The Annual Economic Burden of Uterine Fibroids in the United States (2010 Versus 2022): A Comparative Cost-Analysis

Abstract

In 2010, the estimated annual cost of uterine fibroids in the United States ranged from 5.9 to 34.4 billion USD. In the past decade, more uterine-sparing and fertility preserving interventions have become available to treat symptomatic fibroids. This comparative cost-analysis aims to evaluate change in societal costs of uterine fibroids in the US between 2010 and 2022 given changing fibroid and obstetric management, population growth, and inflation. A systematic review was conducted to update uterine fibroid, treatment, and obstetric complication prevalence, direct costs of medical and surgical interventions, indirect productivity costs, and obstetric costs attributable to fibroids in 2022. A comparative cost-analysis with paired t-tests was performed using baseline data published in 2010. Percent (%) changes between 2010 and 2022 were reported. NIH research funding for fibroids and other common diseases was compared. All costs were converted to 2023 USD. The number of US women with uterine fibroids increased by 10.6% from 2010 to 2022. Over this period, the economic burden of uterine fibroids increased up to 41.4 billion USD compared to 34.4 billion USD in 2010. Overall costs increased to 42.2 billion USD after incorporating new costs associated with MRgFUS and infertility. Direct costs of medical management decreased while costs of surgical interventions increased as a result of evolving treatment-seeking behavior. Lost work costs continue to account for the largest proportion of the economic burden for fibroids. Cesarean section delivery remains the largest contributor (average 80.0%) to indirect obstetrical costs. Despite the rise in the number of individuals affected by uterine fibroids and its sizable annual cost to society, uterine fibroids research continues to be underfunded.

Introduction

In 2010, the estimated annual cost of uterine leiomyomata in the United States ranged from 5.9 to 34.4 billion US dollars (USD), demonstrating the heavy economic toll of uterine fibroids in addition to the personal burden of disease experienced by women [1].

Uterine fibroids are the most common benign gynecological tumor in premenopausal women. By age 50, nearly 70% of white, Hispanic, and Asian women and over 80% of Black women will be diagnosed with uterine fibroids [2–5]. Although many women with fibroids may be asymptomatic and diagnosed incidentally, an estimated 20 to 50% of women experience symptoms including abnormal uterine bleeding, pelvic pain or pressure, urinary frequency, and anemia [6]. These symptoms result in significant health disabilities and poor quality of life [7]. Treatment for uterine fibroids includes medical management, interventional procedures, and surgical options. Uterine fibroids are currently the leading indication for hysterectomy, the most effective treatment for symptomatic fibroids, accounting for 39% of all hysterectomies performed annually in the United States [8].

In the past decade, the landscape for uterine fibroid treatment has changed as more options have become available for women with symptomatic fibroids. In addition to traditional interventions such as hysterectomy and myomectomy, minimally invasive approaches including uterine artery embolization (UAE), endometrial ablation, and magnetic resonance imaging-guided focused ultrasound (MRgFUS) have demonstrated comparable efficacy in improving fibroid-associated symptoms [9]. Surgical techniques for hysterectomy and myomectomy have also expanded to include robotic and laparoscopic approaches, resulting in varying operating room times, hospital stay lengths, and direct costs [10, 11]. New interventions continue to be explored such as recently approved gonadotrophin-releasing hormone (GnRH) analogs for medical treatment and radiofrequency fibroid ablation (RFA) devices for procedural treatment. In light of evolving treatment options for uterine fibroids, it is important to re-evaluate the direct and indirect costs of uterine fibroids in the United States as treatment-seeking behavior among symptomatic women may have changed.

Uterine leiomyomata also have significant impacts on infertility and pregnancy outcomes such as increased risk of preterm labor, placental abruption, postpartum hemorrhage, malpresentation, and cesarean Sects. [6, 12, 13]. In 2010, the estimated annual cost of uterine fibroids included obstetric-related complications attributable to fibroids such as spontaneous abortions requiring dilation & curettage, preterm deliveries, and cesarean section deliveries [1]. The availability of newer, uterine-sparing treatments for fibroids in recent years allows for increased fertility preservation, which may impact the cost of associated adverse reproductive outcomes as more women with fibroids attempt to achieve pregnancy. Furthermore, it is estimated that uterine fibroids may be present in up to 27% of women seeking reproductive assistance, demonstrating the importance of incorporating costs of infertility treatments in the overall societal costs attributable to uterine fibroids in the United States [14].

The objective of this comparative cost-analysis was to calculate the current economic burden of uterine fibroids in the United States given the changing landscape for fibroid treatment between 2010 and 2022. This update will focus on changes in prevalence of uterine fibroid treatments, changes in direct and indirect costs, and incorporating costs associated with newer interventions and infertility treatments attributable to fibroids.

Materials and Methods

A comparative cost-analysis study was performed to evaluate the change in the annual cost of uterine fibroids in the United States between 2010 and 2022. The framework used for evaluating the economic burden of uterine fibroids in the United States drew largely on the approach used in the prior study [1]. The cost analysis was from a societal perspective. A systematic review was conducted in May 2023 via PubMed, Embase, and Cochrane Library as well as private and governmental databases such as the Centers for Disease Control, Bureau of Labor Statistics, and US Census Bureau. The following themes were utilized to create search strategies: fibroids, leiomyomata, pregnancy, preterm, cesarean section, vaginal delivery, infertility, in vitro fertilization, cost, economy, abortion, miscarriage. As in the prior study, only studies based in the United States pertaining to women ages 25 to 54 were included.

