Uterine fibroids (leiomyomas) are among the most common benign uterine tumours, affecting up to 70–80% of women during their reproductive years. While many are asymptomatic, others experience heavy menstrual bleeding, pelvic pressure and fertility concerns that can impact quality of life.
For GPs, early recognition and appropriate investigation are key to effective management. Treatment options now extend beyond hysterectomy to include medical therapies, minimally invasive procedures and fertility-preserving approaches, making shared decision-making essential to achieving optimal outcomes.
Recognising the clinical picture
Fibroids should be considered in women presenting with heavy or prolonged menstrual bleeding, pelvic pain or pressure, urinary frequency, constipation or iron-deficiency anaemia. They may also contribute to subfertility and pregnancy complications, particularly when they distort the uterine cavity.
Symptoms do not always correlate with fibroid size. Small submucosal fibroids may cause significant bleeding, while larger fibroids can remain asymptomatic. Location, number and impact on quality of life are therefore important considerations.
Assessment includes a detailed menstrual, gynaecological and reproductive history, followed by appropriate pelvic examination. Transvaginal ultrasound is generally the first-line investigation, with transabdominal ultrasound or MRI used when indicated. Hysteroscopy may be appropriate if an intracavity abnormality is suspected
Management is increasingly individualised
Not every fibroid requires treatment. Women with asymptomatic fibroids can often be managed conservatively with reassurance and periodic review.
For symptomatic women, first-line medical management may include tranexamic acid, NSAIDs, hormonal contraception or a levonorgestrel intrauterine device where appropriate. Short-term use of GnRH agonists can reduce fibroid size before surgery, while newer oral GnRH antagonists have expanded treatment options for selected women seeking symptom control while delaying or avoiding surgery.
When medical management is insufficient, several uterus-preserving procedures may be appropriate. Uterine artery embolisation and myomectomy each have an important role in selected patients. In selected centres, MRI-guided focused ultrasound may also be considered. Hysterectomy remains the definitive treatment for women who have completed childbearing and desire permanent symptom relief, but it is no longer the only effective option.
The GP’s role extends beyond diagnosis
General practitioners are uniquely positioned to coordinate care from the earliest stages of diagnosis through long-term management. This includes recognising symptoms early, investigating and treating iron deficiency and anaemia, initiating first-line medical therapy, discussing fertility goals and identifying women who may benefit from specialist assessment.
Referral should be considered when symptoms persist despite medical management, where fertility preservation is desired, imaging suggests complex disease, or minimally invasive or surgical treatment options are being explored. Although uterine malignancy is uncommon, rapidly enlarging uterine masses in peri- or postmenopausal women warrant prompt specialist review.
A collaborative approach to care
There is no single ‘best’ treatment for uterine fibroids. Management should consider symptom burden, fibroid size and location, age, future fertility, recovery time, and, importantly, the woman’s own treatment goals.
As therapeutic options continue to expand, GPs play a vital role in helping women understand their choices and access timely specialist care. For many patients, fibroid management is no longer a decision between watchful waiting and hysterectomy, it is an opportunity to develop an individualised treatment plan that reflects both current symptoms and future reproductive goals.
