For a submucosal fibroid, one that bulges into the inside of the uterus, hysteroscopic myomectomy is usually the first treatment to consider. A surgeon removes the fibroid through the cervix with a thin scope, with no skin incision, and most women are back to usual activities within days. Uterine fibroid embolization (UFE) can also treat submucosal fibroids and often relieves bleeding well, but these fibroids are the type most likely to break down and pass out through the vagina afterward, sometimes needing a procedure to finish the job. UFE tends to make more sense when the submucosal fibroid is large or one of many.
The right choice depends mainly on how much of the fibroid sits inside the cavity, its size and what else is going on in your uterus.
What makes a fibroid submucosal
Doctors describe fibroid location using the FIGO system, which numbers fibroids from 0 to 8. The three submucosal types are:
- Type 0: entirely inside the uterine cavity, often on a stalk
- Type 1: more than half inside the cavity
- Type 2: half or less inside the cavity, with the rest in the muscle wall
Type 3 fibroids touch the lining but sit fully in the wall. The type matters because it predicts how easily a fibroid can be shaved out through the cervix. An MRI or a saline ultrasound usually defines it. For the full system, see our guide to types of fibroids.
Hysteroscopic myomectomy vs UFE side by side
| Factor | Hysteroscopic myomectomy | UFE |
|---|---|---|
| Route | Through the cervix, no skin incision | Small artery puncture at wrist or groin |
| Usually suited to | FIGO type 0, 1 and 2; types 1 and 2 generally up to 4 to 5 cm | Submucosal fibroids plus other fibroids; larger or multiple fibroids |
| What happens to the fibroid | Removed during the procedure; tissue examined | Loses blood supply; shrinks, and submucosal ones may be passed |
| Setting | Small ones in an office; types 1 and 2 often in an operating room | Angiography (X-ray) suite in published studies |
| Return to activity | Averaged 0 days, work about 4 days (US registry data cited by ESGE) | Median 8 days off work in one trial |
| Main issues | Incomplete removal and repeat procedures; fluid overload with large or deep fibroids | Tissue expulsion, sometimes needing a procedure; post-procedure pain |
| Treats other fibroids in the wall | No | Yes |
When hysteroscopy wins
For most single submucosal fibroids of moderate size, hysteroscopic myomectomy is the standard first option. The European Society for Gynaecological Endoscopy (ESGE) 2024 recommendations describe how it is done and who it suits:
- Size: "As a general rule, FIGO type 1 and 2 fibroids that are planned to be removed hysteroscopically should not exceed 4–5 cm in maximum diameter."
- Setting: smaller fibroids can be removed in an office with a slim (about 5 mm) scope. Larger type 1 and 2 fibroids are usually removed in an operating room under regional or general anesthesia.
- Recovery: registry data cited by ESGE found an average of 0 days to return to usual activities and about 4 days to return to work.
Hysteroscopy is usually preferred if:
- You have one or two submucosal fibroids within the size range above
- You hope to become pregnant, because the fibroid is removed from inside the cavity without an abdominal incision
- You want tissue examined, for example because of unusual bleeding or imaging findings
- You want the fibroid gone right away rather than over months
- The fibroid is type 0, entirely in the cavity
Questions about your treatment options? Dr. Fox can help.
Book a ConsultationThis article is part of our Fibroid Treatment Guide.
Limits of hysteroscopy
Hysteroscopy is not always one-and-done. ESGE says all women having it "should be aware of the chance of incomplete resection and the need for further procedures," particularly with fibroids larger than 2 cm or those covering a large area of the cavity. Deeper fibroids also take longer to remove, and fluid absorption problems are "more likely when large or multiple fibroids with significant intramural involvement" are treated. ESGE advises that type 3 fibroids be attempted hysteroscopically only by experienced surgeons.
Other risks are uncommon. ESGE reports infection of the lining after resectoscopic myomectomy in about 1 in 200 women, and says clinically significant scarring inside the uterus is thought to be low.
Hysteroscopy also does nothing for fibroids elsewhere in the wall. If you have a submucosal fibroid plus several intramural fibroids causing pressure or bleeding, removing only the submucosal one may not solve your symptoms.
How UFE treats submucosal fibroids
UFE blocks the blood supply to every fibroid at once. Submucosal fibroids often respond well. In the large US FIBROID Registry, a submucosal location was one of the factors that predicted greater symptom improvement after UFE. Our main page on uterine fibroid embolization (UFE) covers how the procedure works.
The trade-off is expulsion. Because a submucosal fibroid faces the cavity, it can soften and pass through the cervix as it dies.
- In a 2010 study of 20 women whose main fibroid was submucosal, 10 of 20 (50%) fibroids were completely expelled within a year. Fibroids of 66 mL or smaller had about a 73% chance of being expelled. One woman (5%) had a major complication.
