washington with lawmakers at the launch of a package of bills on uterine health and announced, with the Foundation for Women’s Health, a research fund for minimally invasive and non-invasive treatments. “I received my uterine fibroid diagnosis and was offered only two options”, she said at the event. The account is public and it is hers; nothing is known, nor asserted here, about the doctors, the tests or the clinical choices along that path. It raises two questions that apply to any woman: is heavy menstrual bleeding with anemia normal? And, when a fibroid is the cause, what are the alternatives to the scalpel and who has the duty to offer them in Brazil?

Common is not normal: what science measures

A fibroid, or leiomyoma, is a benign tumor of the muscle of the uterus, the most frequent tumor of the female reproductive tract. The study that gave the measure of the problem screened 1,364 women aged 35 to 49 from an urban health plan in the United States by ultrasound, regardless of symptoms (Baird and colleagues, American Journal of Obstetrics and Gynecology, 2003): half of those who had never been diagnosed had fibroids on the scan, and the cumulative incidence by age 50 was estimated at more than 80% among Black women and close to 70% among white women, with significantly different curves (odds ratio 2.9). A systematic review of 60 publications (Stewart and colleagues, BJOG, 2017) found prevalences between 4.5% and 68.6%, depending on the population and the diagnostic method, and recorded that Black race was the only factor consistently described as capable of increasing the risk, by two to three times. In Black women, as the report of Conitec (the national commission that assesses health technologies for the SUS, Brazil’s public health system) and the American bill discussed below record, fibroids tend to be larger and more numerous, with more severe symptoms.

A fibroid is one among several possible causes of abnormal uterine bleeding. The International Federation of Gynecology and Obstetrics organized these causes in the PALM-COEIN system, published in 2011 and revised in 2018 (Munro and colleagues, International Journal of Gynecology and Obstetrics): four structural causes (polyp, adenomyosis, leiomyoma, malignancy or hyperplasia) and five non-structural ones (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not otherwise classified). In practice, a fibroid on the report does not close the investigation. The British guideline on heavy menstrual bleeding, NICE NG88, opens with the recommendation to recognise that it has “a major impact on a woman’s quality of life” and that any intervention should aim at that quality of life, and not only at the volume lost; it also calls for a full blood count in all women with heavy bleeding, in parallel with treatment.

Monthly blood loss is a common route to iron-deficiency anemia. The World Health Organization estimates that 30% of non-pregnant women aged 15 to 49, 539 million people in 2019, had anemia, and cites “consistent heavy menstrual losses” among the frequent causes; anemia brings fatigue and lost productivity. In Brazil, the Conitec report that assessed the new treatments for fibroid bleeding records more than 850,000 hospital admissions for leiomyoma in the SUS between 2013 and 2023, 57% of them in women aged 40 to 49, a cost of more than 13 million reais in 2022 alone and 102 deaths attributed to the disease that year. The same report notes that most of the surgeries performed in the SUS for leiomyoma are radical, that is, hysterectomy, and a survey of SUS admissions for benign indications between 2014 and 2023 found 91.4% of hysterectomies by the abdominal route and 0.7% by laparoscopy (Nogueira, master’s dissertation, Escola Bahiana de Medicina e Saúde Pública, 2024).

The alternatives to the scalpel, according to the guidelines

NICE NG88, from 2018, grades the options by the size and position of the fibroid. For women with no identified pathology or with fibroids smaller than 3 cm that do not distort the uterine cavity, the first option to consider is the levonorgestrel-releasing intrauterine system; if it is declined or unsuitable, non-hormonal treatments, such as tranexamic acid and anti-inflammatory drugs, and hormonal ones. For fibroids of 3 cm or more, it calls for considering referral to a specialist and offering tranexamic acid and/or anti-inflammatory drugs while definitive treatment is being arranged, and it lists, side by side, pharmacological treatments, uterine artery embolization, myomectomy and hysterectomy, to be chosen according to the size, location and number of fibroids and the severity of the symptoms.

