Uterine Fibroids: What Drives Them and How to Treat Them

You've probably been told your fibroids are "nothing to worry about" at least once. Maybe you've been handed a pamphlet. Maybe you were told to wait and see.

But you're here because something is off. The bleeding is too heavy. The cramping is disrupting your life. You're waking up in the middle of the night to change. You've canceled plans because you were afraid of leaking through your clothes.

Uterine fibroids affect 70-80% of women by age 50, yet most women go 3.6 years between when symptoms start and when they actually get a diagnosis and a real treatment plan. That delay isn't acceptable, and it doesn't have to be yours.

This article covers everything: why fibroids grow, what they feel like, and every treatment option available in 2026, from the newest FDA-approved oral medications to UFE to hysterectomy. You deserve the full picture, not a waiting room pamphlet.

What Uterine Fibroids Actually Are

Uterine fibroids (also called leiomyomas or myomas) are benign tumors that grow from the muscle tissue of the uterus. They're not cancer. They don't turn into cancer. But "benign" doesn't mean painless or harmless, and for the roughly 30% of women with symptomatic fibroids, they can significantly disrupt quality of life (Giuliani et al., 2020).

Fibroids vary enormously in size, from the size of a pea to, in rare cases, the size of a grapefruit. They also vary in location, and where a fibroid sits determines a lot about what symptoms you'll experience.

Submucosal fibroids grow into the uterine cavity itself. These are the most likely to cause heavy bleeding and interfere with fertility, even when they're relatively small.

Intramural fibroids grow within the uterine wall. They're the most common type and can cause significant bulk symptoms, pelvic pressure, and heavy periods depending on size.

Subserosal fibroids grow on the outer surface of the uterus. They tend to cause pressure symptoms, like urinary frequency or a feeling of fullness, more than bleeding.

Pedunculated fibroids are attached by a stalk to the uterine wall and can extend either inward or outward. They can sometimes cause acute pain if the stalk twists.

Most women have more than one fibroid. And contrary to what many are told, the number and location matter more than size alone.

The Hormone Connection: Why Fibroids Grow

This is the piece most explanations skip. Fibroids are hormone-dependent tumors. They grow in response to estrogen and progesterone, and this isn't a minor detail. It's the entire basis for how most medical treatments work.

Fibroid cells have a significantly higher density of estrogen and progesterone receptors than normal uterine muscle cells. When these hormones rise, fibroid cells proliferate, accumulate extracellular matrix, and grow. When hormone levels fall, as they naturally do after menopause, fibroids typically stop growing and often shrink.

The Estrogen Mechanism

Estrogen is the primary driver of fibroid growth. Fibroid tissue overexpresses aromatase, the enzyme that converts androgens into estrogen locally within the fibroid itself (Bulun et al., 2005). This means fibroids don't just respond to circulating estrogen. They produce their own supply. This local estrogen production amplifies growth signals beyond what you'd predict from a serum estrogen level alone.

This also helps explain a clinical pattern many women notice but aren't told about: fibroids tend to grow faster during perimenopause, when estrogen levels can spike irregularly before eventually declining. The swings are what drive growth, not just the absolute level.

Progesterone's Underappreciated Role

For years, estrogen got all the attention. But progesterone also plays a significant role in fibroid biology. In fibroid tissue, progesterone promotes cellular proliferation, increases cell size (hypertrophy), and stimulates the deposition of extracellular matrix (the collagen-like material that gives fibroids their dense, rubbery consistency) (Kim et al., 2013).

This is why selective progesterone receptor modulators (SPRMs) and GnRH antagonists that suppress progesterone alongside estrogen often outperform estrogen-only suppression approaches. It's also why adding progestins back during GnRH therapy (add-back therapy) requires careful calibration — you need enough to protect bone and manage symptoms, but too much risks restimulating fibroid growth.

Race and Risk

One thing worth naming directly: Black women are 2-3 times more likely to develop fibroids, develop them at younger ages, and experience more severe symptoms. This isn't explained by hormones alone. It involves genetic factors, environmental exposures, and likely differences in the healthcare response to reported symptoms. If you're a Black woman who has been dismissed, that dismissal is part of a documented pattern, not just your experience.

