What Is a Submucosal Fibroid?

Submucosal uterine fibroids are non-cancerous (benign) tumors that grow in the womb (uterus) just under the surface of its lining (endometrium). 

Although these are the least common type of uterine fibroid, they often cause the most problems, including menstrual bleeding that can lead to low red blood cell counts (anemia). If you have symptoms of uterine fibroids, you should see a provider to find out if you have submucosal fibroids and get treatment.

This article will discuss what submucosal fibroids are, their symptoms and risk factors, and how they can be treated. 

Symptoms of Submucosal Fibroids

Submucosal fibroids are associated with heavy menstrual bleeding. They are thought to be the cause of 5% to 10% of cases of abnormal uterine bleeding.

Symptoms of submucosal fibroids include:

• Heavy and prolonged menstrual bleeding between or during periods
• Anemia (which can be severe and is caused by heavy bleeding)
• Pain in the pelvis or lower back
• Passing frequent or large blood clots
• Fatigue
• Dizziness

Causes of Submucosal Fibroids

The exact cause of fibroids is unknown, but there are some risk factors that make you more likely to have them. 

Age

Fibroids become more common as people with uteruses get older, particularly around age 30 and lasting through menopause.

A person's age at first menstruation also affects their risk for fibroids:

• Fibroids rarely develop before a person has had their first menstrual period.
• People who start menstruating when they are younger than the age of 10 appear to have a higher risk of developing fibroids later in life. 
• On the other hand, not getting a first period until after age 16 has been associated with a decreased risk for fibroids.

A later-than-typical onset of menopause may increase the risk of fibroids. After menopause, fibroids will often shrink.

Family History

If you have a uterus and a family member who has/had fibroids, you're at an increased risk of developing uterine fibroids. If a parent had fibroids, your risk is about three times higher than average.

Ethnicity

A person's race/ethnic background also plays a role in their risk for fibroids.

• Black people with uteruses are much more likely to get fibroids than White people. Black people are up to three times more likely to get uterine fibroids and are also more likely to have more severe symptoms and complications from fibroids.
• Research has linked self-reported experiences of racial discrimination to a higher risk of developing uterine fibroids in Black people.
  
• Standard medical treatment for fibroids affects Black people differently, and experts say there is a need for treatment plans to adjust for racial disparities in outcomes.

While the cause of the discrepancy is not known, health disparities and medical racism are thought to have a significant role.

More studies are needed to look at the causes, diagnosis, and treatment of fibroids in Black people with uteruses. 

Medical care for uterine fibroids also needs to be developed with an awareness of the differences to make diagnosis, prevention, and treatment of fibroids in Black people more effective.

Hormones

The sex hormones estrogen and progesterone appear to play a major role in the growth of uterine fibroids.

The theory is supported by evidence showing that artificial hormones (like in birth control pills) and menopause (when estrogen levels go down) are associated with the shrinking of fibroids.

Body Size/Shape

People with uteruses who are overweight are at higher risk for fibroids. People who are very overweight are at a higher risk than people who are less overweight.

Research has shown that obesity is associated with a higher likelihood of uterine fibroids, but it is not clear if obesity causes fibroids or if fibroids are just more common in people who have obesity.

The results of a study in 2014 showed that the presence of uterine fibroids is positively associated with:

• Current body mass index (BMI)
• Waist circumference
• Hip circumference
• Waist-to-height ratio
• Body fat mass
• Body fat percentage
• Intracellular water

The participants in the study who showed the highest risk for fibroids had higher

• Body mass indices
• Waist-to-hip ratios
• Body fat percentages (greater than 30%)

Diet

What people with uteruses eat may affect their risk for fibroids.

An increased incidence of uterine fibroids has been associated with:

• A diet high in red meat (e.g., beef)
• A diet that lacks fruits and vegetables (citrus fruit intake is linked to a lower risk of fibroids)
• Vitamin D deficiency
• Food additives
• Consuming alcohol
• Use of soybean milk (dairy consumption has been linked to a lower risk of fibroids)

Parity

The number of children a person has given birth to (parity) may affect their risk of developing fibroids.

The risk of developing fibroids in people who have had multiple births is reduced, while never having given birth (nulliparity) may increase the risk of fibroids.

How Submucosal Fibroids Are Diagnosed

A uterine fibroid or fibroid cluster is sometimes found during a pelvic exam as part of a routine physical, a gynecological exam, or prenatal care.

To help see the size of the fibroid or fibroid cluster better, a provider may use common objects to make a comparison.

For example, a fibroid might be compared to:

• Types of fruit (e.g., a blueberry, grape, apple, melon)
• Nuts (e.g., an acorn, walnut)
• Sports balls (e.g., a golf ball, softball, soccer ball)

Imaging tests and procedures can be done to get a better view of the fibroids and the areas of the body they are affecting.

Tests that can be used to look at fibroids include:

• Ultrasound
• Magnetic resonance imaging (MRI)
• X-rays
• Cat scan (CT)
• Hysterosalpingogram (injecting dye into the uterus and doing X-rays)
• Sonohysterogram (injecting water into the uterus and doing an ultrasound)

Sometimes, a provider may want to do surgery to make or confirm a diagnosis of fibroids. Types of surgeries for fibroids include:

• Laparoscopy. During this procedure, a long, thin scope with a bright light and camera is put into a tiny incision in or near the navel (belly button). The uterus and other areas being explored are broadcast to a monitor during the procedure for the provider to view. Pictures can also be taken during the surgery.
• Hysteroscopy. During this procedure, a long, thin scope with a light (and sometimes a camera) is put into the vagina through the cervix and into the uterus. This procedure lets the provider check inside the uterus without making an incision.

Treatment for Submucosal Fibroids

The goals of treatment for fibroids include:

• A reduction in menstrual bleeding
• Pain relief
• Relief of cramps and tension
• Improving problems with other organs affected by the fibroids, such as emptying the bladder or bowel and digestion
• Preserving or improving fertility

Which treatment is used for fibroids depends on factors such as:

• Age
• General health
• Type and severity of symptoms
• Type of fibroids
• Pregnancy (currently pregnant or may want to be in the future)

Watchful Waiting

Fibroids do not always need treatment. If the fibroids are not causing problems or symptoms, a "wait and see" approach can be taken. 

The fibroids are watched for changes and growth by having regular pelvic exams and/or ultrasounds.

Hysterectomy

Hysterectomy is a surgery to remove the uterus. It may or may not involve the removal of one or both ovaries and/or fallopian tubes. If the ovaries are removed along with the uterus, menopause will begin immediately.

Types of hysterectomies include:

• Total hysterectomy is the removal of the uterus and cervix
• Subtotal (supracervical) hysterectomy is the removal of the uterus but not the cervix

A hysterectomy completely eliminates fibroids and the symptoms that come with them. It also guarantees the fibroids will not come back.

That said, a hysterectomy has risks and disadvantages, including:

• Major surgery that requires anesthesia and may have surgery-related complications
• Recovery period of two to six weeks, depending on the type of hysterectomy
• Increased risk of urinary incontinence
• Ends menstruation (a person who has had a hysterectomy reaches menopause an average of two years earlier than people who have not had a hysterectomy)
• Makes childbearing impossible, ending fertility
• Can have negative psychological effects

The National Institute for Health and Care Excellence (NICE) recommends that hysterectomy should be considered only when:

• Other treatments are not an option or have not worked
• The person with fibroids wants to end menstruation
• The person with fibroids wants the surgery after being fully informed about the procedure and the risks involved

Myomectomy

During a myomectomy surgery, uterine fibroids are removed but the uterus is left intact.

There are three types of myomectomies:

• Open myomectomy. This procedure is usually used for very large fibroids. The fibroids are taken out through an incision in the abdomen that may go up and down or across like a bikini cut.
• Minimally invasive laparoscopic myomectomy. This procedure involves several small incisions (standard laparoscopic myomectomy) or one slightly larger incision (single port myomectomy).
• Hysteroscopic myomectomy. During this procedure, fibroids are removed through the vagina with no incisions. A camera is used.