The options have their own evidence. In the ECLIPSE trial (Gupta and colleagues, New England Journal of Medicine, 2013), with 571 women in primary care, the levonorgestrel IUD improved bleeding-related quality of life more than usual treatment, over two years. The Cochrane review of antifibrinolytics (Bryant-Smith and colleagues, 2018, 13 trials, 1,312 participants) found a mean reduction of 53 mL of blood per cycle with tranexamic acid compared with placebo, with no clear difference in adverse events, on moderate-quality evidence. And, for those who wish to preserve the uterus and have not responded to medical treatment, the FEMME trial (Manyonda and colleagues, New England Journal of Medicine, 2020), with 254 women in 29 hospitals in the United Kingdom, compared myomectomy and embolization: quality of life at two years was slightly better after myomectomy, and complications occurred in 29% and 24% of cases, respectively. There is no single answer; there is a menu, and the patient should know all of it.

Brazil: the 2017 protocol and the 2026 incorporation

The Protocolo Clínico e Diretrizes Terapêuticas (PCDT, the clinical protocol and therapeutic guidelines) for Leiomyoma of the Uterus in force in the SUS is the one adopted by Joint Ordinance (Portaria Conjunta) No. 11, of 31 October 2017. According to Conitec’s summary of it, the protocol treats surgery as the definitive treatment of choice: hysterectomy for those who do not intend to have children, myomectomy for those who wish to preserve the uterus, and uterine artery embolization as another possibility. On the medicines side, the range was narrow: anti-inflammatory drugs (naproxen and ibuprofen), medroxyprogesterone, norethisterone, a combined oral contraceptive and GnRH analogues. The report itself acknowledges that the protocol in force “covers a restricted set of therapeutic options available in the SUS, especially for women who present heavy uterine bleeding”.

It was to fill that gap that Conitec, in Recommendation Report No. 1066, assessed the 52 mg levonorgestrel IUD and tranexamic acid. Tranexamic acid had never been assessed by the commission for incorporation, in any indication; the IUD had already been incorporated in May 2025 for endometriosis, as the firm noted in the article on Anitta and endometriosis (in Portuguese). The economic analysis concluded that the IUD is cost-effective for those eligible for hormonal treatment and that tranexamic acid is a dominant strategy for those who are not, with a gain in quality of life and a reduction in cost; the report estimated about 311,000 women eligible for the IUD and 517,000 for tranexamic acid in the first year. On 8 December 2025, the committee unanimously recommended incorporation, considering that the expected effects would be a “greater possibility of preserving the uterus and maintaining fertility”, and fewer surgeries and less anemia. Ordinance (Portaria) SCTIE/MS No. 101, of 8 January 2026, published in the Official Gazette of 12 January, incorporated both: tranexamic acid for people of reproductive age with leiomyoma and heavy uterine bleeding “ineligible for or refractory to hormonal treatment” (art. 1, I), and the LNG-IUD for those “eligible for hormonal therapy” (art. 1, II), both “in accordance with the Clinical Protocol of the Ministry of Health”.

The legal point lies in art. 2, which refers to art. 25 of Decreto 7.646/2011 (the decree on the incorporation of health technologies into the SUS): the technical areas have “a maximum period of one hundred and eighty days to make the supply effective in the SUS”, counted from publication. From 12 January, the one hundred and eighty days ran out in July 2026; from then on, unavailability ceases to be an expected wait and becomes a duty whose deadline has expired, which gives the patient who falls within the indication an objective ground to demand the supply and to document its absence. The mechanism is explained in why the incorporated medicine has not arrived yet (in Portuguese). The revision of the protocol was submitted to Public Consultation SCTIE/MS No. 30, of 14 April 2026. Between the protocol and the surgery lies the queue. A technical opinion of NATJUS (the court’s health technical support unit) published by the TJRJ, the Rio de Janeiro State Court (No. 4481/2025, of 30 October 2025), shows how long it is: a 53-year-old woman with myomatosis “refractory to clinical treatment”, progressive bleeding and anemia, who was already using medroxyprogesterone, tranexamic acid and an anti-inflammatory drug without improvement, was entered in SISREG (the SUS referral and regulation system) on 16 September 2024 for a surgical gynecology appointment, classified as yellow, that is, urgent; the request was resubmitted in August 2025 and was still unanswered when the opinion, which recorded that the delay “may negatively influence her prognosis”, was written. The routes for demanding the supply are in the guide on what citizens can demand from the SUS (in Portuguese).

And in the health plan

In supplementary (private) health care, the rol da ANS (the ANS list of mandatory coverage, ANS being the federal health-plan regulator; Annex I of RN 465/2021, a regulatory resolution, in the version updated by RN 680/2026) includes, for plans with hospital coverage, uterine myomectomy, laparoscopic uterine myomectomy, hysteroscopy with resectoscope for myomectomy, abdominal, vaginal and laparoscopic hysterectomies and uterine artery embolization, the latter subject to a utilization guideline. DUT (utilization guideline) No. 23 guarantees embolization to women with symptomatic intramural leiomyomas, or multiple ones in the presence of an intramural one, when there is a complaint of bleeding, cramping, pain or compression and “significant alteration of quality of life or work capacity”, and rules it out, among other cases, for pedunculated subserosal fibroids, for fibroids above 10 cm and where pregnancy is desired, unless myomectomy is contraindicated.

The two treatments incorporated by the SUS in 2026 reach health plans in different ways. Art. 10, § 10, of Lei 9.656/1998 (the Health Plans Act) requires the technologies whose incorporation into the SUS has been published to be included in the list within 60 days; but oral tranexamic acid runs into art. 10, VI, which excludes from mandatory coverage the “supply of medicines for home treatment”, save for the cases of art. 12. The hormonal IUD is an outpatient procedure on the list and, since 1 October 2026, has DUT No. 175, created by RN 680/2026, item 1 of which provides for “mandatory coverage for patients with an indication for use set out in the package insert registered with the National Health Surveillance Agency” (Anvisa); item 2 deals only with endometriosis. Whether bleeding from a fibroid is among the registered indications of the prescribed device is a fact to be checked in the package insert, and the medical report should say so. The detail is in what RN 680 changed for the hormonal IUD (in Portuguese). The deadlines of RN 566/2022 apply: a gynecology appointment within seven business days (art. 3, I), outpatient tests within ten (art. 3, XI) and elective hospital admission within 21 (art. 3, XIII), with full reimbursement if they are not met (art. 10). The general picture of refusals is in the guide on denial of coverage (in Portuguese).

Comparative law: bleeding as a matter of public health and of race

Three countries show distinct paths: the guideline that sets out the menu, the bill that seeks to fund research and the recommendation that requires the alternative to be offered.

1. United Kingdom: the guideline as a standard of care

In the United Kingdom, the answer is technical. NG88 does not treat surgery as the point of entry: it calls for considering the woman’s preferences, her comorbidities and the size, number and position of the fibroids, and it places the levonorgestrel IUD, tranexamic acid, embolization and myomectomy in the same frame as hysterectomy. The question the British model allows one to ask in each case is simple: were the options the guideline lists presented?

2. United States: racial disparity taken to Congress

In the United States, the debate is legislative and explicitly racial. The Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2025 was introduced on 15 July 2025, the day of the event with Lupita Nyong’o, in the House of Representatives (H.R. 4395, Representative Yvette Clarke) and in the Senate (S. 2275). Among the findings of the official text are that more than 80% of Black women develop fibroids by menopause, with more severe symptoms; that symptomatic fibroids account for 39% of annual hysterectomies in the country, with higher rates of hospitalization, hysterectomy and myomectomy among Black patients; and that they cost the country between 5.9 and 34.4 billion dollars a year. The bill authorizes 30 million dollars a year, from 2026 to 2030, for research coordinated with the National Institutes of Health, creates a database on treatment under Medicaid and requires patients and physicians to be informed about the options, including those that avoid hysterectomy. In the official record of legislative actions, the latest action on both versions is referral to committee, on 15 July 2025 itself: neither has become law.

3. France: the alternative that should be offered

In France, the answer came from professional recommendations. The national guidelines of the Collège National des Gynécologues et Obstétriciens Français on the management of fibroids (Marret and colleagues, European Journal of Obstetrics & Gynecology and Reproductive Biology, 2012) list the levonorgestrel IUD, tranexamic acid and anti-inflammatory drugs in the medical treatment of bleeding and state that uterine artery embolization, being effective and of low long-term morbidity, is a validated alternative to myomectomy and hysterectomy that should be offered to patients who do not wish to become pregnant; and they add that, in each case, the patient is informed of the benefit and the risk of each option. The assessment by the Haute Autorité de Santé could not be read (the portal blocks automated access); the article confines itself to the text of the college.

Brazil sits in the middle: the list and the protocol provide for the alternatives, and the two medical treatments that were missing came in in 2026, but there is no specific policy for heavy menstrual bleeding, and the Conitec report turns to foreign literature for the racial dimension.

Information, consent and liability

Lupita Nyong’o’s account, which says nothing about the conduct of those who treated her, touches on two issues that Brazilian law reaches: the normalization of bleeding and the choice presented as binary. The first concerns the duty of diagnosis. The Código de Ética Médica (the Code of Medical Ethics, Resolution 2.217/2018 of the CFM, the Federal Council of Medicine) forbids physicians to fail to use all available means of diagnosis and treatment “scientifically recognized and within their reach” (art. 32), and investigating heavy bleeding includes, at a minimum, a blood count and a search for the cause. The second concerns the duty to inform. The same code forbids failing to inform the patient of the diagnosis, the prognosis, the risks and the objectives of treatment (art. 34), and Lei 15.378/2026, the Estatuto dos Direitos do Paciente (the Patients’ Rights Statute), guarantees information that is “accessible, up-to-date and sufficient” to decide (art. 12, § 1), participation in the decision on the therapeutic plan (art. 11), a second opinion at any stage (art. 18) and access to the medical record without having to give reasons (art. 19). A hysterectomy proposed to a woman of reproductive age without the IUD, medical treatment, myomectomy and, where appropriate, embolization having been presented and recorded tends to be consent given on incomplete information.

In the SUS, Lei 8.080/1990 (the Organic Health Law) guarantees comprehensive care and information about one’s own health (art. 7, II and V), and Lei 13.460/2017 (the Public Service Users’ Law) guarantees access to personal information (art. 6, III). The liability of the hospital, the clinic or the health plan operator is strict as regards their own services (Código de Defesa do Consumidor, the Consumer Protection Code, art. 14); where the failure lies in the physician’s own act, proof of fault is required (art. 14, § 4), and it is the comparison between the medical record and the guideline in force at the time that decides it. When delay or omission deprives the patient of a serious and real possibility of a different outcome, such as preserving the uterus, the Superior Court of Justice (STJ) allows compensation for the loss of a chance; the leading precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, decided on 4 December 2012), a case of inadequate treatment of breast cancer, whose headnote sets the limit: “The chance, however, can never reach the value of the asset lost”. With fibroids, the evidence is a matter for expert examination, case by case, and the delay of the institutional queue is not to be confused with the fault of whoever provided care.

Before deciding

In my view, the merit of Lupita Nyong’o’s account lies in the statement that common is not normal: heavy bleeding with fatigue and anemia calls for investigation, and a fibroid on the report calls for a menu, not a sentence. Three steps. Ask for a blood count and a written record of the probable cause, the plan and the alternatives presented. If the indication is the IUD or tranexamic acid, ask for the fit with Ordinance SCTIE/MS No. 101/2026 to be written into the prescription, because the supply deadline has already expired; if it is surgery, ask why that technique and not the others, and keep the answer. And gather the medical record, reports, SISREG or health plan protocol numbers and refusals. If the indicated treatment was not offered by the public network, if the urgent appointment spent months in the queue or if the health plan denied the IUD, the embolization or the surgery that the list provides for, get in touch with the firm: the analysis starts from the prescription, from whether the case fits the rule and from the response received, and it does not replace medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).