Beyond hysterectomy: Modern approaches to managing uterine fibroids

Background: Common Yet Misunderstood

Uterine fibroids—also known as leiomyomas—are the most prevalent benign tumors in women of reproductive age. Composed of smooth muscle tissue, they can grow within the uterine wall (intramural), into the uterine cavity (submucosal), or on the outer surface (subserosal). While an estimated 70–80% of women will develop fibroids by menopause¹, only 20–25% experience symptoms significant enough to require treatment².

Despite their frequency, fibroids are often misunderstood. Many believe they always require surgery, are inherently cancerous, or lead inevitably to infertility—none of which are true for the majority of patients³.

When Fibroids Cause Trouble

Symptomatic fibroids can lead to heavy menstrual bleeding, pelvic pain, bloating, urinary frequency, and infertility. These symptoms may deeply affect physical health, emotional well-being, relationships, and financial stability⁴. Managing fibroids involves nuanced clinical decision-making that takes into account not only anatomical and symptomatic factors but also a woman’s reproductive goals, treatment preferences, and access to care⁵.

Fibroids and Fertility: Who’s at Risk?

While many fibroids do not impact fertility, certain types—particularly submucosal (FIGO types 0, 1, and 2)—can distort the endometrial cavity, disrupt embryo implantation, and increase miscarriage risk⁶⁻⁷. Large intramural fibroids encroaching on the uterine lining can similarly hinder conception⁸.

During pregnancy, fibroids may increase the likelihood of fetal malpresentation, cesarean delivery, placental abnormalities, and postpartum hemorrhage⁶. Pre-conception imaging via ultrasound or MRI can guide risk stratification and determine whether surgical removal is warranted⁹.

Modern Diagnosis and Mapping

Diagnosis starts with history and pelvic exam; an irregular or enlarged uterus may be felt during bimanual examination. Transvaginal ultrasound is the first-line imaging modality. For better characterization of fibroids that distort the uterine cavity, saline infusion sonohysterography or MRI is helpful. The FIGO classification system remains the global standard for describing fibroid types and guiding treatment strategies¹⁰.

Individualized Treatment Pathways

There is no universal approach to managing fibroids. The following options illustrate the breadth of current care:

Expectant Management: Observation is appropriate for women with no or minimal symptoms. Monitoring may include periodic exams and imaging¹¹.
Medical Therapy: For patients with bleeding symptoms, options include tranexamic acid, NSAIDs, combined oral contraceptives, and progestins. GnRH antagonists or selective progesterone receptor modulators (SPRM) may offer temporary fibroid shrinkage prior to surgery¹².
Endometrial Ablation: For women with heavy bleeding who are not planning future pregnancies and have small fibroids confined to the uterine lining. It reduces bleeding but doesn’t treat fibroids directly¹³.
Uterine Artery Embolization (UAE): Suitable for women wishing to preserve the uterus but not fertility. By reducing blood flow to fibroids, UAE shrinks them and relieves symptoms. Risks include post-procedure pain and potential impact on ovarian reserve¹⁴.
Radiofrequency Ablation (RFA): A minimally invasive option for intramural fibroids. It’s delivered laparoscopically or transcervically and preserves the uterus. It offers rapid recovery and low complication rates¹⁵.
High-Intensity Focused Ultrasound (HIFU): MRI- or ultrasound-guided, non-invasive thermal ablation for select fibroid types. It avoids surgery but is limited by strict eligibility and limited availability¹⁶.
Myomectomy: The treatment of choice for fertility preservation. It can be performed hysteroscopically, laparoscopically, or via open surgery, depending on fibroid size and location. Recurrence is possible⁵.
Hysterectomy: The definitive treatment for women with severe symptoms and no future fertility goals. While highly effective, it should be presented alongside uterus-preserving alternatives¹⁷.

For many women, the burden of fibroids extends beyond physical symptoms. Heavy menstrual bleeding can disrupt social and work life. Some patients report carrying extra clothes or avoiding travel due to fear of sudden bleeding episodes⁴.\n\nAnemia resulting from chronic blood loss can lead to fatigue, dizziness, cognitive fog, and reduced productivity⁶. Economically, the need for frequent use of pads, period underwear, and other menstrual supplies can add hundreds of dollars in out-of-pocket costs, compounded by the “pink tax” on feminine hygiene items¹⁸⁻¹⁹.

Moreover, missed workdays and diminished professional participation due to pain or fatigue can lead to income loss and career disruption²⁰. These layers of emotional and financial burden deserve clinician recognition and integrated care planning.

