Most Likely Fibroid Location
The most likely location is submucosal (Option D), because this patient presents with the classic triad of heavy menorrhagia combined with pelvic pressure and lower-extremity symptoms—a constellation most strongly associated with large submucosal fibroids that both distort the endometrial cavity and exert mass effect on surrounding structures. 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 specifically and strongly associated with menorrhagia through multiple mechanisms: enlargement of the uterine cavity, impairment of endometrial blood supply, and endometrial atrophy with ulceration. 1
In reproductive-age women presenting with heavy menstrual bleeding together with pelvic pressure and lower-extremity edema, the bulk-related symptoms are most often attributable to a large submucosal fibroid that both distorts the endometrial cavity and exerts mass effect on surrounding structures. 1
Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids specifically, with 90% sensitivity and 98% specificity, and can identify the characteristic cavity distortion that confirms submucosal location. 1, 2
Why Other Locations Are Less Likely
Intramural fibroids (Option C) are located within the myometrial wall and cause menorrhagia less frequently than submucosal fibroids; when they do cause bleeding, it is typically less severe than that produced by true submucosal lesions. 1, 2
Subserosal fibroids (Option B) project from the outer uterine surface and typically do not cause menorrhagia at all—they are more associated with bulk symptoms such as pelvic pressure alone, without the prominent bleeding component. 1, 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 as the primary symptom. 2
Diagnostic Confirmation
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 as the preferred approach. 2
Combined transabdominal and transvaginal ultrasound achieves 90–99% sensitivity for detecting uterine fibroids overall, with the transvaginal approach providing superior visualization of submucosal location and cavity involvement essential for treatment planning. 1, 2
Treatment Implications
Hysteroscopic myomectomy is specifically indicated for submucosal fibroids in patients desiring uterus preservation, as these lesions can be resected via a transcervical, transvaginal route. 1, 3
Patients with significant intramural or subserosal fibroid burden causing bulk symptoms are less likely to experience symptom relief from hysteroscopic myomectomy alone, underscoring the need for precise fibroid location assessment before selecting the surgical approach. 1
Common Pitfall to Avoid
- Do not assume that all fibroids causing both bleeding and bulk symptoms are intramural simply because they are large—the combination of severe menorrhagia with mass effect points specifically to submucosal location, where the fibroid both protrudes into the cavity (causing bleeding) and achieves sufficient size to compress adjacent structures (causing pelvic pressure and venous congestion manifesting as lower-limb heaviness and edema). 1