OBJECTIVES: Symptomatic uterine leiomyomas (SUL) impact the health, quality of life and the ability to work. Surgery is still the main therapeutic intervention. We aimed to compare the cost, the quality adjusted life years gained and the number of avoided procedures of uterine artery embolization (UAE), hysterectomy, myomectomy and laparoscopic occlusion of uterine arteries (LOUA).  METHODS: For this purpose we performed a cost-effectiveness / utility analysis using a Markov model from the perspective of the Brazilian public health system (SUS) simulating, for 5 years, a cohort of SUL which was initially submitted to each of the interventions studied. We used efficacy data from our meta-analysis and SUS data on resource use. The incremental cost expected for each additional quality adjusted life-year (QALY) gained and each avoided intervention was calculated and presented as the incremental cost-effectiveness ratio (ICER).  RESULTS: UAE compared to hysterectomy and myomectomy is not cost-effective; on the other hand, UAE is cost-effective compared to LOUA in relation to the number of procedures avoided, but not QALYs. The probabilistic sensitivity analysis showed that these results are robust even when we vary simultaneously and randomly all efficacy values and procedures costs.  CONCLUSIONS: UAE is not cost-effective compared to hysterectomy and myomectomy in SUS.