Systematic review with network meta-analysis: efficacy and safety of minimally invasive interventions for symptomatic uterine fibroids

Background Uterine fibroids (UFs) substantially affect the health of women of reproductive age. Minimally invasive and noninvasive therapies have become the main alternatives to traditional surgery; however, evidence on their comparative efficacy remains fragmented. This network meta-analysis compared high-intensity focused ultrasound (HIFU), radiofrequency ablation (RFA), microwave ablation (MWA), and uterine artery embolization (UAE) with myomectomy (Myo) for symptomatic UFs.Methods Eight databases were searched (Jan 2016–Dec 2025) for randomized controlled trials (RCTs). ROB 2.0 and Stata 15.1 were used to analyze fibroid volume, recurrence counts, luteinizing hormone [LH], follicle-stimulating hormone [FSH], estradiol [E2], and adverse events using surface under the cumulative ranking curve (SUCRA) values, weighted mean differences (WMDs), and 95% confidence intervals (95% CIs).Results Thirty-one RCTs (2622 patients) were included. HIFU ranked highest for fibroid volume reduction (SUCRA = 96.7%; vs UAE: WMD = 10.31, 95% CIs: 3.52–17.10; vs RFA: WMD = 3.66, 95% CIs: 1.71–5.61) and recurrence prevention (SUCRA = 70.1%). Fluctuations in ovarian function indicators across therapies were clinically acceptable. HIFU ranked first for stabilizing LH (SUCRA = 58.4%) and FSH (SUCRA = 68.4%), whereas UAE ranked first for E2 stability (SUCRA = 77.0%). For safety, MWA (SUCRA = 78.8%) and HIFU (SUCRA = 69.7%) had the lowest incidence of adverse events.Conclusion HIFU showed overall efficacy advantages, MWA showed a safety advantage, and UAE may suit specific patient populations. This study provides evidence-based support for individualized treatment decisions for UFs. However, these findings require cautious interpretation due to limited evidence.Systematic Review Registration PROSPERO (CRD420251273503).