Uterine fibroids (UFs) are the most prevalent benign neoplasm, affecting approximately 70% of women and significantly impacting their reproductive health [1]. From 1990 to 2019, the number of incident UF cases rose by 67% globally, with the highest risk observed in women aged 35 to 39 [2]. In South Korea, the number of UF patients exceeded 600,000 in 2021, with an annual growth rate of 12.6% over the past 5 years, particularly among women in their 40s and younger [3]. This increase coincides with rising average age of childbirth and growing percentage of mothers of advanced maternal age (35 years and older), which reached 36.3% in 2023 [4]. These demographic changes are expected to lead to a higher incidence of UFs among women who are planning to conceive [5]. Additionally, the adoption of uterus-preserving treatments has significantly increased in recent years [6].

Despite hysterectomy being the only definitive treatment option, the range of treatments available for these women remains limited. Myomectomy has limited long-term data on its effectiveness and carries a risk of recurrence [7]; moreover, uterine artery embolization lacks adequate evidence regarding its impact on future fertility [8]. Most medical treatments target symptoms associated with UFs rather than the fibroids themselves [7], and there are no clear guidelines on whether or when to treat UFs in women who wish to conceive during their reproductive years [5,9]. Women reportedly wait an average of 3.6 years before seeking treatment for UF-related symptoms [10]. Additionally, 25.5% of women with UFs and heavy menstrual bleeding received no treatment within 6 months of diagnosis despite the significant burden of the disease, and 80.5% of those on contraceptive hormone therapy discontinued it [11]. These findings highlight the confusion women face in managing UFs, forcing them to navigate a condition fraught with uncertainty, without clear resolutions for their reproductive health outcomes.

Approximately 20% to 50% of women with UFs experience symptoms such as abnormal uterine bleeding, pelvic pain, or an enlarged uterus [7,12]. Abnormal bleeding is the most common symptom, occurring in 30.6% to 73.3% of diagnosed cases [13]. This symptom often correlates with fatigue, which is the most frequently reported physical impact of UFs, affecting 86.7% of women who experience heavy bleeding [14]. Anemia, found in over half of the UF patients in outpatient gynecology clinics [15], along with reduced physical activity—more commonly reported among younger women (under 40 years-old) [10]—and sleep disturbances due to frequent changes of sanitary products [14], can contribute to fatigue. Additionally, these physical impacts may be linked to negative emotions associated with UFs, including fear, discouragement [16,17], anxiety, anger, depression, and helplessness [16,18]. These emotions persist from before diagnosis and throughout the course of the condition. The uncertainty of the UF disease process can further exacerbate anxiety [19], with affected women exhibiting higher anxiety levels than those in the general population [20,21].

Furthermore, women’s physical and emotional responses to their condition were often linked to a perceived lack of control, particularly affecting their social lives. This resulted in reduced social activities and weakened relationships [16,18]. In large-scale studies, approximately one-third of women consistently reported that UFs adversely affected their job performance [22], attendance at work, and career potential [10]. These challenges were further linked to financial burdens [14,23]. Qualitative research has shown that women with symptomatic UFs found it challenging to maintain their usual lifestyle [14,16], often avoiding outdoor activities, and limiting social interactions, which frequently led to social isolation and feelings of loneliness [18,24]. Most notably, UFs affected relationships with a spouse or partner in over 20% of cases [10,25] and impacted the sexual lives of 42.9% of women [22]. The negative effects on sexual life were complex, affecting women’s sense of femininity or sexuality [10,25], and their romantic relationships [14,16], with dyspareunia reported to be 2.8 times more common [26]. Therefore, the challenges presented by UFs are interconnected and multifaceted, particularly for women who are trying to preserve their fertility while managing societal expectations during their reproductive years.

However, holistic approaches to addressing these challenges are still relatively uncommon. To address these gaps, this study utilized Levine’s conservation model, which views individuals as holistic beings striving to maintain their integrity [27,28]. The concept of conservation encompasses four dimensions—energy, structural integrity, personal integrity, and social integrity. These dimensions function cohesively rather than in isolation, as they are “joined within the individual” [29,30]. The model has served as a basis for integrative care for postpartum [31,32] and infertile women [33,34], proving effective in reducing fatigue and enhancing physical, psychological, and social health outcomes. These findings indicate its potential as a framework for managing health changes associated with reproductive organs, especially in cases involving UFs and fertility issues.

Fatigue is a key variable that involves an imbalance in energy conservation. Given the challenges inherent in the disease process of UF for women wishing to maintain fertility, anxiety reflects personal integrity as a significant variable. Additionally, sexual function, which is not fully captured by the symptom severity of UF, should be investigated as a variable reflecting structural integrity. For social integrity, we focused on the unintended exclusion of women with UF from work, family, and social activities, and the resulting subjective distress in the form of loneliness. Therefore, this study aimed to investigate the relationships among fatigue, UF symptom severity, sexual function, anxiety, and loneliness, as well as to assess the levels and differences based on general and treatment-related characteristics in women with UFs who wish to maintain fertility (Figure 1). By adopting a holistic perspective, we can gain valuable insights into addressing health issues across these four dimensions, which could lead to targeted strategies and more accessible interventions.

