A 47-year-old woman with perimenopausal heavy menstrual bleeding has a normal-sized uterus on examination and normal pelvic ultrasound with endometrial thickness of 6 mm. She fails medical management with tranexamic acid. Which is the most appropriate next step?

• A GnRH agonist therapy
• B Endometrial ablation
• C Hysterectomy
• D Levonorgestrel-releasing intrauterine system ✓

Explanation

The levonorgestrel-releasing intrauterine system (LNG-IUS, e.g., Mirena) is first-line for heavy menstrual bleeding with a normal uterus and reduces menstrual loss by up to 90%. It is more effective than oral agents and is recommended by NICE before considering surgical options like endometrial ablation or hysterectomy. Endometrial ablation is second-line if LNG-IUS fails.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.