Breaking the Silence on Uterine Fibroids: Treatment Options Beyond Hysterectomy

Uterine fibroids are the most common solid and symptomatic neoplasm in women, affecting up to 70-80% of women by age 50. They are also the leading indication for hysterectomy, a definitive and effective treatment when appropriate.​​ ^1,2

While ACOG guidelines have evolved in recent years to move away from a “hysterectomy default” for many women’s health conditions, there is concern that women are not consistently informed about the full range of treatment options, including for uterine fibroids. Many of these alternatives can help women avoid major surgery, preserve fertility, and reduce recovery time.

To explore this critical topic, I spoke with Dr. Marc Schiffman, co-director of Weill Cornell Medicine Fibroid and Adenomyosis Center: Dr. Jessica Opoku-Anane, minimally invasive surgeon at Columbia; and Tanika Gray Valbrun, founder of The White Dress Project. Their insights underscore the importance of empowering women to make well-informed decisions about their care.

What Are Uterine Fibroids?

Uterine fibroids, also called leiomyomas, are non-cancerous growths of muscle tissue in the uterus. They can vary widely in size, number, and location, causing symptoms like heavy bleeding, pelvic pain, urinary frequency, bloating, constipation, painful intercourse and fertility challenges. ^2,3​​  There are multiple options to treat them, but let’s explore surgical and minimally invasive ones first.

The Problem with a "Hysterectomy-First" Approach

The ACOG Practice Bulletin on Symptomatic Uterine Leiomyomas emphasizes hysterectomy as a definitive treatment but also highlights the need for alternative management options for women who wish to preserve their fertility or avoid major surgery. ¹​  The concern is this could imply that hysterectomy should be first line treatment.  In fact, according to an online survey conducted by Harris Poll on behalf of the Society of Interventional Radiology in June 2017, 20% of women think a hysterectomy is the only treatment for uterine fibroids.⁴

The survey also showed that 44% of women diagnosed with uterine fibroids did not know about uterine fibroid embolization (UFE), despite its recognition as a first-line treatment for symptomatic fibroids since 2008.⁴  Dr. Schiffman expressed concern that this lack of awareness has led to an over-reliance on hysterectomy, often without fully exploring other options. This can have long-term adverse effects on the health of these hundreds of thousands of women each year, including risk of cardiovascular disease.

Follow the Money: The Role of Reimbursement and Structural Barriers

When asked about some of the reasons as to why gynecologists are not informing patients about a less invasive option, Dr. Schiffman noted that it is multi-factorial.  In addition to an educational component, and concerns about  fertility,

Dr. Schiffman shared a revealing story: financial incentives and specialty structures can strongly influence the treatment women receive. He noted that early on when building his practice he often had to "campaign" with OB-GYNs about the benefits of considering UFE.  The alternative would be spending daily morning rounds before going to the office with patients who were admitted or had complications from a more “severe” surgery such as a hysterectomy.  That time could be better spent elsewhere, including seeing more patients.

How Reimbursement Affects Decision-Making

• Reimbursement Bias: While doctors take an oath to "first do no harm," factors such as busy schedules, established practices, and systemic structures may inadvertently influence their decision to perform a procedure rather than refer a patient to another specialty. The way reimbursements are structured can inadvertently reinforce this behavior, as certain procedures, like hysterectomy, may be more familiar or accessible to the provider. This dynamic underscores the importance of multidisciplinary care and patient education to ensure all options are considered.

• Specialty Silos: Traditional care structures often isolate specialties like gynecology and interventional radiology, making collaborative decision-making rare. This can leave patients unaware of non-surgical options like UFE​.  In fact, more Level B procedures such as Radiofrequency Ablation are performed annually in this country than UFE, despite limited long-term randomized prospective data on efficacy and complications.

A Collaborative Solution: Multidisciplinary Care for Uterine Fibroids

To address these challenges, centers like the Weill Cornell Medicine Fibroid and Adenomyosis Center and UCSF’s Comprehensive Fibroid Center have adopted a multidisciplinary model. Their team includes interventional radiologists, and minimally invasive gynecologic surgeons, ensuring that the focus is on the center’s overall performance—not the incentives of individual specialties. This approach allows patients to receive comprehensive counseling on all available options and individually tailored treatment recommendations​.

Dr. Schiffman emphasizes that structural changes like this are essential for improving informed consent and empowering women to choose the best treatment for their unique circumstances.

However, an important point to note is that access to such specialized centers isn’t always realistic. Geographic limitations, insurance barriers, and systemic inequities can make it difficult for many women to receive comprehensive, multidisciplinary care. This underscores the need for greater awareness, patient advocacy, and policy changes to expand access to diverse treatment options beyond hysterectomy.

Exploring All Uterine Fibroid Treatment Options

It is vital for women to be aware of all potential treatments approved by ACOG for fibroids, including minimally invasive procedures and medication.

1. Minimally Invasive Procedures to Treat Uterine Fibroids

• Uterine Fibroid Embolization (UFE): A non-surgical option that uses particles to block blood flow to fibroids, causing them to shrink. UFE typically involves a shorter recovery time and fewer complications than hysterectomy. ^2,3,4

• Myomectomy: A surgical procedure to remove fibroids while preserving the uterus. This option is ideal for women seeking to maintain fertility. ^2,3​

2. Medication to Ease Pain Resulting from Uterine Fibroids

• Hormonal treatments like GnRH agonists can temporarily shrink fibroids and reduce symptoms. ³​

• Non-hormonal options such as tranexamic acid are available to manage heavy bleeding. ³​

Advocating for Better Informed Consent for Uterine Fibroid Patients

Advocate Tanika Gray Valbrun, founder of The White Dress Project, stresses the importance of informed decision-making, which was the opposite of what her experience was.  She stated, "I was offered a hysterectomy the very first time that I was going to see what my treatment options for fibroids were." She also notes the disproportionate impact of fibroids on Black women and the urgent need for more equitable research and care. ⁵​

Dr. Opoku-Anane echoes this sentiment: "You should not be suffering with your periods in any fashion. Most women don’t present early enough, and once we actually treat the fibroids, women always express, 'I wish I would have done this earlier.' If you’re thinking that maybe this is normal—it’s not. That’s the time to go in to see a doctor.” ⁶

For Those Considering or Needing a Hysterectomy

Hysterectomy is sometimes the best or only option for women with severe fibroid symptoms. However, it is essential that the decision is made with full understanding of the procedure, its alternatives, and its long-term impact.

For more information, check out our detailed article - Hysterectomy Unveiled: What Doctors Don’t Always Tell You - which covers the procedure, recovery, and alternative options.

Moving Forward: A Call for Change

Women deserve to have all treatment options presented to them so they can make decisions that align with their values, priorities, and health goals. Together, patients, providers, and advocates can push for a healthcare system that prioritizes education, innovation, and equitable access.

References

1. Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228. Obstetrics & Gynecology 137(6):p e100-e115, June 2021. DOI: 10.1097/AOG.0000000000004401​.

2. Uterine Artery Embolization | ACOG​.

3. Uterine Fibroids | ACOG​.

4. Women largely unaware of uterine fibroid embolization. Interventional News​. 31, August 2017.

5. Gray Valbrun, Tanika. "Uterine Fibroids, Treatment Options, and Self-Advocacy." Transcript from Fempower Health Podcast. December 2023.

6. Opoku-Anane, MD, Jessica​. “Uterine Fibroids: An Interview with a Minimally Invasive Surgeon.” Transcript from Fempower Health Podcast. November 2020.