In a 39-year-old woman with heavy menstrual bleeding, pelvic pressure, lower‑limb heaviness and edema and a uterine fibroid on ultrasound, 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 symptoms, the fibroid is most likely submucosal (Answer D), as this location is specifically and strongly associated with heavy menstrual bleeding due to direct distortion of the endometrial cavity. 1

Clinical Reasoning by Fibroid Location

Why Submucosal Fibroids Are Most Likely

• Submucosal fibroids project into the uterine cavity and directly affect the endometrial surface, making them the primary cause of menorrhagia among all fibroid types. 1

• These lesions cause abnormal uterine bleeding through multiple mechanisms: enlargement of the uterine cavity, impairment of endometrial blood supply, and endometrial atrophy with ulceration. 1

• Transvaginal ultrasound demonstrates 90% sensitivity and 98% specificity for detecting submucosal fibroids specifically, confirming their cavity-distorting nature. 1, 2

• When reproductive-age women present with both heavy menstrual bleeding AND bulk-related symptoms (pelvic pressure, lower extremity edema), this combination is most often attributable to a large submucosal fibroid that both distorts the cavity and exerts mass effect. 1

Why Other Locations Are Less Likely

Intramural fibroids (Option C):

• Cause menorrhagia less frequently than submucosal fibroids 1
• Only affect bleeding when they abut or distort the endometrial cavity, and even then the bleeding is typically less severe than with true submucosal lesions 2
• While they can cause bulk symptoms, the dominant presenting symptom of heavy menorrhagia points away from purely intramural location 3, 4

Subserosal fibroids (Option B):

• Typically do NOT cause menorrhagia 1
• Are primarily associated with bulk symptoms (pelvic pressure, urinary frequency) rather than bleeding 1, 2
• Have little to no effect on menstrual patterns 4
• The prominent menorrhagia in this case makes subserosal location unlikely

Cervical fibroids (Option A):

• Are rare, accounting for less than 5% of all uterine fibroids 2
• More commonly present with dyspareunia, urinary obstruction, or vaginal discharge rather than heavy menstrual bleeding 2
• Have high treatment failure rates and are not characteristically associated with menorrhagia as a primary symptom 1

Diagnostic Confirmation

• Combined transabdominal and transvaginal ultrasound achieves 90-99% overall sensitivity for detecting fibroids, with transvaginal approach providing superior visualization of submucosal location and cavity distortion. 1, 2

• The 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 the preferred intervention for submucosal fibroids in patients wishing to preserve the uterus, as these lesions can be resected via transcervical approach. 1

• Excision of submucosal myomas restores fertility with pregnancy rates after surgery similar to normal controls, and is specifically indicated when the intracavitary component is significant. 4

Common Pitfall to Avoid

Do not assume that bulk symptoms (pelvic pressure, lower limb edema) automatically indicate subserosal location. Large submucosal fibroids can produce both menorrhagia AND mass effect simultaneously, whereas subserosal fibroids cause bulk symptoms WITHOUT significant menstrual bleeding. 1, 2 The presence of heavy menorrhagia is the key discriminating feature pointing to submucosal location in this clinical scenario.