Surgery versus medical therapy for heavy menstrual bleeding

Area of Science:

• Gynecology
• Reproductive Medicine
• Evidence-Based Medicine

Background:

• Heavy menstrual bleeding (HMB) significantly impacts women's quality of life.
• Management of HMB is individualized, with surgical and medical options available.
• Surgical options include hysterectomy and conservative procedures; medical options include oral medication and the levonorgestrel-releasing intrauterine device (LNG-IUS).

Purpose of the Study:

• To compare the effectiveness, safety, and acceptability of surgical interventions versus medical therapies for managing heavy menstrual bleeding.
• To synthesize evidence from randomized controlled trials (RCTs) evaluating different treatment modalities for HMB.

Main Methods:

• Systematic review of 15 parallel-group randomized controlled trials (RCTs) involving 1289 women.
• Searched multiple databases (Cochrane, MEDLINE, EMBASE, PsycINFO, clinical trials registers) up to January 2016.
• Primary outcomes included menstrual bleeding control, patient satisfaction, and adverse events; data were pooled using fixed-effect models; evidence quality was assessed using GRADE.

Main Results:

• Surgery (endometrial resection) demonstrated greater control of menstrual bleeding compared to oral medication at 4 months and 2 years, but not at 5 years.
• Hysterectomy showed better objective bleeding control than LNG-IUS at one year; conservative surgery offered better subjective bleeding control and satisfaction than LNG-IUS at one year.
• Adverse events were fewer with surgery initially, but long-term follow-up revealed significant crossover from medical to surgical treatments, complicating direct comparisons.

Conclusions:

• Surgery, especially hysterectomy, offers more immediate reduction in menstrual bleeding compared to medical treatments.
• The levonorgestrel-releasing intrauterine device (LNG-IUS) and conservative surgery are effective, safe, and acceptable first-line treatments for HMB.
• While hysterectomy is definitive, less radical treatments are advisable initially due to potential serious complications associated with major surgery.