Surgery versus long-term hormone treatment for heavy menstrual bleeding

Marjoribanks J, Lethaby A, Farquhar C

Published Online:

September 8, 2010

Various types of surgery or an intrauterine hormone-releasing device are effective in reducing heavy menstrual bleeding (menorrhagia). These suit most women better than oral medication.
Heavy menstrual bleeding (menorrhagia) is common and can impair a woman's quality of life or cause anaemia (reduce red blood cells). If bleeding is causing major problems, treatment options include surgery (either hysterectomy or surgery to reduce the lining of the uterus) or insertion into the uterus of a device that releases hormones (LNG-IUS). The review of studies found that an LNG-IUS improves the quality of life of women with menorrhagia as effectively as surgical treatment, while a minority of women prefer long-term oral medication. Though all these treatments have potential side effects, hysterectomy is more likely to cause serious complications.

Abstract (click to read)

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:

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.

This record should be cited as:

Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003855. DOI: 10.1002/14651858.CD003855.pub2

Assessed as up to date:

May 5, 2010

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Excessive menstrual bleeding > Idiopathic

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Surgery versus long-term hormone treatment for heavy menstrual bleeding

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