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Uterine fibroids (leiomyomas): Hysteroscopic

myomectomy
Author: Linda D Bradley, MD
Section Editor: Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2021. | This topic last updated: Nov 12, 2020.

INTRODUCTION

Uterine fibroids (leiomyomas) are the most common pelvic tumor in women [1,2]. Abnormal
uterine bleeding, the most common symptom associated with fibroids, is most frequent in
patients with tumors that abut the endometrium (lining of the uterine cavity), including
submucosal and some intramural fibroids [3-5]. This is likely due to distortion of the uterine
cavity and an increase in the bleeding surface of the endometrium [6]. Submucosal
leiomyomas, which derive from myometrial cells just below the endometrium, account for
approximately 15 to 20 percent of fibroids.

Historically, hysterotomy or hysterectomy was performed to remove submucosal leiomyomas.

This has been largely replaced by hysteroscopic myomectomy, a minimally invasive surgical
procedure that effectively and safely removes these lesions [4,7].

Hysteroscopic myomectomy is reviewed here. General principles of hysteroscopy and

abdominal approaches to myomectomy are discussed separately. (See "Overview of
hysteroscopy" and "Uterine fibroids (leiomyomas): Prolapsed fibroids" and "Uterine fibroids
(leiomyomas): Abdominal myomectomy".)

PATIENT SELECTION

Hysteroscopic myomectomy is performed to remove intracavitary fibroids, a term that refers to

(1) submucosal leiomyomas and (2) some intramural leiomyomas for which most of the fibroid
protrudes into the uterine cavity. It is a minimally invasive procedure that is the procedure of
choice for appropriate candidates. The ability to remove intracavitary fibroids depends upon
surgical experience and skill.

Appropriate candidates for hysteroscopic myomectomy are patients with the following
characteristics:

● Symptomatic uterine fibroid(s).

● It is feasible to remove the fibroid(s) hysteroscopically. This is particularly the case if the
fibroids can be removed by hysteroscopy alone, so an abdominal approach is not required
to remove additional fibroids in other locations (eg, intramural or subserosal) or treat other
pathology.

For patients who are candidates for hysteroscopic myomectomy, this procedure is preferred to
an abdominal approach (ie, laparotomy, minimally invasive laparoscopic, robotic) for the
following reasons:

● Outpatient procedure
● Minimal recovery time
● Minimal need for opioids or prolonged pain medication
● Minimal postoperative restrictions with ability to quickly return to activities (eg, work,
sports, intercourse)
● Decreased perioperative morbidity
● Minimal or no scarring of myometrium (a scarred myometrium may require the patient to
have a cesarean delivery for future childbirth)

Indications — The most common indications for hysteroscopic myomectomy in the setting of

intracavitary fibroids are:

● Abnormal uterine bleeding

● Recurrent pregnancy loss
● Infertility

The effects of leiomyomas on reproductive function are discussed in detail separately. (See
"Uterine fibroids (leiomyomas): Treatment overview", section on 'Impact of fibroids on fertility'.)

Hysteroscopic myomectomy is also performed in selected patients with intracavitary fibroids

who have conditions that are more commonly attributed to etiologies other than fibroids. In
these patients, hysteroscopic myomectomy is performed when other therapies have failed or it
is reasonable to attribute symptoms to an intracavitary fibroid. Such conditions include:
 ● Dysmenorrhea
● Leukorrhea
● Necrotic leiomyoma following uterine fibroid embolization, magnetic resonance imaging
(MRI)-focused ultrasound, or transcervical ultrasound therapy
● Histologic evaluation of intracavitary lesions with uncertain findings on pelvic imaging
● History of preterm delivery
● Postpartum hemorrhage [8]
● Puerperal infection arising in or exacerbated by a submucosal fibroid [9]
● Postmenopausal bleeding

Contraindications — Hysteroscopic myomectomy is contraindicated in patients in whom

hysteroscopic surgery is contraindicated (eg, active pelvic infection, pyometra, intrauterine
pregnancy, cervical or uterine cancer).

Medical comorbidities (eg, coronary heart disease, bleeding diathesis) are also potential
contraindications to hysteroscopic surgery. However, since this is a minimally invasive
procedure, medical comorbidities are rarely a contraindication. (See "Overview of the principles
of medical consultation and perioperative medicine".)

Leiomyoma characteristics — Patients who are appropriate candidates for hysteroscopic

myomectomy must conform to appropriate indications and contraindications, but also must
have fibroid characteristics that are amenable to this technique. Hysteroscopic myomectomy
removes fibroids that have an intracavitary component ( figure 1). Removal of fibroids that
penetrate into the myometrium, are large, or are sessile takes longer, has the potential for
increased perioperative complications, and may result in incomplete fibroid resection. In
addition, for patients with additional fibroids that are intramural or subserosal or who have
other uterine pathology (eg, adenomyosis), hysteroscopic myomectomy may not provide
symptomatic relief.

Classification systems — The most commonly used classification system for the extent of
myometrial involvement of a fibroid was described by the European Society of Hysteroscopy
(ESH) ( figure 2) [10]:

● Type 0 – completely within the endometrial cavity

● Type I – extend less than 50 percent into the myometrium
● Type II – extend 50 percent or more within the myometrium

Observational studies support the ability of the ESH system to predict complete fibroid
resection; reported rates of complete resection rates by type were: type 0 (96 to 97 percent),
type I (86 to 90 percent), and type II (61 to 83 percent) [10,11]. In addition, depth of myometrial
penetration appears to correlate with the volume of distension fluid absorbed. This was
illustrated in a series of 339 hysteroscopic myomectomies that reported that the volume of fluid
absorbed during the procedure increased significantly with the degree of myometrial
penetration (type 0: 450 mL, type I: 957 mL, and type II: 1682 mL) [12].

However, the ESH system considers only the degree of penetration of the submucous myoma in
the myometrium. Another classification system was proposed in 2005, which uses transvaginal
ultrasound or MRI to assess the degree of penetration in the myometrium, as well as other
fibroid characteristics: size, distance of the base along the uterine wall, and portion of the cavity
in which the fibroid is located [13]. Further studies are needed to validate this classification
system.

Another classification system, the STEP-W submucosal fibroid classification system takes into
account additional features of the fibroid utilizing transvaginal ultrasound or MRI to assess five
myoma characteristics ( table 1) [14]. Two- and three-dimensional saline infusion sonography
is widely accepted to improve the visualization of the endometrium and myometrial interface.
The STEP-W classification considers size, topography, extension of the fibroid base, depth of
fibroid penetration, and the lateral wall involvement. Each factor is assigned a point value. A low
score of 0 to 4 (low complexity) is associated with safety and successful removal of the fibroid in
one hysteroscopic setting. A score of 5 or 6 is considered high complexity, and may require a
two-stage hysteroscopic procedure. A score of 7 to 9 is considered not amenable to treatment
hysteroscopically.

The International Federation of Gynecology and Obstetrics also has a classification system for
uterine leiomyomas ( figure 3).

Myometrial penetration — For patients with symptomatic fibroids, we suggest

hysteroscopic myomectomy only for fibroids that are completely within the endometrial cavity
or extend less than 50 percent into the myometrium. Removal of fibroids with deeper
myometrial involvement requires advanced hysteroscopic skills or myomectomy using
laparotomy or laparoscopy.

Leiomyoma size and number — Hysteroscopic resection of large fibroids may involve

increased perioperative complications and/or require more than one procedure for
symptomatic relief. The definition of large is not well established. Only one prospective study of
122 patients examined the effect of fibroid size; the risk of subsequent fibroid-related surgery
within four years was significantly lower in patients with fibroids that were ≤3 cm versus 4 cm or
more (10 versus 60 percent) [15]. Increasing size of fibroid requires exquisite hysteroscopic skill,
complete understanding of fluid management, ability to quickly remove myoma chip fragments
that might preclude surgical visualization, and techniques to decrease risk of uterine
perforation when chip fragments are removed.