To perform the comparative analysis, the same variables provided in the baseline 2010 data were collected in the updated 2022 systematic review: prevalence of fibroids, treatments, and associated obstetric complications; direct costs of fibroid treatments; and indirect costs of fibroid treatments. Direct costs included the costs of nonsurgical management (medication, outpatient visits, inpatient admissions) and the costs of surgical management (hysterectomy, myomectomy, UAE, endometrial ablation). Indirect costs included lost work costs (absenteeism, disability) and obstetric complication costs attributable to fibroids (spontaneous abortions requiring dilation & curettage, preterm deliveries, cesarean section deliveries). Additionally, new variables were collected in the 2022 systemic review including the direct cost of assisted reproductive technology (ART) associated with fibroids and the direct and indirect costs of MRgFUS.

In order to accurately compare the annual costs of uterine fibroids over the decade, the updated systematic review utilized the same methodology and formulas described by Cardozo et al. [1]. Therefore, the review yielded a range of prevalences, and costs determined by the lowest and highest estimates found in the literature when possible. For some variables, only a single estimate was found in the systematic review. All monetary values were converted into 2023 US dollars using the Medical Care Index of the Consumer Price Index (CPI) for medical costs and the General CPI for lost work costs [15]. All cost data is presented as the lowest and highest estimates found in the systematic review with the mean calculated from the range when possible. The averages presented in Table 1 were calculated from the average prevalence and average cost per case in order to minimize potential effects of skewed cost data.

Table 1.

Prevalence data for women with fibroids, women obtaining different types of treatments for fibroids, and pregnancy complications attributed to fibroids in the United States

A. Incidence of Fibroidsa
	2010 [1]						2022						Change (2010–2022)
	Incidence (%)			Cases/Year (n)			Incidence (%)		Cases/Year (n)				Incidence (%)			Cases/Year (n)
Fibroids (General Population)	0.92			588,164			1.01 [29]		650,623				0.09			62,460
B. Prevalence of Fibroid Treatment Methods
	2010 [1]						2022						Change (2010–2022)
	Prevalence (%)			Cases/Year (n)			Prevalence (%)			Cases/Year (n)			Prevalence (%)			Cases/Year (n)
	Mean	Low	High	Mean	Low	High	Mean	Low	High	Mean	Low	High	Mean	Low	High	Mean	Low	High
Non-Surgical Managementb	57.31	36.97	77.64	337,047	217,444	456,650	42.35	31.70 [30, 31]	53.00 [30, 31]	275,539	206,248	344,830	−14.96	−5.27	−24.64	−61,508	−11,196	−111,820
Fiysterectomy	36.95	21.00	52.90	217,326	123,514	311,139	25.44	21.75 [30]	29.13 [32]	165,519	141,511	189,527	−11.51	0.75	−23.77	−51,808	17,996	−121,612
Myomectomy	3.47	1.00	5.93	20,380	5,882	34,878	4.72	1.86 [30]	7.58 [32]	30,709	12,102	49,317	1.26	0.86	1.65	10,330	6,220	14,439
Uterine Artery Embolization	0.99	0.20	1.77	5,793	10,410	1,176	1.98	0.77 [30]	3.19 [32]	12,882	5,010	20,755	1.00	0.57	1.42	7,089	3,833	10,344
Endometrial Ablation	1.30	0.16	2.43	7,617	941	14,292	4.15	3.96 [30]	4.33 [30]	26,968	25,765	28,172	2.85	1.90	3.80	19,352	24,824	13,880

C. Prevalence of Pregnancy Complications
	2010 [1]		2022		Change (2010–2022)
	Prevalence (%)	Cases/Year (n)	Prevalence (%)	Cases/Year (n)	Prevalence (%)	Cases/Year (n)
Spontaneous Abortions (All types)c	15.00	960,720	11.50 [33]	633,305	−3.50	−327,415
Spontaneous Abortions (D&C Only)d	19.90	191,183	28.00 [34]	177,325	8.10	−13,858
Preterm Deliverye	12.18	503,034	10.38 [35]	380,713	−1.80	−122,321
Cesarean Section Deliverye	32.90	1,358,770	32.10 [35]	1,177,350	−0.80	−181,420

D. Proportion of Pregnancy Complications Attributed to Fibroids
	2010 [1]			2022			Changef(2010–2022)
	Prevalence (%)			Prevalence (%)			Prevalence (%)
Fibroids (Pregnant Population)	0.37–10.70			10.40 [36]			−0.30
	OR (95% CI)	Proportiong (%)	Cases/Year (n)	OR (95% CI)	Proportiong; (%)	Cases/Year (n)	Proportion (%)	Cases/Year (n)
Spontaneous Abortions (D&C Only)	1.60 (1.30–2.00)	0.22–6.32	421–12,089	1.60(1.30–2.00) [37]	5.87	10,415	−0.45	−1,674
Preterm Delivery	1.50 (1.30–1.70)	0.18–5.08	906–25,560	1.66(1.29–2.14) 6.42 [38]	24,454	1.34	−1,106
Cesarean Section Delivery	3.70 (3.50–3.90)	0.99–22.40	13,455–304,440	2.09(1.69–2.58) 10.18 [39]	119,875	−12.22	−184,565

Note All costs are reported in 2023 US dollars [15]

^a.Incidence for fibroids among general populations was calculated by multiplying prevalence rate with the total number of women ages 25–54 in the United States in 2010 (63,930,821 [1]) and 2022 (64,164,047 [40])

^b.Non-surgical management includes medication, outpatient visits, and inpatient admissions.

