Uterine fibroids, also known as uterine leiomyomas or myomas, are benign monoclonal tumors arising predominantly from the smooth-muscle cells of the myometrium and represent one of the most common gynecological conditions among women of reproductive age.1–3 Their prevalence is substantial, although estimates vary according to age, ethnicity, diagnostic method, and whether symptomatic or asymptomatic disease is considered. Fibroids may be detected incidentally on pelvic imaging in women without symptoms, while others develop clinically important disease characterized by heavy menstrual bleeding, dysmenorrhea, pelvic pain or pressure, urinary and bowel symptoms, infertility, and reproductive complications.1,2 The considerable variation in symptom burden means that the presence of a fibroid alone does not necessarily constitute an indication for treatment. Instead, management increasingly emphasizes the patient's symptoms, fibroid characteristics, reproductive goals, age, comorbidities, and preferences.3–5

The clinical presentation of fibroids depends substantially on their size, number, and anatomical location. Submucosal fibroids may distort the endometrial cavity and are particularly associated with heavy menstrual bleeding and reproductive difficulties, whereas intramural and subserosal lesions may produce uterine enlargement, pelvic pressure, pain, urinary frequency, constipation, or abdominal distension.2,4 Chronic heavy menstrual bleeding can result in iron deficiency and iron-deficiency anemia, contributing to fatigue and impaired quality of life. In addition, symptomatic fibroids can affect sexual function, psychological well-being, work productivity, and social functioning. These effects make fibroid management more than a purely anatomical problem and highlight the importance of assessing the patient's individual symptom burden and quality-of-life priorities.1,5

The management of uterine fibroids has evolved considerably over the past decade. Historically, treatment decisions were often centered on hysterectomy or myomectomy, particularly when symptoms were severe or medical treatment was unsuccessful. Contemporary management, however, encompasses a broad spectrum ranging from expectant or watchful waiting to pharmacological treatment, minimally invasive procedures, uterine-sparing interventions, and definitive surgery.4–6 This expanded therapeutic landscape allows treatment to be individualized according to the clinical circumstances and the woman's reproductive intentions. Recent guidelines and reviews emphasize that there is no single treatment that is appropriate for every patient; rather, treatment should be selected through shared decision-making after discussing expected benefits, limitations, recurrence, complications, fertility implications, and the likelihood of requiring additional treatment.3,4

Watchful waiting is an appropriate component of management for many women with asymptomatic or minimally symptomatic fibroids. Because fibroids are benign tumors and their natural history is variable, immediate intervention is not routinely required solely because a fibroid has been identified. Women who have acceptable symptom control, no significant anemia or pressure-related complications, and no specific indication for intervention may be followed clinically, with reassessment based on symptoms and, when appropriate, imaging findings.3,6 This approach avoids exposing patients to procedural or medication-related adverse effects when the potential benefits of active treatment are limited. Nevertheless, new or worsening bleeding, anemia, pelvic pain, rapidly changing symptoms, reproductive concerns, or significant bulk symptoms should prompt reassessment and consideration of active treatment.

For symptomatic women who do not immediately require an intervention, medical therapy can provide effective control of heavy menstrual bleeding and associated symptoms. Nonhormonal options such as tranexamic acid and nonsteroidal anti-inflammatory drugs may reduce menstrual blood loss and pain but generally do not eliminate fibroids. Hormonal approaches, including progestin-based therapies and the levonorgestrel-releasing intrauterine system in appropriately selected patients, may improve bleeding symptoms. More recently, oral gonadotropin-releasing hormone (GnRH) antagonists have expanded the medical treatment landscape. Relugolix combination therapy, for example, has demonstrated substantial reductions in heavy menstrual bleeding while limiting the hypoestrogenic effects associated with GnRH suppression through the addition of low-dose estrogen and progestin.7 Evidence regarding elagolix similarly demonstrates its ability to reduce fibroid-associated heavy menstrual bleeding, although treatment duration, adverse effects, bone health, and the need for hormonal add-back therapy must be considered.8

For women whose symptoms persist despite medical management, several minimally invasive treatment options are now available. Uterine artery embolization (UAE) reduces fibroid vascular supply and can improve bleeding and bulk-related symptoms while avoiding removal of the uterus. Thermal ablation techniques, including radiofrequency ablation and magnetic resonance-guided focused ultrasound, provide additional uterus-sparing alternatives for selected patients.5,9,10 Recent evidence suggests that these approaches can achieve meaningful symptom improvement with shorter recovery periods than conventional surgery in appropriately selected women. However, their suitability depends on fibroid size, number, location, vascular characteristics, previous treatment, availability of expertise, and the patient's reproductive plans. Fertility considerations remain particularly important because the evidence base for pregnancy outcomes differs among treatment modalities.

