Meningioma — DFSRH MCQ

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EasyMeningiomaDFSRH

A 39-year-old woman requests effective reversible contraception. Three years ago, a WHO grade 1 intracranial meningioma was completely resected; surveillance MRI has shown no recurrence. She has regular heavy menstrual bleeding with flooding for 2 days each cycle, and her haemoglobin is 109 g/L. Pelvic examination and transvaginal ultrasonography are normal, with no fibroids or endometrial pathology. Pregnancy has been excluded, and she has no symptoms or identified risk of sexually transmitted infection. She would prefer a long-acting method and wishes to reduce menstrual bleeding. 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 option because it provides highly effective reversible contraception while addressing her heavy menstrual bleeding. NICE recommends an LNG-IUS as first-line treatment for heavy menstrual bleeding when there is no identified pelvic pathology. Importantly, the available case-control evidence found no association between levonorgestrel intrauterine devices and meningioma requiring surgery. A copper IUD avoids progestogen exposure but may make menstrual bleeding heavier, longer or more painful, making it a poor fit for her symptomatic bleeding and mild anaemia. An etonogestrel implant is effective contraception, but bleeding is unpredictable and it is not the preferred treatment for established heavy menstrual bleeding; evidence specific to previous meningioma is also limited. Depot medroxyprogesterone acetate is contraindicated in patients with a current or previous meningioma. Although amenorrhoea might otherwise make it attractive, that benefit does not override the contraindication. FSRH now also advises that desogestrel should not be used in individuals with a meningioma or history of meningioma following evidence of a small duration-related association with meningioma requiring surgery. Thus, the 52 mg LNG-IUD provides the most favourable combination of contraceptive effectiveness, bleeding control and directly relevant safety evidence.

Reference: FSRH CEU Statement: Response to new study by Roland et al (2024). Use of progestogens and the risk of intracranial meningioma (28 March 2024) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ceu-statement-progresterogens-and-meningioma-roland-et-al-2024.pdf FSRH CEU Statement: Response to Roland et al (2025). Oral contraceptives with progestogens desogestrel or levonorgestrel and risk of intracranial meningioma (3 July 2025) — https://fsrh.org/Common/Uploaded%20files/documents/Use-of-desogestrel-and-risk-of-intracranial-meningioma.pdf NICE NG88: Heavy menstrual bleeding—assessment and management, recommendations (Published 14 March 2018; last updated 24 May 2021; reviewed 19 December 2024) — https://www.nice.org.uk/guidance/ng88/chapter/Recommendations