Up to 80% of women get fibroids; only some ever need anything done. Where the fibroid sits, when to leave it alone, and an honest comparison of the treatments.
Fibroids are the commonest tumour of the female reproductive tract, and one of the most over-treated. Up to 70 to 80% of women develop them at some point, yet only 20 to 50% ever have symptoms from them.1 The gap between those two numbers is where a great many unnecessary operations live.
The question worth answering is not “do I have fibroids” — a scan will often say yes — but “are these fibroids doing anything, and if so, what is the least I can do about it”.
Position matters more than size
Women are usually told a measurement in centimetres, and the measurement is what they worry about. It is the wrong thing to focus on.
A submucosal fibroid bulging into the cavity is the one that causes heavy bleeding out of proportion to its size, and the one most likely to interfere with implantation. A subserosal fibroid on the outer surface can grow large and cause nothing except, occasionally, pressure. An intramural fibroid sits in the muscle wall and its effect depends on whether it reaches the cavity.
So the useful line in an ultrasound report is not the diameter. It is where the fibroid sits and whether the cavity is distorted.
When to leave them alone
An incidental fibroid causing no symptoms is watched, not removed. That remains true even when the fibroid is fairly large, provided it is not pressing on the ureter or bladder and is not growing quickly. “It might cause trouble later” is not a reason to operate now, because most of them do not.
Treatment without surgery
| Option | What it does | Honest limitation |
|---|---|---|
| Hormonal IUD (LNG-IUS) | Reduces heavy bleeding substantially. NICE recommends it first line where fibroids are under 3 cm and the cavity is not distorted.2 | Does nothing for pressure symptoms, and can be expelled if the cavity is distorted. |
| Tranexamic acid, NSAIDs | Reduce bleeding during periods. | Symptom control only. The fibroid is unchanged. |
| GnRH agonists | Up to 50% volume reduction in three months.1 | Regrowth begins within about 12 weeks of stopping. Useful to shrink before surgery or to bridge to menopause — not a cure. |
| Iron replacement | Treats the anaemia the bleeding has caused. | Essential, and routinely forgotten. Correct the anaemia even while deciding about surgery. |
An Indian consideration. NFHS-5 found 57% of Indian women aged 15–49 are anaemic, up from 53% five years earlier.3 A woman here starts heavy menstrual bleeding from a lower reserve than the women in most international guidelines, and reaches a symptomatic haemoglobin sooner. That is a genuine argument for treating heavy bleeding earlier rather than watching it for another year — and for checking a haemoglobin at the first visit, not the third.
Surgery, and which operation
| Operation | Suited to | Where it is done |
|---|---|---|
| Hysteroscopic myomectomy | Submucosal fibroids bulging into the cavity. No cut on the abdomen; the fibroid is shaved out through the cervix. | Performed at Cosmic, for fibroids up to 3 cm. Larger submucosal fibroids are referred or staged. |
| Laparoscopic myomectomy | Intramural and subserosal fibroids where the uterus is to be kept. | Performed at Cosmic by Dr. Rahul Khatri. |
| Hysterectomy | Definitive, where family is complete and symptoms are severe. | Performed at Cosmic, laparoscopically wherever it is appropriate. |
| Uterine artery embolisation (UAE) | Uterus-sparing, no operation, done by an interventional radiologist. | Not performed at Cosmic — patients are referred to an interventional radiology unit where it is indicated. |
Myomectomy improves symptoms in up to 80% of women. It is worth knowing at the outset that new fibroids are found on imaging in 50 to 60% within five years1 — often small and symptomless, but it means myomectomy is not a permanent guarantee, and a woman told otherwise will feel misled later.
Embolisation: the trade-off nobody explains
UAE is technically successful in 95 to 97% of cases and reduces fibroid volume by 50 to 60%.1 It avoids an operation and a scar. The counterpoint, which is often left out of the consultation, is the reintervention rate above. The FEMME trial, which randomised 254 women, also found quality of life at two years modestly better after myomectomy than after UAE.4
None of that makes UAE the wrong choice. For a woman who wants to avoid surgery, or in whom surgery carries particular risk, it is a genuinely good option — and this hospital will refer you for it. It simply should be chosen knowing the numbers rather than as the easy answer.