A myomectomy usually allows the uterus to return to normal functioning, with periods remaining or returning.

A myomectomy also makes future pregnancies possible, but the pregnancy may need to be monitored for risks and a cesarean section might be needed, depending on how deep the fibroids were and if any spanned a large part of the uterine wall.

Recovery from the procedure can take up to six weeks.

Unlike with a hysterectomy, fibroids can return after a myomectomy, with a recurrence rate of 15% to 30% at five years, depending on the size and extent of the fibroids.

A myomectomy may have surgery-related complications including bleeding and infection.

Uterine Fibroid Embolization (UFE)

Uterine fibroid embolization (UFE) is a procedure for treating fibroids. A thin catheter is inserted into the artery at the groin or wrist through a small incision and guided to the fibroid's blood supply.

Small particles (about the size of grains of sand) are released and float downstream to block the small blood vessels, depriving the fibroid of nutrients. 

The lack of blood supply causes the fibroid to soften, bleed less, and shrink in size. About 90% of people who have UFE report significant improvement in their symptoms. For some people, their symptoms go away completely.

Some advantages of UFE are:

• Does not require general anesthesia
• No abdominal incision
• Minimal blood loss
• All fibroids can be treated at the same time
• Does not cause low bone density or other serious side effects associated (as with some hormonal therapies)

Some disadvantages of UFE are:

• Is as expensive as a hysterectomy
• Not recommended for people who hope to become pregnant because of its unpredictable effect on fertility
• A possibility of delayed infection sometime in the first year, which can become life-threatening if not treated
• Not a guaranteed cure—fibroids can return
• Some insurance plans may not cover it

Endometrial Ablation

Endometrial ablation is a procedure that uses heat to destroy the lining of the uterus (endometrium).

It is usually done to stop heavy menstrual bleeding, but it can also be used to treat small fibroids. It is not effective for large fibroids or for fibroids that have grown outside of the interior uterine lining.

It can be done on an outpatient basis and is a quick procedure, taking as few as 10 minutes to complete. While recovery typically takes a few days, watery or bloody discharge can last for several weeks.

This procedure usually stops monthly menstruation. When the flow is not stopped completely, it is usually significantly reduced.

Endometrial ablation is not recommended for people who wish to become pregnant.

The procedure reduces the chances of pregnancy but does not eliminate the possibility. Since the procedure increases the risks of complications, including miscarriage and ectopic (tubal) pregnancies, people who have endometrial ablation must take steps to prevent pregnancy.

Endometrial ablation may delay or make it harder to diagnose uterine cancer in the future because postmenopausal bleeding or irregular vaginal bleeding can be warning signs of uterine cancer.

People who have endometrial ablation should continue to have recommended pap smears and pelvic exams to monitor their uterus and cervix.

Ultrasound Guided Radiofrequency Ablation

With this minimally invasive procedure, high-energy waves are used to generate heat that destroys fibroids.

Using ultrasound, a provider verifies the correct placement of the radiofrequency device within each fibroid before ablation is performed.

The procedure is usually done on an outpatient basis and is considered relatively low-risk.

Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)

Magnetic resonance-guided focused ultrasound (MRgFUS) is a non-invasive procedure that takes about three hours to do. It is a relatively new treatment for fibroids.

While the person with fibroids is in a magnetic resonance imaging (MRI) machine, a radiologist identifies and targets the fibroids.

High-intensity ultrasound waves are used to heat and destroy uterine fibroids while the person is in the MRI machine. The procedure uses a device called the ExAblate, which combines MRI with ultrasound.

Although MRgFUS has a low risk of complications and a short recovery time, it does have some limitations, including:

• A lack of long-term studies because it’s still new
• Few studies on the effects the procedure could have on fertility and pregnancy
• Cannot treat all types of fibroids
• Cannot treat fibroids that are located near the bowel and bladder or are outside of the imaging area
• Requires a lot of time inside MRI equipment
• Not covered by all insurance companies (many consider it investigational, experimental, and unproven)

Medications

While medications do not cure fibroids, they can help manage fibroids and the symptoms of them.

