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Heavy menstrual bleeding in a woman with previous unprovoked venous thromboembolism receiving apixaban — MSRA

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Hardall topics relevant for this examHeavy menstrual bleeding in a woman with previous unprovoked venous thromboembolism receiving apixabanMSRA

A 42-year-old woman presents with a 10-month history of regular but heavy menstrual bleeding, with flooding and clots for 2 days of each 27-day cycle. This is affecting her work and she wishes to avoid pregnancy permanently for the foreseeable future. She has no intermenstrual or postcoital bleeding, pelvic pain, pressure symptoms, or symptoms of pregnancy. Abdominal and bimanual examination are normal. Her haemoglobin is 104 g/L. She had an unprovoked proximal deep-vein thrombosis 18 months ago and remains on apixaban indefinitely. She also has CKD G3b (eGFR 38 mL/min/1.73 m²). She has completed her family and would accept an intrauterine method. What is the most appropriate management for her heavy menstrual bleeding?

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Correct answer: D — Fit a 52 mg levonorgestrel-releasing intrauterine system

A 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) is the best option. She has regular heavy menstrual bleeding without symptoms or examination findings suggesting fibroids, adenomyosis or endometrial pathology, and wants reliable contraception. NICE recommends an LNG-IUS as first-line treatment for heavy menstrual bleeding where there is no identified pathology, while also advising that progestogen-only contraception may suppress menstruation. Mefenamic acid is a recognised non-hormonal option, but is inappropriate here because concomitant apixaban increases bleeding risk and CKD increases the potential for NSAID-related renal harm. Tranexamic acid is otherwise a plausible treatment for cyclical heavy bleeding, but the oral tranexamic acid SmPC lists current or previous venous or arterial thrombosis as a contraindication. A combined oral contraceptive could reduce bleeding and provide contraception, but oestrogen-containing contraception is unsuitable after unprovoked venous thromboembolism. Cyclical norethisterone is a NICE-listed alternative if an LNG-IUS is declined or unsuitable, but it is not the preferred first-line option in this patient who accepts intrauterine treatment. She should also receive treatment for iron-deficiency anaemia as indicated and counselling that bleeding may be irregular initially, with benefit taking several cycles.

Reference: NICE NG88: Heavy menstrual bleeding: assessment and management, Recommendations (Last updated 24 May 2021) — https://www.nice.org.uk/guidance/ng88/chapter/Recommendations Tranexamic Acid 500 mg Tablets: Summary of Product Characteristics (Updated 05 May 2026) — https://www.medicines.org.uk/emc/product/14622/smpc Mirena 20 micrograms/24 hours intrauterine delivery system: Summary of Product Characteristics (Updated June 2026) — https://www.medicines.org.uk/emc/product/1132/smpc