Adenomyosis — DFSRH MCQ

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EasyPain ManagementAdenomyosisDFSRH

A 38-year-old woman requests highly effective reversible contraception. She has ultrasound-confirmed adenomyosis causing heavy menstrual bleeding and severe cyclical pelvic pain despite regular NSAIDs. She does not wish to conceive for at least 5 years. Her medical history includes recurrent migraine with visual aura. Examination shows a mildly enlarged uterus, and ultrasound confirms that the endometrial cavity is not distorted. She would prefer a contraceptive method that is also likely to improve her bleeding and pain. Which is the most appropriate option?

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Correct answer: B — A 52 mg levonorgestrel intrauterine device

A 52 mg levonorgestrel intrauterine device (LNG-IUD) is the best option because it provides highly effective long-acting contraception while addressing both heavy menstrual bleeding and adenomyosis-associated dysmenorrhoea. FSRH states that the 52 mg LNG-IUD reduces pain associated with adenomyosis and that there are no published studies establishing an effect of lower-dose LNG-IUDs on dysmenorrhoea. NICE also recommends an LNG-IUS as first-line treatment for heavy menstrual bleeding associated with suspected or diagnosed adenomyosis. ([fsrh.org](https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf)) Combined oral contraception can improve dysmenorrhoea and bleeding, but migraine with aura is UKMEC category 4 for combined hormonal contraception because estrogen exposure represents an unacceptable health risk. ([fsrh.org](https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf)) The 19.5 mg LNG-IUD is an effective contraceptive but lacks evidence for treating dysmenorrhoea and is not the preferred device when therapeutic control of heavy bleeding is required. Depot medroxyprogesterone acetate may induce amenorrhoea and improve pain in some users, but evidence for alleviating heavy menstrual bleeding is less established and it is not first-line here. A copper IUD provides effective contraception but commonly increases menstrual blood loss and may exacerbate dysmenorrhoea, directly conflicting with this patient's treatment priorities.

Reference: FSRH Guideline: Intrauterine Contraception (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf NICE NG88: Heavy menstrual bleeding—assessment and management (Published March 2018; last updated May 2021; last reviewed December 2024) — https://www.nice.org.uk/guidance/ng88/chapter/Recommendations FSRH Guideline: Combined Hormonal Contraception (January 2019, amended October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf