Most Likely Fibroid Location: Submucosal
The fibroid is most likely submucosal, as this location is specifically and strongly associated with menorrhagia due to direct projection into the uterine cavity and disruption of 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 menorrhagia 1
Multiple mechanisms explain the bleeding: enlargement of the uterine cavity, impairment of blood supply to the endometrium, and endometrial atrophy and ulceration 1
Menorrhagia is the most frequent symptom of uterine fibroids overall, often resulting in iron deficiency anemia 1
Submucosal fibroids are the most common structural cause of menorrhagia, particularly because they distort the endometrial cavity and increase surface area for bleeding 2
Why Other Locations Are Less Likely
Intramural fibroids cause menorrhagia less frequently than submucosal fibroids 1
Subserosal fibroids typically do not cause menorrhagia but are more associated with bulk symptoms such as pelvic pressure 1
Cervical fibroids are rare and are not characteristically associated with menorrhagia as a primary presenting symptom 1
Addressing the Pelvic Pressure and Lower Limb Symptoms
While the patient presents with both menorrhagia AND pelvic pressure/lower limb heaviness, the menorrhagia is the dominant localizing symptom that points specifically to submucosal location. The pelvic pressure symptoms can occur with any large fibroid regardless of location 3, 4, but when combined with significant menorrhagia, submucosal location becomes most likely.
Diagnostic Confirmation
Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids, with a sensitivity of 90% and specificity of 98% 1
Cavity distortion characteristic of submucosal location can be identified on transvaginal ultrasound 1
Answer: D. Submucosal