A female patient of reproductive age, presenting with menorrhagia and pelvic pressure, has been diagnosed with a uterine fibroid via pelvic ultrasound. What is the most likely location of this fibroid?

Most Likely Fibroid Location: Submucosal

In a patient presenting with menorrhagia and pelvic pressure, the fibroid is most likely submucosal (Answer D), as submucosal fibroids are specifically and strongly associated with menorrhagia due to their projection into the uterine cavity and direct effect on the endometrial surface. 1

Clinical Reasoning

Why Submucosal Fibroids Cause Menorrhagia

• Submucosal fibroids project into the uterine cavity and directly affect the endometrial surface, making them the fibroid type most strongly associated with heavy menstrual bleeding 1

• These fibroids cause abnormal uterine bleeding through multiple mechanisms including:

  • Enlargement of the uterine cavity 1
  • Impairment of blood supply to the endometrium 1
  • Endometrial atrophy and ulceration 1

• Menorrhagia is the most frequent symptom of uterine fibroids overall, often resulting in iron deficiency anemia 2

Why Other Locations Are Less Likely

• Intramural fibroids (Answer C) cause menorrhagia less frequently than submucosal fibroids, though they are the most common fibroid type overall 1

• Subserosal fibroids (Answer B) typically do not cause menorrhagia but are more associated with bulk symptoms such as pelvic pressure 1

• Cervical fibroids (Answer A) are rare and are not characteristically associated with menorrhagia as a primary presenting symptom 1

Important Clinical Considerations

Diagnostic Accuracy

• Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids, with 90% sensitivity and 98% specificity for diagnosing submucosal fibroids specifically 1

• Transvaginal ultrasound can identify cavity distortion characteristic of submucosal location 1

Treatment Implications

• Hysteroscopic myomectomy is specifically indicated for submucosal fibroids in patients desiring uterus preservation 2

• Patients with significant intramural or subserosal fibroid burden causing bulk symptoms are less likely to experience symptom relief from hysteroscopic myomectomy 2

• Endometrial ablation has a 23% failure rate in treating patients with submucosal fibroids compared to only 4% in patients with normal uterine cavities 3

Common Pitfall to Avoid

While intramural fibroids are the most common fibroid type by prevalence, the clinical presentation of menorrhagia as the dominant symptom points specifically to submucosal location rather than simply choosing the most common fibroid type overall 1