Uterine Fibroids: When to Watch, When to Treat, and What Your Options Are

Your ultrasound showed a fibroid. Maybe more than one. And now you're wondering whether this is a crisis, a nuisance, or something you'll never notice. The answer depends entirely on the size, location, number, and symptoms — and the truth is that most fibroids need monitoring, not treatment.

Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. They're extraordinarily common — affecting up to 70-80% of women by age 50, with higher prevalence and severity in Black women. But "common" and "problematic" are not the same thing. About half of women with fibroids have no symptoms at all.

Types and Location Matter

Fibroids are classified by where they grow in the uterus, and location predicts symptoms more than size:

• Submucosal — Growing into the uterine cavity. Even small submucosal fibroids can cause significant heavy bleeding, fertility issues, and pregnancy complications. These are the most symptomatic.
• Intramural — Growing within the muscular wall of the uterus. The most common type. Symptoms depend on size. Large intramural fibroids can cause heavy bleeding, pelvic pressure, and bulk symptoms.
• Subserosal — Growing on the outer surface of the uterus. Generally asymptomatic unless large, when they can cause pressure on the bladder or bowel.
• Pedunculated — Fibroids on a stalk, either inside the cavity (submucosal pedunculated) or outside the uterus (subserosal pedunculated). Can occasionally twist (torsion), causing acute pain.

Symptoms to Watch For

When fibroids do cause symptoms, the most common are:

• Heavy menstrual bleeding — The hallmark symptom. Soaking through a pad or tampon every hour, passing clots larger than a quarter, or periods lasting longer than 7 days.
• Pelvic pressure or fullness — Large fibroids can create a sensation of pressure, similar to early pregnancy.
• Urinary frequency — Fibroids pressing on the bladder reduce its capacity.
• Constipation — Posterior fibroids can compress the rectum.
• Pain — Not always present. When it occurs, it may be cyclic (worse with periods) or constant. Acute pain can occur with degeneration (when a fibroid outgrows its blood supply).
• Infertility or pregnancy complications — Particularly submucosal fibroids that distort the uterine cavity.
• Abdominal distension — Very large fibroids can visibly enlarge the abdomen.

When Watching Is the Right Move

Asymptomatic fibroids generally don't need treatment. They need monitoring — typically with ultrasound every 6-12 months to track size. Reasons to watch rather than treat:

• You have no symptoms or mild symptoms
• You're approaching menopause (fibroids typically shrink after menopause as estrogen declines)
• The fibroid is small and not in a submucosal position
• You're not planning pregnancy (or fertility isn't affected)

At CORAL, Dr. Kim emphasizes the distinction between having fibroids and having a fibroid problem. Not every finding on an ultrasound requires action.

Medical Management

When symptoms need treatment but surgery isn't indicated or desired:

Hormonal Treatments

GnRH agonists (leuprolide/Lupron) — Suppress estrogen, causing fibroids to shrink by 30-50%. Used short-term (3-6 months) before surgery to reduce fibroid size, or to bridge to menopause. Side effects are menopausal (hot flashes, bone loss, vaginal dryness). Not a long-term solution.

GnRH antagonists with add-back therapy (Myfembree, Oriahnn) — Newer oral medications that partially suppress estrogen while including add-back hormones to minimize menopausal symptoms and bone loss. FDA-approved for fibroid-related heavy bleeding. Can be used longer-term than GnRH agonists. Myfembree (relugolix/estradiol/norethindrone) is taken as a single daily pill.

Hormonal IUD (Mirena) — Doesn't shrink fibroids but can significantly reduce heavy menstrual bleeding associated with small to moderate fibroids. Particularly useful when heavy bleeding is the primary symptom.

Oral contraceptives and progestins — May reduce bleeding but don't shrink fibroids. Useful for mild symptoms.

Non-Hormonal Medications

Tranexamic acid (Lysteda) — An anti-fibrinolytic that reduces menstrual blood loss by 30-50%. Taken only during menstruation (3 days). Doesn't affect fibroid size but can meaningfully reduce heavy bleeding. Non-hormonal, which matters for some patients.

NSAIDs — Reduce menstrual blood loss modestly (20-30%) and help with pain. Not sufficient alone for severe symptoms.

Iron supplementation — Critically important for women with heavy bleeding. Many women with fibroids are iron deficient, compounding their fatigue.

Procedural and Surgical Options

When medical management isn't enough:

Minimally Invasive Procedures

Uterine artery embolization (UAE) — An interventional radiology procedure that blocks blood flow to fibroids, causing them to shrink. Performed through a catheter inserted in the wrist or groin. 85-90% of patients report significant symptom improvement. Preserves the uterus. Recovery is 1-2 weeks. Not recommended for women planning future pregnancy.

MRI-guided focused ultrasound (MRgFUS) — Uses focused ultrasound waves to heat and destroy fibroid tissue. Non-invasive (no incisions). Not suitable for all fibroid types or sizes. Limited long-term data on recurrence.

Radiofrequency ablation (Acessa/Sonata) — Laparoscopic or transcervical approach using radiofrequency energy to shrink fibroids. Newer technology with promising results. Preserves the uterus and may preserve fertility.

Surgical Options

Myomectomy — Surgical removal of fibroids while preserving the uterus. The preferred option for women who want to maintain fertility. Can be performed hysteroscopically (for submucosal fibroids), laparoscopically, robotically, or through open surgery depending on fibroid size, number, and location. Recurrence rate: 15-30% within 5 years.

Hysterectomy — Removal of the uterus. The only definitive cure for fibroids. Eliminates any possibility of recurrence. Major surgery with 6-8 week recovery for abdominal approach, less for minimally invasive approaches. Should be a last resort, not a first offer — but is sometimes the best option for women with severe symptoms, multiple large fibroids, or failed previous treatments who don't desire future pregnancy.

Fibroids and Fertility

If you're trying to conceive and have fibroids:

• Submucosal fibroids — Should be removed before attempting pregnancy or IVF. They impair implantation and increase miscarriage risk.
• Large intramural fibroids (especially those distorting the cavity) — May benefit from removal, though the evidence is less clear-cut.
• Small intramural and subserosal fibroids — Generally don't affect fertility and don't require removal before pregnancy.

Discuss with both your primary care provider and a reproductive endocrinologist if fibroids are complicating your fertility plans.

Racial Disparities

Fibroids disproportionately affect Black women, who develop fibroids earlier, have larger and more numerous fibroids, and experience more severe symptoms. Black women are also 2-3 times more likely to undergo hysterectomy for fibroids. These disparities are rooted in biological factors (including vitamin D levels and genetic variants) and systemic healthcare factors (later diagnosis, less access to uterus-sparing procedures, and implicit bias in treatment recommendations).

If you're a Black woman with fibroids, advocate for uterus-sparing options and seek providers experienced in the full range of fibroid treatments.

Moving Forward

Fibroids are common, usually benign, and often manageable without surgery. The key is accurate characterization (size, location, number), symptom assessment, and individualized treatment planning.

If you've been told you have fibroids and want to understand your options — or if you're experiencing heavy bleeding, pelvic pressure, or fertility concerns — [start a visit at coral.clinic/start](https://coral.clinic/start). Dr. Kim can review your imaging, assess your symptoms, and help you develop a management plan that aligns with your goals.