Recognizing Fibroid Symptoms

Not every fibroid causes symptoms. Studies estimate that 25-50% of women with fibroids have symptoms significant enough to seek treatment (Giuliani et al., 2020). But when fibroids are symptomatic, they can affect nearly every aspect of daily life.

Heavy Menstrual Bleeding

This is the most common fibroid symptom, and it's often more severe than people expect. "Heavy" means soaking a pad or tampon in an hour or less, passing clots larger than a quarter, or bleeding for more than 7 days. Many women with fibroids experience all three.

The downstream effect is iron deficiency anemia. When you're losing that much blood monthly, your body can't keep up. Fatigue, brain fog, shortness of breath, and heart palpitations in a woman with heavy periods often trace back to anemia, not some other cause.

Pelvic Pain and Pressure

Fibroids, especially large ones or those in certain positions, create a constant sense of pressure or fullness in the lower abdomen. This is different from menstrual cramps. It doesn't go away when your period ends. Some women describe it as feeling permanently bloated or like something is sitting on their pelvis.

Acute pain can occur if a fibroid outgrows its blood supply (degeneration), if a pedunculated fibroid twists, or if bleeding occurs within the fibroid itself.

Urinary Frequency and Retention

The uterus sits directly behind the bladder. A fibroid pressing against the bladder can cause urinary frequency, urgency, or difficulty fully emptying. Women sometimes report waking multiple times at night or never feeling like they've fully urinated. Less commonly, a fibroid can cause complete urinary retention, which requires urgent medical attention.

Back and Leg Pain

When fibroids press on nerves or structures near the spine, pain can radiate into the lower back and even down the legs. This is sometimes misdiagnosed as a musculoskeletal issue until an ultrasound identifies the actual cause.

Impact on Fertility and Pregnancy

Fibroids complicate fertility, particularly submucosal and intramural fibroids. Submucosal fibroids, even small ones, can reduce IVF success rates by nearly half (Eldar-Geva et al., 1998). Intramural fibroids that distort the uterine cavity have similar effects.

During pregnancy, fibroids increase the risk of preterm birth, placental abruption, cesarean delivery, and fetal growth restriction (Vannuccini et al., 2015). The growth often accelerates in the first trimester due to rising estrogen and progesterone, then stabilizes or reverses later in pregnancy.

Diagnosing Uterine Fibroids

Transvaginal ultrasound is the standard first-line test. It's accessible, real-time, and accurately identifies most fibroids, including their number, size, and general location.

MRI offers better detail, particularly for mapping multiple fibroids before surgery or determining candidacy for MRI-guided focused ultrasound therapy. It's also better for distinguishing fibroids from adenomyosis, which can present similarly.

Saline infusion sonography (SIS), where sterile saline is injected into the uterine cavity before ultrasound imaging, gives clearer detail about submucosal fibroids specifically.

A symptom history and lab work are essential alongside imaging. Complete blood count checks for anemia, and thyroid function and a pregnancy test should be part of any workup for abnormal bleeding.

Hormonal Treatment Options

The goal of hormonal fibroid treatment is to reduce the hormonal signals that drive fibroid growth, thereby shrinking the fibroids and reducing symptoms. Different options work through different mechanisms, and no single approach is right for everyone.

GnRH Antagonists: Elagolix (Oriahnn) and Relugolix (Myfembree)

These are the newest FDA-approved medications specifically for heavy menstrual bleeding from uterine fibroids, and they represent a significant improvement over older options.

How they work: GnRH (gonadotropin-releasing hormone) signals the pituitary to produce LH and FSH, which in turn drive estrogen and progesterone production. Antagonists block GnRH receptors immediately and reversibly. Unlike older GnRH agonists, which paradoxically stimulate the system before suppressing it, antagonists suppress ovarian hormone production within days. They come with low-dose estrogen and progesterone "add-back" to manage side effects and protect bone density.

