Cost-effectiveness of Ultrasound Screening for Uterine Fibroids in the United States
aSeth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
bBoston College, Chestnut Hill, MA, USA
cJohns Hopkins University School of Medicine, Baltimore, MD, USA
dDepartment of Gynecology and Obstetrics, Division of Gynecologic Subspecialities, Johns Hopkins University School of Medicine, Baltimore, MD, USA
eDepartment of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
fNuffield Department of Women’s & Reproductive Health (NDWRH), Worcester College, University of Oxford, Oxford, UK
#Corresponding Author: Bhuchitra Singh, MD, MPH, MS, MBA Division of Reproductive Sciences & Women’s Health Research Department of Gynecology & Obstetrics Johns Hopkins University School of Medicine 720 Rutland Avenue Ross Research Building, Room 624 Baltimore, MD, 21205 Phone Number (Work): +1 410-614-2000 Fax Number (Work): 410-614-7060 Email Address: bsingh10@jhmi.eduAbstract
Background
Uterine fibroids cause significant morbidity, psychosocial stress, and poor quality of life due to symptoms including heavy menstrual bleeding, anemia, pain, and bulk symptoms, as well as reproductive complications including infertility, early pregnancy loss, and preterm birth. Fibroids represent a 42.2 billion USD annual economic burden to the United States healthcare system. Despite reported delays in diagnosis of fibroids even in symptomatic women, clinical guidelines do not recommend screening for fibroids. High risk patient groups are well known. Earlier detection of fibroids through ultrasound screening could allow for earlier intervention with secondary prevention strategies or less invasive treatment options and improve the quality of life of women living with fibroids.
Objective
The study aimed to evaluate the cost-effectiveness of annual ultrasound screening for fibroids in women aged 25-54 years in the United States.
Study Design
In this economic evaluation, conducted in January-February 2026, a decision-analytic Markov model was developed using a healthcare payer perspective to analyze the cost-effectiveness of ultrasound screening for women in the United States. The time horizon was 25 to 55 years of age. Costs were adjusted for inflation to 2025 average according to the yearly medical care index of the United States consumer price index. Discounting (3% per cycle) and half-cycle corrections were calculated. Deterministic and probabilistic sensitivity analyses were performed to explore uncertainty, analyzed using TreeAge Pro Healthcare software. Model variables were obtained from published literature. All women residing in the United States aged 25-54 years were assumed to have been invited to the screening program.
Results
Ultrasound screening for fibroids for women was found to be not only cost-effective but also cost-saving, with an incremental cost-effectiveness ratio (ICER) of -$56,605.631 per QALY (quality-adjusted life-year) gained in the base-case analysis, at a willingness to pay threshold of $30,000 per QALY. Ultrasound screening was cost-effective at all starting ages from 25 to 54 years, with even greater benefit at younger ages. Sensitivity analyses demonstrated the robustness of these findings across a wide range of variable ranges. Ultrasound screening for fibroids showed a cumulative potential to save $1,169 billion and increase 20.7 million QALYs per year compared to no screening for a population of 63.89 million American women between 25 and 54 years old. The subset of 9.32 million Black American women experienced greater benefits, with potential savings of 183 billion and an increase of 3 million QALYs.
Conclusion
Based on the model-based analysis, annual ultrasound screening for uterine fibroids for women aged 25-54 years in the United States was cost-effective and cost-saving, even more so for Black women. These model-based findings highlighted the potential value of guidelines for annual ultrasound screening for fibroids, which could enable earlier diagnosis, secondary prevention, and timely intervention, with positive impact on both quality of life and healthcare costs.
Tweetable Statement
Annual ultrasound screening for uterine fibroids in U.S. for women aged 25–54 years was cost-effective and cost-saving.
Study at a Glance
A. Why was this study conducted?
- To evaluate whether annual ultrasound screening for fibroids in women aged 25–54 years in the U.S. is cost-effective.
B. What are the key findings?
- Annual ultrasound screening beginning at 25 years was both cost-effective and cost-saving, with an ICER of –$56,605.631/QALY for women in the US.