Clinician skills ultimately determine the maximal size or number of fibroids that can be
removed. For leiomyomas that are multiple or are >3 cm or deep in myometrium, it is prudent
to include in the informed consent the possibility of a two-stage procedure (ie, two
hysteroscopy procedures).

Presence of other leiomyomas or uterine pathology — Many patients have intracavitary

fibroids in combination with fibroids in other locations (eg, intramural, subserosal). As the
volume of additional fibroids increases, the surgeon must decide whether isolated removal of
the intracavitary fibroid(s) will provide adequate treatment or if a laparoscopic or abdominal
approach to myomectomy or a hysterectomy is preferable. Other factors that influence the
choice of surgical approach include desire for future fertility and presence of other pathology
[16].

The greater the volume of additional fibroids, the greater the likelihood that symptomatic relief
will be provided only by a laparoscopic or abdominal approach to myomectomy and the less
likely that isolated removal of intracavitary fibroids will provide symptomatic relief. Patients with
fibroids that are both intracavitary and in other locations who have bulk symptoms (abdominal
pain, pressure, or distension; urinary urgency, frequency, or retention; or constipation) are not
likely to benefit from hysteroscopic resection alone.

On the other hand, patients without bulk symptoms and normal or slightly enlarged uterine
size who have heavy uterine bleeding or conditions that appear to derive specifically from the
presence of an intracavitary lesion, such as recurrent pregnancy loss or fibroid-associated
leukorrhea, may benefit from the isolated removal of an intracavitary myoma, even if other
leiomyomas are present.

Patients with abnormal uterine bleeding or dysmenorrhea may have adenomyosis in addition
to intracavitary fibroids. For patients with diffuse adenomyosis, a hysteroscopic myomectomy is
unlikely to provide complete symptomatic relief. However, patients with focal adenomyosis and
normal uterine size can be offered hysteroscopic myomectomy. Such patients should be
counseled preoperatively regarding the limited evidence regarding outcome of this procedure
among patients with these two uterine pathologies. These patients can also benefit from
medical therapy or insertion of a levonorgestrel-containing intrauterine device in combination
with hysteroscopic myomectomy. (See "Uterine adenomyosis".)

The differential diagnosis for a uterine mass also includes adenomyoma, endometrial polyp,
calcified retained products of conception, smooth muscle tumor of uncertain malignant
potential, leiomyosarcoma, or endometrial stromal tumor. (See "Uterine fibroids (leiomyomas):
Differentiating fibroids from uterine sarcomas".)

PREOPERATIVE EVALUATION AND PREPARATION

Preoperative evaluation and preparation are generally the same as for other hysteroscopic
procedures. Issues specific to hysteroscopic myomectomy are presented here. (See "Overview
of hysteroscopy", section on 'Preoperative evaluation and preparation'.)

Informed consent — Patients with symptomatic intracavitary fibroids should be counseled

about other medical, interventional radiologic, and surgical options for treatment. (See
"Abnormal uterine bleeding: Management in premenopausal patients" and "Uterine fibroids
(leiomyomas): Treatment overview".)

Patients should be counseled about potential complications of the procedure and about the
likelihood of recurrence of fibroids or symptoms. (See 'Complications' below and 'Recurrence of
leiomyomas or bleeding symptoms' below.)

Patients with intracavitary myomas that are multiple, broad-based, large (>3 cm), and/or
penetrate into the myometrium should be advised that a second procedure may be necessary
to fully remove all myomas (see 'Two-step procedures' below). This discussion should be
documented on the surgical consent form and in the medical record.

History — A thorough history is important to determine whether fibroid-related symptoms are

present (eg, heavy uterine bleeding, bulk symptoms) and whether these symptoms affect the
patient's quality of life. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features,
diagnosis, and natural history", section on 'Clinical features'.)

Evaluation of the uterus — Evaluation of the uterus and cervix for fibroids (both submucosal
and at other locations) or other pathology (eg, adenomyosis, endometrial polyp) with pelvic
imaging and/or diagnostic hysteroscopy are essential prior to hysteroscopic myomectomy.
Knowledge of these fibroid characteristics prior to surgery helps to select appropriate patients
as well as to prepare for or prevent blood loss (eg, measurement of preoperative hematocrit,
preoperative endometrial preparation) and minimize fluid deficit and to ensure that the
appropriate instruments and surgical expertise are available. (See 'Leiomyoma characteristics'
above and 'Perioperative medications' below.)

We suggest three-dimensional saline infusion sonography, where available, since it is a single

modality that can evaluate the relationship of a leiomyoma to both the endometrial cavity and
the myometrium. An alternative is to use a combination of office-based diagnostic hysteroscopy
and transvaginal ultrasound (TVUS). Hysteroscopy can define the extent to which a fibroid
protrudes into the uterine cavity, and TVUS can define the depth of myometrial penetration. It is
useful for the surgeon to view the TVUS images to establish whether a hysteroscopic approach
is feasible. Magnetic resonance imaging (MRI) defines leiomyoma position well, but is
prohibitively expensive to use routinely for this indication. Hysterosalpingography and
computed tomography have limited use in delineating fibroid location. The use of pelvic
imaging for diagnosis of leiomyomas is discussed in detail separately. (See "Uterine fibroids
(leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on
'Diagnostic evaluation'.)

For patients with enlarged uterine size (ie, 14 to 16 weeks or larger on pelvic examination), SIS
may be impractical. Maintenance of uterine distension is difficult and limits the ability to
interpret images of the endometrium and myometrium. MRI may be more useful to evaluate
patients for a type 0, I, or II leiomyoma as described in the International Federation of
Gynecology and Obstetrics and European Society of Hysteroscopy classification systems.
Additionally, MRI is also used in the STEP-W classification system.

In addition, any patient with abnormal uterine bleeding at risk for endometrial hyperplasia or
cancer should undergo evaluation of the endometrium prior to hysteroscopic myomectomy (
table 2). (See "Overview of the evaluation of the endometrium for malignant or premalignant
disease".)

Laboratory testing — Routine preoperative evaluation should be performed. For hysteroscopic

myomectomy, some institutions routinely order a hematocrit. For reproductive-age patients,
pregnancy testing is required. (See "Preoperative medical evaluation of the healthy adult
patient".)

Patients with uterine leiomyomas and abnormal uterine bleeding may be anemic. The blood
loss during hysteroscopic myomectomy does not typically exceed 100 mL. However, if anemia is
a concern, measure should be taken to treat this prior to surgery and/or to prevent bleeding
during surgery. (See "Techniques to reduce blood loss during abdominal or laparoscopic
myomectomy", section on 'Preoperative measures' and 'Agents to decrease bleeding' below.)

PERIOPERATIVE MEDICATIONS

Agents to decrease bleeding

 GnRH agonists — Gonadotropin-releasing hormone agonists (GnRHa) decrease the size of
large fibroids; however, after use of these agents, it is more difficult to dissect fibroids from the
surrounding capsule. While many surgeons use these agents, particularly for large fibroids (>3
cm) [1], we prefer not to use GnRHa, since there are no high-quality data that they make
complete resection possible for large fibroids, or reduce intraoperative blood loss or distention
fluid absorption [12,17-20]. In addition, they result in vasomotor symptoms and may lead to
cervical stenosis (an antiestrogenic effect) or profuse vaginal hemorrhage (due to GnRHa-
induced estrogen flare) [21,22]. Cases in which we make an exception and use a GNRHa to
suppress menses include: patients with severe anemia that may preclude surgery, those in
whom intravenous iron therapy is contraindicated, or those who refuse blood products.

Danazol, an antiestrogenic agent, is not recommended since a randomized trial found that it
did not reduce operative duration or excessive absorption of distension fluid and the adverse
effects are poorly tolerated [17].

Vasopressin — Vasopressin intracervical injection is an option to prevent excessive blood

loss during hysteroscopic myomectomy. Injection of vasopressin into the cervical stroma was
found to decrease blood loss and absorption of distension fluid during hysteroscopic
myomectomy or endometrial resection in one randomized trial [23]. Although generally well
tolerated, vasopressin injection must be performed with caution (by aspirating and confirming
the absence of blood prior to each injection), since intravascular injection or absorption has
been associated with profound hypertension, bradycardia, and intraoperative mortality [24].
There are few data that evaluate the risks versus benefits of the use of vasopressin for
hysteroscopic myomectomy.

We routinely use vasopressin prior to hysteroscopic myomectomy; we mix 10 units in 100 mL of

normal saline and inject into the cervical stroma in 5 mL aliquots at the 10, 2, 5, and 8 o'clock
positions around the ectocervix. This dose can be repeated every 30 to 45 minutes if bleeding is
encountered or the procedure is prolonged. An additional benefit of vasopressin is that it
facilitates cervical dilation [25]. (See "Overview of hysteroscopy", section on 'Cervical stenosis'.)

Cervical preparation — Cervical dilation can be facilitated with use of preoperative misoprostol

or laminaria. This is discussed in detail separately. (See "Overview of hysteroscopy", section on
'Cervical preparation and dilation'.)

Prophylactic antibiotics — Antibiotics are not indicated during hysteroscopy for prevention of

surgical site infection or endocarditis. (See "Overview of preoperative evaluation and
preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)
Thromboprophylaxis — Thromboprophylaxis is generally not required for hysteroscopic
procedures. (See "Prevention of venous thromboembolic disease in adult nonorthopedic
surgical patients".)

INSTRUMENTATION

Advances in operative technology have greatly improved the performance of hysteroscopic

myomectomy since it was first performed in 1976 by Neuwirth and Amin [26]. Surgical
innovations have improved visualization and decreased risk of fluid-related complications.

Distension fluid control — Fluid is instilled to distend the uterus and allow visualization.
General principles of fluid control and avoidance of excessive absorption are the same for
hysteroscopic myomectomy as for other procedures. Risk factors for increased absorption of
fluid includes operating time, depth of myometrial incision, and size of the lesion. Continuous
fluid monitoring is necessary throughout the procedure to avoid complications (eg,
hyponatremia, pulmonary, cardiac, or laryngeal edema) or the need to abort the procedure.
Hypotonic solutions (ie, glycine) are used when a resectoscope with monopolar electrical wire
loop technique is employed. Bipolar resectoscopes are used with isotonic fluids. Tissue
extraction (morcellation) and vaporization devices are used with saline. (See "Hysteroscopy:
Managing fluid and gas distending media".)

Automated fluid pumps with audible alerts and monitoring systems are preferable to manual
techniques [27]. Use of a hysteroscope with a continuous flow operative sheath helps to clear
blood from the uterine cavity and thus improves visualization. Some hysteroscopic tissue
extraction and vaporization devices require use of a proprietary fluid monitoring system.

Leiomyoma resection — The wire loop with a monopolar or bipolar resectoscope has

traditionally been the technique used for hysteroscopic myomectomy ( picture 1).
Hysteroscopic morcellation and vaporization devices have also been introduced.

Most gynecologists are familiar with the wire loop technique and the equipment is cost-
effective and widely available. If a monopolar device is used, a non-electrolytic solution is used
(eg, 1.5 percent glycine, sorbitol 3 percent, or mannitol is used). If a bipolar device is used, the
fluid medium is isotonic saline or Ringer's lactate solution [28]. As an adjunct to this technique,
hysteroscopic scissors can be used for small pedunculated fibroids or fragments that remain
attached to the uterine wall and are not easily removed with the loop. (See "Hysteroscopy:
Managing fluid and gas distending media", section on 'Fluid media'.)
The goals of newer techniques, such as morcellation or vaporization, is to make resection of
fibroids technically easier [29,30], produce fewer tissue fragments, require fewer insertions of
the hysteroscope, and use saline as the distention medium. Fewer insertions of the
hysteroscope is helpful for patients with marked cervical stenosis, a retroverted/retroflexed
uterus, or a small uterine cavity associated with menopause. Any of these factors may increase
the risk of uterine perforation, particularly with repeat insertions of the hysteroscope. The use
of saline avoids use of hypotonic solutions (ie, glycine), that may result in hyponatremia. In
addition, because resection is performed mechanically or with limited bipolar radiofrequency
(Symphion), there is minimal risk of damage to the endometrium. These devices are designed
to enter only to a shallow depth and therefore are not likely to cause an incision that penetrates
the full thickness of the uterine wall. As with any intrauterine instrument, it is possible for
uterine perforation to occur if the entire device is pushed through the wall of the myometrium.

Visual dilation and curettage can be performed with the hysteroscopic morcellators. The
hysteroscopic morcellator cutting aperture is aligned next to or abutting the endometrium.
Under direct hysteroscopic visualization, the endometrium can be sampling with a to and fro
maneuver with the hysteroscope, duplicating the same technique used with a curette.

However, the disposable morcellator or tissue retrieval system is more expensive than a wire
loop and may require a propriety fluid management system, which also adds to the expense.

Comparative studies have reported that myomectomy duration was 8 to 26 minutes shorter
with the intrauterine morcellator versus a resectoscope [29-31]. Of note, some of these studies
were performed in an office setting. In addition, a review of events reported to the US Food and
Drug Administration Manufacturer and User Device Experience (MAUDE) database from 2005 to
2014 included 119 adverse events, including death (2 cases), bowel damage (12), hysterectomy
(6), uterine perforation requiring no other treatment (29), and pelvic infection (4) [32]. The
limitation of these data is that the total number of procedures performed during this time
period is unknown.

The disadvantage for two of the current hysteroscopic morcellators is that they cannot
cauterize bleeding vessels. Only one system, Symphion, utilizes a built-in spot coagulation to
control bleeding to maintain continuous visualization. The hysteroscopic morcellator is also not
designed to treat deeper myomas, and thus, is limited to use in patients with hysteroscopic
type 0 or type I leiomyomas. Since myomas that appear to be type 0 or I upon preoperative
evaluation may "sink" deeper into the myometrium during surgery and may not be retrieved
with a morcellating device, the optimal situation is for a surgeon to have access and surgical
skills to utilize both the wire loop and morcellator if needed.
Tissue removal — Use of the wire loop or tissue extraction (morcellator) techniques yield tissue
fragments (referred to as chips) that need to be removed.

Some operative sheaths aspirate pieces of tissue from the uterine cavity to remove debris or
retrieve specimens for pathologic evaluation (eg, Chip E-Vac, hysteroscopic morcellator). This
allows removal of large debris while maintaining clear visualization.

There are several options to remove tissue fragments with conventional resectoscopy. Options
include grasping as many myoma fragments under direct visualization with the wire loop and
removing tissue fragments, chip by chip. This is safe, but time-consuming. Other techniques
include blind insertion of uterine polyp forceps or myoma graspers, suction curettage, or slow
removal of the hysteroscope through the dilated cervix allowing the tissue fragments to tumble
out. Overall these techniques require multiple insertions of the hysteroscope.

With hysteroscopic tissue retrieval or morcellation devices, tissue fragments are retrieved
throughout the procedure with the device in place, and thus fewer insertions are required. This
may result is a shorter operative duration and decreased risk of cervical trauma.

PROCEDURE

Positioning, sterile preparation, and cervical dilation are performed in the standard fashion for
hysteroscopy (see "Overview of hysteroscopy", section on 'Procedure'). Close attention to the
distension fluid deficit is critical to avoid complications of excessive fluid absorption. (See
"Hysteroscopy: Managing fluid and gas distending media".)

The most important limiting factor in completing operative hysteroscopic myomectomy is fluid
deficit. Guidelines advise in otherwise healthy patients that the procedure be concluded when a
deficit of 2000 mL of saline is reached. If monopolar energy is used, the clinician should halt the
procedure at 1000 mL of 1.5% glycine and check electrolytes. If normal, then the entire
procedure should be halted at 1500 mL 1.5% glycine deficit.