Patient-Centered Care: A New Standard

Effective management of fibroids goes beyond imaging and laboratory results. It involves recognizing the lived experience of the patient, acknowledging the impact on daily life, and offering appropriate support—both medical and non-medical.⁴⁻⁵

True patient empowerment lies in education, empathy, and access. Shared decision-making that respects personal values and life circumstances is central to optimizing outcomes. Whether the path leads to hormonal management, minimally invasive surgery, or hysterectomy, the goal is a solution that restores quality of life with minimal risk.

Conclusion

Uterine fibroids are a complex yet manageable condition. As research advances and treatment options diversify, the paradigm is shifting from one-size-fits-all surgery to nuanced, personalized care. Through evidence-based counseling and shared decision-making, clinicians can guide women toward informed choices that align with both health goals and life priorities.

About the author: Dr. Brandye Wilson-Manigat is a distinguished Board-Certified OB/GYN with over 14 years of experience in the field of women’s health. Her dynamic and informed approach has made her a sought-after expert on both local and national media outlets. She has been featured on TV programs, print publications, radio broadcasts, and the vast online media landscape, educating and informing the public on matters crucial to women’s health. Dr. Wilson-Manigat’s dedication to women’s health extends to her specialized knowledge in menopause and the perimenopausal transition. She is on a mission to educate women well beyond her immediate vicinity. In 2020, Dr. Wilson-Manigat founded Brio® Virtual Gynecology, a trailblazing telemedicine practice dedicated to women who are seeking a departure from the conventional healthcare model. She is also a member of Cure Hydration’s Medical Advisory Board.

References

1. Centini G, et al. Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review. Diagnostics (Basel). 2024;14(18):2046.doi:10.3390/diagnostics14182046
B3

2. Mwikisa D. Uterine Fibroids: A Silent Crisis. [Masters Thesis]. University of Nebraska at Omaha; 2024.

3. Yang Q, et al. Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment. Endocr Rev. 2021;43(4):678–719.

4. Leyland N, et al. A Call-to-Action for Clinicians to Implement Evidence-Based Best Practices When Caring for Women with Uterine Fibroids. Reprod Sci. 2022;29:1188–1196.

5. Stewart EA, et al. Uterine Fibroids. Nat Rev Dis Primers. 2016;2:16043.

6. ACOG Practice Bulletin No. 228: Management of Symptomatic Uterine Leiomyomas: Correction. Obstet Gynecol. 2021;138(4):683.

7. FIGO Working Group. A New System for the Classification of Submucous Myomas. Int J Gynecol Obstet. 2011;113(1):3–13.

8. Practice Committee of ASRM. Uterine Fibroids and Reproduction: A Guide to Management. Fertil Steril. 2021;115(3):671–689.

9. Centini G, et al. Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review. Diagnostics (Basel). 2024;14(18):2046. doi:10.3390/diagnostics14182046

10. FIGO Working Group. A New System for the Classification of Submucous Myomas. Int J Gynecol Obstet. 2011;113(1):3–13.

11. Morris JM, et al. A Systematic Review of Minimally Invasive Approaches to Uterine Fibroid Treatment. Reprod Sci. 2023;30:1495–1505.

12. Krishnan M, et al. Surgery and Minimally Invasive Treatments for Uterine Fibroids. Cochrane Database Syst Rev. 2024;6(6):CD015650.

13. Munro MG. Endometrial Ablation: Techniques and Indications. Clin Obstet Gynecol. 2014;57(3):540–558.

14. Pron G. Uterine Artery Embolization: A Review of Current Evidence. Best Pract Res Clin Obstet Gynaecol. 2008;22(4):641–657.

15. Deb Nath I, Abdurazakova MD. Radiofrequency Ablation of Uterine Fibroids. Int J Gynecol Obstet Res. 2025;3(4):28–30.

16. Yerezhepbayeva M, et al. Comparison of UAE and HIFU—Systematic Review. BMC Womens Health. 2022;22:55.

17. Tinelli A, et al. Abdominal Myomectomy for Large Myomas. Gynecol Obstet Invest. 2015;79(1):1–7.

18. Harper L. The Pink Tax on Women’s Health Products. J Public Health Policy. 2019;40(2):225–231.

19. Fuldeore MJ, Soliman AM. Economic Burden of Uterine Fibroids. Am J Obstet Gynecol. 2015;213(1):38.e1–38.e11.

20. Mwikisa D. Uterine Fibroids: A Silent Crisis. . University of Nebraska at Omaha; 2024