This Cochrane review concerns women with heavy menstrual bleeding (HMB), which is menstrual blood loss that a woman feels to be excessive and that often interferes with her quality of life. Researchers from The Cochrane Collaboration compared endometrial resection or ablation versus hysterectomy for women with HMB. The main factors (thought to be of greatest importance) were how well each operation was able to treat the symptoms of HMB, how women felt about undergoing each operation and what the complication rates were. Additional factors studied were how long each operation took to perform, how long women took to recover from the operation and how much the operation cost the hospital and the woman herself.
Surgical treatments for HMB include removal or destruction of the inside lining (endometrium) of the womb (endometrial resection or ablation) and surgical removal of the whole womb (hysterectomy). Both methods are commonly offered by gynaecologists, usually but not always after a non-surgical treatment has failed to correct the problem. Endometrial resection/ablation is performed via the entrance to the womb, without the need for a surgical cut. During a hysterectomy, the uterus can be removed via a surgical cut to the abdomen, via the vagina, or via 'keyhole' surgery that involves very small surgical cuts to the abdomen (laparoscopy); this last approach is a newer way to perform hysterectomy. Hysterectomy is effective in permanently stopping HMB, but it stops fertility and is associated with all the risks of major surgery, including infection and blood loss. These risks are smaller with endometrial resection/ablation.
A systematic review of the research comparing endometrial resection and ablation versus hysterectomy for the treatment of heavy menstrual bleeding was most recently updated in October 2013 by researchers at The Cochrane Collaboration. After searching for all relevant studies, review authors included eight studies involving a total of 1,260 women.
Only randomised controlled trials (RCTs) are included in Cochrane reviews. RCTs are studies in which participants are randomly allocated to one of two groups, each receiving a different intervention (in this case, endometrial ablation/resection or hysterectomy). The two groups are then compared. RCTs that compared these two interventions were included in this review if they studied women with HMB who had not gone through menopause and who did not have cancer or precancer of the uterus.
Key results and conclusions
The review of studies revealed that endometrial ablation/resection is an effective and possibly cheaper alternative to hysterectomy with faster recovery, although retreatment with additional surgery is sometimes needed. Hysterectomy is associated with more definitive resolution of symptoms but longer operating times and greater potential for surgical complications. For both operations, women generally reported that undergoing the procedure was acceptable and that they were satisfied with their experience.
Since laparoscopic hysterectomy has become more widely used, several of the previously described disadvantages of traditional types of hysterectomy have improved, and some outcomes such as duration of hospital stay, time to return to work and time to return to normal activities have become more comparable with those of endometrial ablation. However, laparoscopic hysterectomy is associated with longer operating time than other modes of hysterectomy and requires more sophisticated surgical expertise and equipment.
Only three of the eight trials included laparoscopic hysterectomy in their comparison. More trials in this area will be needed as this route of hysterectomy becomes more widely available.
Both surgical treatments are considered to be generally safe, and low complication rates are reported. However, hysterectomy is associated with higher rates of infection and requirement for blood transfusion.
Quality of the evidence
Evidence reported in this review was occasionally of low quality, suggesting that further research is likely to change the result. This was the case for outcomes such as a woman’s perception of bleeding and proportion of women requiring further surgery for HMB.