Informed consent for a two-staged procedure should be discussed with the patient when large
fibroids (>3 cm) are anticipated. Additionally, there is greater absorption of fluid when fibroids
are type I or type II due to opening myometrial blood vessels, which increase the risk of
intravasation. With patient-informed consent, the author discusses two-stage procedures in
patients with multiple leiomyomas, especially those who are considering pregnancy and whose
fibroids are on opposing walls. Theoretically, this would decrease the risk of postoperative
intrauterine adhesions. Additionally, those with >2 fibroids that are 3 cm or greater, and those
with type I and type II fibroids, are informed of increased risk of incomplete procedure due to
fluid intravasation.

As surgical acumen increases, the rapidity of hysteroscopic resection often improves, and
surgeons can deftly remove increased amount of fibroid tissue. The upper limit size of the
leiomyoma resected will depend on the surgeon's expertise and how quickly surgery can be
performed before reaching maximal fluid absorption. Removal of fibroids with deeper
myometrial involvement and greater than 3 cm in diameter requires advanced hysteroscopic
skills. Defining what constitutes a "large" leiomyoma was described by comparing outcomes
and need for additional surgery within four years of initial treatment. In one prospective study
of 122 subjects, patients with fibroids 3 cm or less were able to avoid additional fibroid surgery
90 percent of the time compared with patients with fibroids 4 cm or greater, who required
additional surgery 60 percent of the time [15].

In the event of an incomplete procedure, the decision to proceed with additional attempts at
hysteroscopic resection should depend upon the resolution of menstrual abnormalities, desire
for future pregnancy, or if in vitro fertilization is anticipated. Some patients with an incomplete
procedure may spontaneously pass residual leiomyomas and have complete resolution of
clinical symptoms. Others will persist with menstrual aberrations. If a second procedure is
anticipated, the author recommends reevaluating the size, number, and location of the fibroid
with saline infusion sonogram to objectively plan the next surgical procedure.

Expert hysteroscopic experience is required for removal of type I fibroids greater than 5 to 6 cm
and 4 to 5 cm if a type II fibroid is encountered. Several techniques have been described to
approach resectoscopic retrieval of type I and type II fibroids. The main objective is to separate
the fibroid from the pseudocapsule and then, with intermittent uterine decompression, slice
the protruding fibroid and intramural component. It may require a two-step intervention if the
maximal fluid deficit is reached. Patients with type II leiomyomas may have a volumetrically
significant component of the leiomyoma retained within the myometrium. While protrusion of
the leiomyoma may occur with partial resection, it may occur less effectively when there is a
large intramural component remaining. Fibroid protrusion may be hindered by resistance of the
contralateral wall. Attempts of a second-stage hysteroscopic resection may be incomplete. If a
second-stage procedure is considered, then repeat evaluation with saline infusion
sonohysterography or magnetic resonance imaging (MRI) is recommended to objectively
confirm the size and location of the remaining fibroid.

Two additional techniques have been described to increase the likelihood of complete removal
of the leiomyoma. While it lacks evidence-based trials, the author employs the technique of
hydromassage. It involves rapid change in the intrauterine pressure using an automatic fluid
management system. Stopping and starting the fluid as well as periodically removing the
hysteroscope from the endometrial cavity increases myometrial contractions and facilitates
migration of the intramural component into the uterine cavity [33]. Another technique called
"manual massage" is performed by placing a finger into the uterus (similar to obstetric
maneuvers such as Crede's) and massaging the endocavity to help expel the fibroid into the
uterine cavity [34].

The learning curve for operative resectoscopy may be longer than with hysteroscopic tissue
retrieval systems. Deeper lesions (type I and type II leiomyomas) may more often benefit from
resection technology [35]. However, with increased surgical volume, use of simulators, and
increased complexity of removing type I and type II leiomyomas, surgical acumen is improved
and facilitates greater retrieval of larger leiomyomas with both devices.

Some clinicians advocate the release of the fibroid pseudocapsule, with the anticipation that
deeply imbedded leiomyomas will become fully intracavitary, thereby facilitating complete
hysteroscopic resection at a follow-up procedure. If this is a preferred technique, the author
would confirm this with SIS or office hysteroscopy before rescheduling the patient [11,12,36-
39].

Anesthesia — Hysteroscopic myomectomy is performed under general or regional anesthesia

or intravenous sedation. In addition, a paracervical block is sometimes performed to provide
postoperative analgesia. (See "Overview of hysteroscopy", section on 'Pain management'.)

Wire loop technique — This section will describe the wire loop resectoscope technique, which
is the most commonly used for hysteroscopic myomectomy. This technique works well for most
intracavitary leiomyomas, those that protrude entirely or more than 50 percent of their mass
into the uterine cavity (type 0, I, or II). (See 'Myometrial penetration' above.)

● Insert the resectoscope through the cervix under direct visualization.

● After distension with fluid, inspect the uterine cavity. Note the size and location of the
fibroids and whether they are sessile or pedunculated.

● We set a monopolar resectoscope to a cutting current of 60 to 120 watts; fibroids that are
calcified may require a current up to 120 watts. Bipolar technology uses the default setting
for both cutting and hemostasis. The wire loop should easily pass through the tissue. If it
does not, the power setting is increased to prevent tissue adherence to the wire loop.

● Begin incising at the most cephalad surface of the myoma ( figure 4 and picture 2). For
a pedunculated fibroid, the loop electrode can be used to cut directly through the base.
 ● Bring the resectoscope loop towards the surgeon using the spring mechanism of the loop
alone or by moving the entire resectoscope towards the surgeon. To avoid injury, it is
important to keep the loop in view at all times and activate the loop only when moving it
towards the operator.

● Repeat this motion until the fibroid has been resected to the level of the surrounding
endometrium.

● Perform intermittent uterine decompression to facilitate fibroid removal and prevent a

false-negative view of the fibroid (ie, a fibroid can "sink" into the myometrium and no
longer be visualized when pressure is held continuously), which would prevent complete
extraction.

Tissue obtained should be sent for pathologic evaluation. The surgically disrupted area will
become covered with newly proliferated endometrium postoperatively.

During hysteroscopic wire loop resection, the edges of the fibroid tend to fall inward as the
middle is resected, thus increasing the panoramic view. It is more efficient to continue resection
until fibroid fragments, or "chips," preclude further visualization. At that point, carefully remove
the chips ( picture 3). This can be accomplished using the inactivated wire loop or blindly with
a polyp/myoma forceps or suction curette; another option is to remove the inner sheath of the
resectoscope to facilitate the egress of tissue chips. As noted in a preceding section, some
surgical systems evacuate chips (Chip E-Vac, hysteroscopic morcellator). (See 'Tissue removal'
above.)

Occasionally, as the fibroid is cut, the previously round myoma becomes more irregularly
shaped and can be grasped bluntly and avulsed with polyp/myoma forceps. Care must be taken
to avoid uterine perforation. If this is done, hysteroscopic reinspection is imperative to ensure
complete resection and hemostasis. Excessive traction should be avoided to decrease the risk of
uterine eversion, perforation, or injury to surrounding intraabdominal viscera. To minimize the
risk of uterine perforation, the tissue fragments can be removed with the wire loop under direct
visualization.

In the event of heavy perioperative bleeding, the endometrium should be reinspected with the
hysteroscope. Small areas of bleeding can be desiccated with the resectoscope using
coagulating current. When using a monopolar system, set the coagulating current at 60 to 80
watts. With bipolar technology, the coagulating current is set to the default setting. Additionally,
reinjection of a dilute solution of vasopressin, as described above, is recommended. Further
measures for management of excessive bleeding are described elsewhere. (See 'Excessive
bleeding' below.)
Tissue extraction device — A hysteroscopic tissue extraction device, also referred to as a
morcellator (eg, Intra Uterine Morcellator, Truclear, and Myosure), utilizes a rotary blade for
resection and suction tubing to remove tissue fragments. The Symphion system utilizes a
bladeless resection technology with radiofrequency energy and has a proprietary self-contained
recirculating fluid management fluid and internal uterine pressure monitoring system.

