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Heavy menstrual bleeding — DFSRH MCQ

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EasyNICE CG30Heavy menstrual bleedingDFSRH

A 19-year-old nulligravid woman requests long-acting reversible contraception because rotating shifts make user-dependent methods difficult. She prefers an intrauterine method. Her regular periods are heavy, with flooding for the first 2 days and dysmenorrhoea that interferes with work. Haemoglobin is 112 g/L. Pregnancy has been excluded, assessment identifies no underlying pelvic pathology, and she has no symptoms or identified risk of sexually transmitted infection. She is concerned that an intrauterine device may be unsuitable because she has never been pregnant, and asks whether a smaller, lower-dose device would be preferable. Which intrauterine contraceptive is most appropriate?

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Correct answer: E — 52 mg levonorgestrel intrauterine device

The 52 mg levonorgestrel intrauterine device is the best fit because she requires highly effective contraception and has clinically significant heavy, painful menstruation without identified pathology. Current FSRH guidance states that young age and nulliparity are not contraindications to intrauterine contraception. Nulliparity therefore does not justify selecting a lower-dose device merely because it is smaller. The 52 mg device has direct evidence of substantial reduction in menstrual blood loss and can also reduce primary dysmenorrhoea. By contrast, no studies identified by FSRH established the 13.5 mg or 19.5 mg devices as treatments for heavy menstrual bleeding. They remain effective contraceptive options but do not best address her principal non-contraceptive requirement. Both copper options are plausible hormone-free intrauterine methods. A smaller copper device may sometimes be considered for a young nulliparous user, but copper intrauterine contraception can increase menstrual bleeding and pain, making either copper option poorly matched to this presentation. The larger copper load does not overcome that disadvantage. Counselling should include expected early irregular bleeding with the 52 mg device, insertion analgesia options and the right to choose another method after informed discussion.

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 CG30: Long-acting reversible contraception — Recommendations (Published 26 October 2005; last updated 2 July 2019) — https://www.nice.org.uk/guidance/cg30/chapter/Recommendations