Pulse ·

Uterine fibroids in your 40s: reassure, refer, or treat?

By Dr HB Lo, FACRRM 4 min read
Verdict Yes — worth knowing about

Uterine fibroids affect up to 70–80% of women by age 50, with peak incidence in the 40s. Most are asymptomatic. When symptoms occur, management is guided by symptom burden and patient values — not fibroid size.

Options range from watchful waiting and hormonal management through to procedural approaches — uterine artery embolisation, myomectomy, endometrial ablation, and hysterectomy. The right path depends on symptoms, fertility goals, fibroid location, and what the individual wants.

Many women have been told fibroids are simply something to live with, when medical or procedural options were available and appropriate. A GP conversation is the right starting point.

What just happened

The Medical Republic published a GP-focused clinical guidance piece this week on uterine fibroid management — specifically on the question of when to reassure, when to refer, and when to treat. The framing matters: it pushes back on an older approach in which fibroid management decisions were largely driven by size. The new guidance is explicit. Management should be individually tailored based on symptom burden, fertility intentions, and patient values — not fibroid measurements.

That is a meaningful shift in clinical emphasis, and it arrives at the right moment. Fibroids affect an estimated 70–80% of women by age 50, with peak incidence in the 40s. They are among the most common gynaecological findings a GP encounters, and yet the gap between “fibroid on the ultrasound report” and “appropriate management conversation” has historically been wide. Women have been told their fibroids are something to manage stoically, or that surgery is the only real option, when the evidence base for medical and procedural alternatives is substantial.

The both-and

”I’ve had fibroids for years and been told they’re fine — why is guidance changing now?”

Fibroids being common does not make them uniformly benign in their effects on daily life. A 4 cm fibroid in one woman may cause no symptoms whatsoever. The same-sized fibroid in another may cause periods heavy enough to require planning every outing around toilet access, disrupt sleep with nighttime flooding, and produce iron-deficiency anaemia. Size alone — the older management shorthand — does not capture that difference. Symptom burden does.

The guidance shift being reinforced in this week’s GP-facing clinical piece is not a new finding so much as a consolidation of practice that has been building in the literature. A 2024 RACGP Australian Journal of General Practice paper on contemporary fibroid management by Kirshenbaum, Rozen, and Polyakov categorises fibroids using the FIGO system (nine types by anatomical position) — distinguishing submucosal fibroids that distort the uterine cavity from intramural and subserosal types that do not. That distinction matters because the impact on menstrual blood loss, fertility, and procedural approach differs significantly by fibroid location, not size. When a woman presents to general practice with heavy periods and the ultrasound shows fibroids, the question “would you like to do something about this?” is now unambiguously appropriate — it does not require waiting for a size threshold that may never arrive.

”What are the actual options? I thought it was just surgery.”

The management ladder for symptomatic uterine fibroids is considerably wider than many women are aware of. Within general practice, non-surgical options include:

  • The levonorgestrel intrauterine device (Mirena), which is effective at reducing menstrual blood loss in many women with fibroids, though its placement may be technically more difficult depending on uterine anatomy.
  • Hormonal management including the combined oral contraceptive pill and progestogen-only options, which can reduce period volume and associated pain.
  • Tranexamic acid — a non-hormonal antifibrinolytic — and mefenamic acid for acute period management.
  • GnRH agonists, which temporarily shrink fibroids by inducing a menopause-like hormonal state. Used as a bridge to surgery or to reduce fibroid volume pre-operatively; not a long-term solution because of bone density effects, but useful in the right context.

Procedural and surgical options — including uterine artery embolisation, endometrial ablation (for submucosal fibroids affecting the endometrial cavity), myomectomy, and hysterectomy — remain available for women where medical management has not adequately controlled symptoms, or where the clinical picture warrants a procedural approach. The correct referral depends on fertility plans, fibroid location and number, anaesthetic risk, and patient preference.

None of these options is universally right. The decision is a conversation, not an algorithm.

2 cents

The clinical point worth taking from this week’s guidance piece is simple: if your periods have been heavy, disruptive, or difficult to manage and fibroids are present — the fact that your GP has previously said “they’re not big enough to worry about” does not mean the conversation is closed. The new framing is explicit that symptom burden, not size, drives management decisions.

If heavy periods are affecting your work, sleep, social plans, or physical energy, that is a symptom burden worth bringing back to your GP as a specific agenda item. Not “I have fibroids,” but “my periods are affecting my daily life and I want to talk through what options I have.”

It is also worth knowing — and this piece names it clearly — that many women living with fibroid-related heavy periods have iron-deficiency anaemia that is either unrecognised or undertreated. If fatigue has been your constant companion alongside heavy periods, asking your GP to check your iron studies as part of this conversation is entirely appropriate.

Verdict: yes — the guidance shift from size-based to symptom-and-values-based management is clinically significant, and it opens conversations that should have been happening earlier.

Sources cited

  1. The Medical Republic — Uterine fibroids: reassure, refer or treat? 3 July 2026. https://www.medicalrepublic.com.au/uterine-fibroids-reassure-refer-or-treat/126988
  2. RACGP Australian Journal of General Practice — Contemporary management of uterine fibroids. Kirshenbaum, Rozen & Polyakov, July 2024. https://www1.racgp.org.au/ajgp/2024/july/contemporary-management-of-uterine-fibroids
  3. RANZCOG — Clinical guidelines: gynaecology. https://ranzcog.edu.au/training-hub/clinical-guidelines-and-publications/clinical-guidelines

Frequently asked questions

  • My ultrasound showed fibroids but I have no symptoms. Do I need to do anything?

    In most cases, no. Asymptomatic fibroids found incidentally on ultrasound do not require treatment. They may be monitored with occasional repeat imaging, particularly if they are large or growing, but watchful waiting is entirely appropriate for fibroids that are not causing problems. The decision to intervene is driven by symptoms and patient preferences, not the presence of fibroids on a scan.

  • What symptoms would make my GP want to look at fibroid management more actively?

    Heavy or prolonged periods (menorrhagia) are the most common reason fibroids come to active management. Pelvic pressure or pain, urinary frequency, and the impact on daily functioning and quality of life all factor in. If your periods are heavy enough to affect work, sleep, or daily activities — soaking through pads or tampons quickly, passing large clots, or feeling fatigued from blood loss — that is worth a specific conversation with your GP about management options.