Submucosal Fibroid: Symptoms, Pregnancy, & Treatment

Fibroid location is generally described relative to the three main layers of the uterus: the inner lining of the uterine cavity called the endometrium, the smooth muscle of the uterine wall called the myometrium, and the outer surface of the uterus known as the serous membrane.

A submucosal fibroid is a type of intramural fibroid where part of the fibroid projects into the uterine cavity and another part resides in the smooth muscle of the myometrium. According to the International Federation of Gynecology and Obstetrics (FIGO) classification system, there are two types of submucosal fibroids which are differentiated by how much of the fibroid extends into the uterine cavity vs. how much of it is intramural [2].

• Type 1 Submucosal Fibroid: <50% intramural
• Type 2 Submucosal Fibroid: ≥50% intramural

Larger fibroids can sometimes exert pressure on surrounding organs and nerves, which can lead to more severe and noticeable symptoms, but larger fibroids aren’t always associated with more severe symptoms [4].

Many women with uterine fibroids are able to become pregnant and deliver their baby without a problem, but complications such as miscarriage, c-section, preterm labor and postpartum hemorrhage occur in approximately 10 to 40% of pregnancies when fibroids are present [5,6].

Submucosal fibroid treatment options vary from conservative medical therapy, to minimally invasive interventions, to surgical submucosal fibroid removal by removing the entire uterus. The optimal submucosal fibroid treatment for you will depend on your desire to preserve fertility, your age, any other existing medical issues, ability to take time off for recovery, as well as other factors. Some therapies treat symptoms while others eliminate the fibroids completely. Some treatment options, while less invasive, may require subsequent treatment or re-intervention. These are all factors to consider when deciding which submucosal fibroid treatment option is best for you, and some treatment options are only viable for certain types of fibroids.

Medications

The most conservative submucosal fibroid treatment option is medical therapy. Medicine can be effective if symptoms are mild, if a woman is in perimenopause (so treatment is only needed in the short term), or if pre-operative intervention to reduce the size of the fibroids would make a surgery less technically challenging [7, 8]. Nonsteroidal anti-inflammatory drugs (NSAIDs), hormones (estroprogestins or progestogens), and oral contraceptives can help with symptomatic bleeding and fibroid pain. Gn-RH analogues and selective progesterone receptor modulators (sPRMs) like ulipristal acetate (UPA) help treat bulk symptoms such as pelvic pressure, pelvic pain, and frequent urination [9]. Medical treatments are only used for the short-term due to the significant health risks associated with long-term use of these medicines [7].

Uterine Fibroid Embolization

Myolysis

Myolysis does impact future fertility and pregnancies. As fibroid tissue is destroyed with myolysis, scar tissue can form in the endometrium. While some women may achieve successful pregnancies, there could be potential complications. Myolysis is not always a definitive treatment. Surgical intervention may be required down the line [7].

Endometrial Ablation

Pregnancy is not recommended after endometrial ablation. A single endometrial ablation procedure may require follow-up intervention in the future. A recent study compared the re-intervention rates for women after they underwent endometrial ablation, myomectomy, or uterine artery embolization to treat fibroids. One year after the initial procedure, the need for a second procedure was 12.4% for endometrial ablation, 4.2% for myomectomy, and 7.0% for uterine artery embolization [12,13].

Myomectomy

Myomectomy isn’t without its shortcomings, and isn’t always ideal for women with multiple large fibroids. Failure rates range from 14.5% to 30% at 3 to 4 years’ follow-up [9]. Between 10 and 25 percent of women will require a second fibroid surgery [10]. Still, many women choose myomectomy in order to preserve their uterus for future pregnancies. Most women who have myomectomy are able to have children afterwards.

Hysterectomy

Hysterectomy is the most definitive treatment available for uterine fibroids, particularly for women who have no desire to conceive [7]. It can be very effective for patients with extremely large fibroids or a large quantity of fibroids. However, after hysterectomy, once the uterus or parts of it are removed, pregnancy is no longer possible.