Uterine fibroids: symptoms, tests and treatment options
Uterine fibroids are non-cancerous growths of muscle and fibrous tissue in or around the womb. Many cause no symptoms, but they can drive heavy bleeding, anaemia, pelvic pressure, bladder or bowel symptoms, pain during sex and fertility or pregnancy concerns. The useful question is not simply "do I have fibroids?", but where they are, how big they are, whether they distort the womb cavity, and which symptom you are trying to treat.12
Key facts
- NHS guidance says fibroids are non-cancerous growths that often cause no symptoms and may only be found on routine tests.1
- Symptoms can include heavy or painful periods, tummy pain, lower back pain, frequent urination, constipation and pain or discomfort during sex.1
- NICE heavy menstrual bleeding guidance recommends full blood count for all women with heavy menstrual bleeding, and investigation choices based on symptoms and examination.2
- If fibroids are 3 cm or larger, NICE says to consider specialist referral and use ultrasound to assess number, size and location.2
- Treatment depends on symptoms, fibroid size and position, fertility goals, anaemia, age, menopause status and preference.
What fibroids are
Fibroids are also called leiomyomas or myomas. They can grow within the muscle wall of the womb, bulge into the womb cavity, sit on the outside of the womb, or grow on a stalk. Those locations matter. A small submucosal fibroid that distorts the womb cavity can cause heavy bleeding and fertility problems, while a larger outer fibroid may cause pressure, bladder symptoms or visible abdominal swelling without much bleeding.
Fibroids are hormone-sensitive, but that does not mean they can be managed by vague "oestrogen detox" advice. They tend to grow during reproductive years and often shrink after menopause when hormone levels fall. They are more common with age up to menopause, in people of African-Caribbean origin, with higher body weight, and in those with family history, according to NHS guidance.1
The main mistake is treating all fibroids as the same condition. Someone with small fibroids and heavy bleeding needs a different plan from someone with a 10 cm fibroid pressing on the bladder, someone trying to conceive, or someone with postmenopausal bleeding. The scan report should guide the conversation, not just confirm the word "fibroids".
Symptoms and red flags
Heavy menstrual bleeding is the commonest reason fibroids are investigated. NICE defines heavy menstrual bleeding by impact on physical, emotional, social and material quality of life, not by a fixed number of millilitres.2 If bleeding floods through protection, causes clots, disrupts work or sleep, causes iron deficiency, or makes leaving the house difficult, it deserves assessment.
Fibroids can also cause pelvic pressure, bloating, a feeling of fullness, lower back pain, pain during sex, constipation, frequent urination or difficulty emptying the bladder. These pressure symptoms usually depend on size and position. If symptoms are mainly cyclical severe pain, bowel pain around periods, painful sex or chronic pelvic pain, endometriosis or adenomyosis may need to be considered too.
| Pattern | Possible driver | What to ask |
|---|---|---|
| Heavy bleeding, clots, iron deficiency | Fibroid affecting the womb lining, adenomyosis or another bleeding cause | Full blood count, ferritin, ultrasound or hysteroscopy depending on symptoms |
| Bladder pressure or frequent urination | Large or front-wall fibroid pressing on the bladder | Size, position and whether kidney or bladder symptoms need review |
| Infertility or recurrent miscarriage | Cavity-distorting fibroid, submucosal fibroid or another fertility factor | Whether the fibroid affects the cavity and whether myomectomy is relevant |
| Postmenopausal bleeding | Not assumed to be fibroids | Urgent assessment for endometrial pathology or cancer-related causes |
| Rapidly enlarging mass or new severe pain | Degeneration, torsion of a stalked fibroid, pregnancy-related issue or rarer cause | Prompt clinical review, especially if pregnant or unwell |
Red flags should not be blamed on known fibroids without checking. Seek medical help for bleeding after menopause, bleeding after sex, new persistent bleeding between periods, severe one-sided pelvic pain, a positive pregnancy test with pain or bleeding, fever, foul discharge, unexplained weight loss, or anaemia symptoms such as breathlessness, chest pain, fainting or marked fatigue. NHS womb cancer guidance lists postmenopausal bleeding as the most common symptom.5
Tests and diagnosis
NICE recommends considering pelvic ultrasound if the uterus is palpable abdominally, if examination suggests a pelvic mass, or if examination is inconclusive or difficult, for example because of body habitus.2 Ultrasound can show size, number and location of fibroids, and whether the womb looks enlarged.
If heavy bleeding is present with symptoms suggesting submucosal fibroids, polyps or endometrial pathology, NICE recommends outpatient hysteroscopy rather than starting with ultrasound.2 Hysteroscopy uses a small camera to look inside the womb cavity. That matters because cavity problems can be missed or underestimated on routine ultrasound.