^c.Prevalence of all spontaneous abortions was multiplied by the number of total pregnancies in the United States in 2010 (6,404,800 [1]) and 2022 (5,507,000 [41]) to determine cases per year.

^d.Prevalence of all spontaneous abortions requiring D&C was multiplied by the number of spontaneous abortions in the United States in 2010 and 2022 respectively to determine cases per year. Only data spontaneous abortions requiring dilation and curettage were utilized in all remaining cost calculations

^e.Prevalence of both preterm and cesarean section deliveries were calculated by multiplying the respective prevalence by the number of annual births in the United States in 2010 (4,131,019 [1]) and 2022 (3,667,758 [35])

^f.The change for prevalence and cases/year were calculated using the 2010 value closest to the 2022 value

^g.The proportion attributed to fibroids was calculated using published ORs and the methodology reported by Adams et al. [42]. Proportion Attributable = p*(OR-1) / p*(OR-1) + 1 (P = prevalence of fibroids in pregnancy)

New calculations were completed to incorporate the costs of assisted reproductive technology (ART) and MRgFUS to the total annual cost of uterine fibroids in 2022. To incorporate the costs of ART associated with fibroids, the prevalence of infertility in the general population was first multiplied by the number of women ages 25–54 in 2022 to determine the number of infertility cases per year in the study population. The systematic review produced a percent range for infertility solely attributed to fibroids, so the average of that range was used to calculate the number of infertility cases per year caused by uterine fibroids. Further calculations assumed that the percent of women seeking ART services would be uniform in the fibroid-associated infertility population to estimate the number of infertility cases per year caused by fibroids and pursuing ART. To incorporate the costs of MRgFUS, the prevalence of MRgFUS was calculated by manipulating cohorts presented in Marsh et al. to match our study population [16].

The total societal cost of uterine fibroids was compared to other common diseases such diabetes, asthma, breast cancer, prostate cancer, and benign prostate hyperplasia. Estimated annual costs, estimated number of affected individuals, and NIH research funding for each disease were reported in both 2010 and 2023. Percent change calculations were performed to determine the change in NIH research funding from 2010 to 2023.

Statistical Analysis

We calculated the percent change in direct, lost work and obstetric complication costs between 2010 and 2022. Paired t-tests were used to compare 2022 total annual costs with the baseline 2010 data reported by Cardozo et al. [1] to determine how the cost of fibroids has changed over the last decade. Statistical significance was defined at the α = 0.05 level. Sensitivity analyses were performed for groups representing the largest percentage of total costs attributable to uterine fibroids.

Results

Uterine Fibroids: Prevalence, Treatment, and Pregnancy Complication Rates (Table 2)

Table 2.

Collected data for the prevalence of infertility, cost of assisted reproductive technology, and use and cost of MRgFUS associated with uterine fibroids

A. Prevalence of Assisted Reproductive Technology Use and MRgFUS
	2022
	Prevalence (%)		Cases/Year (n)
Infertility Among the General Population	13.40 [43]		8,597,982
Infertility Caused by Fibroidsa	2.00 [14]		171,960
Use of Assisted Reproductive Technologyb	12.20 [43]		20,979
Use of MRgFUS	1.11 [16]		7,222
B. Estimated Direct Cost per case
	2022 ($)
	Mean	Low		High
Assisted Reproductive Technology	23,765	15,240 [44]		32,289 [45]
MRgFUS	19,267 [46]	-		-
C. Estimated Indirect Cost per case
	2022 ($)
	Mean	Low		High
MRgFUS	7,701 [46]	−		−

Note All costs are reported in 2023 US dollars [15]

^a.The percent utilized is an average of the range (1–3%) as provided by the cited source

^b.We utilized the assumption that the percent of women who utilized fertility services would be uniform in the fibroid-associated infertility population

The total number of women with uterine fibroids in the United States increased from 588,164 in 2010 to 650,623 cases in 2022. This increase was driven by the rise in incidence rate of uterine fibroids from 0.92 to 1.01% as well as a 0.36% growth in the number of women aged 25–54 years in the United States. Between 206,248 and 344,830 women sought non-surgical management for fibroids in 2022, which is a decrease from the number of women seeking non-surgical management in 2010 (217,444–456,650). Conversely, more women underwent myomectomy (1.26% average increase), uterine artery embolization (1.00% average increase), and endometrial ablation (2.85% average increase) in 2022 compared to 2010. Hysterectomy remained the most utilized surgical treatment for fibroids in 2022, with a reported range of 141,511to 189,527 women undergoing hysterectomy compared to a range of 123,514 to 311,139 cases in 2010. The numbers of spontaneous abortions requiring dilation & curettage, preterm deliveries, and cesarean section deliveries attributed to fibroids all decreased in 2022 compared to 2010. Among the studied obstetric outcomes, cesarean section continues to have the highest association with uterine fibroids in 2022 with 10.18% of cesarean deliveries attributable to fibroids per year.

