Fibroids — Do They Always Need Surgery? A Modern Look

What fibroids are (and how common)

Uterine fibroids — medically *leiomyomas* — are non-cancerous growths of the muscular wall of the uterus. By the age of 50, around 70–80% of women have at least one, although most never notice them. They can be:

Subserosal — on the outer surface of the uterus.

Intramural — within the muscular wall.

Submucosal — bulging into the uterine cavity (these cause the most bleeding).

Pedunculated — attached by a stalk.

When fibroids are causing trouble

A fibroid only needs treatment if it's actually *causing* a problem:

Heavy, prolonged or painful periods.

Pressure symptoms — frequent urination, constipation, low backache, pelvic heaviness.

Difficulty conceiving, or recurrent miscarriage (especially submucosal types).

Rapid growth.

Rare: bleeding after menopause from a fibroid.

A 4-cm symptomless fibroid found during a routine scan often needs nothing more than yearly follow-up.

Treatment options — from least to most invasive

1. Watchful waiting

For small, asymptomatic fibroids. Annual scan, ferritin check, symptom diary.

2. Medical management

Tranexamic acid for heavy bleeding.

NSAIDs for pain.

Combined OC pills or oral progestins.

Mirena IUS — excellent for heavy bleeding from small/medium fibroids that don't distort the cavity.

Ulipristal / GnRH analogues — short-term shrinking before surgery or near menopause.

3. Minimally-invasive procedures

Uterine artery embolisation (UAE): done by interventional radiology, shrinks fibroids by cutting off blood supply. Good for women who want to avoid major surgery and don't have immediate pregnancy plans.

HIFU (high-intensity focused ultrasound): non-surgical, MRI-guided heat destruction of fibroid tissue. Available in select centres.

4. Surgery — myomectomy

*Removes the fibroid, keeps the uterus.* Routes:

Hysteroscopic (through the cervix) — for submucosal fibroids inside the cavity.

Laparoscopic / robotic — for most subserosal and intramural fibroids.

Open abdominal — only for very large or multiple fibroids.

Myomectomy preserves fertility. Recovery: 1–2 weeks (laparoscopic), 4–6 weeks (open).

5. Surgery — hysterectomy

*Removes the uterus completely.* Considered when:

Family is complete.

Fibroids are very large or numerous.

Earlier treatments have failed.

The woman herself, after counselling, prefers a one-time definitive solution.

It is *definitive* — fibroids cannot recur. But it ends the possibility of pregnancy, so the decision is never rushed.

A simple guide to choosing

Situation First-line treatment
------
Small, asymptomatic Observation
Heavy bleeding, fibroid not in cavity Mirena IUS or medical therapy
Submucosal fibroid causing bleeding/infertility Hysteroscopic myomectomy
Wants to preserve fertility, larger fibroids Laparoscopic/robotic myomectomy
Family complete, multiple/large fibroids, no improvement with other options Hysterectomy or UAE |

Two things almost everyone gets wrong

1. "Fibroids always need to be removed." False — most don't. Symptoms decide.
2. "Fibroids become cancer." Extremely rare. The cancerous form (leiomyosarcoma) is a different disease, not a fibroid that "turned bad" — and it's less than 1 in 1000.

If you've been told you have a fibroid, take a breath. Get an ultrasound report with measurements, list your symptoms honestly, and ask for the *least* invasive option that solves the real problem.