Elagolix (Oriahnn) received FDA approval in 2020 specifically for heavy menstrual bleeding associated with uterine fibroids. In the ELARIS trials (two identical phase 3 studies, UF-1 and UF-2), 68.5% of women in UF-1 and 76.5% in UF-2 met the primary endpoint of menstrual blood loss under 80 mL with at least a 50% reduction from baseline, compared to 8.7% and 10% respectively on placebo (Schlaff et al., 2020). The formulation used in these trials was elagolix 300 mg twice daily combined with estradiol 1 mg and norethindrone acetate 0.5 mg.

Relugolix (Myfembree) is a combination tablet approved in 2021 containing relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg taken once daily. In the LIBERTY trials, 71.2% of women on Myfembree met the primary endpoint compared to 14.7% on placebo (Giuliani et al., 2020). Once-daily dosing is a practical advantage over Oriahnn's twice-daily regimen.

Important limitations: Neither elagolix nor relugolix is FDA-approved for long-term use beyond 24 months due to the risk of bone mineral density loss. They're not fertility-preserving in the traditional sense either. Both suppress ovulation, so pregnancy isn't possible during treatment. These medications are appropriate for women approaching menopause or those who need a bridge while planning surgery.

Safety signals: The combination add-back formulations carry a boxed warning for thromboembolic events (similar to combined hormonal contraceptives). Women with a history of blood clots, stroke, or certain cardiovascular conditions are not candidates. Side effects include hot flashes, headache, nausea, and mood changes, though these are typically milder with add-back therapy than without.

Bone loss: GnRH antagonists can reduce lumbar spine bone mineral density by 1-3% over 6 months (FDA prescribing information). Add-back therapy substantially mitigates this, but monitoring bone density is appropriate in any woman on these medications for more than 6 months.

GnRH Agonists with Add-Back Therapy

GnRH agonists (leuprolide, goserelin, nafarelin) work differently from antagonists. They initially cause a "flare" of estrogen and progesterone before inducing a hypoestrogenic state. They've been used for fibroids for decades, typically as a preoperative tool to shrink fibroid volume and reduce bleeding before myomectomy or hysterectomy (Lethaby et al., 2001).

Like antagonists, GnRH agonists can only be used short-term (typically 3-6 months) without add-back therapy due to bone loss risk. With add-back therapy, the duration can be extended, but these are generally not long-term standalone treatments.

They remain useful in specific scenarios: when surgery is planned and the surgical team wants to reduce fibroid size first, when the patient is near menopause, or when rapid bleeding control is needed before another treatment can be initiated.

Hormonal IUD (Mirena)

The levonorgestrel-releasing IUD (52 mg Mirena) releases a local progestin that thickens cervical mucus and thins the uterine lining. It doesn't significantly reduce fibroid size or change fibroid biology, but it can substantially reduce menstrual bleeding.

For women whose primary concern is heavy periods rather than fibroid bulk or pressure symptoms, a hormonal IUD is worth considering. It's particularly appropriate when fibroids are small and located mainly in the intramural or subserosal position without significant cavity distortion. If there's significant uterine cavity distortion from submucosal fibroids, IUD placement may be technically difficult and less effective.

Insertion can be painful, especially in women with a narrow cervical canal, and may require cervical preparation or procedural sedation.

Combined Oral Contraceptives

Combined hormonal contraceptives (estrogen plus progestin pills, patches, or rings) are often prescribed for fibroid-related bleeding. They don't shrink fibroids and don't address bulk symptoms, but they can regulate and reduce menstrual blood flow for many women.

The evidence for effectiveness specifically in women with fibroids is less strong than for GnRH antagonists, but combined OCs are widely accessible, affordable, and familiar to most women and their providers. They're a reasonable first step for women with mild-to-moderate bleeding and no contraindications. They're not appropriate for women at elevated cardiovascular or clotting risk.