Surgical treatment remains an important part of fibroid management when symptoms are severe, medical or minimally invasive treatment is ineffective or unsuitable, or when the anatomical characteristics of the fibroid warrant removal. Myomectomy removes fibroids while preserving the uterus and is therefore an important option for women who wish to retain fertility or the uterus for personal reasons. Depending on the location and size of the lesion, myomectomy may be performed hysteroscopically, laparoscopically, robotically, or through an open abdominal approach.5,9 Hysteroscopic myomectomy is particularly useful for appropriately selected submucosal fibroids, whereas laparoscopic or open myomectomy may be required for larger, deeper, or multiple lesions. Comparative evidence indicates that both UAE and myomectomy can improve quality of life, although their profiles regarding reintervention, fertility, recovery, and procedural risks differ.11,12

Hysterectomy remains the definitive treatment because removal of the uterus eliminates the possibility of fibroid recurrence. It may be considered for women with severe symptoms who do not desire future pregnancy, particularly when other treatments are unsuitable, unsuccessful, or inconsistent with the patient's preferences.4,6 Nevertheless, the availability of effective uterus-preserving medical, radiological, and surgical approaches has broadened the decision-making process beyond a simple choice between medication and hysterectomy. Current evidence supports an individualized treatment pathway extending from observation and symptom control to minimally invasive intervention and definitive surgery according to disease characteristics and patient goals.4,5,13

Therefore, contemporary management of uterine fibroids should be viewed as a continuum rather than a single therapeutic strategy. The optimal approach depends on symptom severity, fibroid number, size and location, anemia, age, fertility intentions, desire for uterine preservation, previous treatment, comorbidities, available expertise, and informed patient preference. A comprehensive understanding of options ranging from watchful waiting and pharmacological therapy to UAE, ablation, myomectomy, and hysterectomy is essential for providing individualized care. This article reviews these treatment options and considers how clinicians can select an appropriate management strategy while balancing symptom control, treatment effectiveness, procedural risks, recurrence, quality of life, and reproductive goals [3–6,9,13].

A hospital-based prospective observational study was conducted at Ayub Teaching Hospital, Abbottabad, over a period of six months from 1 January to 30 June 2026, to evaluate the clinical presentation and treatment options for women diagnosed with uterine fibroids, ranging from conservative watchful waiting and medical management to minimally invasive procedures and surgery. A total of 80 patients with clinically and/or radiologically diagnosed uterine fibroids were included in the study. Women presenting to the gynecology outpatient department or admitted for fibroid-related symptoms were assessed through clinical history, physical examination, and relevant investigations. Information regarding age, presenting symptoms, menstrual pattern, anemia, reproductive history, parity, infertility, fibroid number, size and location, and associated comorbidities was recorded. Pelvic ultrasonography was used as the primary imaging modality, while additional imaging such as magnetic resonance imaging was performed when clinically indicated for further characterization or treatment planning. Management was individualized according to symptom severity, fibroid characteristics, age, reproductive intentions, and patient preference. Patients with asymptomatic or minimally symptomatic fibroids and no immediate indication for intervention were managed expectantly with clinical follow-up, whereas symptomatic patients received appropriate medical treatment, including nonsteroidal anti-inflammatory drugs, tranexamic acid, hormonal therapy, or other indicated pharmacological options. Patients with persistent or severe symptoms despite medical treatment, significant fibroid-related complications, or specific anatomical indications were considered for minimally invasive or surgical management, including uterine artery embolization, hysteroscopic or abdominal/laparoscopic myomectomy, or hysterectomy, according to clinical suitability and availability. Treatment outcomes were assessed in terms of improvement in abnormal uterine bleeding, pelvic pain or pressure symptoms, anemia, and overall clinical status. Data were entered and analyzed using SPSS version 27.0. Continuous variables were summarized as mean ± standard deviation or median with interquartile range according to data distribution, while categorical variables were presented as frequencies and percentages. Appropriate statistical tests were applied to compare treatment groups, and a p-value <0.05 was considered statistically significant. Ethical approval was obtained from the relevant institutional ethics/review committee of Ayub Teaching Hospital before commencement of the study, and informed written consent was obtained from all participants.