Hormone Therapy

Some medications typically prescribed for birth control can also be used to help control symptoms of fibroids. They do not cause fibroids to grow and can help control heavy bleeding.

These medications include:

• Low-dose birth control pills
• Progesterone-like injections (e.g., Depo-Provera)
• An IUD (intrauterine device) called Mirena

Another type of medication used to treat fibroids is gonadotropin-releasing hormone agonists (GnRHa), most commonly a drug called Lupron.

These medications can be given by injection or nasal spray, or they can be implanted.

GnRHa can shrink fibroids and is sometimes used before surgery to make fibroids smaller and easier to remove.

GnRHa side effects can include:

• Hot flashes
• Depression
• Sleep difficulties
• Decreased sex drive
• Joint pain

Most people with uteruses do not menstruate when taking GnRHa. This can help people with anemia from heavy bleeding recover to a normal blood count.

Since GnRHa can cause bone thinning, they are generally only used for 6 months or less. 

The relief offered by GnRHa is considered temporary. The fibroids often grow back quickly once the medication is stopped.

Cost is a consideration when choosing the treatment, too, as the drugs are quite expensive. Insurance companies may not cover all or any of the costs.

Other medications used to treat fibroids include:

• Tranexamic acid (TXA). This medication helps boost the blood’s ability to clot, which helps decrease the amount of vaginal bleeding. It's usually used in severe cases, such as heavy bleeding, and is generally not used long-term. It does not shrink fibroids or help with pain but can prevent excessive bleeding and anemia.
• Over-the-counter (OTC) pain relievers. Ibuprofen (Motrin, Advil), acetaminophen (Tylenol), or naproxen (Aleve) do not shrink fibroids, but they can relieve cramping and pain caused by fibroids. These drugs should not be used at high doses for a long time.
• Iron supplements. These can help prevent or treat anemia caused by heavy bleeding.

Complications with Submucosal Fibroids

Submucosal fibroids often cause more bleeding problems than other types of fibroids because they can crowd the uterine space. Even very small submucosal fibroids may cause symptoms.

Submucosal fibroids are also the most likely type of fibroid to lead to pregnancy and fertility problems, including:

• Cesarean (c-section) delivery
• Breech presentation (baby enters the birth canal upside down with feet or buttocks emerging first)
• Preterm birth or miscarriage
• Placenta previa (placenta covering the cervix)
• Postpartum hemorrhage (excessive bleeding after giving birth)

Other complications of fibroids can include:

• Severe pain or very heavy bleeding (may require emergency surgery)
• Twisting of the fibroid (may require surgery)
• Anemia (low red blood cell count)
• Urinary tract infections
• Infertility (in rare cases)
• Kidney damage (in rare cases)

Coping with Submucosal Fibroids

If you have symptoms of fibroids, talk with your provider about treatment. Symptom management may not be enough.

To help cope with fibroid symptoms while you’re waiting for treatment, you can:

• Place a hot water bottle on your abdomen
• Use a heating pad set on low (protect your skin by putting a thin cloth between the heating pad and your skin, and never go to sleep with a heating pad turned on)
• Take a warm bath
• Lie down and put a pillow under your knees
• Lie on your side and bring your knees up to your chest
• Use stress management and relaxation techniques such as yoga and meditation
• Get at least 2.5 hours of exercise a week
• Keep track of how many pads or tampons you use each day (your provider can use this information to figure out how heavy your menstrual bleeding is)
• Ask your provider about taking a daily multivitamin with iron if you have heavy or prolonged menstrual bleeding

Summary

While submucosal fibroids are the least common type of uterine fibroids, they can cause serious and unpleasant symptoms such as excessive menstrual bleeding.

If you are experiencing symptoms of fibroids, make an appointment to see a healthcare provider, especially if you are or plan to become pregnant.

Several treatments exist for submucosal fibroids that can get rid of fibroids for good or help manage the symptoms they cause.