Tranexamic Acid and NSAIDs

These aren't hormonal, but they're worth mentioning. Tranexamic acid (Lysteda) reduces heavy menstrual bleeding by preventing clot breakdown. NSAIDs like ibuprofen reduce prostaglandin-driven bleeding and cramping. Both can meaningfully reduce blood loss during heavy periods without affecting hormones or fibroid biology. They're often used alongside other treatments rather than as standalone therapy.

Non-Surgical Procedural Options

Uterine Fibroid Embolization (UFE)

UFE is performed by an interventional radiologist, not a gynecologist. Under fluoroscopy, tiny particles are injected through a catheter into the uterine arteries, cutting off blood supply to the fibroids. Without blood flow, fibroid tissue dies and shrinks.

Results are strong: 85-90% of women experience significant improvement in symptoms (Spies et al., 1999). In a study of 400 women followed over 16.7 months, 84% had improved menstrual bleeding and 79% had improved menstrual pain (Walker & Pelage, 2002). The randomized EMMY trial confirmed that UFE and hysterectomy produce comparable quality-of-life outcomes at 1 year, with UFE requiring shorter hospitalization and faster return to work (Edwards et al., 2007).

UFE preserves the uterus. It does not require general anesthesia for the procedure itself (conscious sedation is typical). Recovery is usually 1-2 weeks, compared to 4-6 weeks for open myomectomy.

The limitations matter, though. Fibroids don't disappear immediately. Shrinkage occurs over 3-6 months. Post-embolization syndrome, a flu-like response lasting a few days, is common. A small percentage of women (roughly 10%) require additional intervention within the first year. And while UFE doesn't directly destroy fertility, it can affect ovarian reserve, and the evidence for pregnancy after UFE is weaker than after myomectomy. Women who are hoping to conceive should discuss this carefully with their physician before choosing UFE.

MRI-Guided Focused Ultrasound (MRgFUS)

This is a non-invasive outpatient procedure where high-intensity ultrasound waves are focused on fibroid tissue under MRI guidance, heating and destroying it without incisions. No anesthesia, no hospital admission.

In early multicenter studies, 79.3% of women reported significant symptom improvement at 6 months (Hindley et al., 2004). Average fibroid volume reduction at 6 months was 13.5%, though non-enhancing (destroyed) volume persisted within the fibroid.

MRgFUS is FDA-approved but has limited availability. It's most effective for women with a small number of fibroids in accessible locations, fibroids that show good contrast on MRI, and women who prioritize non-invasive treatment and have time for a gradual response. It's not appropriate for women with large or numerous fibroids, or those with poor imaging characteristics.

Endometrial Ablation

Endometrial ablation destroys the uterine lining to reduce or eliminate menstrual bleeding. It does not treat fibroids. It's only appropriate for women who are certain they don't want future pregnancies and whose primary symptom is bleeding rather than bulk, pressure, or pain.

Women with large or submucosal fibroids are generally not good candidates, and ablation is less effective in their presence. Subsequent pregnancy after ablation carries significant risks and is strongly discouraged.

Surgical Options

When medications and minimally invasive procedures aren't enough, or when fibroid size, number, or location makes them the more appropriate choice, surgery becomes the answer.

Myomectomy

Myomectomy removes fibroids while preserving the uterus. It's the standard surgical approach for women who want to maintain fertility or who strongly prefer to keep their uterus.

It can be performed hysteroscopically (through the cervix, for submucosal fibroids), laparoscopically (minimally invasive, through small abdominal incisions), robotically, or by open laparotomy for very large or numerous fibroids.

Recovery ranges from 1-2 weeks for hysteroscopic procedures to 4-6 weeks for open surgery. The procedure works: most women experience significant symptom relief. But fibroids recur. Studies show a 10-27% recurrence rate at 5 years, and the likelihood increases with the number of fibroids removed (Donnez & Dolmans, 2016). Women with multiple fibroids are at higher risk for recurrence than those with a single fibroid.

Myomectomy is also technically demanding. Blood loss can be significant, and in some cases, the surgeon may need to convert to hysterectomy if unexpected bleeding or complexity is encountered during the procedure. This possibility should be discussed preoperatively.