There are no data or guidelines regarding the risk of dissemination of potentially malignant
tissue with hysteroscopic tissue extraction devices, as with laparoscopic morcellation of uterine
leiomyomas. The risk of this is likely lower, since the uterus is mostly contained, although tissue
and fluid may extrude from the fallopian tubes. This has been raised as a concern when
hysteroscopy is used in the evaluation of abnormal uterine bleeding. In addition, the traditional
wire loop technique also disrupts the tissue into small fragments. (See "Overview of the
evaluation of the endometrium for malignant or premalignant disease", section on 'Risk of
tumor dissemination'.)

This section will describe the techniques utilized for use of hysteroscopic tissue extraction
devices. This technique can be used for most type 0 (completely within the endometrial cavity)
and some type I leiomyomas (extend less than 50 percent into the myometrium), endometrial
polyps, or retained products of conception [40].

The procedure is as follows:

● Saline is used as the distention medium. A fluid monitoring pump is utilized.

● The hysteroscope is inserted through the cervix into the uterine cavity under direct
visualization. The uterine cavity is examined and confirms that a hysteroscopically
removable lesion is present. Once this is confirmed, the disposable morcellator device can
be opened and inserted through the working channel of the hysteroscope.

● The hysteroscopic aperture is aligned so that the aperture touches the surface of the
lesion. Activate the foot pedal. It is important to keep the morcellator aperture closely
approximated to the lesion to facilitate complete removal.

● The hysteroscope's working channel is at the distal tip equipped with a tissue removal
device with a distal window that captures intracavitary pathology and resects it through a
reciprocating or rotating cutting edge with simultaneous aspiration retrieval.

● Intermittently decompress the uterine cavity by lowering the intrauterine pressure on the
fluid monitoring system. This will decrease the likelihood of a "negative hysteroscopic
view," make it easier to remove fundal lesions and help enucleate type 0 leiomyomas.
There are several available hysteroscopic morcellator devices; the manufacturer instructions
should be followed.

Vaporization technique — Vaporization electrodes (eg, VaporTrode, Force FX, and Gyne-Pro

Perforated roller electrode) can be used with a monopolar or bipolar hysteroscope, operate at a
higher power density (120 to 220 watts versus 60 to 120 watts with a monopolar resectoscope),
and vaporize the tissue. This eliminates accumulation of tissue fragments that can occlude the
view; however, it also prohibits evaluation of the tissue for pathology. Clinically, these devices
are useful to desiccate the fibroid, making it smaller, and then exchange the vaporization
electrode for a wire loop to complete the procedure. In so doing, histologic retrieval is possible.
In addition, vaporization may lead to the formation of bubbles in the distension fluid, thereby
interfering with visualization.

The vaporization technique should be avoided at the cornua and isthmus, since these anatomic
regions are thinner and at increased risk of perforation, bowel burns, and intraperitoneal
injuries. With the higher power settings used, two dispersive pads should be placed to ground
the patient [41].

Radiofrequency ablation — Ultrasound-guided radiofrequency ablation (RFA) of fibroids is a

technique that can be accomplished using a hysteroscopic (eg, Sonata) or, more commonly,
laparoscopic approach; the technique and its outcomes are described in detail elsewhere. (See
"Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments",
section on 'Radiofrequency fibroid ablation'.)

By integrating ultrasonography and a needle array, one advantage of RFA is the potential to
treat fibroids that may not be amenable to treatment with other forms of hysteroscopic
resection (ie, intramural fibroids with significant myometrial involvement) [42] (see 'Myometrial
penetration' above). This technique is not used to treat submucous pedunculated fibroids
(which are easily amenable to resection) or subserous pedunculated fibroids (to prevent
thermal injury to nearby structures). In one prospective study of 147 patients, hysteroscopic
RFA was associated with a reduction in menstrual bleeding in 95 percent of patients; no adverse
effects were reported, and only one patient required reintervention through 12 months of
follow-up [43].

Safety and effectiveness regarding fertility and fecundity after hysteroscopic RFA have not been
established.

Techniques for challenging resections — When a leiomyoma is large (>3 cm), sessile, or

penetrates into the myometrium, advanced hysteroscopy skills are necessary to differentiate
the fibroid from the myometrium and apply techniques to achieve complete fibroid resection
[44]. Excessive resection of the myometrium will increase blood loss, fluid absorption, and
myometrial scar tissue, and potentially result in uterine perforation.

Difficult-to-reach myomas — It is very helpful to have the patient's buttocks at the end of
the operating table. Additionally, the cervix should be grasped tightly with a single-toothed
tenaculum. An extra-long operative hysteroscope may be utilized if available. Ergonomics is
important during surgery and each surgeon should determine whether the sitting position or
standing position facilitates difficult-to-reach fibroids. Use of Trendelenburg position should
never be utilized during hysteroscopy in order to decrease the risk of air embolism.

Obese patients — Obese patients may require use of a larger open-sided speculum, an

extra-long heavy weighted speculum, or an extra-long operative hysteroscope in order to
traverse a long vagina to gain access to the uterine cavity.

Distinguishing myoma versus myometrium — To distinguish the border between the

leiomyoma and surrounding myometrium, a surgeon should recognize differences in texture
and appearance between the two types of tissue. The fibroid is firm, with a whorled
appearance, while the myometrium is soft and the muscular fascicles are apparent.

In addition, adenomyomas must be differentiated from leiomyomas. Adenomyosis is defined as

the presence of ectopic stroma and glandular tissue in the myometrium and thickened
junctional zone on imaging. The diagnosis is made histologically with biopsy. MRI of the pelvis,
two-dimensional and three-dimensional transvaginal ultrasound, and, on occasion,
hysteroscopy can be used to identify adenomyosis. During operative hysteroscopy, glandlike
openings may be seen and appear as multiple small pits in the endometrium, best identified
during the early proliferative phase. The endometrium may appear irregular with superficial
gland openings; irregular and spongy texture of the subendometrium is noted, and, unlike a
leiomyoma, no pseudocapsule is identified and the tissue appears spongy and soft.
Additionally, visually altered vascularity and intramural cystic hemorrhage (appears with a dark
blue hue) can be noted. Most adenomyosis occurs on the posterior wall. When a hysteroscopic
loop is used, the surgeon can obtain an endomyometrial biopsy by extending the wire loop and
obtaining a long strip of myometrium. This tissue would include the endometrium and
superficial myometrium, thereby facilitating a histologic diagnosis of superficial adenomyosis.
While the hysteroscopic findings above are suggestive of adenomyosis, a pathognomonic
feature for adenomyosis in hysteroscopy is elusive [45,46].

Enucleating a myoma — Techniques for enucleating the fibroid from its pseudocapsule

include placing the wire loop electrode strategically behind the myoma to elevate and separate
the myoma ( picture 4). Initially, the inactive electrode is used to elevate the leiomyoma out of
the pseudocapsule, followed by using the activated electrode to incise the myoma and facilitate
its retrieval. Another technique is to use the inactive loop to partially enucleate the fibroid with
mechanical dissection and then deflate the uterine cavity to cause further protrusion of the
myoma (see 'Use of uterine contractions' below). The wire loop technique, described in a
preceding section, is then resumed to achieve complete resection. (See 'Wire loop technique'
above.)

Use of uterine contractions — Deflation of the uterine cavity refers to removing the

operative hysteroscope and waiting for several minutes to permit myometrial contractions to
cause extrusion of the myoma. When the hysteroscope is replaced, the surgeon will commonly
see more of the myoma extruding into the cavity. Facilitation of uterine contractions with
administration of a prostaglandin has been proposed [47-49]; a series of 13 patients reported
successful use of carboprost (125 mcg in 5 mL of saline, injected intracervically) for this purpose
[49]. However, profound diarrhea and difficult uterine distention may be associated with
carboprost.

