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.
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.
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.
The objective of this review is to compare the effectiveness, acceptability and safety of techniques of endometrial destruction by any means versus hysterectomy by any means for the treatment of heavy menstrual bleeding.
Electronic searches for relevant randomised controlled trials (RCTs) targeted but were not limited to the following: the Cochrane Menstrual Disorders and Subfertility Group Register of Trials, MEDLINE, EMBASE, PsycINFO and the Cochrane CENTRAL register of trials. Attempts were made to identify trials by examining citation lists of review articles and guidelines and by performing handsearching. Searches were performed in 2007, 2008 and 2013.
Included in the review were any RCTs that compared techniques of endometrial destruction by any means with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women.
Two review authors independently searched for studies, extracted data and assessed risk of bias. Risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes were estimated from the data. Outcomes analysed included improvement in menstrual blood loss, satisfaction, change in quality of life, duration of surgery and hospital stay, time to return to work, adverse events and requirements for repeat surgery due to failure of the initial surgical treatment.
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, I2 = 31%), at two years (RR 0.92, 95% CI 0.86 to 0.99, two studies, 292 women, I2 = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99, two studies, 237 women, I2 = 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, I2 = 0%), at two years (RR 23.4, 95% CI 8.3 to 65.8, six studies, 930 women, I2 = 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, I2 = 62%), blood transfusion (RR 0.2, 95% CI 0.1 to 0.6, four studies, 751 women, I2 = 0%), pyrexia (RR 0.2, 95% CI 0.1 to 0.4, three studies, 605 women, I2 = 66%), vault haematoma (RR 0.1, 95% CI 0.04 to 0.3, five studies, 858 women, I2 = 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.