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Contraceptive selection in Wilson disease with heavy menstrual bleeding — DFSRH MCQ

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EasyWilson DiseaseContraceptive selection in Wilson disease with heavy menstrual bleedingDFSRH

A 29-year-old woman with genetically confirmed Wilson disease requests contraception. Her disease is stable on zinc acetate, with normal liver function and no evidence of cirrhosis. She has no history of breast cancer or venous thromboembolism. She describes regular, objectively heavy menstrual bleeding that affects her work; examination and pelvic ultrasonography show no structural uterine pathology. She does not plan pregnancy for at least 5 years and prioritises a highly effective reversible method that requires no regular action and is likely to reduce menstrual blood loss. Which contraceptive method is most appropriate?

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Correct answer: C — Recommend a 52 mg levonorgestrel intrauterine device.

A 52 mg levonorgestrel intrauterine device best integrates her medical eligibility, bleeding symptoms and contraceptive priorities. FSRH recommends against copper IUD use in Wilson disease because the disorder causes pathological copper accumulation and there is a theoretical risk of adding to this burden. Copper IUDs can also increase menstrual blood loss, making option D particularly unsuitable. By contrast, levonorgestrel intrauterine contraception is highly effective, requires no regular user action and is associated with decreasing bleeding over time. NICE recommends an LNG-IUS as first-line treatment for heavy menstrual bleeding when there is no identified uterine pathology. The implant in A is highly effective and user independent, but unpredictable or prolonged bleeding is common and it does not best address her heavy menstrual bleeding. Depot medroxyprogesterone acetate in B may eventually produce amenorrhoea, but requires repeat injections and bleeding can initially be irregular; it is less closely aligned with her stated preferences than an LNG-IUD. The combined oral contraceptive in C can reduce menstrual blood loss and her compensated liver status does not itself establish a contraindication, but daily adherence conflicts with her request for a method requiring no regular action. The 52 mg LNG-IUD therefore provides the best combined contraceptive and therapeutic benefit.

Reference: FSRH Clinical 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 NICE NG88: 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