Fibroids and fertility
The evidence here is more specific than the advice usually given.
- Submucosal fibroids reduce fertility, and removing them helps — clinical pregnancy roughly doubled in the pooled data.5
- Intramural fibroids not distorting the cavity: the evidence is genuinely insufficient to say removal helps.5 A woman being pushed towards myomectomy purely to improve IVF odds deserves to be told that.
- Subserosal fibroids: no measurable effect on fertility.5
If a myomectomy is done and the uterine wall is entered, a future pregnancy is managed as higher risk. Uterine rupture after myomectomy occurred in 0.79% across 3,685 pregnancies, with 80% of those between 28 and 36 weeks.1 That is a small number, but it changes how the pregnancy is monitored and how delivery is planned — see high-risk pregnancy care.
Fibroids in pregnancy
Fibroids are seen in 3 to 11% of pregnancies. Placenta praevia, abruption, premature rupture of membranes, preterm birth and stillbirth are all statistically raised — but the absolute difference for each is under 2%.1 Both halves of that sentence matter. The risk is real enough to warrant closer monitoring; it is not a reason for the alarm many women are sent home with.
The rare thing, stated honestly. A very small proportion of what look like fibroids turn out to be a leiomyosarcoma — roughly 1 in 2,000 procedures for presumed fibroids, and 1 in 8,300 when only prospective studies are counted.6 The risk rises with age: about 0.11–0.13% under 50 and 0.37–0.81% over 50. This is why a fibroid that grows quickly, or one that appears after menopause, is taken seriously rather than watched, and why morcellation is discussed explicitly before laparoscopic surgery.
This article is not a substitute for emergency care. If you have heavy bleeding that soaks a pad in under an hour, severe one-sided abdominal pain, fainting, or fever with abdominal pain, go to a hospital now rather than waiting for an OPD appointment. Cosmic Women’s Hospital & IVF Center has obstetric and gynaecological emergency cover 24 hours; if you are far from Naroda, go to your nearest hospital with an operating theatre.
Sources
- Chen I, Kives S, Randle E, et al. Guideline No. 461: The Management of Uterine Fibroids. Journal of Obstetrics and Gynaecology Canada 2025;47(8):102970.
- National Institute for Health and Care Excellence. NG88: Heavy menstrual bleeding: assessment and management. nice.org.uk
- National Family Health Survey (NFHS-5), 2019–21, India. rchiips.org/nfhs
- Manyonda I, Belli A-M, Lumsden M-A, et al. Uterine-Artery Embolization or Myomectomy for Uterine Fibroids. New England Journal of Medicine 2020;383:440–451.
- Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertility and Sterility 2009;91(4):1215–1223.
- Pritts EA, Vanness DJ, Berek JS, et al. The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids. Gynecological Surgery 2015;12(3):165–177.
- American College of Obstetricians and Gynecologists. Practice Bulletin No. 228: Management of Symptomatic Uterine Leiomyomas, 2021.
Been advised gynaecological surgery, or want a second opinion on the approach?
Dr. Rahul Khatri consults at Cosmic Women’s Hospital & IVF Center, Naroda, Ahmedabad. Bring your scans and any previous operation notes to the consultation — the choice of approach usually turns on what those show.
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3rd Floor, The Capital Corporate, Nr. Naroda Muktidham, Naroda, Ahmedabad 382330 · Book an appointment
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Cosmic Women's Hospital
Cosmic Women’s Hospital & IVF Center is a registered Level 2 ART clinic in Naroda, Ahmedabad — obstetrics, gynaecological surgery, IVF and ICSI, with ultrasound in-house and 24-hour emergency obstetric cover. Articles here are written by the clinical team and medically reviewed by Dr. Rahul Khatri or Dr. Bhargavi Khatri before publication.