- The CIRSE 2015 guideline reports that passing of fibroid tissue occasionally requires surgery, in about 5% of UFE procedures, and major infection in about 2.5%.
- A 2025 systematic review across minimally invasive fibroid treatments found expulsion in 14.4% overall, with 1.4% needing extra care to remove leftover tissue.
Complete expulsion can be a good outcome, since the fibroid is gone. But it can cause cramping, discharge and bleeding for a time, and sometimes a hysteroscopy is still needed to remove tissue that gets stuck. Our article on passing fibroid tissue after UFE explains what is normal.
When UFE may be the better choice
- The submucosal fibroid is larger than hysteroscopy can comfortably handle
- You also have intramural or subserosal fibroids causing symptoms
- A previous hysteroscopic removal was incomplete and symptoms returned
- You want to avoid surgery and are not planning pregnancy
ESGE notes that embolization right before surgery has been described to reduce blood flow to very large submucosal fibroids, but advises using it only in selected cases or research. That is a different use from UFE as your main treatment.
Questions to ask your doctor
- What FIGO type is my fibroid, and how big is it?
- Can it be removed in one hysteroscopic session, or might it take two?
- Do I have other fibroids that are also causing symptoms?
- If I choose UFE, how likely is expulsion, and what would happen if tissue got stuck?
When to call your doctor after either procedure
Call promptly for fever, foul-smelling discharge, heavy bleeding that soaks a pad an hour, or pain that keeps getting worse rather than better. After UFE, these can be signs of infection or tissue that is stuck. To compare all your options, including medication and other procedures, see our fibroid treatment guide, and read UFE vs myomectomy for the evidence on surgery through the abdomen.
Frequently Asked Questions
What is the usual first treatment for a submucosal fibroid?
For most single submucosal fibroids within the size range guidelines suggest, hysteroscopic myomectomy is usually the first option. UFE may be better for larger submucosal fibroids or when there are many fibroids.
Will a submucosal fibroid come out after UFE?
It often does. In a 2010 study of 20 dominant submucosal fibroids, half were completely expelled within a year. Smaller fibroids were more likely to pass.
Is passing a fibroid after UFE dangerous?
It is usually expected rather than dangerous, but it can cause cramping, discharge and bleeding. CIRSE 2015 reports that expulsion occasionally requires surgery, in about 5% of procedures. Call your doctor for fever, foul discharge or worsening pain.
How big can a fibroid be for hysteroscopic removal?
European guidance says that, as a general rule, type 1 and 2 fibroids planned for hysteroscopic removal should not exceed 4 to 5 cm. Larger ones may need more than one procedure or another approach.
Which is better if I want to get pregnant?
Hysteroscopic myomectomy is usually preferred, because the fibroid is removed from inside the cavity without an abdominal incision. Pregnancy data after UFE are limited.
Keep Reading
- Uterine Fibroid Embolization (UFE) in New York City
- Passing Fibroid Tissue After UFE: Why It Happens and When to Call
- Types of Uterine Fibroids: Submucosal, Intramural, Subserosal and the FIGO System
- UFE vs Myomectomy: Results, Recovery and Fertility Compared
- Am I a Candidate for UFE? A Practical Checklist
- Pregnancy After UFE: Honest Numbers and What They Mean
- Fibroid Treatment Guide: every option, compared
Sources
- Clark et al., Facts Views Vis Obgyn, 2024 — ESGE good practice recommendations, part 2: hysteroscopic myomectomy
- Saridogan et al., Facts Views Vis Obgyn, 2024 — ESGE good practice recommendations, part 1: abdominal myomectomy
- Munro et al., Int J Gynaecol Obstet, 2018 — FIGO classification of causes of abnormal uterine bleeding (revised)
- Radeleff et al., Eur J Radiol, 2010 — UAE for dominant submucosal fibroids (20 women)
- Systematic review of fibroid expulsion after minimally invasive treatment, Eur J Obstet Gynecol Reprod Biol, 2025
- Spies et al., Obstet Gynecol, 2005 — FIBROID Registry 1-year outcomes
- van Overhagen and Reekers, Cardiovasc Intervent Radiol, 2015 — CIRSE standards of practice for UAE
- Barnard et al., Am J Obstet Gynecol, 2017 — FIRSTT trial periprocedural outcomes
Medically reviewed by David Fox, MD, FACS, RPVI. This article is general information, not a substitute for a medical evaluation.
Living with heavy periods, pelvic pressure or other fibroid symptoms? Schedule a consultation with Dr. David Fox at Fox Vein & Vascular in Manhattan to find out whether uterine fibroid embolization is right for you. Call (212) 362-3470 or request a UFE consultation online.
