Most Likely Fibroid Location: Submucosal
In a 39-year-old woman presenting with heavy menorrhagia combined with pelvic pressure and lower extremity symptoms, the fibroid is most likely submucosal (Answer D). 1
Clinical Reasoning
Submucosal fibroids are specifically and strongly associated with menorrhagia because they project into the uterine cavity and directly affect the endometrial surface. 1 The combination of severe menstrual bleeding with bulk symptoms (pelvic pressure, lower limb heaviness and edema) points to a large submucosal fibroid that both distorts the endometrial cavity and exerts mass effect on surrounding structures. 1
Why Other Locations Are Less Likely:
Subserosal fibroids (Option B) typically do NOT cause menorrhagia; they are primarily associated with bulk symptoms such as pelvic pressure but lack the direct endometrial contact needed to produce heavy bleeding. 1
Intramural fibroids (Option C) can cause menorrhagia, but the bleeding is typically less severe than that produced by true submucosal lesions. 2 While they may contribute to symptoms when they abut the endometrium, they are not the primary culprit when heavy menstrual bleeding is the dominant presenting feature. 2
Cervical fibroids (Option A) 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 They also have high treatment failure rates and are not characteristically associated with menorrhagia as a primary symptom. 1
Pathophysiologic Mechanism
Submucosal fibroids cause abnormal uterine bleeding through multiple mechanisms including enlargement of the uterine cavity, impairment of blood supply to the endometrium, and endometrial atrophy and ulceration. 1 The resulting vascular irregularities and aberrations in vascular architecture explain the heavy menstrual bleeding observed. 3
Diagnostic Confirmation
Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids, with 90% sensitivity and 98% specificity for diagnosing submucosal location specifically. 2, 1 The ultrasound should explicitly assess whether the fibroid distorts the endometrial cavity, as 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 who wish to preserve the uterus, because these lesions can be resected via a transcervical, transvaginal route. 1 This is particularly relevant for this 39-year-old patient who may still desire fertility preservation. 2