Do Large Fibroids Need To Be Removed and Fibroids: What to Know

September 13, 2025

Do Large Fibroids Need To Be Removed? What to Know

Uterine fibroids (leiomyomas) are very common, benign (noncancerous) growths of the muscle of the uterus. Many people have fibroids without ever knowing it, while others experience heavy bleeding, pelvic pressure, pain, or fertility challenges. One of the most frequent questions we hear is: “If my fibroid is large, does it have to be removed?” The answer depends on your symptoms, goals (such as preserving fertility), and the specific features of your fibroids. Below is an evidence-based guide to help you understand when removal is recommended, when watchful waiting is reasonable, and what treatment options exist.

What counts as a “large” fibroid?

Clinicians often describe fibroids by size (in centimeters) or compare the uterus to how large it would be during pregnancy (for example, “12-week size”). There is no universal cutoff for “large,” but many consider fibroids around 5 cm or greater to be large. Size alone, however, is not the main reason to treat—your symptoms and risks are.

Do large fibroids always need to be removed?

No. As leading organizations such as the American College of Obstetricians and Gynecologists (ACOG) note, treatment is typically recommended based on symptoms and complications rather than size alone. Many people with large fibroids but minimal symptoms can be safely monitored. Removal or other treatment is usually considered when one or more of the following is present:

Heavy menstrual bleeding (HMB) leading to anemia or affecting quality of life
Significant pelvic pain, pressure, or bulk symptoms (e.g., urinary frequency, constipation)
Rapidly worsening symptoms or fibroid-related complications (e.g., hydronephrosis from ureteral compression)
Infertility or recurrent pregnancy loss thought to be related to fibroids, especially submucosal fibroids that distort the uterine cavity
Fibroids that complicate or are expected to complicate pregnancy
Postmenopausal growth or new symptoms (rare, but warrants evaluation)

Cancer arising from a fibroid is rare. The U.S. Food and Drug Administration (FDA) emphasizes that unsuspected uterine sarcoma is uncommon but a serious consideration when choosing surgical techniques. Growth rate alone is not a reliable indicator of cancer, but new or rapid growth after menopause should be assessed by a specialist.

When watchful waiting is reasonable

If you are not having bothersome symptoms, many experts support watchful waiting, even with larger fibroids. This may include:

Periodic evaluation (history, exam) and imaging if symptoms change
Monitoring blood counts if bleeding is heavy
Lifestyle measures to support iron levels and overall health

Fibroids often stabilize or shrink after menopause due to lower estrogen and progesterone levels. That said, if your symptoms are impacting daily life—or if complications develop—active treatment should be discussed.

Medical treatments that may help avoid or delay surgery

Several medications can reduce bleeding and improve symptoms. These treatments do not permanently eliminate fibroids but may be used short- or long-term depending on your goals.

Nonsteroidal anti-inflammatory drugs (NSAIDs): Can reduce menstrual cramps and bleeding for some.
Hormonal options: Combined hormonal contraceptives (pill, patch, ring) and the levonorgestrel-releasing intrauterine system (LNG-IUS) can decrease bleeding. An LNG-IUS may be less effective if the uterine cavity is distorted by a submucosal fibroid.
Tranexamic acid: A non-hormonal antifibrinolytic taken only during menses; FDA-approved for heavy menstrual bleeding.
GnRH agonists (e.g., leuprolide): Temporarily shrink fibroids and reduce bleeding; commonly used to correct anemia or shrink fibroids before surgery. Long-term use is limited by side effects (hot flashes, bone loss).
Oral GnRH antagonist combinations: FDA-approved options (e.g., elagolix combination; relugolix combination) reduce heavy menstrual bleeding associated with fibroids. These are often used with “add-back” therapy to protect bone and reduce side effects.

Discuss benefits, side effects, and how these medicines align with timing for pregnancy or surgery.

Uterus-sparing procedures

For those who want to keep the uterus or preserve fertility, several procedural options may relieve symptoms:

Myomectomy: Surgical removal of fibroids while preserving the uterus. Approaches include hysteroscopic (for submucosal fibroids inside the cavity), laparoscopic/robotic, or open abdominal. Myomectomy is the standard uterus-sparing option for people seeking pregnancy, particularly when fibroids distort the uterine cavity.
Uterine fibroid embolization (UFE/UAE): An interventional radiology procedure that blocks the fibroid’s blood supply, shrinking fibroids and improving bleeding/pressure symptoms. Many patients experience significant relief and a quick recovery. Fertility after UFE is possible but less predictable; counseling with a gynecologist and interventional radiologist is recommended if pregnancy is a goal.
Radiofrequency ablation (RFA): Laparoscopic or transcervical ultrasound-guided ablation (e.g., Acessa, Sonata) uses heat to shrink fibroids. Recovery is typically rapid; data on future fertility are evolving.
MRI-guided focused ultrasound (MRgFUS): Noninvasive thermal ablation for select patients and fibroid locations; availability may be limited.

Hysterectomy: A definitive option

Hysterectomy (removal of the uterus) provides permanent relief from fibroid-related bleeding and pressure. It is appropriate for those who do not desire future pregnancy and want a definitive solution. The ovaries can often be left in place if not otherwise indicated for removal. Surgical approach depends on uterine size, anatomy, prior surgeries, and surgeon expertise.

About power morcellation and safety

For minimally invasive hysterectomy or myomectomy, surgeons sometimes fragment tissue to remove it through small incisions. The FDA advises that power morcellation should only be used in carefully selected patients and with a legally marketed tissue containment system, because it can spread unsuspected cancer. Discuss with your surgeon whether morcellation is planned, what alternatives exist, and how tissue will be removed safely.

Fertility and pregnancy considerations

Fibroids can be compatible with healthy pregnancies. However, submucosal fibroids that distort the cavity are more strongly linked to infertility and miscarriage. Large intramural fibroids may also affect implantation or growth, depending on location. If you plan pregnancy:

Ask whether your fibroid’s size and location are likely to affect fertility or pregnancy.
Hysteroscopic myomectomy can improve outcomes when submucosal fibroids are present.
Timing matters: After myomectomy, your clinician may recommend a healing interval before conception.

When to seek care promptly

Severe pelvic pain, fever, or sudden worsening pain (could suggest degeneration or, rarely, torsion of a pedunculated fibroid)
Heavy bleeding soaking through pads or tampons every hour for several hours, or signs of anemia (fatigue, shortness of breath, dizziness)
New urinary obstruction, kidney pain, or swelling of one leg (potential compression effects)

How to decide what’s right for you

The “right” plan depends on your symptoms, size and location of fibroids, your age, desire for future pregnancy, medical conditions, and personal preferences. A gynecologist experienced in fibroid management can review imaging, explain trade-offs, and coordinate care with interventional radiology when appropriate. Shared decision-making—grounded in your goals—leads to the best outcomes.

Key takeaways

Large fibroids do not automatically require removal.
Treat if symptoms are significant, complications occur, or fertility is affected.
Options range from medications to uterus-sparing procedures to hysterectomy.
Discuss surgical safety, including tissue removal methods and FDA guidance on morcellation.

Trusted resources

This article is for educational purposes and does not replace personalized medical advice. If you have fibroids or symptoms, consult a qualified clinician.