Why this situation happens
Hysteroscopic myomectomy treats fibroids that project into the uterine cavity. It can be very effective for selected submucosal fibroids, but it is sometimes not possible to remove the whole fibroid safely in one sitting. This can happen when the fibroid extends deeply into the muscle wall, the visible intracavity part is only one component of a larger fibroid, operating time or fluid limits are reached, or the surgeon appropriately stops to reduce risk.
If a significant fibroid remnant remains and heavy bleeding continues, the next step is not always immediate hysterectomy. The reasonable options may include observation, medication, repeat hysteroscopic surgery, abdominal or laparoscopic myomectomy, uterine artery embolisation, or hysterectomy. The right choice depends on symptoms, anaemia, fibroid position, uterine anatomy, age, fertility goals and the patient's preference.
Where uterine artery embolisation may fit
Uterine artery embolisation, also called UAE or UFE, treats the fibroid by reducing its blood supply rather than cutting it out. A catheter is guided through a pinhole in the wrist or groin into the uterine arteries, and tiny particles are used to block the vessels supplying the fibroid tissue. Over the following months, fibroids usually shrink and soften, and bleeding often improves over the first few menstrual cycles.
After incomplete hysteroscopic resection, UAE may be worth discussing when the remaining fibroid is still vascular, when bleeding remains the dominant problem, when the uterus is enlarged by additional intramural fibroids or adenomyosis, or when the patient wants to avoid hysterectomy if a less invasive option is reasonable.
When UAE may not be the best next step
UAE is not the right answer for every patient. Repeat hysteroscopic surgery may be better if there is a small, mostly intracavity residual fibroid that can be removed safely. Myomectomy may be preferred when future pregnancy is the main priority and the fibroid anatomy is surgically favourable. Hysterectomy remains the definitive option when the patient wants certainty, no future pregnancy, or when imaging or pathology raises concern.
It is also important to be clear that UAE is not an emergency treatment for uncontrolled bleeding, and it is not a substitute for appropriate gynaecological assessment of abnormal bleeding. Recent endometrial sampling or hysteroscopic pathology is often helpful before proceeding.
What information is needed before deciding
- Current symptoms: bleeding pattern, flooding, clots, pain, pressure and fatigue
- Blood count and iron studies, especially if there has been iron deficiency anaemia
- Recent ultrasound, and usually pelvic MRI if treatment is being planned
- Hysteroscopy findings and pathology from the resected tissue
- Whether there are additional fibroids or adenomyosis outside the uterine cavity
- Pregnancy plans, previous pregnancies, and views about uterine preservation
- Current hormonal treatment, tranexamic acid use, anticoagulants and other medical issues
How I usually approach this referral
I review the gynaecologist's correspondence, the procedure report and the imaging. If UAE looks plausible, I see the patient to discuss all reasonable options, including repeat surgery and hysterectomy, not just embolisation. I then write back to both the GP and gynaecologist so the treatment plan is coordinated.
For patients who proceed with UAE, follow-up is usually arranged at around two weeks, then again after several months with symptom review and imaging where appropriate. The goal is not just a technically successful embolisation but a clear clinical outcome: less bleeding, recovery from anaemia where present, and a plan if symptoms persist.
Questions to ask at consultation
- Is the residual fibroid mostly intracavity, intramural, or mixed?
- Is there adenomyosis or more than one fibroid contributing to symptoms?
- Would repeat hysteroscopic resection be realistic, or was the first procedure limited by fibroid depth?
- How important is future pregnancy compared with symptom control and avoiding hysterectomy?
- What improvement is realistic, and what would the plan be if bleeding does not settle?