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Heavy Menstrual Bleeding — DFSRH MCQ

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HardHeavy Menstrual BleedingDFSRH

A 38-year-old nulliparous woman with polycystic ovary syndrome and a BMI of 37 kg/m² requests a 52 mg levonorgestrel intrauterine device for contraception and heavy menstrual bleeding. She menstruates every 2–4 months; each bleed lasts 10–14 days with flooding. During the past 6 months she has also developed persistent spotting between the heavy bleeds. Tranexamic acid has been ineffective. Her haemoglobin is 104 g/L. Pregnancy is reasonably excluded. Cervical screening is up to date, speculum examination shows a normal cervix, and bimanual examination is unremarkable. A recent transvaginal ultrasound reported no fibroid or polyp and an endometrial thickness of 7 mm. She asks whether the device can be fitted today. Which management plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Arrange outpatient hysteroscopy with endometrial biopsy during the procedure, then plan treatment according to the findings

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as E

Her presentation requires investigation before empirical treatment. Persistent intermenstrual/irregular bleeding suggests possible intracavitary or endometrial pathology. Infrequent heavy bleeding in a woman with obesity and PCOS further increases the risk of endometrial hyperplasia through prolonged unopposed oestrogen exposure; unsuccessful HMB treatment is an additional NICE biopsy criterion. NICE therefore recommends outpatient hysteroscopy as the investigation of choice and consideration of endometrial biopsy during that procedure. A normal ultrasound and a premenopausal endometrial thickness of 7 mm do not reliably exclude focal intracavitary disease or histological abnormality. A is incorrect because NICE advises that endometrial sampling for HMB should be obtained in the context of hysteroscopy, not by blind biopsy, which may miss focal treatable lesions. C overlooks multiple risk features requiring assessment; although a 52 mg LNG-IUD is effective for HMB, that benefit does not remove the need to investigate suspicious bleeding. D is less appropriate because ultrasound-based techniques do not provide simultaneous direct visualisation and targeted sampling. E is unnecessarily invasive: hysteroscopy under general or regional anaesthesia is offered when outpatient hysteroscopy is declined or unsuitable, and dilatation and curettage is not recommended as treatment for HMB.

Reference: Heavy menstrual bleeding: assessment and management — Recommendations (Published 14 March 2018; updated 24 May 2021; reviewed 19 December 2024) — https://www.nice.org.uk/guidance/ng88/chapter/recommendations FSRH Guideline: Intrauterine Contraception (March 2023; amended 21 January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf