Heavy menstrual bleeding (HMB), which includes both
menorrhagia and
metrorrhagia, is an important cause of ill health in women. Surgical treatment of HMB often follows failed or ineffective medical
therapy. The definitive treatment is
hysterectomy, but this is a major
surgical procedure with significant physical and emotional complications, as well as social and economic costs. Several less invasive surgical techniques (e.g. transcervical resection of the endometrium (TCRE),
laser approaches) and various methods of
endometrial ablation have been developed with the purpose of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.
OBJECTIVES: Eight RCTs that fulfilled the inclusion criteria for this review were identified. For two trials, the review authors identified multiple publications that assessed different outcomes at different postoperative time points for the same women.An advantage in favour of
hysterectomy compared with
endometrial ablation was observed in various measures of improvement in
bleeding symptoms and satisfaction rates. A slightly lower proportion of women who underwent
endometrial ablation perceived improvement in
bleeding symptoms at one year (RR 0.89, 95% confidence interval (CI) 0.85 to 0.93, four studies, 650 women, I(2) = 31%), at two years (RR 0.92, 95% CI 0.86 to 0.99, two studies, 292 women, I(2) = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99, two studies, 237 women, I(2) = 79%). The same group of women also showed improvement in pictorial blood loss assessment chart (PBAC) score at one year (MD 24.40, 95% CI 16.01 to 32.79, one study, 68 women) and at two years (MD 44.00, 95% CI 36.09 to 51.91, one study, 68 women). Repeat surgery resulting from failure of the initial treatment was more likely to be needed after
endometrial ablation than after
hysterectomy at one year (RR 14.9, 95% CI 5.2 to 42.6, six studies, 887 women, I(2) = 0%), at two years (RR 23.4, 95% CI 8.3 to 65.8, six studies, 930 women, I(2) = 0%), at three years (RR 11.1, 95% CI 1.5 to 80.1, one study, 172 women) and at four years (RR 36.4, 95% CI 5.1 to 259.2, one study, 197 women). Most adverse events, both major and minor, were significantly more likely after
hysterectomy during
hospital stay. Women who had a
hysterectomy were more likely to experience
sepsis (RR 0.2, 95% CI 0.1 to 0.3, four studies, 621 women, I(2) = 62%),
blood transfusion (RR 0.2, 95% CI 0.1 to 0.6, four studies, 751 women, I(2) = 0%),
pyrexia (RR 0.2, 95% CI 0.1 to 0.4, three studies, 605 women, I(2) = 66%), vault haematoma (RR 0.1, 95% CI 0.04 to 0.3, five studies, 858 women, I(2) = 0%) and
wound haematoma (RR 0.03, 95% CI 0.00 to 0.5, one study, 202 women) before hospital discharge. After discharge from hospital, the only difference that was reported for this group was a higher rate of
infection (RR 0.2, 95% CI 0.1 to 0.5, one study, 172 women).For some outcomes (such as a woman's perception of
bleeding and proportion of women requiring further surgery for HMB), a low GRADE score was generated, suggesting that further research in these areas is likely to change the estimates.
AUTHORS' CONCLUSIONS: Endometrial resection and ablation offers an alternative to
hysterectomy as a surgical treatment for
heavy menstrual bleeding. Both procedures are effective, and satisfaction rates are high. Although
hysterectomy is associated with longer operating time (particularly for the laparoscopic route), a longer recovery period and higher rates of postoperative complications, it offers permanent relief from
heavy menstrual bleeding. The initial cost of endometrial destruction is significantly lower than that of
hysterectomy, but, because
retreatment is often necessary, the cost difference narrows over time.