Additional Costs of Infertility and MRgFUS Attributable to Uterine Fibroids in 2022 (Table 3)

Table 3.

Estimated direct treatment costs/case, estimated lost work costs/case, and estimated pregnancy complication costs/case due to uterine fibroids between 2010 and 2022 in the United States with percent changes

A. Estimated Direct Costs per Case
	2010 ($) [1]			2022 ($)			Percentage Change (%)
	Mean	Low	High	Mean	Low	High	Mean	Low	High
Non-Surgical Management	10,056	7,864	12,249	11,852	11,251 [47]	12,453 [47]	17.86	43.08	1.67
Surgical Management
Hysterectomy	12,599	8,887	16,310	19,948	12,988 [48–50]	26,908 [48–50]	58.33	46.14	64.98
Myomectomy	15,305	9,619	20,992	16,870	12,449 [23, 46, 48, 49]	21,291 [23, 46, 48, 49]	10.22	29.41	1.43
Uterine Artery Embolization	13,901	9,619	18,183	18,401	13,273 [23, 46, 48, 49]	23,529 [23, 46, 48, 49]	32.37	37.98	29.40
Endometrial Ablation	6,987	6,987	6,987	8,179	7,092 [48, 49]	9,267 [48, 49]	17.06	1.50	32.62
Total Direct Costs per Case	58,849	42,977	74,720	75,251	57,053	93,448	27.87	32.75	25.06
MRgFUS				19,267 [46]	19,267	19,267
Total Direct Costs per Case (including MRgFUS)				94,518	76,320	112,715
B. Estimated Lost Work Costs per Case
	2010 ($) [1]			2022 ($)			Percentage Change (%)
	Mean	Low	High	Mean	Low	High	Mean	Low	High
Non-Surgical Management	13,087	6,217	19,957	15,674	11,274 [51]	20,074 [51]	19.77	81.35	0.59
Surgical Management
Hysterectomy	24,121	6,217	42,026	33,006	23,741 [51]	42,272 [51]	36.83	281.88	0.59
Myomectomy	20,690	6,217	35,163	27,616	19,865 [51]	35,368 [51]	33.48	219.53	0.58
Uterine Artery Embolization	16,269	6,217	26,321	20,671	14,868 [51]	26,474 [51]	27.06	139.16	0.58
Endometrial Ablation	15,255	6,217	24,293	19,080	13,724 [51]	24,435 [51]	25.07	120.75	0.59
Total Lost Work Costs per Case	89,422	31,084	147,759	116,047	83,471	148,623	29.78	168.53	0.58
MRgFUS				7,701 [46]	7,701	7,701
Total Lost Work Costs per Case (including MRgFUS)				123,748	91,172	156,324
C. Estimated Costs per Case for Pregnancy Complications related to Fibroids
	2010 ($) [1]			2022 ($)			Percentage Change (%)
	Mean	Low	High	Mean	Low	High	Mean	Low	High
Spontaneous Abortion (D&C Only)	8,122	3,301	12,944	6,327	3,163 [52]	9,490 [52]	−22.11	−4.17	−26.68
Preterm Delivery	81,221	81,221	81,221	58,192 [53]	58,192	58,192	−28.35	−28.35	−28.35
Cesarean Section Delivery	24,061	19,430	28,693	49,965	10,485 [54]	89,444 [54]	107.66	−46.04	211.73
Total Cost per Case for Pregnancy Complications	113,405	103,952	122,858	114,483	71,840	157,126	0.95	−30.89	27.89
Assisted Reproductive Technology				23,765	15,240 [44]	32,289 [45]
Total Cost per Case for Pregnancy Complications (including ART)				138,248	87,080	189,415

Note All costs are reported in 2023 US dollars [15]

Among women ages 25–54 in the United States, it was estimated that 13.4% (8,597,982) have impaired fertility. Of these women, 2.0% (171,960) were estimated to have infertility solely caused by uterine fibroids. Assuming that the percent of women utilizing fertility services is uniform in the fibroid-associated infertility population, 12.2% (20,979) were estimated to use ART such as in vitro fertilization due to fibroids. With an average cost of ART ranging from $15,240 to $32,289 per case, an estimated 319.7 to 677.4 million USD is annually spent on ART due to uterine fibroids.

An estimated 1.11% (7,222) of women with symptomatic uterine fibroids seek MRgFUS treatment. With an average direct cost of $19,267 and indirect lost work cost of $7,701, an estimated 194.8 million USD is annually spent on women utilizing MRgFUS treatment.

Cost of Uterine Fibroids in the United States: 2010 vs. 2022

After updating 2010 costs, the total annual economic burden of uterine fibroids in the United States ranges between 13.6 and 41.4 billion USD in 2022. Incorporating additional costs of ART and MRgFUS increases the total economic burden attributable to uterine fibroids up to between 14.1 and 42.2 billion USD annually (Table 4).

Table 4.

