Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

 

Abstract

Background

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 and the definitive treatment is hysterectomy but this is a major surgical procedure with significant physical and emotional complications and social and economic costs. A number of less invasive surgical techniques (e.g. endometrial resection (TCRE), laser and thermal balloon ablation) have been developed with the purpose of removing the entire thickness of the endometrium.

Objectives

The objective of this review is to compare endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding (HMB).

Search strategy

Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Sub fertility Group Register of Trials, MEDLINE, EMBASE, Cinahl and the Cochrane CENTRAL register of trials were undertaken in 2007. Attempts were also made to identify trials from citation lists of review articles, guidelines and hand searching. Registers of ongoing trials were searched in December 2008.

Selection criteria

The inclusion criteria were randomised comparisons of endometrial destruction techniques by any means with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women.

Data collection and analysis

Seven RCTs were identified that fulfilled the inclusion criteria for this review. For two trials, a number of publications were identified which assessed different outcomes and different follow up time points for the same patients. The reviewers extracted the data independently and odds ratios for dichotomous outcomes and weighted mean differences 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 requirement for repeat surgery because of failure of the initial surgical treatment.

Main results

There was a significant advantage in favour of hysterectomy in the improvement in HMB (OR=0.04, 0.01 to 0.2 at one year) and satisfaction rates (up to four years post surgery) (OR=0.5, 0.3 to 0.8 at 2 years) compared with endometrial ablation. Although many quality of life scales reported no differences between surgical groups, there was some evidence of a greater improvement in some health domains (social functioning, energy, pain and general health) for hysterectomy patients. Duration of surgery, hospital stay and recovery time were all shorter following TCRE or endometrial ablation, although these outcomes varied between trials. Most adverse events, both major and minor, were significantly more likely after hysterectomy and before discharge from hospital. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection (OR=0.2, 0.1 to 0.5). Repeat surgery because of failure of the initial treatment, either endometrial ablation or hysterectomy, was more likely after endometrial ablation than hysterectomy (OR=16.7, 5.8 to 48.6). The total cost of endometrial destruction was significantly lower than the cost of hysterectomy but the difference between the two procedures narrowed over time because of the high cost of re-treatment in the endometrial destruction group.

Authors' conclusions

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 a longer operating time, a longer recovery period and higher rates of post-operative complications, it offers permanent relief from heavy menstrual bleeding. The initial cost of endometrial destruction is significantly lower than hysterectomy but, since re-treatment is often necessary, the cost difference narrows over time.

 

Plain language summary

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

Destruction of endometrial tissue by either TCRE (transcervical resection) or ablation is an effective alternative to hysterectomy for heavy menstrual bleeding. Heavy menstrual bleeding (HMB) is excessive menstrual blood loss (sometimes defined as a loss of 80mls or more of blood per menstrual cycle) which interferes with a woman's quality of life. Hysterectomy is effective in stopping HMB permanently, but also ends fertility and has all the risks of major surgery including infection and blood loss. Endometrial resection and other methods of ablation are less invasive methods of surgery that aim to remove the entire thickness of the endometrium (lining of the uterus). The review of trials found TCRE or ablation is an effective and possibly cheaper alternative to hysterectomy with faster recovery although re-treatment is sometimes needed.