This study is the first, to our knowledge, to assess the challenges encountered by women with UFs who wish to maintain their fertility, using Levine’s conservation model as a framework. The results indicated that the four dimensions of integrity are significantly interconnected and complex, influenced by both general and treatment-specific characteristics.

Fatigue, the most prevalent physical effect of UFs, mirrors the overall energy levels of the women involved, with 91.9% of participants falling into the fatigued category. The average fatigue score of 4.93 not only surpassed that of the normative control group, which stood at 2.19, but also exceeded the fatigue group’s average of 4.35 [35]. This score is nearly on par with levels seen in patients with chronic fatigue syndrome, who had an average score of 5.04 [44]. The substantial fatigue observed correlates with all other variables studied, suggesting that these women’s broader health challenges stem from an inability to conserve energy, especially those who wish to preserve their reproductive potential for future conception. Furthermore, fatigue likely plays a crucial role in female fertility, affecting hormonal balance, immune function, and cellular energy production [45]. Consequently, addressing fatigue should be a priority in this population.

Studies that applied the conservation model to postpartum women [31,32] and those experiencing infertility [33,34] have shown that energy-generating activities such as yoga and Pilates can effectively reduce fatigue. This suggests that these strategies may also be beneficial for women with UFs. Moreover, optimizing energy use is crucial, given the varied social roles women of reproductive age play, particularly in light of the direct relationship between fatigue, the varying severity of bleeding, and the disruptions it causes in daily life. Systematic examination of daily routines and monitoring of hemoglobin levels can help pinpoint the triggers of fatigue. Understanding the fluctuations in energy levels—possibly in sync with the cyclical nature of their symptoms—enables women to rearrange their activities and prioritize tasks during times of higher energy. This adjustment can also better prepare them for future pregnancy plans. Educational nursing interventions can facilitate this process by empowering women to manage fatigue proactively and tailor strategies to their individual contexts.

Similar to the pattern observed with fatigue, the proportion of women with sexual dysfunction (85.5%) was remarkably higher than that of general Korean women (46.7%) [46] and even higher than that of pregnant women (74.9%) [47]. Likewise, the average sexual function score (17.35) was also lower than that of obstetric and gynecologic outpatients (18.9), with consistently lower scores across all sexual function domains [38]. These findings are particularly concerning because sexual dysfunction has been suggested as a possible factor contributing to the negative impact of UFs on fertility [48]. This underscores the importance of addressing sexual function in women with UFs, especially in the context of their reproductive goals.

While numerous studies have reported improvements in sexual function following specific treatments for UFs [49,50], there remains a scarcity of research focused on managing sexual function in women with an intact uterus who live with UFs. Since better sexual function is linked to open discussions about sexual matters with partners [51] and healthcare professionals [52], it is essential to promote transparent and informed conversations about sexual health. This approach is a vital initial step in addressing sexual function in the care of women with UFs. In this study, variations in sexual function were solely attributed to differences in pregnancy plans. Women with specific pregnancy plans exhibited better sexual function compared to those without such plans. This difference may highlight the opportunities for these women to address sexual issues during their detailed pregnancy planning process. Furthermore, significant correlations between sexual function and all other studied variables indicate that sexual function could be a comprehensive indicator of the broader impacts of UFs on women’s lives. In fact, yoga and Pilates were found to improve sexual function in pregnant women [53] and in premenopausal women with sexual dysfunction [54], respectively. These energy-generating strategies may also be effective in improving sexual function in our study population, where fatigue was a prominent issue. Therefore, the primary nursing strategy should focus on the intricate interplay between UF-related challenges and their potential effects on sexual function. It is crucial to ensure that these aspects are incorporated into discussions with healthcare providers and partners.

Interestingly, while UF symptoms were not noted as severe, the state anxiety score observed in this study (47.52) was close to the levels reported in women diagnosed with serous ovarian cancer (47.96) [55]. This suggests that, despite their benign nature, UFs can be perceived as a significant threat. In research focusing on anxiety among first-time UF patients, the trait anxiety score was recorded at 41.9, with UF-related fears such as “no possibility of pregnancy” and “loss of the uterus” showing a significant correlation with trait anxiety (r=.37, p<.001) [20]. In contrast, the current study recorded higher trait anxiety scores (47.75), indicating that the increased and persistent anxiety might be due to uncertainties and concerns about fertility. Notably, women without specific plans for pregnancy reported significantly higher anxiety levels than those who were actively trying to conceive. This difference could be attributed to less frequent discussions about the impact of UFs on fertility, potentially leading to internalized concerns. These findings underscore the importance of tailored counseling and proactive interventions to address fertility-related concerns and alleviate persistent anxiety in this population.