A total of 80 women with uterine fibroids were included in the study. The mean age of the participants was 39.6 ± 8.2 years, with the majority belonging to the 31–40-year age group. The most frequent presenting complaint was heavy menstrual bleeding (61.3%), followed by pelvic pain or pressure symptoms (43.8%). Anemia was documented in 35 patients (43.8%).

Fibroids were solitary in 47 (58.8%) patients and multiple in 33 (41.3%). Intramural fibroids were the most frequently observed type (46.3%), followed by submucosal (28.8%) and subserosal fibroids (25.0%).

Table 1. Demographic and clinical characteristics of patients with uterine fibroids (n=80)

*Multiple responses were possible for presenting symptoms.

The management approach varied according to symptom severity, fibroid characteristics, reproductive intentions, and clinical indications. Medical therapy was the most frequently used treatment modality, administered to 32 (40.0%) patients. Myomectomy was performed in 18 (22.5%) patients, while 12 (15.0%) patients with asymptomatic or minimally symptomatic disease were managed by watchful waiting. Uterine artery embolization (UAE) was performed in 10 (12.5%) patients, whereas 8 (10.0%) underwent hysterectomy. Overall, 60 (75.0%) patients received active treatment, while 12 (15.0%) remained under observation during the study period.

Table 2. Treatment approaches used for uterine fibroids (n=80)

Figure 1. Distribution of treatment approaches among women with uterine fibroids.

Among the 32 patients managed medically, improvement in abnormal uterine bleeding and pelvic symptoms was observed in the majority. Patients undergoing myomectomy and UAE generally demonstrated improvement in bleeding and pressure-related symptoms during follow-up. Among patients managed expectantly, most remained clinically stable during the study period, although some required subsequent escalation of treatment because of persistent or worsening symptoms.

Overall, 46 (57.5%) patients demonstrated marked clinical improvement, while 20 (25.0%) experienced partial improvement. Fourteen (17.5%) patients had no significant improvement or persistent symptoms and required continued follow-up or consideration of alternative treatment. Improvement was assessed according to reduction in bleeding, pelvic pain/pressure, and other fibroid-related symptoms.

Table 3. Clinical outcome following management (n=80)

Figure 2. Overall clinical outcome following management of uterine fibroids.

Patients selected for surgical treatment generally had larger or symptomatic fibroids, persistent heavy menstrual bleeding, significant pressure symptoms, or failure of conservative treatment. Myomectomy was predominantly used in women in whom uterine preservation was desired, whereas hysterectomy was performed in women who had completed their families or had clinical indications for definitive treatment. Watchful waiting was primarily used among patients with limited symptoms and no immediate indication for intervention.

Overall, the findings demonstrate that management of uterine fibroids involved a stepwise spectrum ranging from observation and medical therapy to minimally invasive intervention and definitive surgery, with treatment selection individualized according to clinical presentation and patient-related factors.

Uterine fibroids are a heterogeneous condition in which treatment decisions depend not only on fibroid size and location but also on symptom severity, age, reproductive intentions, comorbidities, and the patient's preference regarding uterine preservation. The present study evaluated 80 women with uterine fibroids managed over six months at Ayub Teaching Hospital and demonstrated a broad spectrum of treatment strategies, ranging from watchful waiting and medical therapy to uterine artery embolization (UAE), myomectomy, and hysterectomy. This pattern reflects the contemporary concept that fibroid management should be individualized rather than based solely on the presence or size of a fibroid. Recent evidence emphasizes that treatment selection should consider the balance between symptom relief, treatment invasiveness, recurrence, fertility considerations, and long-term quality of life.16,17 In the present study, heavy menstrual bleeding was the most frequent presenting symptom, reported in 49 (61.3%) patients, followed by pelvic pain or pressure in 35 (43.8%) and dysmenorrhea in 29 (36.3%). These findings are clinically important because abnormal uterine bleeding is one of the principal reasons women with fibroids seek medical care and may subsequently develop iron-deficiency anemia. The present study identified anemia in 35 (43.8%) patients, supporting the importance of evaluating hemoglobin status in women presenting with prolonged or heavy menstrual bleeding. Contemporary reviews similarly emphasize that treatment should address not only the fibroid itself but also its effects on bleeding, anemia, pain, and quality of life.16,18 The anatomical distribution observed in this study also has implications for treatment selection. Intramural fibroids were the most common type, accounting for 37 (46.3%) cases, followed by submucosal and subserosal lesions. The location of a fibroid can influence the severity and nature of symptoms and determines whether hysteroscopic, laparoscopic, radiological, or open approaches are technically appropriate. Current evidence supports tailoring treatment to fibroid characteristics rather than applying one treatment uniformly to all patients.16,17 Watchful waiting was used in 12 (15.0%) women in the current study. This approach is particularly relevant for women with asymptomatic or minimally symptomatic fibroids in whom immediate intervention is unlikely to provide sufficient benefit to justify procedural risks. Expectant management also allows clinicians to monitor symptom progression and reconsider treatment if bleeding, anemia, pain, pressure symptoms, or reproductive concerns develop. The modern treatment literature increasingly supports individualized observation as part of the management spectrum, particularly when symptoms are limited and there is no immediate clinical indication for intervention.16 Medical treatment was the most frequently used management strategy in our cohort, accounting for 32 (40.0%) patients. This finding may reflect the fact that pharmacological treatment can provide symptom control without surgical intervention and may be particularly useful as initial therapy in women with heavy menstrual bleeding. Contemporary medical options include hormonal and nonhormonal treatments as well as oral GnRH antagonists. Elagolix-based therapy has demonstrated reductions in fibroid-associated heavy menstrual bleeding, with add-back therapy used to reduce hypoestrogenic adverse effects and improve treatment tolerability.18,19 The use of minimally invasive approaches in our study, including UAE in 10 (12.5%) patients, reflects the expanding role of uterus-preserving treatment. UAE reduces fibroid vascularity and can provide substantial symptom improvement without requiring removal of the uterus. Evidence from the FEMME randomized trial demonstrated improvement in quality of life following both UAE and myomectomy, although differences between the procedures changed over longer follow-up and repeat intervention was more frequent after UAE.20 In addition, comparative observational evidence indicates that hysterectomy, myomectomy, and UAE can all produce substantial improvements in symptom severity and health-related quality of life.21 Myomectomy was performed in 18 (22.5%) patients in the present cohort. Its continued importance is related to its ability to remove symptomatic fibroids while retaining the uterus, making it particularly relevant for women who wish to preserve reproductive potential or avoid hysterectomy. Comparative evidence suggests that myomectomy and UAE both improve fibroid-related quality of life, although their profiles differ regarding recovery, repeat intervention, and reproductive considerations.20,22 Therefore, the choice between these procedures should be based on fibroid characteristics and individualized counseling rather than assuming that one procedure is universally preferable. The role of other minimally invasive uterus-preserving techniques is also expanding. Radiofrequency ablation (RFA), for example, can reduce fibroid volume and improve symptom severity while avoiding conventional uterine surgery. Long-term observational evidence has demonstrated sustained reductions in fibroid size and symptom severity following RFA, although some women require subsequent intervention.23 A recent systematic review and meta-analysis conducted by the AAGL Practice Committee further evaluated RFA as a treatment option, reflecting the increasing evidence base surrounding minimally invasive fibroid ablation.24 Hysterectomy was performed in 8 (10.0%) patients in our study. Although it is the definitive treatment for uterine fibroids, its use must be considered in the context of the patient's age, reproductive plans, symptom severity, uterine pathology, and willingness to undergo definitive uterine removal. Evidence from the COMPARE-UF registry showed that women undergoing hysterectomy, myomectomy, or UAE all experienced improvement in health-related quality of life and symptom severity, although the magnitude and timing of improvement differed between treatment groups.21 These findings reinforce the importance of discussing both definitive and uterus-preserving approaches with appropriately selected patients. In the present study, 46 (57.5%) patients demonstrated marked clinical improvement and a further 20 (25.0%) showed partial improvement, resulting in an overall improvement in 82.5% of participants. Although the present study did not use a standardized validated quality-of-life instrument, the overall clinical improvement is consistent with contemporary evidence showing that appropriately selected medical, minimally invasive, and surgical treatments can reduce fibroid-related symptom burden. Recent systematic evidence also indicates that different treatment modalities provide meaningful improvements but differ in recovery time, durability, complications, and likelihood of additional treatment.17 The 14 (17.5%) patients with no significant improvement highlight an important aspect of fibroid management: treatment response is not uniform. Persistent symptoms may result from large or multiple fibroids, unfavorable anatomical location, inadequate response to medical therapy, coexisting gynecological conditions, or recurrence after previous treatment. Current evidence emphasizes the need for individualized treatment selection and longer-term assessment because many available interventions have different rates of reintervention and variable durability.16,17 The findings of this study should be interpreted in light of several limitations. The study was conducted at a single tertiary-care hospital with a relatively small sample of 80 patients and a follow-up period limited to six months. Therefore, the findings may not represent the wider population of women with uterine fibroids. Furthermore, treatment allocation was based on clinical judgment and patient-related factors rather than randomization, making direct comparison between treatment modalities inappropriate. The study also did not evaluate long-term recurrence, subsequent interventions, fertility outcomes, or validated quality-of-life scores. Future multicenter prospective studies with larger samples and longer follow-up should incorporate standardized symptom and quality-of-life measures and evaluate reproductive outcomes and treatment durability. Overall, the findings support a stepwise and individualized approach to uterine fibroid management, beginning with observation when clinically appropriate and progressing through medical therapy, minimally invasive treatment, myomectomy, or hysterectomy according to symptoms, fibroid characteristics, reproductive goals, and patient preference. The contemporary evidence base increasingly supports shared decision-making because the benefits and limitations of each treatment differ across patients.16,17

Uterine fibroids represent a diverse clinical condition requiring individualized assessment and management. The findings of this study demonstrate that treatment decisions should not be based solely on the presence of fibroids but should consider symptom severity, fibroid characteristics, anemia status, reproductive plans, and patient expectations. In the present cohort, heavy menstrual bleeding and pelvic pain were the predominant clinical presentations, highlighting the significant impact of fibroids on women's health and quality of life.

A wide range of therapeutic approaches was utilized, including watchful waiting, medical management, minimally invasive procedures, and surgical interventions. Conservative management provided an appropriate option for women with limited symptoms, while medical therapy successfully controlled symptoms in a significant proportion of patients. For women with persistent symptoms, larger fibroids, or inadequate response to conservative measures, minimally invasive procedures and surgery remained important treatment options. Overall clinical improvement observed in the majority of patients emphasizes the effectiveness of individualized treatment planning.

Modern fibroid management should therefore follow a stepwise approach, beginning with less invasive strategies when appropriate and progressing toward procedural or surgical treatment according to clinical indications. Shared decision-making between clinicians and patients is essential to achieve optimal symptom control while considering fertility preservation, treatment risks, recurrence potential, and quality of life.

Recommendations

Based on the findings of this study, women diagnosed with uterine fibroids should undergo comprehensive evaluation including clinical assessment, imaging evaluation, and consideration of reproductive goals before selecting a treatment strategy. Watchful waiting should remain an important option for women with asymptomatic or minimally symptomatic fibroids, with regular follow-up to identify disease progression or development of complications.

Medical therapy should be considered as an initial management option for women with symptomatic fibroids, particularly those presenting with abnormal uterine bleeding or pain, while monitoring treatment response and adverse effects. Women who fail medical therapy or develop significant symptoms should be evaluated for minimally invasive procedures or surgical interventions according to fibroid characteristics and individual preferences.

Future multicenter studies with larger sample sizes and longer follow-up periods are recommended to evaluate long-term outcomes, recurrence rates, fertility outcomes, and comparative effectiveness of different treatment modalities. Incorporation of validated quality-of-life assessment tools and patient-reported outcome measures should be encouraged to better evaluate the impact of treatment beyond clinical symptom improvement. Furthermore, increasing awareness among women regarding available treatment options may facilitate earlier diagnosis and informed decision-making regarding fibroid management.