Uterine Leiomyomas Across the Menopausal Transition

Leiomyomas remain highly prevalent by midlife, with persistent racial disparities in age at onset and tumor burden. Although they are traditionally expected to regress after menopause, longitudinal data demonstrate variable behavior, with many leiomyomas persisting, some regressing modestly, and a subset continuing to grow. This structured, nonsystematic review of the contemporary literature was conducted using PubMed and Embase, supplemented by guideline and reference review, with the objective of guiding the evaluation and management of uterine leiomyomas across the menopausal transition. In perimenopausal and postmenopausal patients, abnormal uterine bleeding and pelvic pain require systematic evaluation to exclude endometrial pathology and alternative causes. Transvaginal ultrasonography with structured assessment provides the foundation for evaluation, and magnetic resonance imaging serves as an adjunct when findings are indeterminate or clinical concern is elevated. No single imaging feature reliably distinguishes benign leiomyoma from leiomyosarcoma, and the prevalence of unsuspected leiomyosarcoma at surgery remains low, increasing with age. Management should be individualized and symptom driven, incorporating patient age, comorbidities, hormonal exposures, imaging findings, and preferences, with expectant management appropriate for asymptomatic patients and intervention reserved for refractory symptoms or diagnostic uncertainty.