2010 versus 2022 comparison of total estimated annual direct and indirect costs for uterine fibroids in the United States

Type of Cost	2010($)			2022 ($)			Percent Change (%)			SS
	Mean	Low	High	Mean	Low	High	Mean	Low	High
A. Direct Costs
Non-Surgical Management	3,389,407,626	1,709,920,563	5,593,343,850	3,265,747,740	2,320,532,485	4,294,253,882	−3.6	35.7	−23.2
Surgical Management	3,183,666,436	1,172,159,963	6,095,926,236	4,277,417,801	2,237,745,773	6,899,186,462	34.4	90.9	13.2
Hysterectomy	2,737,987,179	1,097,691,193	5,074,621,221	3,301,706,930	1,837,870,489	5,099,741,394	20.6	67.4	0.5
Myomectomy	311,924,046	56,577,735	732,147,479	518,072,743	150,651,295	1,050,034,879	66.1	166.3	43.4
Uterine Artery Embolization	80,534,851	11,315,547	189,292,305	237,050,656	66,496,235	488,345,488	194.3	487.7	158.0
Endometrial Ablation	53,220,359	6,575,488	99,865,230	220,587,473	182,727,755	261,064,701	314.5	2,678.9	161.4	*
Total (Direct Costs)	6,573,074,062	2,882,080,526	11,689,270,086	7,543,165,541	4,558,278,258	11,193,440,345	14.8	58.2	−4.2
B. Indirect Costs
Lost Work Cost	10,285,187,290	2,169,412,443	24,036,778,924	11,410,929,625	6,353,334,594	17,915,917,165	10.9	192.9	−25.5
Non-Surgical Management	4,410,916,716	1,351,814,900	9,113,389,417	4,318,894,354	2,325,326,129	6,922,214,269	−2.1	72.0	−24.0
Surgical Management	5,874,270,574	817,597,543	14,923,389,507	7,092,035,271	4,028,008,465	10,993,702,896	20.7	392.7	−26.3
Hysterectomy	5,242,167,912	767,868,891	13,075,752,174	5,463,116,585	3,359,541,002	8,011,584,350	4.2	337.5	−38.7
Myomectomy	421,658,658	36,565,185	1,226,421,464	848,086,006	240,394,052	1,744,266,875	101.1	557.4	42.2
Uterine Artery Embolization	94,251,409	7,313,037	274,010,573	266,290,172	74,486,062	549,460,995	182.5	918.5	100.5
Endometrial Ablation	116,192,595	5,850,430	347,205,296	514,542,507	353,587,349	688,390,676	342.8	5,943.8	98.3	*
Obstetric Complications Cost	4,949,410,320	337,973,745	10,962,727,896	7,478,422,729	2,712,821,091	12,244,024,368	51.1	702.7	11.7
Spontaneous Abortion D&C	48,523,446	1,396,756	149,179,316	65,893,447	32,944,318	98,842,577	35.8	2,258.6	−33.7
Preterm Delivery	1,075,147,274	75,445,994	2,074,848,555	1,422,997,495	1,422,997,495	1,422,997,495	32.4	1,786.1	−31.4
Cesarean Section Delivery	3,825,739,600	261,130,995	8,738,700,025	5,989,531,787	1,256,879,278	10,722,184,295	56.6	381.3	22.7
Total (Indirect Costs)	15,234,597,610	2,507,386,188	34,999,506,820	18,889,352,354	9,066,155,685	30,159,941,533	24.0	261.6	−13.8
C. Total Annual Costs	21,807,671,672	5,389,466,714	46,688,776,907	26,432,517,895	13,624,433,943	41,353,381,877	21.2	152.8	−11.4
D. Additional Costs
MRgFUS (Direct and Indirect)				194,760,742	194,760,742	194,760,742
ART				498,557,271	319,721,131	677,393,411
Total Annual Costs				27,125,835,908	14,138,915,816	42,225,536,030
(including MRgFUS and ART)

Note All costs are reported in 2023 US dollars [15]. SS = statistical significance.

^*indicates a p-value < 0.05

Direct Cost

Table 4(A) lists the estimated direct cost per case for each treatment modality. In 2022, non-surgical and surgical management of uterine fibroids led to an annual direct cost per case ranging between $57,053 and $93,448 and up to $112,715 per case when the direct cost of MRgFUS is included. This is an average 28% increase from the direct cost per case of uterine fibroids in 2010.

In total, non-surgical management contributed 2.3 to 4.3 billion USD annually and surgical management (hysterectomy, myomectomy, uterine artery embolization and endometrial ablation) added 2.2 to 6.9 billion USD annually to the overall direct cost of uterine fibroids. The total direct cost of non-surgical management in 2022 slightly decreased an average of −3.6% compared to 2010. In contrast, the total direct cost of surgical management rose by an average of 34.4% compared to 2010. Hysterectomy was the largest contributor to the overall direct cost in 2022, accounting for 1.8 to 5.1 billion USD annually, whereas non-surgical management was the largest contributor to the total direct cost reported in 2010. The total direct cost of endometrial ablation significantly increased between 2010 and 2022, increasing an average of 315% compared to 2010 (p = 0.03).

Indirect Cost: Lost Work and Obstetric Complications

Table 4(B) summarizes the estimated lost work cost per case for each treatment modality. In 2022, non-surgical and surgical management of uterine fibroids led to an annual lost work cost per case ranging between $83,471 and $148,623, and up to $156,324 per case when the lost work cost of MRgFUS is included. This is an average 30% increase from the lost work cost per case of uterine fibroids in 2010.

