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Premature ovarian insufficiency — MSRA MCQ

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Moderateall topics relevant for this examPremature ovarian insufficiencyMSRA

A 37-year-old woman presents with 7 months of amenorrhoea, troublesome hot flushes and night sweats. Pregnancy tests are negative. She has an intact uterus and no history of venous thromboembolism, breast cancer, liver disease or cardiovascular disease. Her FSH concentrations were elevated on 2 samples taken 5 weeks apart. She has migraine with visual aura and wishes to avoid pregnancy. She has no contraindication to intrauterine contraception. What is the most appropriate management now?

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Correct answer: E — Start transdermal oestradiol and arrange insertion of a 52 mg levonorgestrel intrauterine system

This woman has premature ovarian insufficiency (POI): she is under 40, has menopause-associated symptoms and amenorrhoea, and has elevated FSH concentrations on 2 samples taken 4 to 6 weeks apart. NICE recommends sex-steroid replacement with either HRT or combined hormonal contraception, generally until at least the age of natural menopause. Combined hormonal contraception is initially attractive because it would provide both hormonal replacement and contraception. However, migraine with aura makes a combined pill unsuitable. HRT remains appropriate, and transdermal oestradiol is a suitable route where migraine with aura affects the choice of preparation. Because she has a uterus, oestrogen must be opposed to protect the endometrium. A 52 mg levonorgestrel intrauterine system provides effective contraception and endometrial protection during oestrogen replacement. It therefore addresses both decisive issues in this case: the need for sex-steroid replacement in POI and the need to avoid pregnancy despite intermittent ovarian activity. Oestrogen alone is unsafe with an intact uterus. Continuous combined HRT supplies endometrial protection but is not reliable contraception. Deferring treatment unnecessarily prolongs hypo-oestrogenic symptoms and exposure; specialist input may be appropriate for wider POI assessment but should not delay indicated hormone replacement.

Reference: NICE NG23: Menopause: identification and management — Recommendations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng23/chapter/Recommendations NHS: Who can take the combined pill (2024) — https://www.nhs.uk/contraception/methods-of-contraception/combined-pill/who-can-take-it/ Mirena 20 micrograms/24 hours intrauterine delivery system — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/1132/smpc