Black women face earlier, more severe fibroids, and fewer uterus-sparing options

The 2003 Baird cumulative-incidence study screened 1,364 women ages 35 to 49 enrolled in an urban health plan and found that by age 50, cumulative incidence exceeded 80 percent in Black women and approached 70 percent in white women, per Baird et al. in the American Journal of Obstetrics and Gynecology. Prior ultrasound-confirmed estimates had placed lifetime prevalence lower because they relied on clinically detected fibroids, which miss asymptomatic cases.

The 2017 BJOG systematic review by Stewart and colleagues pooled epidemiologic studies across North America and Europe and concluded that Black race is the most consistent risk factor for fibroids across the literature, with a two-to-three-fold higher incidence and earlier onset relative to white women, per Stewart et al. in BJOG. The same review documented that Black patients present with larger fibroids and greater symptom severity at diagnosis, which shapes every downstream treatment decision.

Jacoby and colleagues in the American Journal of Obstetrics and Gynecology in 2010 reviewed racial and ethnic disparities in benign gynecologic conditions and reported that Black women have larger, more numerous fibroids and higher rates of myomectomy complications than white women with fibroids, per Jacoby et al.. The review also documented that Black women undergo hysterectomy at higher absolute rates than white women, and that when they do have hysterectomy, they are more likely to have the open abdominal route rather than minimally invasive approaches, with longer length of stay and higher complication rates.

As a practicing OB-GYN, I see this pattern every month in clinic. A patient in her early 30s walks in with menorrhagia and iron-deficiency anemia, she has been told by a prior provider that the only permanent fix is hysterectomy, and no one has mentioned that she has four other procedural options that preserve the uterus.

ACOG Practice Bulletin 228, published in Obstetrics and Gynecology in June 2021, lays out the menu, per ACOG Practice Bulletin 228. Uterine fibroid embolization (UFE) is a catheter-based procedure performed by interventional radiology that occludes the blood supply to fibroids. Laparoscopic or robotic myomectomy removes the fibroids through small incisions and preserves the uterus for future pregnancy. Radiofrequency ablation delivers targeted heat to shrink individual fibroids and is FDA-cleared for laparoscopic and transcervical approaches. Each has evidence on symptom relief, bleeding reduction, and reintervention rates that ACOG summarizes in the bulletin, and each is appropriate for a defined subset of patients based on fibroid number, size, location, and fertility goals.

The COMPARE-UF cohort, published in the Journal of Women's Health in 2021, enrolled 1,196 Black women and 1,141 white women scheduling fibroid procedures at eight U.S. academic centers and found that once patients reached specialty care, Black women were more likely to choose uterine-artery embolization over hysterectomy (15.1 percent of Black patients versus 4.7 percent of white patients received UFE; adjusted odds ratio 4.24), per Wegienka et al.. That finding sits alongside the higher overall population-level hysterectomy rate in Black women documented by Jacoby. The plain reading: when Black patients are offered the full menu by a fibroid-specialty team, they pick uterus-sparing care at high rates. The gap is in getting into that room.

The LIBERTY 1 and LIBERTY 2 trials, published together by Al-Hendy and colleagues in the New England Journal of Medicine in February 2021, randomized women with heavy menstrual bleeding from fibroids to relugolix combination therapy (relugolix 40 mg with estradiol and norethindrone acetate) versus placebo over 24 weeks, per Al-Hendy et al.. In the two trials, 73 percent and 71 percent of women on the combination reached the primary endpoint of menstrual blood loss under 80 mL with at least a 50 percent reduction from baseline, compared with 19 percent and 15 percent on placebo. The combination is now marketed as Myfembree and sits on the ACOG-referenced list of medical options for fibroid-associated heavy bleeding in patients who are not pursuing near-term pregnancy.

Oral therapy does not replace procedural options for a patient with a 10-centimeter submucosal fibroid and a history of miscarriage. It does give a clinician a legitimate non-surgical path for a patient whose main symptom is bleeding and who wants to defer surgery, avoid it, or bridge toward fertility planning. Patients should ask whether their insurance covers Myfembree and what the step-therapy requirements look like, because cost and prior-authorization rules vary.

Patients with diagnosed or suspected fibroids can take three specific questions into the visit. First, ask the gynecologist to name every treatment option that applies to your fibroid map (number, size, location on imaging) and to explain why any option is off the table. A yes-or-no on UFE, laparoscopic myomectomy, radiofrequency ablation, and relugolix combination therapy is reasonable to expect. Second, if UFE is a candidate, ask for a referral to interventional radiology for a consultation. The procedure is performed by IR, not by OB-GYN, and referral is the step that most often does not happen. Third, if hysterectomy is being recommended, ask what specifically rules out a uterus-sparing approach in your case, and get that reasoning documented in the chart.

If the answers are vague or the menu is truncated, a second opinion at a fibroid-focused center is appropriate. ACOG Bulletin 228 is a reasonable reference to bring with you. The evidence on Black women and fibroids is not in dispute. What happens inside the exam room is where the outcome gets decided.