- Screening resulted in potential savings of $1,169 billion for US healthcare payers and 20.7 million QALYs for U.S. women.
C. What does this study add to what is already known?
- Annual ultrasound screening for fibroids is not only cost effective but also cost saving, highlighting its potential to reduce diagnostic delays and enable earlier, less invasive interventions.
- The results support development and implementation of fibroid screening guidelines.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
This research was funded, in part, by the Howard and Georgeanna Seegar Jones Endowment to JHS.
Introduction
Uterine fibroids are the most common benign tumors affecting women of reproductive age,1 with an estimated cumulative incidence of ∼70% for white women and >80% for Black women by the age of 50 years.2 Fibroids contribute to significant morbidity and poor quality of life due to symptoms including heavy menstrual bleeding, anemia, pain, and bulk symptoms,3 as well as reproductive complications including infertility, early pregnancy loss, and preterm birth.1,2,4–6 Fibroid disease exhibits a rising incidence and disease burden globally,2,7 and living with uterine fibroids is a significant psychosocial stressor.5 Notably, Black women are disproportionately affected by uterine fibroids because they experience a higher prevalence of fibroids and are more likely to be diagnosed with multiple and larger fibroids.2,8,9 In addition to biological differences, systemic racism and inequities in care further contribute to healthcare neglect and delayed diagnosis among Black women.1,10,11
Reports indicate that many women with fibroids remain undiagnosed and frequently experience delays in diagnosis.6,11 Delays up to three to five years are reported in symptomatic women,6 and result in many women having to endure a significant symptom burden without a clinical diagnosis.1,12,13 Women may reinterpret or normalize fibroid-related symptoms, particularly non-bleeding manifestations such as pain or bulk symptoms, which may contribute to under-recognition and treatment delays.14 Such delays in diagnosis and treatment are major contributors to the estimated annual economic burden of $42.2 billion in the United States.15,16 However, despite high risk segments of the population with a disease prevalence exceeding 50%, no clinical guidelines recommend screening for fibroids. Other screening programs for diseases that have a lower incidence in the target population have demonstrated improved outcomes with favorable cost-effectiveness, such as those for lung cancer,17 cervical cancer,18 cardiovascular diseases, and diabetes.19 Screening helps to identify people in a general population who are at higher risk of a health problem or a condition.20 By identifying conditions or risk factors at an early stage of a disease, screening programs may reduce the severity of a condition and allow a wide range of options for prophylaxis and effective treatment.21
Ultrasonography is an economical22 and feasible imaging modality for detecting fibroids with its high sensitivity and specificity 23–24 acknowledged by the American College of Obstetricians and Gynecologists (ACOG) and American Association of Family Physicians (AAFP).25–26 Early detection of fibroids through ultrasound screening could allow for the use of medical therapy or minimally invasive surgery, theoretically reducing the need for more expensive and complex surgeries typically required to treat a more extensive burden of disease.27,28 Hence, the objective was to evaluate the cost-effectiveness of annual ultrasound screening of women aged 25-54 years in the U.S. for uterine fibroids, compared with the current practice of no ultrasound screening for uterine fibroids.
Materials and Methods
Study Design and Decision Tree
This cost-effectiveness evaluation was conducted in January-February 2026 in accordance with the recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine and the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement (Table A.1). A decision-analytic Markov model was developed for assessing cost-effectiveness using a U.S. healthcare payer perspective. The study analyzed two strategies, where women either received or did not receive ultrasound screening at age 25. The target population was all adults with a uterus (“women” in this article) aged 25-54 years residing in the United States. Considering the higher prevalence and earlier incidence of fibroids in Black women,2,8,9 a model was also run with the same variables for Black women in the U.S. The time horizon was chosen from 25 years up to 55 years of age (age of menopause including 90% population) because the risk of fibroids, their symptoms, and complications decrease considerably after menopause. A cycle length of one year (annual screening) was chosen. Based on a state-transition diagram (Figure 1), a decision tree (Appendix C) was developed analyzing two strategies, where women either received or did not receive ultrasound screening starting at age 25. In the Markov model, if a woman was diagnosed to have symptomatic fibroids, they were treated (or no treatment) based on their choice, resulting in either treatment success (recurrence-free following treatment), or failure (accounting persistence of symptomatic fibroids due to failure of treatment itself as well as for recurrence). Women with asymptomatic fibroids were not treated in the decision tree, while still allowing for the possibility that these fibroids could become symptomatic in future cycles.
