From prevalence to precision: Integrating phenotype, symptoms, reproductive goals, and treatment in leiomyoma care.

Uterine fibroids (leiomyomas) are present in most women during their reproductive years, yet only a subset becomes clinically meaningful. This disparity poses a central clinical challenge: distinguishing symptoms caused by fibroids from those unrelated to them. In this FIGO series summary, evidence on epidemiology, pathogenesis, diagnosis, clinical manifestations, and treatment is integrated to propose a framework linking fibroid phenotype, symptom attribution, and patient-centered goals to individualized management. Currently, leiomyoma phenotype is defined by size, number, and tumor location, with imaging used to categorize fibroids according to the FIGO classification system, which provides a framework for research, education, and clinical care. However, these features alone do not reliably predict clinical relevance, as molecular mechanisms-including effects of leiomyoma expression on endometrial hemostasis and embryo receptivity-offer biologically plausible explanations for infertility and heavy menstrual bleeding. Management should be guided by symptom attribution and patient goals, incorporating expectant, medical, image-guided, and surgical options. For heavy menstrual bleeding, medical therapy can be effective and, in the later reproductive years, may provide a nonsurgical bridge to menopause. While myomectomy remains the current standard for infertility, other procedural interventions show promise. When surgery is chosen, preoperative recognition and treatment of iron deficiency and patient blood management principles are critical components of care. Important evidence gaps persist, particularly in identifying or predicting clinically meaningful fibroids. Future progress will depend on improved risk stratification and longitudinal research that is molecular-, genetic-, and phenotype-informed. The goal is to determine which fibroids matter, when treatment should occur, and which interventions improve outcomes.