Uterine Fibroids: Symptoms and Treatment Options

What are uterine fibroids?

Fibroids (also called uterine leiomyomas or myomas) are benign tumors made of smooth muscle and connective tissue that grow within or on the wall of the uterus. They range from microscopic to large enough to distort the shape of the uterus. Fibroids are the most common noncancerous tumors in women of childbearing age 3Ref 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (2024).Uterine Fibroids.Fibroids are the most common noncancerous uterine tumors; occur in 70–80% of women by age 50; Black women are disproportionately affected; hysterectomy is the only permanent cure; fibroids shrink after menopause. They are classified by their location:

• Submucosal: protrude into the uterine cavity — most likely to cause heavy bleeding and affect fertility
• Intramural: within the uterine wall — the most common type
• Subserosal: project outward from the uterus — more likely to cause pressure or bulk symptoms
• Pedunculated: attached by a stalk, either inside or outside the uterus 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids

Race substantially affects fibroid burden: Black women are more likely to develop fibroids, do so at younger ages, have more and larger fibroids, and experience more severe symptoms than women of other racial groups 3Ref 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (2024).Uterine Fibroids.Fibroids are the most common noncancerous uterine tumors; occur in 70–80% of women by age 50; Black women are disproportionately affected; hysterectomy is the only permanent cure; fibroids shrink after menopause.

What symptoms do fibroids cause?

Many fibroids are discovered incidentally during a pelvic ultrasound performed for another reason. When symptoms occur, they include:

• Heavy menstrual bleeding — the most common symptom, sometimes severe enough to cause iron-deficiency anemia 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids
• Prolonged periods (lasting more than seven days)
• Pelvic pressure or fullness, particularly with larger fibroids
• Frequent urination when fibroids press on the bladder
• Constipation or a feeling of rectal pressure
• Low back or leg pain
• Pain during intercourse (less common)
• Fertility challenges — submucosal fibroids in particular can interfere with implantation or pregnancy 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids

Fibroid-related bleeding can be significant. Heavy periods that lead to iron-deficiency anemia cause fatigue, shortness of breath on exertion, and impaired daily functioning — all reversible once treated effectively 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids.

How are fibroids diagnosed?

Fibroids are typically diagnosed with pelvic ultrasound, which can identify the number, size, and location of fibroids. When more detail is needed — particularly before a procedure — a saline infusion sonogram (SIS) or MRI provides a more complete map of the uterine cavity and fibroid positions 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids. MRI is particularly useful for pre-operative planning and for evaluating candidates for uterine fibroid embolization.

What non-surgical options are available?

Hormonal medications can shrink fibroids or manage symptoms 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids: - GnRH agonists (such as leuprolide) create a temporary menopause-like state that reduces estrogen and can shrink fibroids substantially, but effects reverse when the medication is stopped; used mainly as short-term preoperative treatment - GnRH antagonists (relugolix combination tablet, approved as Myfembree; elagolix combination, approved as Oriahnn) are oral options that can be taken longer-term with add-back hormone therapy to limit menopausal side effects - Hormonal IUDs (levonorgestrel-releasing IUDs) are effective at reducing fibroid-associated heavy bleeding in selected patients - Tranexamic acid and NSAIDs can reduce bleeding and discomfort during periods without addressing the fibroids themselves 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids

Uterine fibroid embolization (UFE): A radiologist threads a catheter into the arteries supplying the fibroids and injects particles that cut off blood flow, causing the fibroids to shrink. A randomized trial found that UFE produced symptom relief and quality-of-life improvements comparable to surgical treatment at one year, with shorter hospitalization 2Ref 2Edwards RD, Moss JG, Lumsden MA, Wu O, Murray LS, Twaddle S, Murray GD; REST Investigators (2007).Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids.Randomized trial showing UFE produced comparable quality-of-life improvement to surgical treatment (hysterectomy or myomectomy) at one year with shorter hospitalization. UFE preserves the uterus and is effective for many patients, though it is generally not recommended when future pregnancy is a priority 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids.

High-intensity focused ultrasound (HIFU) / MRI-guided focused ultrasound: Uses ultrasound waves to heat and destroy fibroid tissue without incisions. Less widely available but effective for selected patients with specific fibroid characteristics.

What surgical options are available?

Myomectomy removes fibroids while preserving the uterus. It is the preferred surgical option for people who want to maintain fertility or retain their uterus. It can be performed: - Hysteroscopically (through the cervix) for submucosal fibroids - Laparoscopically or robotically for intramural or subserosal fibroids - Open (abdominal) for very large or numerous fibroids 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids

Fibroids can recur after myomectomy, particularly when they are numerous.

Hysterectomy (surgical removal of the uterus) is the only permanent cure for fibroids 3Ref 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (2024).Uterine Fibroids.Fibroids are the most common noncancerous uterine tumors; occur in 70–80% of women by age 50; Black women are disproportionately affected; hysterectomy is the only permanent cure; fibroids shrink after menopause. It eliminates the possibility of future pregnancy. Depending on the individual situation, it may be performed vaginally, laparoscopically, or abdominally. For many patients who have completed childbearing and have significant symptoms, hysterectomy offers definitive relief 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids.

Endometrial ablation destroys the uterine lining and is effective for heavy bleeding. It is not a treatment for fibroids themselves and is appropriate only for those who do not wish to conceive.

What factors guide the choice of treatment?

The right treatment depends on several factors, best explored with an OB-GYN 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids: - Severity of symptoms - Number, size, and location of fibroids - Desire for future pregnancy - Age and proximity to menopause (fibroids typically shrink after menopause as estrogen levels fall 3Ref 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (2024).Uterine Fibroids.Fibroids are the most common noncancerous uterine tumors; occur in 70–80% of women by age 50; Black women are disproportionately affected; hysterectomy is the only permanent cure; fibroids shrink after menopause) - Underlying health conditions and surgical risk

For fibroids that are asymptomatic, watchful waiting with periodic monitoring is entirely appropriate — no treatment is required simply because fibroids are present 1Ref 1American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Fibroid classification by location, symptom description, diagnostic approach, iron-deficiency anemia from heavy bleeding, surgical and non-surgical treatment options including UFE, myomectomy, and hysterectomy, and watchful waiting for asymptomatic fibroids.