She is not sexually active. What is the SINGLE most appropriate management?

A 17 year old senior schoolgirl has prolonged irregular menstrual periods and menorrhagia. She is not sexually active. What is the SINGLE most appropriate management?

A. Mefenamic acid
B. Combined oral contraceptive pills
C. Progestogen-only pill
D. Copper intrauterine contraceptive device
E. Levonorgestrel intra-uterine system

Combined oral contraceptive pills suppresses production of gonadotrophins and is thought to reduce menstrual blood loss by up to 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, improve premenstrual symptoms, COCP is very useful in adolescence. Also note that tranexamic acid is also effective.

Although levonorgestrel intra-uterine system is first line for menorrhagia, it is difficult to fit in a nulliparous woman as her cervix has not yet been dilated before. However, there has been more and more research regarding the use of levonorgestrel intrauterine systems in nulliparous woman and some clinicians would prefer levonorgestrel intra-uterine system to combined oral contraceptives. Their argument is that the levonorgestrel intra-uterine systems such as Jaydess® may be fitted more easily, as the frame is smaller and narrower compared to the Mirena® IUS.

NSAIDS such as mefenamic acid may decrease menstrual blood loss by up to 20–30% and also significant decreases in dysmenorrhoea. But it will not regulate her periods whereas COCP will regulate an irregular cycle.