Most Likely Fibroid Location: Submucosal
In a 39-year-old woman presenting with heavy menorrhagia, pelvic pressure, and lower extremity symptoms, 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 Based on Symptom Profile
Heavy Menorrhagia as the Key Discriminator
Submucosal fibroids cause menorrhagia through multiple mechanisms: enlargement of the uterine cavity, impairment of endometrial blood supply, and endometrial atrophy and ulceration, making them the primary culprit when heavy bleeding is the dominant symptom 1
Transvaginal ultrasound achieves 90% sensitivity and 98% specificity for detecting submucosal fibroids specifically, confirming these cavity-distorting lesions that are most strongly associated with heavy menstrual bleeding 2, 1
Intramural fibroids cause menorrhagia less frequently than submucosal fibroids, though they can contribute when they abut the endometrium 1
Subserosal fibroids typically do not cause menorrhagia and are instead associated primarily with bulk symptoms such as pelvic pressure, urinary frequency, or constipation 2, 1
Cervical fibroids are rare (accounting for less than 5% of all uterine fibroids) and more commonly present with dyspareunia, urinary obstruction, or vaginal discharge rather than heavy menstrual bleeding 2
Addressing the Additional Symptoms
The pelvic pressure and lower limb symptoms (heaviness and edema) in this case likely represent bulk-related effects from a potentially large submucosal fibroid that is causing both cavity distortion (menorrhagia) and mass effect (pressure symptoms) 3
While subserosal fibroids are classically associated with bulk symptoms alone, the presence of heavy menorrhagia as the primary presenting complaint strongly points away from a purely subserosal location 2, 1
Diagnostic Confirmation
Combined transabdominal and transvaginal ultrasound provides 90-99% sensitivity for detecting fibroids overall, with transvaginal approach being superior for characterizing submucosal location and cavity distortion 3, 2
Ultrasound should explicitly assess whether the fibroid distorts the endometrial cavity; confirmation of cavity distortion indicates submucosal location and directs treatment toward hysteroscopic resection 2
Treatment Implications
Hysteroscopic myomectomy is specifically indicated for submucosal fibroids in patients desiring uterus preservation, as these fibroids are amenable to transvaginal, transcervical resection 3, 1
Patients with significant intramural or subserosal fibroid burden are less likely to experience symptom relief from hysteroscopic myomectomy, further supporting the importance of accurate location diagnosis 3, 1