Heavy menstrual bleeding (HMB) is menstrual blood loss that interferes with women's quality of life. Cochrane researchers compared two surgical treatments 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 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). Hysterectomy is effective in permanently stopping HMB, but it halts 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 December 2018 by Cochrane researchers. After searching for all relevant studies, review authors included nine studies involving a total of 1300 women.
Only randomised controlled trials (RCTs) are included: these are studies in which participants are randomly allocated to one of two groups, each receiving a different intervention. The two groups are then compared. This review included RCTs that compared endometrial ablation or resection and hysterectomy as treatment for heavy menstrual bleeding. The studies did not include women who had gone through menopause or had 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 there are 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.
Laparoscopic hysterectomy has become more widely used 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 frequently associated with longer operating time than other modes of hysterectomy and requires specific surgical expertise and equipment.
Both surgical treatments are considered to be generally safe, with low complication rates. Hysterectomy, however, is associated with higher rates of infection, requirement for blood transfusion, and haematoma (collection of blood in soft tissues after surgery).
Quality of the evidence
Evidence reported in this review was of moderate to low quality, suggesting that further research may 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 offers permanent and immediate relief from heavy menstrual bleeding, it is associated with a longer operating time and recovery period. Hysterectomy also has higher rates of postoperative complications such as sepsis, blood transfusion and haematoma (vault and wound). The initial cost of endometrial destruction is lower than that of hysterectomy but, because retreatment is often necessary, the cost difference narrows over time.
Heavy menstrual bleeding (HMB) is an important cause of ill health in women of reproductive age, causing them physical problems, social disruption and reducing their quality of life. Medical therapy has traditionally been first-line therapy. 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. Less invasive surgical techniques, such as endometrial resection and ablation, have been developed with the purpose of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.
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 Gynaecology and Fertility Group's specialised register, CENTRAL via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, and the ongoing trial registries. We made attempts to identify trials by examining citation lists of review articles and guidelines and by performing handsearching. Searches were performed in 1999, 2007, 2008, 2013 and on 10 December 2018.
Any RCTs that compared techniques of endometrial resection or ablation (by any means) with hysterectomy (by any technique) for the treatment of heavy menstrual bleeding in premenopausal women.
Two review authors independently selected trials for inclusion, extracted data and assessed trials for risk of bias.
We identified nine RCTs that fulfilled our inclusion criteria for this review. For two trials, the review authors identified multiple publications that assessed different outcomes at different postoperative time points for the same women. No included trials used third generation techniques.
Clinical measures of improved bleeding symptoms and satisfaction rates were observed in women who had undergone hysterectomy compared to endometrial ablation. A slightly lower proportion of women who underwent endometrial ablation perceived improvement in bleeding symptoms at one year (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.85 to 0.93; 4 studies, 650 women, I² = 31%; low-quality evidence), at two years (RR 0.92, 95% CI 0.86 to 0.99; 2 studies, 292 women, I² = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99; 2 studies, 237 women, I² = 79%). Women in the endometrial ablation group also showed improvement in pictorial blood loss assessment chart compared to their baseline (PBAC) score at one year (MD 24.40, 95% CI 16.01 to 32.79; 1 study, 68 women; moderate-quality evidence) and at two years (MD 44.00, 95% CI 36.09 to 51.91; 1 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 16.17, 95% CI 5.53 to 47.24; 927 women; 7 studies; I2 = 0%), at two years (RR 34.06, 95% CI 9.86 to 117.65; 930 women; 6 studies; I2 = 0%), at three years (RR 22.90, 95% CI 1.42 to 370.26; 172 women; 1 study) and at four years (RR 36.32, 95% CI 5.09 to 259.21;197 women; 1 study). The satisfaction rate was lower amongst those who had endometrial ablation at two years after surgery (RR 0.87, 95% CI 0.80 to 0.95; 4 studies, 567 women, I² = 0%; moderate-quality evidence), and no evidence of clear difference was reported between post-treatment satisfaction rates in groups at other follow-up times (1 and 4 years).
Most adverse events, both major and minor, were more likely after hysterectomy during hospital stay. Women who had an endometrial ablation were less likely to experience sepsis (RR 0.19, 95% CI 0.12 to 0.31; participants = 621; studies = 4; I2 = 62%), blood transfusion (RR 0.20, 95% CI 0.07 to 0.59; 791 women; 5 studies; I2 = 0%), pyrexia (RR 0.17, 95% CI 0.09 to 0.35; 605 women; 3 studies; I2 = 66%), vault haematoma (RR 0.11, 95% CI 0.04 to 0.34; 858 women; 5 studies; I2 = 0%) and wound haematoma (RR 0.03, 95% CI 0.00 to 0.53; 202 women; 1 study) before hospital discharge. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection (RR 0.27, 95% CI 0.13 to 0.58; 172 women; 1 study).
Recovery time was shorter in the endometrial ablation group, considering hospital stay, time to return to normal activities and time to return to work; we did not, however, pool these data owing to high heterogeneity. Some outcomes (such as a woman’s perception of bleeding and proportion of women requiring further surgery for HMB), generated a low GRADE score, suggesting that further research in these areas is likely to change the estimates.