Uterine massage via bimanual examination or other techniques have also been described to
help to extrude the remaining portion of a fibroid [34,50].

Sonographic guidance — Use of intraoperative pelvic ultrasonography to delimit the

endometrial, myometrial, and serosal boundaries can be useful, in our experience. The only
study to evaluate this approach was a retrospective cohort study of 126 patients that reported
that complete fibroid resection was more likely with sonographic versus laparoscopic guidance
[51].

Two-step procedures — A two-step procedure is occasionally necessary for fibroids that are
multiple, large, broad-based, or penetrate deeply within the myometrium [52]. The most
common reason for this is that the initial procedure was halted when the maximal fluid
absorption was reached. Such patients should be seen for a follow-up visit two to four months
after the initial procedure to assess whether fibroid-related symptoms persist. If so, evaluation
of the uterine cavity is repeated: the size, number, and location of the leiomyoma(s). With this
information, the surgeon can offer appropriate management, whether hysteroscopic
myomectomy or another treatment.

CONCOMITANT PROCEDURES

Endometrial polypectomy — Removal of a coexisting endometrial polyp is standard practice at

the time of hysteroscopic myomectomy. There are no data regarding the outcomes of such
concurrent procedures. In our experience, removing both types of lesions during the same
procedure does not increase operative duration or complications. (See "Endometrial polyps".)

Endometrial ablation — In patients who have abnormal uterine bleeding and do not plan a
subsequent pregnancy, some surgeons perform a concomitant myomectomy and endometrial
ablation or resection. It is uncertain whether this procedure is more effective at improving
uterine bleeding symptoms than myomectomy alone.

This topic is discussed in detail separately. (See "Overview of endometrial ablation", section on
'Concomitant procedures'.)

FOLLOW-UP

Most patients experience postoperative cramping or light bleeding, and some complain of
vaginal discomfort. Acetaminophen or nonsteroidal anti-inflammatory drugs are usually
adequate for postoperative pain control, if necessary. The patient may resume most normal
activities within 24 hours and should follow standard postoperative instructions for gynecologic
procedures. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit four to six weeks postoperatively to assess for further
complications and review pathology results.

COMPLICATIONS

Series of 200 or more hysteroscopic myomectomy procedures report a complication rate of 0.8
to 2.6 percent [53,54]. In a retrospective series of 235 procedures, the complication rate was
lower for procedures involving single versus multiple fibroids (1.4 versus 6.7 percent) [53].

Few large studies of hysteroscopic complications report specific complications for hysteroscopic
myomectomy. General complications of hysteroscopy are discussed in detail separately. (See
"Overview of hysteroscopy", section on 'Complications'.)

Uterine perforation — Extensive resection increases the risk of uterine perforation, but this
complication is uncommon [18]. There are no data to suggest that laparoscopic guidance
decreases the frequency of uterine perforation.

Uterine perforation associated with hysteroscopy can be diagnosed by direct visualization of the
defect, or suspected if visualization becomes suddenly difficult (because uterine distension
cannot be achieved or visualization is obscured by blood) or if rapid loss of uterine pressure and
marked fluid loss occur. Uterine perforation usually results in excessive bleeding, and the
evaluation for uterine perforation is discussed as part of the management of bleeding below.
(See 'Prevention or management of bleeding' below.)

If electrosurgical energy, morcellation, or suction curettage were utilized during the procedure
and perforation is suspected, the potential for visceral injury (eg, bowel, bladder) is increased.
In such patients, immediate abdominal exploration should be performed.

The evaluation and management of uterine perforation is discussed in detail separately. (See
"Uterine perforation during gynecologic procedures".)

Excessive fluid absorption — Extensive endometrial or myometrial resection increases the risk

of absorption of distension fluid, potentially resulting in hyponatremia or volume overload. A
common reason for termination of a technically difficult procedure is excessive absorption of
distension fluid [11].

Diagnosis and management of excessive fluid absorption are discussed in detail separately.
(See "Hysteroscopy: Managing fluid and gas distending media" and "Hyponatremia following
transurethral resection, hysteroscopy, or other procedures involving electrolyte-free irrigation".)

Excessive bleeding — Excessive bleeding was reported in 4 of 235 patients who underwent

hysteroscopic myomectomy in a retrospective series [53]; 4 of 94 patients required
perioperative blood transfusion in another series [55].

Bleeding is usually minimal and averages 5 to 100 mL, in our experience. When there is
excessive bleeding encountered, it is often associated with preoperative factors, such as
patients who present with heavy bleeding or performing the procedure at the time of
menstruation. The most common reason for excessive bleeding is uterine perforation when the
uterus is sounded and is seen immediately at the beginning of the procedure. Perforation may
also occur during resection. Heavy bleeding may also occur if the resection involves deep
myometrial blood vessels. Cervical laceration from the cervical tenaculum can also lead to
increased bleeding. If this occurs, placement of a figure-of-eight suture may be all that is
required. Transfusion is rarely indicated, and the risk is generally related to the degree of
preoperative anemia encountered.

Prevention or management of bleeding — Heavy intraoperative bleeding can be

prevented or managed with several approaches.

For prevention, a preoperative intracervical injection of vasopressin may be used. In some

cases, gonadotropin-releasing hormone agonists are used preoperatively to reduce leiomyoma
size, thus reducing bleeding. (See 'Agents to decrease bleeding' above.)

For management intraoperatively, measures to assess and control bleeding include:

● Assess hemodynamic status – The hemodynamic status at the time of onset of bleeding
should be assessed and checked again at regular intervals throughout the perioperative
period. The volume of blood loss that results in hemodynamic changes depends upon the
patient's age and health status.

● Evaluate for uterine perforation – Signs of a uterine perforation include:

• Rapid increase in the fluid deficit, especially when prior absorption was minimal
• Visualization of bowel loops or bowel contents
• Hemodynamic changes (this may occur due to visceral or vascular injury)

To assess for perforation, the hysteroscope should be inserted and the intrauterine
pressure increased briefly to 100 to 125 mmHg to visualize the endometrial cavity and
inspect for a perforation. There should be a high suspicion of perforation if the uterine
cavity cannot be adequately distended and visualization is poor, particularly if distension
and visualization were achieved easily prior to the onset of bleeding. Evaluation and
management of uterine perforation is discussed in detail separately. (See "Uterine
perforation during gynecologic procedures".)

● Evaluate for cervical laceration – To evaluate for a cervical laceration, remove the
hysteroscope and visualize the cervix. A single-tooth tenaculum is placed on the anterior lip
of the cervix as the mechanical dilation of the cervix at the beginning of the procedure. If
the tenaculum pulled off and/or if the tenaculum had to be replaced multiple times, it is
important to look for cervical laceration. Cervical laceration is an uncommon complication;
in our experience, this occurs in approximately 1 percent of procedures. Factors that are
associated with an increased risk of cervical laceration include difficult cervical dilation (eg,
due to cervical stenosis), a cervix that is flush with the vaginal vault, a small loop
electrosurgical excision procedure (LEEP) was required due to marked cervical stenosis (a
mini-shallow LEEP was performed at the time of hysteroscopy to resect the stenotic
external os), or postmenopausal or postpartum status. If a cervical laceration is noted, it is
repaired with a figure-of-eight or running and locked suture. A very curved suture (eg, a
UR-6 needle) is ideal for cervical repairs.

● Apply intrauterine pressure – Intrauterine pressure may be applied using a bladder

(Foley) catheter balloon place inside the uterine cavity.
Care should be taken to evaluate the uterine size and compliance to estimate the amount
of fluid that should be instilled into the balloon. Excessive inflation may result in
postoperative pain or uterine rupture. For this reason, the Bakri balloon should not be
used for intrauterine tamponade in cases of heavy bleeding that occurs during
hysteroscopic surgery. The Bakri balloon is too large and may cause uterine rupture if
inflated too much; it is intended only for obstetric hemorrhage.