Model Variables
All variable values of the Markov model, including probabilities, costs, and utilities, are summarized in Table 16,16,22,23,29–59 with ranges and distribution details (with detailed description of calculations and assumptions in Appendix B). The model variables were obtained through a thorough review of scientific literature on PubMed and Embase. Cycle-dependent variations were incorporated for prevalence, death, and treatment choices. When multiple values were available, averages were calculated; when unavailable, values were derived from indirect data or well-vetted online resources. All values were validated by six clinical specialists with expertise in benign gynecology.
Probabilities reflected how women transitioned between health states. A statistical probability of death was considered at every cycle. If the patient did not receive ultrasound screening for fibroids, which is the current practice, then a woman was treated only if clinically diagnosed. Costs were based on direct costs of screening tests, interventions, and complications, inflated using the Medical Care Index of the Consumer Price Index (CPI) from annual average of the source year USD to annual average 2025 USD.60 Costs of living were attributed to conditions associated with fibroids, owing to a higher risk of spontaneous abortion, preterm delivery, cesarean delivery, anemia, endometriosis, inflammatory diseases, and menstruation disorders in women with symptomatic fibroids (as shown in Appendix B). The decision tree was limited to these conditions for simplicity and a conservative approach. Costs due to infertility were excluded, given that fibroids are the primary cause of infertility in about 2-3% of cases.61 Indirect costs associated with the loss of productivity were also excluded. Disutilities were applied to the utility of living with symptomatic fibroids per cycle for the worsening of symptoms over time (as explained in Appendix B), and to the occurrence of procedural complications when treated in a particular cycle.
Outcomes and Analysis
All analyses were conducted using TreeAge Pro Healthcare software version 2025.62 The model incorporated half-cycle corrections and 3% discounting per cycle for pay-offs.63 The main outcomes were costs, QALYs, incremental cost-effectiveness ratios (ICERs), incremental net monetary benefits (INMBs), absolute numbers of cases detected, interventions performed, and cumulative effect on U.S. healthcare spending and QALYs. Cost-effectiveness was reported in terms of ICERs and INMBs. A conservative willingness-to-pay (WTP) threshold of $30,000/QALY was considered.64
A base-case analysis was conducted deterministically, assuming no uncertainty in model variables. Absolute cumulative numbers of cases detected and interventions performed over 30 years in a cohort of 10,000 women were obtained by multiplying relevant nodal probabilities by the cohort size, which represented cumulative totals over 30 years including repeated events. Case detection was estimated from true-positive ultrasound cases (screening) and diagnosed cases (no screening), while interventions were based on treatment nodes in both strategies.
Deterministic/ univariate sensitivity analyses (DSAs) were conducted using ranges to evaluate uncertainty in individual variables, represented graphically in a Tornado diagram. Alternative analyses examined the effect of age at starting ultrasound screening on outcomes. Probabilistic sensitivity analyses (PSAs) were conducted using a second-order Monte-Carlo simulation for 10,000 trials and 1,000 samples to estimate the effect of varying variables simultaneously.
Results
In a base-case analysis for all women, ultrasound screening was found to have higher effectiveness and lower costs, making it a dominant (cost-saving) strategy. As shown in Table 2, ultrasound screening was dominant with an ICER of -$56,605.631 per QALY gained and an INMB of $28,001.314. Similar results were found in a base-case analysis for Black women with an ICER of -$60,934.859 per QALY gained and an INMB of $29,374.165 (Table 2).
