A hysteroscopic myomectomy is a minimally invasive surgery that removes fibroids from inside the uterus without any incisions. A thin, lighted scope is passed through the vagina and cervix into the uterine cavity, where the surgeon can see and remove fibroids that grow along the inner lining. Because there’s no cutting through the abdomen, recovery is remarkably fast: most people need only one to two days and can return to work as soon as they feel ready.
Which Fibroids Can Be Removed This Way
Not all fibroids are candidates for this approach. Hysteroscopic myomectomy works specifically for submucosal fibroids, the type that grow into or bulge into the uterine cavity. These fibroids are classified by how deeply they extend into the uterine wall. Type 0 fibroids sit entirely within the cavity. Type 1 fibroids are mostly inside the cavity but extend partially into the wall. Type 2 fibroids are mostly embedded in the wall with less than half protruding into the cavity.
The classification matters because it predicts how smoothly the procedure will go. Type 0 fibroids can almost always be fully removed in a single session, regardless of their size, because there’s no portion buried in the muscle. Type 1 fibroids also have good single-session success rates. Type 2 fibroids are trickier and more often require a second procedure to finish the job, since the surgeon has to coax embedded tissue out of the uterine wall without damaging it.
Size plays a role too. Fibroids 3 centimeters or smaller can often be removed with smaller, less invasive instruments, with single-session success rates around 89%. Larger fibroids require a bigger resectoscope and may take longer or require staged procedures. Very small submucosal fibroids, under about 1.5 to 2 centimeters, can sometimes be removed in an office setting without general anesthesia.
How the Procedure Works
The surgeon inserts a hysteroscope, a narrow tube with a camera and light, through the cervix. The uterus is expanded with fluid so the surgeon can clearly see the cavity on a monitor. Once the fibroid is located, it’s removed using one of two main techniques.
The traditional approach uses a resectoscope with an electrically heated wire loop that shaves the fibroid into small chips, piece by piece. This method has been used for decades and works well, but it requires the surgeon to repeatedly remove tissue fragments from the cavity, which adds time. The frequent movement of instruments in and out of the cervix also carries a small risk of cervical injury or uterine perforation.
Newer tissue removal systems use a small rotating blade combined with suction that simultaneously cuts and extracts fibroid tissue in one step. These devices have a higher rate of complete removal in a single session, about 95.5% compared to 86.3% with conventional resectoscopy. For fibroid removal specifically, the two approaches take about the same amount of time, but the newer systems simplify the process and may reduce certain risks like perforation and bleeding. Both methods have low overall complication rates with no significant difference between them.
Anesthesia and Setting
Hysteroscopic myomectomy has traditionally been performed in an operating room under general anesthesia. That’s still common, especially for larger fibroids that require cervical dilation and longer operating times. But a growing body of evidence supports performing these procedures under procedural sedation instead, where you receive intravenous sedative and pain medication that keeps you comfortable without fully putting you under. A multicenter trial found that sedation-based approaches work well for hysteroscopic myomectomy and can be done in an outpatient setting rather than a full operating room.
For very small fibroids, some surgeons perform the procedure in an office using miniaturized instruments that don’t require cervical dilation, sometimes with only local anesthesia or minimal sedation. This is generally limited to fibroids under about 2 centimeters.
What It Treats
Submucosal fibroids, even small ones, can cause symptoms that are disproportionate to their size. Because they sit right along the uterine lining, they commonly cause heavy or prolonged menstrual bleeding, irregular periods, and fertility problems. Removing them hysteroscopically is one of the primary treatments for heavy bleeding caused by these fibroids.
For women trying to conceive, the procedure can significantly improve outcomes. In one multi-center study, 63% of women who underwent hysteroscopic myomectomy achieved spontaneous pregnancy afterward. Among women with primary infertility (meaning they had never been pregnant before), 95.8% of post-surgical pregnancies occurred in the myomectomy group compared to just 4.2% in women who had a different type of uterine correction surgery. The procedure has also been shown to improve cumulative pregnancy and live birth rates in women with a history of reproductive failure, and the rate of term pregnancies was significantly higher after fibroid removal.
Risks and Complications
Hysteroscopic myomectomy is considered safe, but like any surgical procedure, it carries some risks. The most important ones are specific to the technique.
- Uterine perforation occurs when an instrument passes through the uterine wall. This is rare, with complication rates around 2.3% in published series, and it’s more likely during removal of deeply embedded fibroids or dense scar tissue.
- Fluid overload is a risk unique to hysteroscopic surgery. Because fluid is continuously pumped into the uterus to keep the cavity open, some of it gets absorbed into the bloodstream. If too much is absorbed, it can cause dangerous shifts in blood chemistry. Surgeons closely monitor how much fluid goes in versus how much comes back out. For healthy women, the procedure is stopped if the deficit exceeds 2,500 milliliters with standard saline or 1,000 milliliters with older non-electrolyte solutions. For women with heart or lung conditions, those limits are lower: 1,000 and 750 milliliters respectively.
- Intrauterine adhesions (scar tissue inside the uterus) can form after surgery, potentially affecting future fertility or menstrual flow. This is more of a concern after repeat procedures or when large areas of the uterine wall are involved.
- Incomplete removal sometimes occurs, particularly with type 2 fibroids or very large ones. When the fluid deficit limit or a one-hour procedure time is reached, the surgeon will stop even if tissue remains, scheduling a second session rather than risking complications.
Recovery and What to Expect After
Recovery from hysteroscopic myomectomy is one of its biggest advantages over open or laparoscopic myomectomy. Johns Hopkins Medicine estimates a recovery period of about 48 hours. Most people can return to work within a day or two. You can expect some mild cramping and light vaginal bleeding or discharge for several days afterward. Because no abdominal incisions are made and the uterine muscle is preserved, there are far fewer restrictions on physical activity compared to other types of fibroid surgery.
The procedure preserves the uterus and, when done carefully, maintains the structural integrity of the uterine wall. This makes it particularly well suited for women who want to become pregnant in the future. Unlike procedures that cut through the full thickness of the uterine muscle, hysteroscopic removal doesn’t typically create the kind of scar that would require a cesarean delivery in a future pregnancy.