In a 39-year-old woman with heavy menorrhagia, pelvic pressure, lower‑limb heaviness and edema, and an ultrasound confirming a uterine fibroid, what is the most likely location of the fibroid?

Most Likely Fibroid Location: Submucosal

In a 39-year-old woman presenting with heavy menorrhagia, pelvic pressure, and lower limb heaviness/edema, the most likely fibroid location is submucosal (Answer D), as these fibroids have the strongest association with heavy menstrual bleeding due to their direct contact with and distortion of the endometrial cavity. 1

Clinical Reasoning for Submucosal Location

Heavy menorrhagia is the key distinguishing symptom that points specifically toward submucosal fibroids:

• Submucosal fibroids are located beneath the endometrium and protrude into the uterine cavity, causing direct distortion of the endometrial lining 1
• This anatomic relationship creates maximal disruption of normal endometrial hemostasis, resulting in the characteristic heavy menstrual bleeding pattern 1
• Transvaginal ultrasound demonstrates 90% sensitivity and 98% specificity for diagnosing submucosal fibroids specifically 2, 1, making them readily identifiable on the pelvic ultrasound mentioned in this case

Why Other Locations Are Less Likely

Intramural fibroids (Answer C) are located within the myometrial wall without significant cavity distortion:

• While intramural fibroids can cause menorrhagia, they typically produce less severe bleeding than submucosal types 1
• Pelvic pressure symptoms predominate over bleeding with intramural location 1

Subserosal fibroids (Answer B) project from the uterine surface:

• These cause minimal to no menstrual bleeding abnormalities 1
• Subserosal fibroids primarily produce bulk symptoms (pressure, urinary frequency) rather than menorrhagia 2
• The prominent menorrhagia in this case essentially excludes subserosal location as the primary pathology

Cervical fibroids (Answer A) are uncommon (representing <5% of all fibroids):

• While they can cause bleeding, cervical fibroids more characteristically present with dyspareunia, urinary obstruction, or vaginal discharge 2
• The combination of heavy menorrhagia with pelvic pressure makes cervical location unlikely

Additional Clinical Context

The lower limb heaviness and edema described in this patient likely represents:

• Venous or lymphatic compression from a large fibroid uterus causing pelvic congestion 3
• This symptom reflects the overall fibroid burden and uterine enlargement rather than specific fibroid location 3
• Both submucosal and large intramural fibroids can produce this compressive effect, but the menorrhagia remains the location-specific symptom 1

Diagnostic Confirmation

The pelvic ultrasound should specifically identify:

• Whether the fibroid distorts the endometrial cavity (confirming submucosal location) 2, 1
• Combined transabdominal and transvaginal approaches provide optimal visualization, with transvaginal ultrasound achieving 90-99% sensitivity for detecting fibroids overall 2, 1

Critical Clinical Pitfall

Do not assume all fibroids causing bleeding are submucosal—intramural fibroids that contact the endometrium can also cause menorrhagia, but the severity is typically less pronounced than with true submucosal fibroids that protrude into the cavity 1. The ultrasound report should clarify the degree of cavity distortion to guide treatment planning, as submucosal fibroids may be amenable to hysteroscopic resection while intramural fibroids require alternative approaches 2.