Univariate sensitivity analyses are visualized in Figure 2, a tornado diagram. These analyses determined the effect of variations in model variables (multiple univariate analyses) on the INMB with a willingness-to-pay threshold of $30,000/QALY. For both analyses (all women and Black women), the model was most sensitive to the probability of being diagnosed without having an ultrasound screening, followed by the cost of associated conditions in women with fibroids, the probability of symptomaticity, the cost of ultrasound screening, and the utilities in women treated successfully. For varying values of each of the model variables, the highest and lowest extremes of resultant INMBs in the univariate sensitivity analyses were $63,323.977 and $3,661.925 for all women, and $65,090.224 and $2,264.744 for Black women, respectively. The lowest values of INMB for all variables in both analyses were above zero, indicative of cost-effectiveness even in extremes of the ranges of model variables.
A univariate sensitivity analysis of the effect of starting age on screening showed that a starting age of 25 years is most cost-effective. As shown in Figure 3 and Appendix D, increasing the starting age of screening was associated with increasing incremental costs (decreasing cost-saving) and decreasing incremental utilities; overall leading to decreasing INMB of $27,306.429 (for starting at 25 years) to $1,194.465 (for a starting at 54 years). Similar trends were seen for ultrasound screening for Black women. These results indicated cost-effectiveness at all starting ages, with greater benefit at younger ages.
Next, probabilistic sensitivity analyses were considered. Monte-Carlo simulations of 10,000 trials and 1,000 samples demonstrated that ultrasound screening was the preferred strategy for 92.3% of all women (Figure 4 A), considering both a negative incremental cost and a positive incremental effectiveness. In the 6.3% of the samples, a decrease in effectiveness was observed, which represents the cohort for which ultrasound screening is not a preferred strategy. Similarly, for Black women, ultrasound screening was found to be the preferred and dominant strategy for 91.2% of the cohort (Figure 4 B). For 6.9% of Black women, ultrasound screening had lower effectiveness.
Through subsequent analysis for a population of 63.89 million women65 in the U.S. between the ages of 25 and 54 years, annual ultrasound screening for fibroids has the cumulative potential to save $1,169 billion and increase QALYs by 20.7 million compared to no ultrasound screening for fibroids (Refer to Appendix E for calculation). Similarly, for a subset population of 9.32 million Black women65 in the U.S. between the ages of 25 and 54 years, ultrasound screening could save $183 billion and increase QALYs by 3 million.
Supporting information
Data Availability
The decision tree used for the cost-effectiveness evaluation has been shared in Figure 1 and Figure C.1. The model parameters used and all the derivations and other calculations of values have been shared in Table 1 and Appendix B.
Glossary
- Willingness-to-pay (WTP) threshold: the maximum amount a healthcare system or society is considered willing to spend to gain one additional QALY, used as a benchmark to judge whether an intervention is cost-effective; often decided by national specialty organizations.
- Half-cycle correction: a correction that reduces bias by assuming events occur mid-cycle rather than only at the start or end, thereby better reflecting real-world scenarios
- Discounting of pay-offs: an adjustment that values future costs and health benefits slightly less than those occurring today, to reflect time preference and allow fair comparison across years.
- Incremental cost-effectiveness ratio (ICER): a measure that compares the difference in costs and health outcomes between two strategies, expressed as the additional cost required to gain one QALY.
- Incremental net monetary benefit (INMB): a measure that converts health benefits into monetary terms using a willingness-to-pay threshold (net monetary benefit), allowing the difference in total value between two strategies to be expressed as a single number, where positive values favor the intervention.
Acknowledgments
The authors gratefully acknowledge Miriam Doyle-Baschat and the faculty and staff of the Reproductive Sciences Division in addition to administrative support from the Department of Gynecology and Obstetrics at Johns Hopkins and the assistance of the VISMED program. The authors acknowledge efforts and early discussions with Chelsea Henshaw and the BEAD Core at Johns Hopkins for initial conceptualization and discussions of methodology.
