This is a real-world medical entrance exam question, please give the true answer based on the question and selection. Topic name: Endometriosis, Adenomyosis, Subject name: Gynaecology & Obstetrics
A 48 year old woman, P2L2 with menorrhagia, diagnosed with adenomyosis, is not responding to medical management with NSAIDs and hormonal therapy. Next step in management should be? 
Select and explain. 
A. Mirena (LNG IUD) inseion, B. GnRH analogues, C. Hysterectomy, D. Hysteroscopy biopsy
D: Hysteroscopy biopsy
Answer: D: Hysteroscopy biopsy 
Explanation: Any menorrhagia in woman of perimenopausal age group should be evaluated with an endometrial biopsy , preferably hysteroscopy guided, even if a diagnosis of adenomyosis is made on USG, to rule out malignancy Treatment options for adenomyosis Medical: NSAIDs, GnRH analogues, danazol Mirena IUCD (LNG IUCD) Hysterectomy: most definitive treatment