Objective To explore the clinical efficacy and quality of life between hysterectomy and myomectomy in patients with multiple uterine fibroids （≥4 lesions） ，and to provide evidence for surgical options. Methods The patients undergoing surgical treatment for multiple uterine fibroids （≥4 lesions） at the First Affiliated Hospital of Zhengzhou University from August 2023 to June 2024 were selected. Participants were grouped into hysterectomy group and myomectomy group. The baseline data of the two groups were analyzed. Propensity score matching （PSM） was performed to match at 1∶1，after which the differences in perioperative data，quality of life （QoL），and ovarian function were compared between the two groups. Results The study enrolled 495 patients，of whom 256 patients were in the hysterectomy group and 239 patients in the myomectomy group. The hysterectomy group exhibited higher proportions of patients with age≥40 years，BMI ≥25 ，multiparity，absence of fertility requirements，symptomatic presentation，anemia，preoperative blood transfusion，adenomyoma/adenomyosis comorbidity，hypertension/diabetes comorbidity，and fibroid counts>10 （all P<0.05）. After PSM，95 patients were included in each group. The hysterectomy group demonstrated significantly larger uterine volume [（291.10±218.79） cm³ vs. （217.19±166.84） cm³，P<0.05], and the difference was statistically significant. Compared to myomectomy，hysterectomy was associated with less intraoperative blood loss [（40.11±15.89） mL vs.106.11±43.86） mL]，shorter operative duration [（109.42±44.12） min vs. （135.85±60.42） min]，earlier postoperative flatus [1 （1，1）d vs. 1 （1，2） d]，lower proportion of drainage tube placement （6.4% vs. 26.3%），less postoperative analgesia use （15.8% vs. 33.7%），shorter drainage tube retention [2.5 （2，3）d vs. 3 （2，3） d]，shorter hospitalization [4（3，5）d vs. 4 （4，5） d]，and higher rate of symptom relief （96.7% vs. 77%）, with all the differences being statistically significant （all P<0.05）. No significant intergroup differences were observed in SF-36，FSFI，SAS，or SDS scores across preoperative，3-month，and 6-month postoperative assessments （all P>0.05）. Both groups exhibited transient SF-36 decline at 3 months after surgery followed by significant improvement at 6 months after surgery（all P<0.05）. Hysterectomy group maintained higher Kuppermann scores than the myomectomy group before surgery and at 3 months and 6 months after surgery （P<0.05），though score changes before and after surgery showed no intergroup differences（all P>0.05）. Preoperative and postoperative AMH was lower in the hysterectomy group than in the myomectomy group，and the difference was statistically significant （all P<0.05）. There was no statistically significant change in preoperative and postoperative AMH in each group（all P>0.05）. Conclusion For patients with multiple uterine fibroids (≥4)，hysterectomy demonstrates superior clinical efficacy compared to myomectomy without compromising QoL and ovarian function in the short term.