The COEQUaL initiative seeks to reduce racial disparities in uterine fibroid care by promoting earlier diagnosis, equitable treatment discussions, and values-congruent, patient-centered decision-making.
The National Institutes of Health–funded COllaboration for EQuity in Uterine Leiomyomas (COEQUaL) was developed in response to longstanding differences in outcomes among Black patients with fibroids, including higher rates of invasive procedures. “There’s a lot of data, ours and others, that say Black women are more likely to have more invasive surgery and to have open surgeries instead of minimally invasive surgeries,” said Ebbie A. Stewart, MD.
A central challenge, she noted, is determining the relative contribution of biology vs inequities in care delivery. “Is that an issue of access? Is it an issue of preferentially giving minimally invasive options to one group of people and not to another? Or is it really that the disease is more advanced?” Stewart said. “At this time, we can’t disentangle it.”
Rather than assuming a single explanation, COEQUaL investigators are examining multiple drivers across the care continuum. “We can start to ask the questions, am I offering the full range of options to every individual and not preferentially deciding this is better for this person and that is better for another person,” she said. The program also emphasizes earlier diagnosis, recognizing that delayed referral to gynecologic care may contribute to advanced disease at presentation.
“We’re studying not just OB-GYNs—we’re trying to look at primary care doctors, nurse practitioners, women’s health PAs to see what are the barriers to treatment at these earlier places,” Stewart said. “We know that it often takes time to get referred to an OB-GYN, and if there’s a bad interaction and somebody walks out the door, they may not come for a long time.”
A key concept guiding the initiative is “values-congruent care,” which shifts the clinical conversation away from directive decision-making. “The first thing is to not come in and say, ‘With this fibroid, you should have X,’” she said. “Start by asking, what are your goals? What informs your decisions?”
She described how patient perspectives can reshape treatment discussions. In one case, a patient hesitated about hysterectomy because “my mother had a hysterectomy and died on the table,” underscoring the importance of understanding lived experience. Even routine recommendations can be misinterpreted. “Many of us say, well, you could take birth control pills,” Stewart said. “But what many individuals hear is, ‘Why are you telling me to take birth control pills? I already told you I’m not sexually active.’”
Investigators believe disparities may emerge early in the care pathway. Black patients often develop fibroids at younger ages and may delay pregnancy while pursuing education or career goals, making early recognition critical. “Diagnosing and intervening early may be an important tool to minimize disparities,” Stewart said.
She envisions a model similar to cardiovascular care, in which frontline clinicians initiate evaluation and treatment. “You don’t have to see a cardiologist to get placed on a statin,” she said. Empowering primary care clinicians to identify fibroids and begin early management could reduce progression to severe disease requiring invasive surgery.
Ultimately, COEQUaL aims to improve outcomes by integrating earlier diagnosis, shared decision-making, and equitable access to the full spectrum of fibroid treatments.
Reference:
Stewart EA, Venable S, Borah BJ, et al. Fibroids and Health Disparities: The COllaboration for EQuity in Uterine Leiomyomas (COEQUaL) Specialized Center. Am J Obstet Gynecol. 2026 Jan 12:S0002-9378(26)00009-8. doi:10.1016/j.ajog.2025.12.068