Unlike other measured dimensions, loneliness levels (41.79) remained within normative ranges when compared to college students from the original scale development study (40.08) [43] and those from the Korean validation study (41.46) [42]. The participants in this study were recruited from online communities for individuals with similar conditions, which may have helped conserve their social integrity. Notably, a stronger correlation between trait anxiety and loneliness (r=.82, p<.001) was observed in our sample compared to that in the Korean validation study (r= .68, p<.001) [41]. Additionally, the larger standard deviations for both anxiety and loneliness scores suggest significant individual variation, highlighting the importance of exploring the factors that contribute to these differences.

Women diagnosed for over 5 years and those with a history of myomectomy reported greater anxiety and loneliness in this study. Since there were no differences in UF symptom severity based on the time since diagnosis or a history of myomectomy, these women likely faced ongoing UF-related challenges. UF recurrence rates exceed 30% within 3 years and 50% within 5 years post-myomectomy [56], compared to lower rates (17.1%) among premenopausal women over 45 [57]. This suggests that women of childbearing age in our study, who are seeking to maintain their fertility, encounter a higher risk of recurrence and a prolonged disease burden, which contributes to increased anxiety and loneliness. Therefore, it is crucial to prioritize nursing interventions that address the psychological impact and provide targeted support for women dealing with long-term and recurring UFs.

Another noteworthy finding was the variation in key variables based on the experience of medical treatment. Women currently undergoing medical treatment reported the highest UF symptom severity, indicating that they are the most affected by these symptoms. Importantly, the study participants were not only managing these symptoms but were also dealing with concerns about fertility while seeking relevant information. Consequently, they exhibited the highest levels of fatigue but the lowest levels of anxiety and loneliness among all groups. This could be attributed to the comforting effects of regular medical interactions. This comforting effect might also explain why, contrary to expectations, no significant correlations were found between UF symptom severity and levels of anxiety or loneliness.

Accordingly, the primary concern may lie with women who are overlooked by medical attention or who do not pursue follow-up care. This is where nursing interventions, leveraging online platforms, can make a significant impact. In our study, 83.7% of participants were not currently undergoing medical treatment. Although this study did not examine the specific purposes for which participants used these communities, such platforms have the potential to provide reassurance through information-seeking and to bridge gaps in insufficient in-person social networks. Given the sensitive nature of UFs and fertility, these platforms can also offer a private and supportive space for women to seek information and address their concerns. The internet is a key information source for women with UFs [20], but they express a preference for high-quality information from healthcare professionals [58]. In this context, utilizing online platforms to deliver reliable, accessible educational interventions addressing symptom management and fertility concerns could serve as an effective medium for meeting these needs.

Regarding the women’s general characteristics, low subjective economic status was associated with worse physical, psychological, and social health indicators among women with UFs wishing to maintain fertility. Despite experiencing similar levels of UF symptom severity, women of lower economic status may suffer greater fatigue, anxiety, loneliness, and diminished sexual health due to additional barriers. These barriers encompass the costs associated with hygiene products, diagnostic tests, and fertility treatments, potentially delaying prevention, screening, and treatment efforts [59]. Therefore, it is crucial to recognize the social determinants impacting this group to ensure that vulnerable populations are adequately addressed within nursing care practices.

A limitation of this study is that it recruited participants from online communities focused on gynecological diseases. This approach may have resulted in the inclusion of individuals specifically motivated to seek information on UFs or discuss sexual health, potentially introducing selection bias and limiting the generalizability of the results to broader populations. Furthermore, since all data on UFs were self-reported and not verified against medical records, the study may be prone to recall bias. Despite these limitations, this study is unique in its focus on women who wish to maintain fertility and in its recruitment of participants from non-medical settings, which allowed for a diverse range of backgrounds. Given the variability in UF manifestations, symptoms, and treatment options, this research enhances our understanding of the less explored aspects of UFs in women.

In conclusion, this study sheds light on the multifaceted challenges faced by women with UFs who wish to maintain their fertility. It emphasizes the interconnected physical, psychological, and social dimensions they encounter, including fatigue, symptom severity, sexual function, anxiety, and loneliness. The significant fatigue observed, comparable to that seen in chronic conditions, underscores the critical need for prioritizing fatigue management to help conserve energy. Additionally, addressing fertility concerns is crucial for effectively managing anxiety. Given the strong association between loneliness and anxiety, nursing interventions that bridge gaps in consistent medical engagement—especially for those with long-standing or recurrent cases—represent an impactful strategy. Furthermore, interventions that address the interplay of these factors could improve sexual function, a vital aspect of women’s quality of life. Collectively, these strategies can help women better adapt to the challenges of UFs while supporting their integrative health and reproductive well-being.