Surgery versus medical therapy for heavy menstrual bleeding

Abstract

Background: Heavy menstrual bleeding (HMB) significantly impairs the quality of life of many otherwise healthy women. Perception of HMB is subjective and management usually depends upon what symptoms are acceptable to the individual. Medical treatment options include oral medication and a hormone-releasing intrauterine system (LNG-IUS). Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy.Objectives: To compare the effectiveness, safety and acceptability of surgery versus medical therapy for HMB.Search methods: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and PsycINFO (March 2010). We also searched the reference lists of retrieved articles and contacted experts in the field.Selection criteria: Randomised controlled trials (RCTs) comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB.Data collection and analysis: Two review authors independently assessed studies for quality and extracted data.Main results: Twelve parallel-group RCTs that included 1049 women met the inclusion criteria. In comparisons of oral medication versus surgery, 58% of the women randomised to medical treatment had received surgery by two years. Compared to oral medication, endometrial resection was significantly more effective in controlling bleeding (at four months: RR 2.66 (95% CI 1.94 to 3.64); NNT = 2 (95% CI 2 to 3), one study) and hysterectomy resulted in significantly greater improvements in mental health (at six months: P = 0.04, one study). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates nor in most measures of quality of life, though adverse effects were significantly less likely with conservative surgery (RR 0.51 (95% CI 0.36 to 0.74); NNT = 4 (95% CI 3 to 7), three studies). Conservative surgery was significantly more effective than LNG-IUS in controlling bleeding at one year (RR 1.19 (95% CI 1.07 to 1.32); NNT = 7 (95% CI 5 to 19), five studies). Two small studies with longer follow up found no difference or favoured LNG-IUS, but both of these studies had skewed data and there were high losses to follow up. Hysterectomy stopped all bleeding but caused serious complications for some women.Authors' conclusions: Surgery, especially hysterectomy, reduces menstrual bleeding more than medical treatments at one year but LNG-IUS may be comparable in improving quality of life. The evidence for longer-term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.