Beyond hysterectomy: Modern approaches to managing uterine fibroids

Beyond hysterectomy: Modern approaches to managing uterine fibroids | Image Credit: © Carl - stock.adobe.com.

Uterine fibroids, or leiomyomas, are the most common benign tumors affecting women of reproductive age. These smooth muscle neoplasms can occur within the uterine wall, protrude into the uterine cavity, or bulge from the uterine surface. Though nearly 70% to 80% of women will develop fibroids by menopause¹, only about 20% to 25% become symptomatic.² Despite this high prevalence, misconceptions abound—many patients mistakenly believe fibroids always require surgery, are cancerous, or inevitably cause infertility.³

For those women with symptoms—heavy menstrual bleeding, pelvic pain, pressure symptoms, and reproductive complications—fibroids can have a profound impact on their daily life, as well as on their physical, mental, and financial health.⁴ Clinical management demands a nuanced approach that factors in symptom burden, fertility desires, treatment access, and personal preferences.⁵

Fibroids, fertility, and pregnancy: When to be concerned

While many fibroids are asymptomatic and have no bearing on fertility, some can impair implantation, distort the uterine cavity, and increase the risk of miscarriage or preterm labor.⁶ Submucosal fibroids (FIGO types 0, 1, and 2) are most commonly associated with infertility and adverse pregnancy outcomes, including fetal growth restriction and abnormal placentation.⁷ Patients with large intramural fibroids that encroach on the endometrial cavity may also experience impaired fertility.⁸

In pregnancy, fibroids can increase the risk of fetal malpresentation, the need for cesarean delivery due to fibroids potentially obstructing fetal passage through the birth canal, and postpartum hemorrhage.⁶ While not all fibroids require removal prior to conception, pre-pregnancy evaluation with ultrasound or MRI can help evaluate risk and guide the timing of intervention.⁹

Advances in diagnosis and treatment: More options, better outcomes

Diagnosis begins with a thorough clinical history and pelvic examination. Bimanual exam may reveal an enlarged or irregular uterine contour. Transvaginal ultrasound remains the first-line modality for confirming the diagnosis of fibroids. For submucosal or cavity-distorting fibroids, sonohysterography or MRI can enhance characterization and surgical planning. The FIGO classification system remains the gold standard for fibroid mapping, offering a common language across treatment modalities.¹⁰

Fibroid management now spans a broad spectrum—from no intervention at all to advanced, image-guided procedures. Individualizing treatment depends on fibroid size, the overall number of fibroids and their locations, symptom severity, fertility goals, and the availability of the various treatment options.⁵

Expectant management: Observation is appropriate for asymptomatic patients or those with mild symptoms not interfering with quality of life. Regular monitoring with pelvic exams and/or imaging is recommended to track growth and assess for evolving symptoms.¹¹

Medical management: Ideal for patients with abnormal bleeding as the primary concern. First-line options include tranexamic acid, NSAIDs, and hormonal agents such as combined oral contraceptives or progestins. GnRH antagonists and selective progesterone receptor modulators (where available) can reduce bleeding and temporarily shrink fibroids, often used as a bridge to definitive treatment.¹²

Endometrial ablation: A viable option for patients with heavy menstrual bleeding who have completed childbearing and have small fibroids confined to the uterine cavity (FIGO types 0–1). While not a treatment for the fibroids themselves, ablation can significantly reduce bleeding.¹³

Uterine artery embolization (UAE): Recommended for women who wish to preserve the uterus but are not pursuing future pregnancy. It is effective for intramural and subserosal fibroids and reduces symptoms by inducing ischemia within the fibroid tissue. Counseling should include potential impacts on fertility and risk of post-procedure pain¹⁴ and other complications.

Radiofrequency ablation (RFA): A minimally invasive approach for intramural and transmural fibroids. Delivered laparoscopically or transcervically, RFA offers rapid symptom relief, low complication rates, and uterine preservation. It's an attractive option for women seeking symptom relief without hysterectomy.¹⁵

High-intensity focused ultrasound (HIFU): A noninvasive, MRI- or ultrasound-guided ablation option for well-positioned fibroids. Ideal for women seeking uterus-sparing treatment with minimal downtime. However, limited availability and strict eligibility criteria can restrict its use.¹⁶

Myomectomy: The preferred approach for women with symptomatic fibroids who desire fertility. Can be performed via hysteroscopy, laparoscopy (with or without robotic assistance), or laparotomy. Myomectomy provides targeted fibroid removal, though recurrence is likely.⁵

Hysterectomy: The definitive solution for those with severe symptoms and no desire for future fertility. While effective, hysterectomy should be offered alongside less invasive options when clinically appropriate, not as the default.¹⁷

There is no one-size-fits-all algorithm. Shared decision-making—anchored in a detailed assessment of symptoms, reproductive goals, treatment preferences, and local resource availability—is essential for optimizing both clinical outcomes and patient satisfaction.⁵^,¹²

Navigating the emotional, physical, and financial toll

Living with fibroids can be physically draining, emotionally isolating, and financially burdensome. For many women, heavy bleeding is not just inconvenient—it’s disruptive and distressing. Patients often report carrying extra clothing, avoiding travel or social events, and feeling anxious about sudden, unpredictable bleeding.⁴ The resulting anemia can lead to fatigue, palpitations, brain fog, and a diminished capacity to participate in work, caregiving, or everyday activities.⁶

The financial toll is significant and often overlooked. Repeatedly purchasing high volumes of sanitary products—including overnight pads, menstrual cups, and period underwear—can lead to substantial out-of-pocket expenses. These costs are further amplified by the so-called "pink tax" that inflates prices for feminine hygiene items.¹⁸ In severe cases, women may spend hundreds of dollars monthly just to manage bleeding.¹⁸^,¹⁹

Lost wages are another hidden cost. Women with symptomatic fibroids may miss work due to pain, heavy bleeding, or complications from anemia. Some reduce their hours, decline promotions, or exit the workforce altogether.²⁰ Over time, this can add up to significant income loss and professional setbacks.

This layered toll underscores the need for clinicians to look beyond imaging and hemoglobin levels. Although benign, the impact of uterine fibroids is not inconsequential. Effective care includes validating a patient’s lived experience, asking about quality-of-life impacts, and offering support for both medical and non-medical aspects of living with fibroids⁴^,⁵, while providing treatment options that adequately address a woman’s symptomatology and decrease morbidity. Empowering patients with education, empathy, and access to appropriate care can transform what often feels like a silent burden into a shared clinical priority.

Conclusion

Uterine fibroids represent a complex, chronic condition with highly individualized implications. While advancements in diagnosis and treatment have broadened options beyond hysterectomy, tailoring care still depends on a thoughtful, collaborative approach. As ob-gyns, we are uniquely positioned to dispel myths, address quality of life, and empower our patients with science-backed, personalized solutions.

In the face of evolving technologies and patient-centered care models, the future of fibroid management is not only less invasive but also more compassionate.

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.

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