In total, lost work costs contributed 6.4 to 17.9 billion USD annually to the overall cost of uterine fibroids in 2022. Similar to 2010, the largest component of lost work cost attributable to fibroids in 2022 remained the productivity costs of hysterectomy. Among the various treatment modalities, the lost work cost of endometrial ablation significantly increased in 2022, increasing an average of 343% compared to 2010 (p = 0.006).

Table 4(C) shows the estimated cost per case for each of the studied obstetric outcomes attributed to fibroids (spontaneous abortion requiring dilation & curettage, preterm delivery, and cesarean section delivery) In 2022, obstetric complications due to fibroids led to an annual cost per case ranging between $71,840 and $157,126, and up to $189,415 per case when the cost of ART is included. This is an average 1% increase from the obstetric complication cost per case of uterine fibroids in 2010.

In total, obstetric complications added 2.7 to 12.2 billion USD annually to the overall cost of uterine fibroids in 2022. Cesarean section delivery continued to be the largest contributor of indirect obstetrical complication costs in 2022 contributing between 1.3 and 10.7 billion USD annually. The overall cost of obstetric outcomes attributable to fibroids increased an average of 51% compared to 2010.

Combining lost work and obstetric complication costs, the total indirect cost of uterine fibroids in 2022 ranged between 9.1 and 30.2 billion USD, increasing an average of 24% compared to2010 (Table 1).

Cost Savings

Similar to the 2010 report, a sensitivity analysis was performed on the cost of lost work for women undergoing hysterectomy and women undergoing non-surgical management, as these groups represented the largest contributors to total costs of uterine fibroids (Appendix A). The implied cost savings were calculated as a percentage of the highest estimate of total annual costs. Based on this analysis, if both the percentage of women undergoing hysterectomy and the cost of lost work for these women were minimized, it would result in a 11.3% savings in the total annual costs. Even if the percentage of women undergoing a hysterectomy was at maximum, minimizing the cost of lost work still resulted in 8.5% savings on the total annual costs, demonstrating that lost work costs were a significant driver in this analysis.

Comparison of Estimated Annual Costs and NIH Research Funding (Table 5)

Table 5.

Estimated annual costs and NIH research funding costs for diabetes, asthma, breast cancer, prostate cancer, benign prostate hyperplasia and uterine fibroids in 2010 versus 2023

Disease	Estimated Annual Cost (in billions)			Affected Population			NIH Research Funding (in millions)			NIH Funding per Affected Person ($)
	2010	Current	Change (%)	2010	Current	Change (%)	2010	2023	Change (%)	2010	2023	Change (%)
Diabetes	272.4 [1]	377.7 [55]	38.7	20,700,000 [56]	29,400,000 [57]	42.0	1,478.6 [58]	1,281.0 [58]	−13.4	71.43	43.57	−39.0
Asthma	58.7 [59]	50.2 [60]	−14.5	25,710,000 [61]	24,963,874 [61, 62]	−2.9	344.9 [58]	301.0 [58]	−12.7	13.42	12.06	−10.1
Breast Cancer	22.7 [1]	31.5 [63]	38.8	219,161 [64]	297,790 [65]	35.9	1,078.6 [58]	782.0 [58]	−27.5	4,921.50	2,626.01	−46.6
Prostate Cancer	16.8 [66]	23.6 [63]	40.5	217,730 [67]	288,300 [65]	32.4	467.9 [58]	295.0 [58]	−37.0	2,148.99	1,023.24	−52.4
Benign Prostatic Hyperplasia	1.7 [68]	2.5 [69]	47.1	3,106,806 [70]	3,668,565 [70]	18.1	40.1 [71]	24.1 [71]	−39.9	12.91	6.57	−49.1
Uterine Fibroids	21.8 [1]	27.1	24.3	588,164 [1]	650,623	10.6	17.0 [58]	16.0 [58]	−5.9	28.90	24.59	−14.9

Note All costs are reported in 2023 US dollars [15, 16]. The information for cost and affected population for uterine fibroids in 2023 was found based on the data calculated in our study

The average annual societal cost of uterine fibroids in the United States was estimated to be 27.1 (14.1–42.2) billion USD in 2022. This is comparable to the current annual costs of breast and prostate cancer, and is significantly higher than the cost of benign prostate hyperplasia. NIH research funding per individual affected by uterine fibroids in 2023 is only $24.59, compared to the $2,626.01 spent per breast cancer patient, $1,023.24 spent per prostate cancer patient and $6.57 spent per benign prostate hyperplasia patient.

Discussion

The current cost-analysis study found that uterine fibroids may result in up to 41.4 billion USD in total annual societal costs. Incorporating additional costs related to ART and MRgFUS increases the total annual economic burden attributable to uterine fibroids up to 42.2 billion USD.

Treatment seeking-behavior for uterine fibroids has changed in the past decade with the availability of newer, uterine-sparing interventions. Notably, the average estimate of women pursuing hysterectomy decreased by 11.5% from 2010 to 2022 while prevalence of myomectomy, UAE, and endometrial ablation all increased in the same time period. The decrease in hysterectomy prevalence is consistent with predictions in the literature that as more interventions became available, patients younger than 55 years would opt for uterine-sparing alternatives to hysterectomy in order to preserve fertility [11, 17]. Notably, the lower estimate of women pursuing hysterectomy remained similar, from 21.00% in 2010 to 21.75% in 2022. Hysterectomy remains the most common surgical intervention for symptomatic uterine fibroids.

