What is the most likely location of a uterine fibroid in a patient presenting with menorrhagia (heavy menstrual bleeding) and pelvic pressure, accompanied by lower limb heaviness or edema, confirmed by pelvic ultrasound?

Most Likely Fibroid Location: Submucosal

The most likely location is submucosal (Answer D), as submucosal fibroids are specifically associated with menorrhagia and are the fibroid type most strongly linked to heavy menstrual bleeding. 1

Clinical Reasoning

Menorrhagia as the Key Symptom

The presentation of menorrhagia (heavy menstrual bleeding) is the critical diagnostic clue in this case:

• Submucosal fibroids are specifically and strongly associated with menorrhagia, as they project into the uterine cavity and directly affect the endometrial surface 1
• These fibroids cause abnormal uterine bleeding through multiple mechanisms including enlargement of the uterine cavity, impairment of blood supply to the endometrium, and endometrial atrophy and ulceration 1
• Submucosal fibroids have the highest clinical impact on menstrual bleeding despite potentially being smaller than other fibroid types 2

Why Not the Other Locations?

Intramural fibroids (Option C):

• While intramural fibroids are the most common fibroid type overall, they cause menorrhagia less frequently than submucosal fibroids 1
• Intramural fibroids without cavity distortion have lower pregnancy rates but are not as strongly associated with heavy bleeding as submucosal types 1

Subserosal fibroids (Option B):

• Subserosal fibroids project outward from the uterine surface and typically do not cause menorrhagia 1
• These fibroids are more associated with bulk symptoms (pelvic pressure) rather than bleeding 1
• Studies show pregnancy and implantation rates are not significantly affected by subserosal fibroids, indicating minimal impact on the endometrial cavity 1

Cervical fibroids (Option A):

• Cervical fibroids are rare and have high treatment failure rates with interventions like uterine artery embolization 1
• They are not characteristically associated with menorrhagia as a primary presenting symptom 1

Pelvic Pressure and Lower Limb Symptoms

The additional symptoms of pelvic pressure with lower limb heaviness/edema suggest:

• A fibroid of significant size causing mass effect 3
• Submucosal fibroids can grow to substantial sizes while still maintaining their characteristic bleeding symptoms 2
• The combination of menorrhagia with bulk symptoms is consistent with a large submucosal fibroid 3, 4

Diagnostic Confirmation

Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids:

• Sensitivity of 90% and specificity of 98% for diagnosing submucosal fibroids specifically 1
• Can identify cavity distortion characteristic of submucosal location 1