The uterine cavity normally sounds to 8 cm and holds approximately 8 mL of fluid.

Preoperative bimanual examination, hysteroscopic visualization of the uterine cavity, and
gentle sounding of the cavity will aid in determining the uterine size.

Overall uterine size can be evaluated with bimanual examination, but in some cases the
overall size may not correspond to the size of the cavity. There are several factors to
consider: Does the patient have a 10 cm exophytic pedunculated fibroid that is attached to
a normal size uterus? If so, the uterine cavity will be normal size, yet on bimanual
examination, the uterine size is large. Does the patient have multiple intramural fibroids
that make the uterus enlarged? Does the patient have a 10 cm intracavitary fibroid that
grossly enlarges the uterus? Hysteroscopic visualization of the endometrium is useful in
determining the volume of the cavity and presence of myomas within the cavity.

The ability to instill fluid for hysteroscopy gives a sense of the uterine distensibility. A
surgeon may note that higher intrauterine pressure is required to maintain uterine
distention when the uterus has multiple uterine fibroids. Factors that decrease compliance,
in our experience, include gonadotropin-releasing hormone agonists, tamoxifen, prior
endometrial ablation, multiple intramural fibroids greater than 4 cm, and adenomyosis.

The bladder catheter is inserted through the cervix and into the uterine cavity. We use a
size 16 French catheter with a 3 to 30 mL balloon. Inflate the balloon with sterile water until
mild resistance is encountered. There is a subtle tactile feeling when it becomes more
difficult to distend the balloon; recognizing this feeling is achieved with experience with
intrauterine procedures. The amount of fluid instilled into the balloon should be recorded
in the operative note. If the patient complains of lower pelvic pain after emerging from
anesthesia, the balloon should be deflated until tolerated by the patient.

After inflation, the catheter bag should be monitored for volume of blood drainage. In our
practice, we generally leave the intrauterine catheter in place four to eight hours; however,
surgeons must individualize the care of each patient. To remove the catheter, it should be
deflated over several hours and blood loss monitored. The balloon can be reinflated if
 increased bleeding occurs. With the balloon removed, if bleeding is minimal, the patient
can be discharged from the surgical unit.

In terms of efficacy, in one series of 216 resectoscope procedures, four patients (1.9
percent) developed postoperative uterine bleeding and were successfully treated with this
procedure [23].

● Vasopressin – If the patient continues to bleed briskly with the intrauterine balloon in place,
we administer an intracervical injection of vasopressin (eg, 20 units in 100 mL of normal
saline, injected into the cervical stroma in 5 mL aliquots at the 12, 3, 6, and 9 o'clock
positions around the ectocervix). This dose can be repeated every 30 to 45 minutes, if
bleeding increases. (See 'Vasopressin' above.)

● Evaluate for anemia and coagulopathy – If the estimated blood loss is ≥500 mL and/or if
bleeding persists after injection of vasopressin, the patient should be evaluated for anemia
and coagulopathy, and treated if appropriate. (See "Management of hemorrhage in
gynecologic surgery", section on 'Medical stabilization'.)

If the patient is hemodynamically unstable or massive bleeding occurs, the hysteroscopic

procedure should be terminated and a laparoscopy or laparotomy may be required for further
evaluation and management. This may include evaluation for uterine perforation with vascular
or visceral injury or surgical approaches to controlling bleeding. (See "Management of
hemorrhage in gynecologic surgery", section on 'Management of intraoperative bleeding'.)

Intrauterine adhesions — Formation of intrauterine adhesions can interfere with fertility or

menstruation. In studies in which patients had a second-look hysteroscopy after the initial
hysteroscopic myomectomy report, the rates of this complication varied widely, from 0 to 46
percent [17,53,56]. The rate appears to be higher if more than one fibroid is resected (in one
study, 31 percent for single versus 46 percent for multiple fibroids) [17]. Evaluation and
treatment for intrauterine adhesions are discussed in detail separately. (See "Intrauterine
adhesions: Clinical manifestation and diagnosis".)

Infection — Infection is uncommon; it was reported in 2 of 128 subjects in one series [18].

OUTCOME

Outcomes after hysteroscopic surgery have been difficult to compare due to the lack of
consistency across studies regarding the type of myoma treated, menopausal status, objective
measurement of blood loss, complication rates, duration of follow-up, and rates of subsequent
reoperation or pregnancy [57]. However, many studies and surgeons report high patient
satisfaction, resolution of abnormal uterine bleeding, and a low rate of complications [53].

Complete myoma resection — Complete resection of a fibroid depends upon the extent of

myometrial penetration, as noted in a preceding section (see 'Leiomyoma characteristics'
above). The rate of incomplete myoma resection ranges from 5 to 17 percent in retrospective
series [11,53].

Incomplete myoma resection does not commit a patient to reoperation. In a series of 41

patients with incomplete hysteroscopic resection of fibroids, only 44 percent underwent further
fibroid-related surgery within three years [11]. In addition, in another series, at three-month
follow-up, saline infusion sonohysterography revealed that incompletely resected fibroids had
regressed in 21 of 38 patients [58].

Recurrence of leiomyomas or bleeding symptoms — The recurrence rate of fibroids and/or

abnormal uterine bleeding was approximately 20 percent in most studies in which patients
were followed for three or more years after hysteroscopic electrosurgical myomectomy
[15,55,59]. A subsequent study of 320 patients treated with hysteroscopic morcellation reported
a three-year recurrence rate of approximately 1 percent [60].

Across all studies, 3 to 21 percent of patients underwent subsequent surgery for fibroid-related
complaints. In one study, the risk was highest in those with fibroids >3 cm or when two or more
fibroids were present [15].

Reproductive outcomes

Infertility and recurrent pregnancy loss — Patients with cavity-distorting fibroids who

undergo myomectomy are more likely to conceive a pregnancy; however, the effect on the risk
of miscarriage is uncertain.

In addition, observational studies have reported that the presence of intracavitary leiomyomas
decreases pregnancy rates in patients undergoing in vitro fertilization (IVF). Thus, many IVF
units advise patients with these lesions to undergo myomectomy.

The effects of leiomyomas on reproductive function are discussed in detail separately. (See
"Uterine fibroids (leiomyomas): Treatment overview", section on 'Impact of fibroids on fertility'.)

Obstetric issues — It is not known whether hysteroscopic myomectomy affects placentation

in subsequent pregnancies. In addition, there have been no case reports of uterine rupture
after hysteroscopic myomectomy [61,62].
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Gynecologic surgery"
and "Society guideline links: Uterine fibroids (leiomyomas)".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Hysteroscopic myomectomy is performed for intracavitary fibroids (ie, submucosal and

some intramural leiomyomas for which most of the fibroid protrudes into the uterine
cavity). (See 'Patient selection' above.)

● The most common indications for hysteroscopic myomectomy are abnormal uterine
bleeding, recurrent pregnancy loss, and infertility. Hysteroscopic myomectomy is
contraindicated in patients in whom hysteroscopic surgery is contraindicated (eg, active
pelvic infection, intrauterine pregnancy). (See 'Indications' above and 'Contraindications'
above.)

● For patients planning hysteroscopic myomectomy, we suggest preoperative evaluation of

the uterus with saline infusion sonography (SIS). Use of both diagnostic hysteroscopy and
 transvaginal sonography is a reasonable option where SIS is not available. (See 'Evaluation
of the uterus' above.)

● The following recommendations are for patients with fibroid-associated symptoms who
desire surgical treatment:

• We suggest not performing hysteroscopic myomectomy in patients with intracavitary

fibroids that extend 50 percent or more into the myometrium (Grade 2C). Removal of
fibroids with deep myometrial involvement requires advanced hysteroscopic skills or
myomectomy using laparotomy or laparoscopy. (See 'Myometrial penetration' above.)