Despite increased utilization of cheaper and more minimally invasive approaches for uterine fibroid treatment, direct treatment costs increased by an average of 14.8% from 2010 to 2022. Specifically, direct costs of endometrial ablation significantly increased, in line with its marked increase in utilization resulting in approximately 20,000 additional cases of endometrial ablation compared to 2010. Conversely, direct costs for medical or non-surgical management of uterine fibroids decreased slightly. This decrease in medical management costs was driven by a lower prevalence of women seeking medical management in 2022 (average 42.4%) compared to estimates used in 2010 (average 57.3%) rather than a substantial change in direct cost per case of medical management. Previously, the number of women pursuing medical management was calculated by subtracting those pursuing surgical management from the total estimate of women seeking treatment in the 2010 cost-analysis. The current systematic review produced specific upper and lower estimates of women pursuing medical management for symptomatic uterine fibroids, more accurately reflecting the portion of the study population seeking medical management and strengthening the 2022 cost-analysis.

Importantly, the updated range of women pursuing medical management in 2022 revealed a gap in access and/or utilization of fibroid treatment. Assuming upper estimates of all treatment modalities, 98.34% of women pursue treatment annually, indicating a gap in care for at least 1.66% of women with symptomatic fibroids, or a minimum of 10,800 women per year. Assuming lower estimates, as few as 61.15% of women with symptomatic fibroids pursue treatment annually. While some women may seek other forms of treatment beyond the scope of this cost-analysis, the underutilization of fibroid treatment could also indicate that some women with symptomatic fibroids may not have access to medical care or may choose to delay or forego care altogether. This delay of treatment-seeking behavior is consistent with prior literature on the impact of the disproportionate prevalence of uterine fibroids in Black women, who face systemic barriers to accessing healthcare overall. Several studies focused on racial disparities in access to uterine fibroid treatment have demonstrated that Black women frequently face bias and discrimination in the context of seeking treatment for fibroids, leading to negative experiences with health care providers in addition to existing systemic barriers [18, 19]. Furthermore, Black women may be more likely to delay or forego treatment for uterine fibroids due to feelings of distrust as a result of historical and present-day mistreatment [18, 20]. Future research in fibroid treatment is needed to address racial disparities in access and utilization by reducing care barriers for Black women.

Although lost work cost per uterine fibroid case increased an average of 30% relative to 2010, the indirect costs of lost work associated with uterine fibroids remained fairly constant in 2022. The increased cost per case is most likely mitigated by decreasing prevalence of medical management and hysterectomy treatments, which have higher associated lost work costs. Furthermore, as utilization of minimally invasive treatment procedures increases, patients seem to have faster recovery times and a quicker return to work [21, 22]. It is also possible that more flexibility in the workplace such as work from home options have made symptom management easier to handle, resulting in less absenteeism. Future cost-analysis research focused on how shifts in labor market trends impact the societal cost of disease might provide clarity to this question.

Even though indirect productivity costs remained relatively stable, these costs continued to account for the greatest portion of the overall economic burden just as in 2010. Notably, the upper estimate of annual lost work costs (17.9 billion USD) was greater than the lower estimate of total annual costs (14.1 billion USD). A sensitivity analysis revealed that the cost of lost work rather than the number of women undergoing each treatment was the principal driving factor for overall productivity costs. Even if the maximum estimated percentage of women undergo hysterectomy and medical management each year, minimizing lost work costs would result in a 15.5% reduction in total economic burden, resulting in an annual savings of up to 6.5 billion USD. The considerable impact of minimizing lost work costs suggests that future innovation in uterine fibroid treatment should continue to optimize minimally invasive approaches to promote faster recovery and return to work.

The cost of obstetric outcomes attributable to uterine fibroids increased an average of 51% between 2010 and 2022, demonstrating the highest average increase compared to direct treatment costs and lost work costs. Adverse reproductive outcomes were predicted to increase as more women opted for treatments that allow them to preserve their fertility. Borah et al. [23] estimated that approximately 69.5% of women who underwent myomectomy or uterine artery embolization for fibroid treatment experienced adverse reproductive outcomes, potentially increasing obstetric complications costs related to fibroids in the past decade. However, the 2022 cost-analysis demonstrates that the proportion of pregnancy complications attributable to fibroids has not significantly changed in the past decade, even with increased prevalence of fertility-preserving treatments. Additionally, the average increase in obstetric complication costs did not meet the threshold for statistical significance. This is especially promising as more symptomatic women seek uterine-sparing options although more research and analysis of additional adverse pregnancy outcomes associated with newer interventions is needed.

