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Surgery versus medical therapy for heavy menstrual bleeding
J Marjoribanks1, A Lethaby, C Farquhar
1Cochrane Menstrual Disorders and Subfertility Group, Obstetrics and Gynaecology, University of Auckland, PO Box 92019, Auckland, New Zealand, 1003. j.marjoribanks@auckland.ac.nz
Insights
Surgery, particularly hysterectomy, is more effective than medical treatments for heavy menstrual bleeding (HMB) at one year. However, the hormone-releasing intrauterine system (LNG-IUS) offers comparable quality of life improvements, with weaker long-term evidence for all treatments.
Area of Science:
- Gynecology
- Surgical Interventions
- Pharmacological Treatments
Background:
- Heavy menstrual bleeding (HMB) significantly impacts women's quality of life.
- Management is subjective, with options including oral medication, hormone-releasing intrauterine systems (LNG-IUS), and surgical procedures like hysterectomy or endometrial ablation.
Purpose of the Study:
- To compare the effectiveness, safety, and acceptability of surgical interventions versus medical therapies for managing HMB.
Main Methods:
- Systematic review of controlled randomized trials comparing surgery (conservative or hysterectomy) with medical therapy (oral or LNG-IUS) for HMB.
- Data extraction and quality assessment by two independent reviewers.
Main Results:
- Surgery, especially hysterectomy, demonstrated greater reduction in bleeding compared to oral medication. Endometrial resection was more effective and safer than oral medication in the short term.
- LNG-IUS showed comparable quality of life improvements to conservative surgery or hysterectomy at one year, though conservative surgery had fewer adverse effects.
- Hysterectomy effectively stopped bleeding but carried risks of serious complications; long-term evidence for all treatments remains limited and inconsistent.
Conclusions:
- Surgical options, particularly hysterectomy, offer superior bleeding control for HMB compared to medical treatments within one year.
- LNG-IUS provides comparable quality of life benefits to surgery, with fewer side effects than conservative surgery.
- Long-term comparative data are weak, and oral medications are suitable for a minority of women.
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 Strategy:
In September 2005 we searched the Cochrane Menstrual Disorders and Subfertility Group trials register Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2005), MEDLINE EMBASE, Current Contents, Biological Abstracts, PsycINFO, and CINAHL. We also searched reference lists of articles retrieved and contacted pharmaceutical companies and experts in the field.
Selection Criteria:
Controlled randomised trials comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials for quality and extracted data .
Main Results:
The eight included trials randomised 821 women. In comparisons of oral medication versus surgery, 58% of 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: OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (at four months: OR 0.15, 95% CI 0.07 to 0.31) and hysterectomy resulted in significantly greater improvements in mental health (at six months p = 0.04). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates or quality of life, though adverse effects were significantly less likely with conservative surgery (OR 0.24, 95% CI 0.11 to 0.49). Two trials found conservative surgery significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38). Two other small trials with longer follow-up found no difference or favoured LNG-IUS - however in both these studies the data were skewed and fewer than two thirds of participants were analysed. Hysterectomy stopped all bleeding but caused serious complications for some women.
Authors' Conclusions:
Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.
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