• For patients with intracavitary fibroids in combination with three or more intramural or
subserosal fibroids with a total volume of >3 cm who have fibroid-associated bulk
symptoms (abdominal or pelvic pressure or pain, urinary symptoms, constipation), we
suggest myomectomy using laparotomy or laparoscopy rather than hysteroscopy
(Grade 2C). Isolated removal of intracavitary fibroids is reasonable in some patients,
such as those with menstrual aberrations only, recurrent miscarriage, or fibroid-
associated leukorrhea. (See 'Presence of other leiomyomas or uterine pathology'
above.)

● We suggest against use of gonadotropin-releasing hormone agonists prior to

hysteroscopic myomectomy (Grade 2C). Use of these agents is reasonable in patients with
large fibroids (>3 cm) who are willing to tolerate the vasomotor symptoms and by surgeons
who find an operative benefit. (See 'GnRH agonists' above.)

● Potential complications of hysteroscopic myomectomy include uterine perforation,

excessive absorption of distension fluid with resultant hyponatremia or volume overload,
excessive perioperative bleeding, intrauterine adhesions, and infection. (See
'Complications' above.)

● Following hysteroscopic myomectomy, the recurrence rate of fibroids and/or abnormal

uterine bleeding is approximately 20 percent. (See 'Recurrence of leiomyomas or bleeding
symptoms' above.)

● Patients with cavity-distorting fibroids who undergo myomectomy are more likely to
conceive a pregnancy; however, the effect on the risk of miscarriage is uncertain. (See
'Reproductive outcomes' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 3314 Version 23.0
GRAPHICS

Fibroid locations in the uterus

These figures depict the various types and locations of fibroids. An individual may have one or more types of fibroids.

Graphic 53241 Version 6.0

Submucosal leiomyma position: European Society of Hysteroscopy
classification

The European hysteroscopic classification of submucous leiomyomas.

Reproduced with permission from: Baggish MS, Valle RF, Guedj H. Hysteroscopy: Visual Perspectives of Uterine
Anatomy, Physiology and Pathology. Philadelphia: Lippincott Williams & Wilkins, 2007. Copyright © 2007 Lippincott
Williams & Wilkins.

Graphic 59668 Version 2.0

STEPW submucosal fibroid classification system

Extension
  Size (cm) Topography Penetration Lateral wall Total
of the base

0 <2 Low <1/3 0  

1 >2 to 5 Middle >1/3 to 2/3 <50% +1

2 >5 Upper >2/3 >50%

Score + + + + +  
 

Score Group Complexity and therapeutic options

0 to 4 I Low-complexity hysteroscopic myomectomy.

5 to 6 II High-complexity hysteroscopic myomectomy. Consider GnRH use? Consider two-step

hysteroscopic myomectomy.

7 to 9 III Consider alternatives to the hysteroscopic technique.

STEPW: size, topography, extension, penetration, wall; GnRH: gonadotropin-releasing hormone.

Reproduced from: Lasmar RB, Xinmei Z, Indman PD, et al. Feasibility of a new system of classification of submucous myomas: a multicenter
study. Fertil Steril 2011; 95:2073. Table used with the permission of Elsevier Inc. All rights reserved.

Graphic 105588 Version 2.0

PALM-COEIN subclassification system for leiomyomas

FIGO leiomyoma subclassification system. System 2 classification system including the FIGO leiomyoma subclassification system. T
that includes the tertiary classification of leiomyomas categorizes the submucous group according to the original Wamsteker et al s
and adds categorizations for intramural, subserosal, and transmural lesions. Intracavitary lesions are attached to the endometrium
stalk (≤10% or the mean of three diameters of the leiomyoma) and are classified as Type 0, whereas Types 1 and 2 require a portion
lesion to be intramural: with Type 1 being less than 50% of the mean diameter and Type 2 at least 50%. Type 3 lesions are totally int
also about the endometrium. Type 3 are formally distinguished from Type 2 with hysteroscopy using the lowest possible intrauterin
necessary to allow visualization. Type 4 lesions are intramural leiomyomas that are entirely within the myometrium, with no extens
endometrial surface or to the serosa. Subserous (Types 5, 6, and 7) leiomyomas represent the mirror image of the submucous leiom
with Type 5 being at least 50% intramural, Type 6 being less than 50% intramural, and Type 7 being attached to the serosa by a stal
≤10% or the mean of three diameters of the leiomyoma. Classification of lesions that are transmural are categorized by their relatio
both the endometrial and the serosal surfaces. The endometrial relationship is noted first, with the serosal relationship second (eg,
An additional category, Type 8, is reserved for leiomyomas that do not relate to the myometrium at all, and would include cervical le
(demonstrated), those that exist in the round or broad ligaments without direct attachment to the uterus, and other so-called "para
lesions.

FIGO: International Federation of Gynecology and Obstetrics.

Reference:
1. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: Results r
degree of intramural extension. Obstet Gynecol 1993; 82:736.

From: Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press, 2010. Copyright © 2010 M. Munro. Reprinted with the permi
Cambridge University Press.

Updated with information from: Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and ab
uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. In J Gynaecol Obstet

Graphic 91085 Version 3.0

Patients who should undergo evaluation for endometrial hyperplasia or endometrial cancer

Abnormal uterine bleeding

Postmenopausal patients – Any uterine bleeding, regardless of volume (including spotting or staining). Pelvic ultrasound to
evaluate endometrial thickness is an alternative to endometrial sampling in appropriately selected patients. A thickened
endometrium should be further evaluated with endometrial sampling.

Age 45 years to menopause – In any patient, bleeding that is frequent (interval between the onset of bleeding episodes is
<21 days), heavy, or prolonged (>8 days). In patients who are ovulatory, this includes intermenstrual bleeding.

Younger than 45 years – Any abnormal uterine bleeding in obese patients (BMI ≥30). In nonobese patients, abnormal
uterine bleeding that is persistent and occurs in the setting of one of the following: chronic ovulatory dysfunction, other
exposure to estrogen unopposed by progesterone, failed medical management of the bleeding, or patients at high risk of
endometrial cancer (eg, Lynch syndrome, Cowden syndrome).

In addition, endometrial neoplasia should be suspected in premenopausal patients who are anovulatory and have
prolonged periods of amenorrhea (six or more months).

Cervical cytology results

Presence of AGC-endometrial.

Presence of AGC-all subcategories other than endometrial – If ≥35 years of age or at risk for endometrial cancer (risk factors
or symptoms).

Presence of benign-appearing endometrial cells in patients ≥40 years of age who also have abnormal uterine bleeding or
risk factors for endometrial cancer.

Other indications

Monitoring of patients with endometrial pathology (eg, endometrial hyperplasia).

Screening in patients at high risk of endometrial cancer (eg, Lynch syndrome).

These recommendations are based on an average age of menopause of 51 years. Evaluation of patients who undergo
menopause earlier should be individualized based on gynecologic history and risk of endometrial neoplasia.

BMI: body mass index; AGC: atypical glandular cells.

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Hysteroscopy: Resectoscopic instruments

(A) Rollerball.

(B) Loop electrode.

(C) Punctate electrode.

Courtesy of William J Mann, Jr, MD.

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Myomectomy with hysteroscope

Resection of uterine leiomyoma.

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Hysteroscopic myomectomy: Wire loop technique

During hysteroscopic myomectomy using the wire loop technique, the wire loop is
placed at the most cephalad surface of the leiomyoma. The activated electrode is then
passed through the tissue.

Courtesy of Linda D Bradley, MD.

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Hysteroscopic myomectomy: Copious leiomyoma shavings
(chips)

This picture depicts multiple leiomyoma shavings (chips) that were removed during a
hysteroscopic myomectomy.

Courtesy of Linda D Bradley, MD.

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Hysteroscopic myomectomy: Leiomyoma pseudocapsule

Hysteroscopic shelling out of the pseudocapsule surrounding a myoma.

Courtesy of Linda D Bradley, MD.

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