Importantly, the cost of caesarean section deliveries remains the most significant obstetric-related costs, contributing to more than three quarters of the indirect obstetrical costs attributable to fibroids and almost a quarter of the upper estimate of the overall annual cost in 2022. While the cost of caesarean deliveries due to fibroids did not significantly increase in 2022, percent changes show an average increase of 57% in cost despite less caesarean sections attributable to fibroids overall compared to 2010. Minimizing the indirect cost of caesarean sections would have a profound effect on the total annual cost of uterine fibroids. Currently, the standard of care in pregnancy following both open and laparoscopic myomectomy is to perform scheduled caesarean section deliveries due to the risk of uterine rupture. However, scheduled caesarean section deliveries are not indicated following minimally invasive treatment such as UAE and MRgFUS or medication treatment. More widespread use of these therapies could greatly reduce the number of caesarean sections attributable to fibroids and the overall economic burden of uterine fibroids in the United States. Future research on medication and minimally invasive treatment options for fibroids should continue to evaluate associated adverse reproductive outcomes, specifically indications for caesarean section deliveries, as well as evaluate barriers to accessing minimally invasive fibroid treatment such as insurance coverage. This 2022 cost-analysis also included costs of assisted reproductive technology attributable to fibroids for the first time in the overall economic burden of uterine fibroids in the United States. Although treatment options for fibroids have shifted to prioritize fertility preservation in the past decade, women still struggle to achieve pregnancy in the setting of uterine fibroids. The presence of fibroids is approximated to cause infertility among 1–3% of women [14, 24]. Though women with uterine fibroids are a small subset of the women pursuing assisted reproductive technology, this group faces additional unexpected economic hardship as the cost of ART continues to rise. It is also important to consider that much of this spending may not result in a successful pregnancy as in vitro fertilization embryo transfers only have a 41–47% success rate [25]. Improving fertility rates among women with uterine fibroids and those who pursue uterine-sparing treatment is essential in order to minimize ART costs attributable to fibroids and highlights the importance of evaluating impact on fertility in newer interventions.

Despite its sizable annual cost to society, research in uterine fibroids continues to be underfunded by the National Institutes of Health. In 2023, the NIH was projected to dedicate 782 million dollars to breast cancer research. In contrast, uterine fibroids research only secured 16 million dollars in funding. In other words, uterine fibroids research received the equivalent of 2% of the funding dedicated to breast cancer research despite impacting more than double the number of individuals. The disparity in funding is even more exaggerated when comparing research funding per affected individual. When comparing uterine fibroids to another benign disease that greatly impacts quality of life in men, uterine fibroids research received only two thirds of the funding that benign prostate hyperplasia secured despite representing a significantly higher estimated annual societal cost in the United States. The lack of funding for uterine fibroid research to pursue more cost-effective treatments and improve fertility options for women may perpetuate systemic racism in health care as the burden of disease for uterine fibroids disproportionately impacts Black women due to higher incidence rates [8].

Limitations

As in the prior cost-analysis, the 2022-cost analysis used a conservative estimate to calculate the total number of women seeking treatment from fibroids. Our calculations used pooled odds ratios and published costs from many recent studies, resulting in a wide range of estimated costs with an indeterminate distribution skew. Whenever possible, low- and high-end ranges of the number of women undergoing and the cost of each intervention or outcome were used to provide the most accurate range of the estimated societal economic burden. The total annual cost is still likely to be a conservative estimate though as our calculation does not account for all possible treatments and complications related to fibroids.

Specifically, we were unable to incorporate direct treatment costs of recently approved treatment options such as GnRH antagonist combinations and radiofrequency ablations for fibroid treatment due to a lack of published data on either their utilization or cost-effectiveness in representative populations, highlighting the importance of evaluating cost and utilization in addition to treatment efficacy for newly approved interventions [26, 27]. We were unable to calculate diminished productivity at work or “presenteeism” that may be experienced by women with symptomatic fibroids as part of lost work costs. Furthermore, we estimated lost work costs based on ranges of women pursuing interventions, which prevented us from accounting for absenteeism and short-term disability costs related to women with symptomatic fibroids not pursuing treatment. Additionally, we did not include medical management of spontaneous abortions, separate costs based on the gestational age of preterm deliveries, the lifetime cost of caring for preterm infants, or costs of additional obstetric outcomes such as placenta previa, placental abruption, and preterm premature rupture of membranes as part of overall obstetric-related costs attributable to fibroids. Further research in cost-analysis for uterine fibroids could individually account for these various factors and would likely contribute to an even greater total societal cost of uterine fibroids than our conservative estimate.

Additionally, our model only accounts for women with symptomatic fibroids pursuing a singular intervention annually. Our systemic review revealed that given the context of changing treatment patterns for uterine fibroids, approximately 1 in 7 women undergoing uterine-sparing procedures will need a reintervention and 1 in 10 end up eventually undergoing hysterectomy [17, 23]. Davis et al. provided 5-year reintervention rates by procedure: 19% for myomectomy, 33% for endometrial ablation, and 24% for uterine artery embolization [28]. Our model may have understated the overall economic burden of fibroid treatment per person, again resulting in a conservative estimate.

Conclusion

The economic burden of women with symptomatic uterine fibroids has substantially increased in the past decade. Although treatment-seeking behavior among women with fibroids demonstrates increased utilization of uterine-sparing and minimally invasive interventions, direct costs of treatment continue to rise. Lost work costs continue to account for the largest proportion of the overall societal cost of fibroids but may be attenuated by minimally invasive treatment approaches that allow for quicker recovery and return to work. Promisingly, costs related to obstetric complications did not significantly increase in the past decade even with a shift towards fertility preservation in uterine fibroid treatment.

Supplementary Material

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s43032-024-01727-0.

Data Availability

The data that support the findings of this study were derived from the following resources available in the public domain: PubMed, Embase, Cochrane Library databases, as well as governmental databases (Centers for Disease Control, Bureau of Labor Statistics, and US Census Bureau).