Blood tests matter too. NICE recommends a full blood count for all women with heavy menstrual bleeding.2 In practice, ferritin is also useful when fatigue, hair shedding, restless legs, breathlessness or heavy bleeding suggests iron deficiency, because haemoglobin can look normal before iron stores are restored. Pregnancy testing, thyroid testing, STI testing, cervical screening status and endometrial sampling depend on age, symptoms and risk factors.
Treatment options
If fibroids are small, symptoms are mild and blood count is normal, watchful waiting may be reasonable. If the main symptom is heavy bleeding, treatment can start before a final surgical decision. NICE options for heavy menstrual bleeding include the levonorgestrel-releasing intrauterine system, tranexamic acid, NSAIDs, combined hormonal contraception and cyclical oral progestogens, with the best choice depending on fibroid size, cavity distortion, contraception needs and contraindications.2
For fibroids 3 cm or larger, NICE advises considering referral to specialist care to discuss additional investigations and treatment options, and using tranexamic acid or NSAIDs while investigations and definitive treatment are being organised.2 This is important: symptom control while waiting is not the same as ignoring the fibroids.
Relugolix-estradiol-norethisterone acetate is one newer medical option. NICE recommends it for treating moderate to severe symptoms of uterine fibroids in adults of reproductive age.3 It is a prescription hormonal treatment, not suitable for everyone, and should be discussed in the context of bleeding, contraception needs, bone health, risk factors and alternatives.
Procedural options include hysteroscopic removal of submucosal fibroids, myomectomy, uterine artery embolisation and hysterectomy. NICE HealthTech guidance says uterine artery embolisation is a less invasive alternative to hysterectomy or myomectomy that preserves the uterus and is intended to reduce blood supply to fibroids, causing them to shrink.4 Myomectomy removes fibroids while keeping the womb, but fibroids can recur. Hysterectomy removes the womb and is definitive for uterine bleeding, but it is major surgery and ends the possibility of carrying a pregnancy.
Treatment choice is anatomy plus goals. A medicine can reduce bleeding without shrinking every pressure symptom. Myomectomy may protect fertility goals better than hysterectomy. Embolisation may suit some people who want uterine preservation, but it is not the same as a fertility treatment. Ask how each option fits your scan and priorities.
Fertility and pregnancy questions
Fibroids do not always affect fertility. Location matters most. Fibroids that distort the uterine cavity are more likely to interfere with implantation or pregnancy than small outer fibroids. If you are trying to conceive, planning IVF, or have recurrent miscarriage, ask whether the fibroid changes the cavity and whether removal is likely to improve the specific outcome you care about.
During pregnancy, fibroids can sometimes grow, degenerate and cause pain, or affect pregnancy and birth depending on size and position. Do not assume all pelvic pain in pregnancy is fibroid pain. Pregnancy with pain, bleeding, fever, dizziness, shoulder-tip pain or feeling very unwell needs urgent maternity or emergency advice.
Perimenopause changes the decision too. If symptoms are manageable and menopause is near, watchful waiting or symptom control may be reasonable. If bleeding is severe, anaemia is present, pressure symptoms are disabling or red flags exist, waiting for menopause is not a plan. It is a gamble.
A practical plan
Start by getting the facts from the scan: number of fibroids, largest size, location, whether the cavity is distorted, whether ovaries were seen, and whether adenomyosis or polyps were mentioned. Ask for a copy of the report. Then match treatment to the main problem: bleeding, pain, pressure, fertility, anaemia or uncertainty about diagnosis.
Track bleeding and anaemia symptoms for 2 to 3 cycles if it is safe to wait: number of heavy days, flooding, clots, night waking, days off work, pain score, bladder or bowel pressure, iron tablets, and whether symptoms affect sex, exercise or sleep. This gives a GP or gynaecologist more to act on than "heavy periods".
If fibroids overlap with endometriosis, adenomyosis, perimenopause, PCOS, iron deficiency or bowel symptoms, use the health library to map the differential. The start here guide can help prepare for GP review, while insights can help challenge hormone-detox claims. If you are considering iron, painkillers, tranexamic acid, hormonal treatment, DIM, herbal products or supplements, the stack builder can help organise safety questions.
- Do my symptoms fit fibroids, adenomyosis, endometriosis, polyps, thyroid disease, pregnancy-related causes or another problem?
- Should I have a full blood count, ferritin, pregnancy test, ultrasound, hysteroscopy or gynaecology referral?
- How many fibroids are there, where are they, how large are they, and do they distort the womb cavity?
- What can we use for bleeding and pain while investigations or referral are underway?
- Given my fertility goals, is myomectomy, embolisation, medical treatment or hysterectomy appropriate to discuss?
References
- NHS, 2023. Fibroids. link
- NICE, 2018. Heavy menstrual bleeding: assessment and management, NG88. link
- NICE, 2022. Relugolix-estradiol-norethisterone acetate for treating moderate to severe symptoms of uterine fibroids, TA832. link
- NICE, 2026. Uterine artery embolisation for fibroids, HTG240. link
- NHS, 2025. Womb cancer symptoms. link
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This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.