Uterine Fibroids: Symptoms and Treatment — from Watchful Waiting to Surgery

Symptoms and treatment choice depend largely on where a fibroid sits relative to the uterine wall, not just on its size. The International Federation of Gynecology and Obstetrics (FIGO) classifies fibroids on a 0-8 scale based on their relationship to the uterine cavity and serosa. In simplified terms, there are three main types: submucosal fibroids (growing toward the uterine cavity, most strongly linked to heavy bleeding and infertility despite relatively small size), intramural fibroids (within the thickness of the muscle wall, the most common type), and subserosal fibroids (growing on the outside of the uterus, more often causing pressure symptoms than bleeding).

A large international survey-based study covered almost 22,000 women across eight countries and compared symptom frequency between women with a fibroid diagnosis and those without.

The mechanism of fibroid growth is closely tied to the sex hormones estrogen and progesterone, which stimulate proliferation of uterine smooth-muscle cells. That's why fibroids typically grow during the reproductive years, can enlarge during pregnancy, and typically shrink after menopause, when levels of these hormones naturally decline. This hormonal dependence is also the basis of some of the drug-therapy strategies described below.

The primary test is transvaginal ultrasound, which allows the number, size, and approximate location of fibroids to be assessed with good accuracy in most cases. For submucosal fibroids, especially when fertility-sparing treatment is being planned, sonohysterography (ultrasound with saline instilled into the uterine cavity) or diagnostic hysteroscopy can be helpful, since they show the tumor's relationship to the uterine cavity more precisely. Pelvic MRI is used less often, mainly when planning a procedure in women with numerous, large fibroids, or when the ultrasound picture is ambiguous and a rarer malignant tumor — uterine leiomyosarcoma — needs to be ruled out.

Not every diagnosed fibroid requires treatment. Under the current position of the American College of Obstetricians and Gynecologists (ACOG), for asymptomatic women or those with mild, well-tolerated symptoms, a reasonable strategy is watchful waiting — periodic follow-up visits and ultrasounds, without intervention, until symptoms start to meaningfully affect quality of life or health (for example, through iron-deficiency anemia from chronically heavy bleeding). This approach avoids procedure-related risk in women who are otherwise doing well despite having fibroids.

For anemia caused by chronically heavy menstrual bleeding, it's worth checking our knowledge-base entry on iron — it explains how to recognize and monitor the deficiency that, in women with fibroids, is often the most common, and at the same time relatively easy to correct, consequence of chronic bleeding.

Drug therapy has an important limitation: in most cases it eases symptoms (bleeding, pain) but doesn't remove the fibroids themselves permanently — after stopping the medication, especially GnRH analogs, the tumors usually return to their previous size. That's why it's often used as a stopgap, a bridge to a procedure (for example, shrinking a fibroid and correcting anemia before a planned operation), or as a strategy for women approaching natural menopause, after which symptoms usually resolve on their own.

Myomectomy is a surgical procedure that removes fibroids while leaving the uterus in place — an option for women who want to preserve the possibility of future pregnancy or, for other reasons, prefer not to have the whole organ removed. Depending on the number, size, and location of the fibroids, it can be performed hysteroscopically (through the vagina, without an abdominal incision — mainly for submucosal fibroids), laparoscopically, or via open surgery (laparotomy) for large, numerous lesions.

Hysterectomy, the surgical removal of the uterus, remains the only treatment that gives complete, definitive certainty that fibroid-related symptoms won't return — and it's still the most common reason for hysterectomy in women overall. However, it's an irreversible solution that rules out future pregnancy, so it's typically considered for women who have finished family planning and have severe symptoms resistant to other methods.

Uterine artery embolization (UFE) is a procedure performed by an interventional radiologist, involving the introduction of small particles into the arteries feeding the fibroids to block their blood supply, which leads to the tumors gradually shrinking. UFE preserves the uterus and typically involves a shorter recovery time than surgery, though it isn't recommended as a first choice for women planning pregnancy because of limited data on its effect on fertility and the course of a later pregnancy compared with myomectomy.

Uterine fibroids are a good example of a medical condition where the diagnosis alone says relatively little without context — two women with an identical ultrasound diagnosis can have completely different prognoses and treatment needs. Instead of one universal protocol, a wide range of options is available — from watchful waiting, through drug therapy, to procedures that preserve or remove the uterus — and these should be matched to the specific symptoms, family-planning goals, and the size and location of the fibroids, not to the mere fact of their presence.