Funding Information
This research was funded, in part, by the Howard and Georgeanna Seegar Jones Endowment to JHS.
Declaration of Competing Interests
We declare no competing interests.
Comment
Principal Findings
This Markov model-based cost-effectiveness evaluation demonstrated that annual ultrasound screening for fibroids was not only cost-effective but also cost-saving. Ultrasound screening led to earlier identification of women with symptomatic fibroids, with greater cost savings and QALY gains observed in Black women, who face a disproportionately higher burden of disease. Screening was cost-effective at all ages of starting screening. While most screening simulations demonstrated benefit, a minority of those suggested lower QALYs, possibly due to overdiagnosis and unnecessary interventions, underscoring the need for careful follow-up and shared decision-making.
Results in the Context of What is Known
Due to its high sensitivity and specificity,23,24 ultrasound screening is a highly accurate method for identifying women who are at elevated risk of uterine fibroids, thereby facilitating the opportunity for potential secondary prevention, early treatment or intervention.20,21 Although we found no prior cost-effectiveness analyses of routine fibroid screening, considerable evidence exists for the clinical burden of fibroids, longstanding diagnostic delays, and racial disparities. Studies have shown that many women experience delays in the diagnosis of uterine fibroids due to misattribution or dismissal of symptoms by healthcare providers or self-management of symptoms.6 These delays often result in more complex presentations, which typically require more extensive surgical management. In contrast, early diagnosis through ultrasound screening could significantly enhance the range of treatment options available to women.
Black women face a higher prevalence and symptom burden from uterine fibroids, making them an important sub-population to consider in the cost analysis of ultrasound screening.2,8,9,30 Evidence reveals that disparities in fibroid severity are exacerbated by disparate treatment options, and inequities in access to care.1,10,11 These considerations necessitated a separate analysis focusing on disparities in fibroid prevalence,2,30 while maintaining consistent parameters for symptomaticity and probability of diagnosis without a screening. The model demonstrated that ultrasound screening would be more cost-saving for Black women. This finding affirms the need for a disparities-conscious approach to healthcare analysis.
Clinical Implications
The impact of screening on clinical care is especially important if earlier detection may shape treatment choices and secondary prevention of disease progression. When detected earlier, women with fibroids may benefit from more prompt symptomatic management, including reducing fibroid size with gonadotropin-releasing hormone (GnRH) agonists and selective progestin receptor modulators, or providing symptomatic relief from heavy bleeding with levonorgestrel intrauterine devices (IUDs), combined oral contraceptive pills, non-steroidal anti-inflammatory drugs (NSAIDs), and tranexamic acid.37 Additionally, secondary prevention strategies, such as green tea or Vitamin D supplementation are low cost options that have been shown to reduce fibroid size or alleviate fibroid-associated symptoms.67–70 Minimally invasive, uterine-sparing techniques, including uterine artery embolization, myomectomy, endometrial ablation, magnetic resonance guided focused ultrasound surgery (MRgFUS), and radiofrequency ablation techniques show higher success rates and lower complication rates with treatment of smaller fibroids.37,71,72 However, the impact of these techniques on fertility and obstetric outcomes varies. For instance, myomectomies preserve fertility, and may enhance fertility depending on fibroid location,37,71 but may sometimes increase obstetric complications such as uterine rupture, preterm delivery, and cesarean section.37 Some reports indicate that uterine artery embolization is associated with both poorer fertility and obstetric outcomes, including lower postoperative pregnancy rates, increased miscarriage rates, cesarean section, and postpartum hemorrhage.37,73,74 The long-term impacts of fibroid radiofrequency ablation on fertility and obstetric outcomes remains to be determined,74 though studies are on-going.
Integrating ultrasound screening into routine care may aid early fibroid diagnosis and thus empower women with more effective and less invasive treatment options, balancing varying postoperative fertility and obstetric outcomes.
