Objectives:\ud \ud To assess the cost-effectiveness of uterine artery embolization (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy.\ud \ud Design:\ud \ud Economic evaluation alongside the FEMME randomised controlled trial.\ud \ud Setting:\ud \ud 29 UK hospitals.\ud \ud Population:\ud \ud Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127).\ud \ud Methods:\ud \ud A within trial cost-utility analysis was conducted from the perspective of the UK NHS.\ud \ud Main outcome measures:\ud \ud Quality-adjusted life years measured using the EuroQoL 3L, combined with costs to estimate cost-effectiveness over two and four years of follow-up.\ud \ud Results:\ud \ud Over a two-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1,381 to 2,580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the four-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the basecase results for both years. Over two years, UAE was associated with higher costs (difference £456; 95% CI -1,823; 3,164) and lower QALYs (difference -0.06; 95% CI (-0.11; -0.02).\ud \ud Conclusions:\ud \ud Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and quality-adjusted life years are small. Women should be fully informed and have the option to choose between the two procedures.