In a 42-year-old woman with pelvic pressure, bloating, lower abdominal heaviness, prolonged heavy menstrual bleeding, and ultrasound showing a uterine fibroid, which type of fibroid is most likely: cervical, parasitic, subserosal, or submucosal?

Most Likely Diagnosis: Submucosal Fibroid

The most likely diagnosis is D. Submucosal fibroid, as this patient's presentation of prolonged heavy menstrual bleeding combined with pelvic pressure directly points to a fibroid that projects into the uterine cavity and distorts the endometrial surface. 1

Clinical Reasoning Based on Symptom Pattern

Heavy Menstrual Bleeding as the Key Discriminator

• Submucosal fibroids are specifically and strongly associated with menorrhagia (heavy menstrual bleeding) because they project into the uterine cavity and directly affect the endometrial surface 1
• These fibroids cause abnormal uterine bleeding through multiple mechanisms: enlargement of the uterine cavity, impairment of blood supply to the endometrium, and endometrial atrophy and ulceration 1
• Menorrhagia is the most frequent symptom of uterine fibroids overall, often resulting in iron deficiency anemia 2, 1

Why Other Fibroid Types Are Less Likely

• Subserosal fibroids typically do NOT cause menorrhagia; they are more associated with bulk symptoms such as pelvic pressure alone without significant bleeding 1
• Intramural fibroids cause menorrhagia less frequently than submucosal fibroids 1
• Cervical fibroids are rare (less than 5% of all uterine fibroids) and more commonly present with dyspareunia, urinary obstruction, or vaginal discharge rather than heavy menstrual bleeding 3
• Parasitic fibroids are extremely rare variants that have detached from the uterus and obtained blood supply from other organs—not a typical presentation for new-onset symptoms 1

Diagnostic Confirmation

Ultrasound Performance

• Transvaginal ultrasound has excellent diagnostic accuracy for submucosal fibroids, with a sensitivity of 90% and specificity of 98% for diagnosing submucosal fibroids specifically 1, 3
• Transvaginal ultrasound can identify cavity distortion characteristic of submucosal location 1
• The combination of transabdominal and transvaginal ultrasound achieves 90-99% sensitivity for detecting uterine fibroids overall 3, 4

Clinical Pitfall to Avoid

• Do not assume all fibroids causing pelvic pressure are subserosal—the presence of heavy menstrual bleeding shifts the diagnosis strongly toward submucosal location, as subserosal fibroids produce minimal or no menstrual bleeding abnormalities 3
• Ultrasound should explicitly assess whether a fibroid distorts the endometrial cavity; confirmation of cavity distortion indicates a submucosal location 3

Treatment Implications of This Diagnosis

• Hysteroscopic myomectomy is specifically indicated for submucosal fibroids in patients desiring uterus preservation 1
• Submucosal fibroids may be amenable to hysteroscopic resection if intracavitary, particularly when less than 4 cm 5, 6
• Patients with significant intramural or subserosal fibroid burden are less likely to experience symptom relief from hysteroscopic myomectomy 1