A 45-year-old perimenopausal woman has menorrhagia due to anovulatory cycles with normal uterine anatomy. The MOST appropriate first-line pharmacological management is:

• A Cyclical oral norethisterone (NET) 5 mg days 5–26
• B Levonorgestrel-releasing intrauterine system (LNG-IUS, 52 mg) ✓
• C Combined oral contraceptive pill
• D Tranexamic acid on days of heavy bleeding

Explanation

NICE guidelines (Heavy Menstrual Bleeding, 2007, updated 2021) recommend the levonorgestrel-releasing IUS (Mirena 52 mg) as first-line treatment for heavy menstrual bleeding with normal uterine anatomy, including perimenopausal anovulatory menorrhagia. LNG-IUS reduces menstrual blood loss by 85–97% through local progestogen-mediated endometrial atrophy, lasts 5 years, and provides contraception. It is superior to cyclic norethisterone and COC for menorrhagia and has excellent long-term efficacy.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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