Surgery versus medical therapy for heavy menstrual bleeding

Marjoribanks J, Lethaby A, Farquhar C

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Summary

Surgery versus long term hormone treatment for heavy menstrual bleeding

Various types of surgery or an intrauterine hormone-releasing device are effective in reducing heavy menstrual bleeding. 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 (reduced 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 a device inserted into the uterus that releases hormones (LNG-IUS). The review of trials 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.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 1, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
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.

This version first published online: April 22. 2003
Last assessed as up-to-date: December 09. 2005

Abstract

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

In September 2005 we searched the Cochrane Menstrual Disorders and Subfertility Group trials register Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2005), MEDLINE EMBASE, Current Contents, Biological Abstracts, PsycINFO, and CINAHL. We also searched reference lists of articles retrieved and contacted pharmaceutical companies and experts in the field.

Selection criteria

Controlled randomised trials comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB

Data collection and analysis

Two reviewers independently assessed trials for quality and extracted data .

Main results

The eight included trials randomised 821 women. In comparisons of oral medication versus surgery, 58% of 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: OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (at four months: OR 0.15, 95% CI 0.07 to 0.31) and hysterectomy resulted in significantly greater improvements in mental health (at six months p = 0.04). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates or quality of life, though adverse effects were significantly less likely with conservative surgery (OR 0.24, 95% CI 0.11 to 0.49). Two trials found conservative surgery significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38). Two other small trials with longer follow-up found no difference or favoured LNG-IUS - however in both these studies the data were skewed and fewer than two thirds of participants were analysed. Hysterectomy stopped all bleeding but caused serious complications for some women.

Authors' conclusions

Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.

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