Uterine smooth muscle tumors of uncertain malignant potential (STUMP) represent a group of rare and challenging leiomyoma neoplasms. Knowledge of these tumors continues to evolve as information emerges about pathology, molecular genetics, and recurrence rates. Currently STUMP tumors are diagnosed based upon histologic features of mitotic index, cytologic atypia, and coagulative tumor cell necrosis. World Health Organization (WHO) classification of these uterine smooth muscle tumors defines them as neither benign nor malignant as they can show a spectrum of clinical behavior. It is therefore a clinical dilemma and concern about proper patient management and surveillance guidelines. In this article, there is a focus on pathophysiology, classification of leiomyoma variants to include STUMP tumors, diagnosis, treatment, and discussion of appropriate follow up.