For women planning pregnancy after myomectomy, conception is generally recommended to wait 3-6 months to allow adequate uterine healing. Most large case series show that pregnancy outcomes after myomectomy are good, though the evidence is largely observational.

Hysterectomy

Hysterectomy is the only definitive cure for uterine fibroids. Removing the uterus eliminates any possibility of fibroid recurrence. For women who've completed childbearing and have severe symptoms that haven't responded to other treatments, hysterectomy offers certainty that other options can't match.

Hysterectomy can be performed in several ways: vaginally, laparoscopically, robotically, or abdominally. The ovaries are usually retained unless there are separate indications for removal, and retaining the ovaries avoids surgical menopause.

The EMMY trial confirmed that at 10 years of follow-up, women who underwent hysterectomy had higher rates of freedom from reintervention compared to those who chose UFE initially (de Bruijn et al., 2007). This is the trade-off: hysterectomy is more definitive but more invasive, while UFE is less invasive but carries a small risk of needing additional procedures.

Recovery from laparoscopic hysterectomy is typically 2-4 weeks. Open abdominal hysterectomy requires 4-8 weeks.

Fibroids and Perimenopause

If you're in your 40s and your fibroid symptoms seem to be getting worse despite being told that menopause will fix things, you're not imagining it.

Perimenopause is characterized by irregular, sometimes dramatically elevated estrogen levels before ovarian function declines. These estrogen spikes can stimulate fibroid growth at precisely the stage of life when many women expect things to start improving. Symptomatic fibroids may actually worsen during perimenopause before they ultimately improve after menopause.

After natural menopause, when estrogen production drops substantially, most fibroids stabilize or shrink. Symptoms usually resolve. This is why "waiting it out" can be a reasonable strategy for a woman who is 52 and experiencing mild symptoms, but it's a much less reasonable recommendation for a 44-year-old who may have 6-8 more years of fluctuating hormones ahead.

The practical question for perimenopausal women with fibroids is: how far away are you from menopause, and how severe are your symptoms? For women who are very close to natural menopause and have manageable symptoms, expectant management may be appropriate. For those with severe bleeding, significant anemia, or symptoms affecting quality of life, waiting is not a treatment plan.

Dr. Felice Gersh, a board-certified OB/GYN with expertise in integrative gynecology, advises individualized risk assessment for perimenopausal women with fibroids, noting that the answer depends heavily on fibroid characteristics, symptom burden, and proximity to natural menopause.

HRT and Existing Fibroids

This question comes up frequently, and the answer requires nuance.

Menopausal hormone therapy (HRT), estrogen with or without progesterone, can maintain or reactivate fibroid activity. In most postmenopausal women, fibroids have already shrunk or stabilized by the time HRT is initiated. Low-dose HRT, which uses the minimum effective estrogen dose, carries a lower risk of fibroid reactivation than higher-dose protocols.

The key factors to assess are fibroid size at the time of menopause and the HRT formulation being used. Standard low-dose estrogen replacement is unlikely to significantly reactivate small, already-shrunken fibroids. Higher-dose estrogen, or estrogen combined with synthetic progestin at higher doses, may carry more risk.

If you have a history of large or symptomatic fibroids and are considering HRT, the conversation with your physician should include a baseline pelvic ultrasound, a choice of the lowest effective HRT dose, and a plan to monitor fibroid size every 6-12 months.

Transdermal estrogen (patch, gel, spray) avoids first-pass liver metabolism and is generally preferred for women with fibroid history due to lower impact on clotting factors and a potentially lower systemic estrogenic effect compared to oral estrogen at equivalent symptom-relief doses.

Cost, Coverage, and Accessing Treatment

The newest fibroid medications, Oriahnn (elagolix with add-back) and Myfembree (relugolix with add-back), carry list prices of $800-1,200 per month. This is the number that makes most women stop reading. But it's not necessarily what you'd pay.

