Transfusion-dependent beta-thalassaemia with heavy menstrual bleeding and osteoporosis — DFSRH MCQ

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EasyThalassaemiaTransfusion-dependent beta-thalassaemia with heavy menstrual bleeding and osteoporosisDFSRH

A 30-year-old woman with transfusion-dependent beta-thalassaemia requests contraception. Cardiac and hepatic surveillance shows no clinically significant iron-overload complications. She has regular heavy menstrual bleeding and wishes to minimise blood loss. Her specialist metabolic bone team has diagnosed osteoporosis following a low-trauma vertebral fracture. She wants a highly effective reversible method and would accept intrauterine contraception. Which contraceptive method is most appropriate?

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Correct answer: D — 52 mg levonorgestrel intrauterine device

The 52 mg levonorgestrel intrauterine device is the best fit because it combines highly effective reversible contraception with established treatment of heavy menstrual bleeding. Thalassaemia itself is UKMEC 1 for an LNG-IUD, whereas a copper IUD is UKMEC 2 because increased menstrual blood loss may be clinically disadvantageous. The implant is also UKMEC 1 in thalassaemia and is highly effective, but unpredictable or persistent bleeding can occur and it does not have the established therapeutic role in heavy menstrual bleeding provided by the 52 mg LNG-IUD. DMPA commonly produces reduced bleeding or amenorrhoea, making it an initially attractive option; however, it causes a small reduction in bone mineral density, and FSRH advises considering other methods in women with significant medical risk factors for osteoporosis. This patient has established osteoporosis and a fragility fracture. Combined hormonal contraception is UKMEC 1 for uncomplicated thalassaemia and may reduce menstrual bleeding. Nevertheless, it is user-dependent and does not provide the same combination of long-acting efficacy and evidence-based treatment of heavy menstrual bleeding. The absence of cardiac or hepatic iron-overload complications prevents those conditions, rather than thalassaemia alone, from altering eligibility.

Reference: UK Medical Eligibility Criteria for Contraceptive Use (2016, amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf 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 FSRH Guideline: Progestogen-only Injectable Contraception (December 2014, amended July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/progestogen-only-injectable-december-2014-amended-11july2023.pdf