A thirty-seven-year-old marketing executive in Ikoyi books a gynaecology appointment because her periods, which used to last four days, now last eight, and on the third and fourth day she is changing a super pad every ninety minutes and planning her week around it. She has two children. She has not closed the door on a third. The gynaecologist palpates a lower-abdominal mass to roughly umbilical level, sends her for a pelvic ultrasound, and at the follow-up tells her, in a tone that does not invite discussion, that she needs a hysterectomy. The uterus is too distorted for anything else, he says. You already have two children. There is no reason to keep it.
She seeks a second opinion. The second gynaecologist agrees the uterus is too distorted for a clean hysteroscopic resection but says the right procedure is an open myomectomy — uterus-preserving, longer recovery, leaves the option of another pregnancy. Neither doctor mentions uterine artery embolisation. Neither mentions medical management to shrink the fibroids first. Neither refers her to an interventional radiologist. She is presented with two surgical options and sent home.
She calls a friend in London who is also a doctor. Have they offered you UAE? A Mirena? A GnRH agonist for three months first to shrink them? She has not been offered any of those. The friend gives her the name of an interventional radiologist in Lagos.
She gets the spectrum-of-options consultation eventually, because she has the network to find it. This piece is for the patient who does not have that friend.
This is not hypothetical
The composite above is not one woman. It is the version of the same consultation that arrives in the office of every concierge physician in Abuja and Lagos two or three times a quarter. What to do about a symptomatic fibroid uterus in a thirty-something Nigerian woman is one of the most common decisions Nigerian gynaecology makes. How the decision is framed for the patient is what this piece is about.
Black women carry one of the highest uterine-fibroid prevalences in the world. Nigerian women present earlier, with larger fibroids, more symptoms, and at younger ages than the international literature on the general population would predict. Roughly three quarters of Nigerian women will develop fibroids during their reproductive years. The overwhelming majority will be asymptomatic and will never require treatment. Among the minority who do, the modern field offers a spectrum that has expanded considerably in the last fifteen years — medical, interventional radiological, focused-ultrasound, and surgical. Nigerian gynaecology in routine private practice defaults overwhelmingly to the surgical category, and within it to two procedures: myomectomy and hysterectomy. The other rungs are mentioned rarely, offered less often, and explained, when explained at all, in language that nudges the patient back toward the operating theatre.
That default is the problem this piece names.
What fibroids actually are
Uterine fibroids — leiomyomas, in the textbook — are benign tumours of the smooth muscle of the uterine wall. They almost never become cancerous; the rate of malignant transformation to leiomyosarcoma is on the order of one in a thousand or lower, and overwhelmingly in post-menopausal women. For a woman in her reproductive years, the cancer question must be considered but is not the dominant clinical question. The dominant question is symptom burden.
Fibroids are classified by location. Submucosal fibroids sit inside the uterine cavity, distort the endometrium, and are disproportionately responsible for heavy bleeding and fertility difficulty. Intramural fibroids sit within the muscle wall and can cause bleeding, pain, and pressure depending on size and number. Subserosal fibroids sit on the outer surface and most often cause pressure on the bladder, bowel, or ureters. The international FIGO system assigns each fibroid a numerical position on this map; a competent report locates every fibroid by FIGO category, size, and number.
The symptoms that matter clinically are heavy menstrual bleeding severe enough to drop the haemoglobin or interrupt the patient's life; pressure symptoms; pelvic pain beyond ordinary dysmenorrhoea; and demonstrated impact on fertility or pregnancy. A fibroid uterus causing none of these — even a large one — does not necessarily require treatment. Size alone is not an indication for surgery. The first question of a proper fibroid consultation is not which procedure. It is which symptoms, at what severity, with what impact. The second is what does the imaging show. Only then does treatment enter the conversation.
The full management spectrum
Here is the ladder, named in order.
Watchful waiting. For asymptomatic fibroids — regardless of size — the appropriate answer is most often serial imaging at twelve-month intervals and nothing else. Fibroids are hormone-responsive and most involute at menopause. The historical instinct to operate on any fibroid that can be felt on examination is not supported by the evidence.
Medical management. For heavy menstrual bleeding with or without anaemia, several options exist before surgery is on the table. Combined oral contraceptives and progestin-only pills reduce blood loss substantially. The levonorgestrel-releasing intrauterine system — the Mirena coil — reduces blood loss by seventy to ninety percent in suitable candidates and is, in many women with non-cavity-distorting fibroids, definitive. Tranexamic acid on bleeding days reduces blood loss by around forty percent and is cheap, well-tolerated, and underused. GnRH analogues shrink fibroids by twenty to fifty percent over three to six months and are most often used for pre-operative optimisation. Ulipristal acetate, where regulatory status permits, is another medium-term option.
Uterine artery embolisation (UAE). This is the procedure most Nigerian women with symptomatic fibroids are not being told about. An interventional radiologist advances a catheter through the femoral or radial artery to the uterine arteries and injects particles to occlude the blood supply. The fibroids shrink. The uterus, fed by collateral circulation, is preserved. Hospital stay is overnight rather than four to seven days; recovery two weeks rather than six to eight. It is available at several centres in Lagos and a smaller number in Abuja; operator volume matters. The fertility implications were historically counselled as definitive — UAE will end your ability to carry a pregnancy. The contemporary evidence is more nuanced; subsequent pregnancies are well documented, and current guidance for a woman with fertility intent is that UAE is a discussion, not an absolute contraindication. Many Nigerian gynaecologists are still counselling from the older position.
MR-guided focused ultrasound (HIFU). Non-invasive thermal ablation under MRI guidance. Availability in Nigeria is currently limited; mentioned here for completeness.
Myomectomy. Surgical removal of fibroids with preservation of the uterus — hysteroscopic, laparoscopic, robotic, or open, depending on fibroid number, size, and location. Recurrence over a decade is real — fifteen to thirty percent — and the patient should be told so.
Hysterectomy. Definitive removal of the uterus. The right answer for the woman who has completed her family, has failed less invasive measures, has refractory bleeding or pain, or explicitly does not want to preserve the uterus. It is rarely the first answer for a woman in her thirties, and almost never the only answer to discuss with a woman who has not been offered the rungs below it.
A consultation that begins at the top of this ladder and works downward is different from one that begins at the bottom and mentions the others only if the patient asks the right questions.
The second story
A forty-one-year-old public servant in Abuja, two children, presents with heavy menstrual bleeding and a fibroid uterus on imaging. She is told she needs a hysterectomy. She consents. The procedure is uncomplicated. Four years later, in front of a different physician for an unrelated complaint, she mentions the surgery in passing.
The new physician looks at the original imaging report. The fibroids were not enormous. The bleeding pattern would very plausibly have responded to a trial of medical management. The imaging would very plausibly have made her a good candidate for UAE. At the original consultation she was not asked whether she might want another pregnancy, not offered a Mirena, not offered tranexamic acid, not referred to interventional radiology.
She does not regret the hysterectomy. She cannot. The patient given only one option cannot meaningfully regret choosing it — there was nothing to compare against. The question the new physician sits with, quietly, is whether the surgery was the right answer for her specific case, or the right answer for her gynaecologist's default workflow. The patient could not have asked it. The first gynaecologist did not.
This is the silent cost of under-counselled consultation. Not malpractice. Not catastrophic harm. A series of decisions that compound across thousands of Nigerian women a year into a quietly unnecessary load of major surgery, lost uteri, and lost optionality.
Why Nigerian fibroid management defaults to surgery
Three structural reasons, layered.
The surgical-culture default. Nigerian gynaecology training has historically been a surgical training. The skill the residency programme prizes, the procedure the registrar wants to log enough cases of to qualify — all of it is surgical. The medical and interventional alternatives are recent additions to the international toolkit, unevenly absorbed, frequently treated as the lesser path rather than as the appropriate first answer for an entire class of presentations. The bias is not malicious. It is what the training built.
The patient-decision asymmetry. The standard Nigerian fibroid consultation is not a spectrum-of-options conversation. It is a recommendation. The patient is told what she needs, the procedure is named, the date is offered. The consultation that begins here are the four ways this can be managed; here are the trade-offs of each; the decision is yours is the exception, not the rule. The patient who does not know the rungs of the ladder exist cannot ask to climb them.
The fertility-mythology problem. UAE specifically suffers from outdated counselling. In its early years it was presented as a fertility-ending intervention, and a generation of gynaecologists were trained to counsel it that way. The data is more nuanced now. Many clinicians making the referral decision have not updated — so the patient who would benefit most from a uterus-preserving non-surgical option is routed away by a clinician who genuinely believes he is protecting her fertility.
These three reasons do not absolve the gynaecologist. They explain him.
What proper fibroid counselling actually looks like
Operationally, the consultation has a clear shape.
It begins with symptom characterisation — which symptoms, at what severity, with what specific impact on work, sleep, and life. A woman changing a super pad every ninety minutes for two days a month is in one clinical category. A woman whose periods are heavier than they used to be but who is not anaemic and whose life is not interrupted is in another. The conversation calibrates to the actual burden, not the imaging finding.
It includes imaging by an operator who can characterise the uterus properly — ultrasound by a sonographer who locates every fibroid by FIGO category, size, and number, and reports uterine volume; MRI in selected cases. It includes bloods — full blood count, ferritin and iron studies, thyroid function where indicated, beta-hCG before any procedural decision. Heavy bleeders are often more anaemic than they realise; iron replacement matters regardless of treatment path.
It then unfolds into the spectrum-of-options conversation. Every relevant rung of the ladder is named. Trade-offs are explained in plain language. The patient's own priorities — fertility intent, recovery time, tolerance for recurrence risk, willingness to lose the uterus — are elicited explicitly, not assumed. The clinician recommends, with reasons. The patient decides.
Where surgery is the right answer, surgeon selection matters as much as procedure selection — annual volume, complication rates, conversion-to-hysterectomy rate for laparoscopic and robotic myomectomy. The same logic applies to the interventional radiologist for UAE. Pre-operative optimisation matters too: iron status corrected, GnRH analogue shrinkage where indicated, a frank fertility consultation about whether egg or embryo banking makes sense.
That sequence is what international guidelines have described as standard practice for a decade. It is not happening in most Nigerian fibroid consultations.
The third story
A thirty-nine-year-old finance director in Abuja, one child and an open question about a second, presents with heavy menstrual bleeding and a fibroid uterus on imaging. The gynaecologist she sees walks her through the ladder. They start with three months of a GnRH analogue plus oral iron, which corrects her anaemia and shrinks the dominant fibroid by about a third. He refers her to an interventional radiologist in Lagos. She elects UAE. She is back at her desk in ten days. At twelve months her menstrual loss is roughly half what it was; at twenty-four months it has stabilised. The smaller residual fibroids are managed with annual imaging. The door on a second pregnancy stays open. The whole conversation took ninety minutes across two visits.
That outcome is not unusual when the counselling is done properly. It looks unusual in the Nigerian context because the counselling rarely is.
The arc this piece belongs to
The previous piece in this series, on endometriosis and the seven-year diagnostic delay, described a different version of the same script. Pain minimised. Bleeding minimised. The surgical default preferred over the medical spectrum. The patient under-counselled. The endometriosis version of the script delays diagnosis for years. The fibroid version reaches diagnosis quickly — fibroids are easier to see — and then narrows the treatment conversation to the part of the spectrum the gynaecologist is most comfortable performing. The two conditions are clinically distinct. The structural problem is the same.
What we do at Kinedic
We do not perform fibroid surgery and we do not perform UAE. When a member presents with a fibroid uterus, what we do is the consultation above, and then the referral. The referral matters. We refer to gynaecologists and interventional radiologists in Abuja and Lagos who do enough volume of the specific procedure under discussion to give honest counselling and a competent operation. We refer on case volume and outcomes, not personal relationship.
Where the patient elects medical management we run it. Where she elects UAE or surgery we handle the pre-procedure work-up and optimisation, coordinate with the operating team, and manage the recovery and follow-up. The patient decides. Our job is to put every rung of the ladder in front of her, plainly, before she has to.
Closing
A fibroid uterus is a clinical situation, not a sentence. Most women carrying one will never need treatment at all. Of the minority who do, a meaningful proportion will be best served by medical management, and a further proportion by uterine artery embolisation, before any consideration of surgery. The women who genuinely need surgery — and there are many — deserve a consultation in which surgery is named as the right answer after the alternatives have been weighed, not as the only answer ever discussed.
That consultation is missing from default Nigerian gynaecology in 2026. It is not missing because the clinicians are bad. It is missing because the structure around them does not build it in.
The first conversation is private and costs nothing.