As with any population screening program, there is a possibility of false positives, overdiagnosis or unnecessary interventions that may not ultimately improve patient outcomes. However, by definition,21 screening should be viewed as an initial identification step among apparently healthy individuals that requires confirmatory evaluation before any treatment decisions are made. Similarly, it is crucial to address the lack of established guidelines for managing asymptomatic fibroids. Specifically, ACOG recommends expectant management when symptoms are not severe, with treatment decisions guided by shared decision-making.25 American Society for Reproductive Medicine (ASRM) recommends treatment for cavity-distorting or fertility-impacting fibroids, though these scenarios were not included in the model as stated in the methods.75 But, given that approximately 30% of fibroids may become symptomatic over time,76 a modified monitoring schedule and early referrals to fibroid specialists may be valuable. Moreover, widespread screening may reduce the normalization of symptoms by enabling patients to associate previously overlooked complaints with a confirmed diagnosis, facilitating earlier presentation and management.14 Collectively, a shared decision-making approach integrating patient preferences, symptoms, and fertility goals with provider expertise can lead to the selection of interventions with favorable risk-benefit profiles.
This study offers a robust foundation for developing guidelines to improve healthcare access, decrease diagnostic delays, and expand treatment options. However, given the model-based nature of the study, the findings of this study should be interpreted in context, as the model may not fully capture the nuances of real-world clinical practice. In addition, there are potential challenges to real-world implementation like variations in healthcare infrastructure, access to ultrasound technology, provider adherence, patient preferences, payer and reimbursement structures, and system-level administrative policy decisions. Given these and other unforeseen barriers, initial adoption could be pursued through pilot programs or phased implementation to assess feasibility and inform wider scale-up.
Research Implications
Owing to the uncertainty of available literature, the study adopted a conservative assumption that 30% ± 20% of unscreened symptomatic women with fibroids would be diagnosed.33 Costs and utilities related to infertility and indirect costs associated with the loss of productivity were also excluded. Despite these factors, the incremental net monetary benefit remained positive, suggesting applicability to real-world scenarios. Further research providing more refined data and reduced parameter uncertainty could help to strengthen future cost-effectiveness analyses of ultrasound screening for fibroids. Similarly, new minimally invasive techniques, such as radiofrequency ablation, are available clinically but are not included in the model due to insufficient data. The decision tree could also be adapted to include variables such as the effects of fibroids on infertility and pregnancy, and the impact of quicker referrals, alternative screening frequencies, medical and surgical management, and secondary prevention options.
Strengths and Limitations
The study has the inherent limitations of any cost-effectiveness analysis, including assumptions and uncertainties in model variables, such as ultrasonography operator-variance on accuracy, fibroid progression, symptomaticity, and patient preferences. For simplicity we assumed an annual screening which may not be the optimal screening interval for cost effectiveness and less frequent screening intervals could be examined. These limitations were mitigated through the inclusion of values from high-quality evidence, employment of appropriate mathematical techniques, and validation of all values and assumptions by clinical experts. While published data is ideal, this is an acceptable approach to filling in gaps in the literature for decision-analytic modeling.77,78
A major strength of this cost-effectiveness evaluation is the use of validated variables, payoff discounting, and probabilistic sensitivity analyses to report net monetary benefits for a large population-based screening trial. Additionally, the use of a sub-analysis for Black women, a group disproportionately impacted by fibroids, further strengthens the utility of this study. The study’s findings underscore the substantial cumulative benefits of screening strategies in gynecology and suggest avenues for improved cost-effectiveness in the U.S.
Conclusions
Based on this decision-analytic Markov model, ultrasound screening for uterine fibroids in women aged 25 to 54 years in the United States was cost-saving, even more so for Black women. These model-based findings highlight the potential value of developing the current clinical practices to include annual ultrasound screening for fibroids, which could aid in early diagnosis, potential secondary prevention, and timely intervention. The screening can have a significant positive cumulative impact on enhancing the quality of life of women with fibroids and decreasing costs for healthcare payers. Future research and pilot implementation studies are warranted to validate these results in real-world settings, assess feasibility, and determine their actual impact.