Second generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis

Abstract

Objective: To determine the relative effectiveness of second generation ablation techniques in the treatment of heavy menstrual bleeding.

Design: Network meta-analysis on the primary outcome measures of amenorrhoea, heavy bleeding, and patients' dissatisfaction with treatment.

Data sources: Nineteen randomised controlled trials (involving 3287 women) were identified through electronic searches of the Cochrane Library, Medline, Embase and PsycINFO databases from inception to April 2011. The reference lists of known relevant articles were searched for further articles. Two reviewers independently selected articles without language restrictions.

Eligibility criteria for selecting studies: Randomised controlled trials involving second generation endometrial destruction techniques for women with heavy menstrual bleeding unresponsive to medical treatment.

Results: Of the three most commonly used techniques, network meta-analysis showed that bipolar radiofrequency and microwave ablation resulted in higher rates of amenorrhoea than thermal balloon ablation at around 12 months (odds ratio 2.51, 95% confidence interval 1.53 to 4.12, P<0.001; and 1.66, 1.01 to 2.71, P=0.05, respectively), but there was no evidence of a convincing difference between the three techniques in the number of women dissatisfied with treatment or still experiencing heavy bleeding. Compared with bipolar radio frequency and microwave devices, an increased number of women still experienced heavy bleeding after free fluid ablation (2.19, 1.07 to 4.50, P=0.03; and 2.91, 1.23 to 6.88, P=0.02, respectively). Compared with radio frequency ablation, free fluid ablation was associated with reduced rates of amenorrhoea (0.36, 0.19 to 0.67, P=0.004) and increased rates of dissatisfaction (4.79, 1.07 to 21.5, P=0.04). Of the less commonly used devices, endometrial laser intrauterine thermotherapy was associated with increased rates of amenorrhoea compared with all the other devices, while cryoablation led to a reduced rate compared with bipolar radio frequency and microwave.

Conclusions: Bipolar radio frequency and microwave ablative devices are more effective than thermal balloon and free fluid ablation in the treatment of heavy menstrual bleeding with second generation endometrial ablation devices.

Fig 1 Study selection process for systematic review and network meta-analysis of second generation endometrial destruction techniques for heavy menstrual bleeding

Fig 2 Network of studies evaluating second generation endometrial destruction devices for treatment of heavy menstrual bleeding. Number of women randomised to second generation treatment are shown in parentheses

Fig 3 Amenorrhoea rate at 12 months from network meta-analysis (odds ratio and 95% confidence intervals). Results reflect those in table 2 (*indicates reversed ratios so all are pointing in direction of increased amenorrhoea rate). Only results with P≤0.05 are shown

Fig 4 Trends in types of endometrial ablation procedures performed in England, 2004-11 (data from hospital episode statistics)