Most major commercial insurance plans cover Oriahnn and Myfembree with prior authorization for qualifying patients. Coverage criteria typically require documentation of heavy menstrual bleeding, fibroid confirmation by imaging, and in some cases, prior failure of less expensive treatments (like OCs or tranexamic acid). Prior authorization paperwork is genuinely burdensome, but most women who meet clinical criteria do get approved.

Pharmaceutical assistance programs also exist. AbbVie (Oriahnn) and Pfizer/Myovant (Myfembree) both offer patient assistance options for uninsured or underinsured patients.

UFE and surgical options (myomectomy, hysterectomy) are typically covered by insurance when medically indicated. Verification of individual coverage and pre-authorization requirements varies significantly by plan.

At HEXIS Health, our providers can help you evaluate which treatment approaches make the most sense for your specific situation, review options across the full spectrum from medical management to referral for procedural or surgical care, and support the prior authorization process for covered medications. Your protocol starts with a complete picture of your health, not a one-size-fits-all recommendation. Schedule a consultation to begin with labs and a full evaluation.

Frequently Asked Questions

What causes uterine fibroids to grow?

Fibroids grow in response to estrogen and progesterone. Fibroid cells have a high density of hormone receptors and also produce local estrogen through an enzyme called aromatase. Fibroids tend to grow during the reproductive years when these hormones are active, often accelerate during perimenopause, and typically shrink after natural menopause when hormone levels decline significantly.

Do fibroids shrink or go away after menopause?

Most fibroids stabilize or shrink after natural menopause, as estrogen production drops substantially. Symptoms usually resolve. This is not a reliable timeline for women in early or mid-perimenopause, when estrogen fluctuations can actually accelerate fibroid growth before eventually declining. If you're perimenopausal and symptomatic, "waiting for menopause" may mean years of worsening symptoms before improvement.

What is the difference between elagolix (Oriahnn) and relugolix (Myfembree)?

Both are GnRH antagonists FDA-approved for heavy menstrual bleeding from uterine fibroids, combined with low-dose add-back hormones. Oriahnn (elagolix 300 mg twice daily plus estradiol/norethindrone) showed a 68.5-76.5% response rate in the ELARIS trials. Myfembree (relugolix 40 mg once daily plus estradiol/norethindrone) showed a 71.2% response rate in the LIBERTY trials. The main practical difference is dosing: Myfembree is once daily, Oriahnn is twice daily.

Can I get pregnant after a myomectomy?

Yes. Myomectomy preserves the uterus specifically to maintain fertility. Most physicians recommend waiting 3-6 months after surgery before attempting conception to allow adequate uterine healing. IVF and natural conception are both generally possible after myomectomy, though outcomes depend on fibroid location, the extent of surgery, and individual fertility factors.

Is uterine fibroid embolization (UFE) permanent?

UFE destroys the specific fibroids treated by cutting off their blood supply. Those fibroids don't grow back. However, new fibroids can develop from existing smooth muscle cells that weren't treated. Studies show about 10% of women need additional intervention within the first year, and reintervention rates increase over longer follow-up. UFE is more durable than myomectomy for treating the fibroids present at the time of procedure, but it doesn't eliminate the possibility of new fibroid development.

When to Seek Evaluation

Don't normalize symptoms that are affecting your life. Heavy periods that soak through protection, pelvic pain that doesn't resolve after your period, urinary symptoms you've been attributing to "getting older," or any combination of these symptoms warrants a conversation with a physician who will actually investigate, not just reassure.

If you've already been diagnosed with fibroids but your current management isn't working, that's worth pursuing too. Treatment options have expanded significantly in the past few years with the approval of Oriahnn and Myfembree. Options that didn't exist five years ago are now covered by most major insurers.

At HEXIS Health, we start with your complete picture. Labs, imaging review, symptom history, fertility goals, and a treatment approach built around your actual situation. Our providers understand the low estrogen symptoms that often accompany fibroid-related hormone shifts, the perimenopause relationship to fibroid activity, and the full list of hormone imbalance signs that may be driving what you're experiencing.

If you've been told fibroids are just something you have to live with, you deserve a second opinion. Schedule a consultation and get a plan that actually fits your body and your goals.

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