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Meta-Analysis
. 2016 Jan 29;2016(1):CD003855.
doi: 10.1002/14651858.CD003855.pub3.

Surgery versus medical therapy for heavy menstrual bleeding

Jane Marjoribanks  1 , Anne Lethaby, Cindy Farquhar
Affiliations
Meta-Analysis

Surgery versus medical therapy for heavy menstrual bleeding

Jane Marjoribanks et al. Cochrane Database Syst Rev. .

Abstract

Background: Heavy menstrual bleeding significantly impairs the quality of life of many otherwise healthy women. Perception of heavy menstrual bleeding is subjective and management usually depends upon what symptoms are acceptable to the individual. Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy. Medical treatment options include oral medication and a hormone-releasing intrauterine device (LNG-IUS).

Objectives: To compare the effectiveness, safety and acceptability of surgery versus medical therapy for heavy menstrual bleeding.

Search methods: We searched the following databases from inception to January 2016: Cochrane Gynaecology and Fertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and clinical trials registers (clinical trials.gov and ICTRP). We also searched the reference lists of retrieved articles.

Selection criteria: Randomised controlled trials (RCTs) comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for heavy menstrual bleeding.

Data collection and analysis: Two review authors independently selected the studies, assessed their risk of bias and extracted the data. Our primary outcomes were menstrual bleeding, satisfaction rate and adverse events. Where appropriate we pooled the data to calculate pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), using a fixed-effect model. We assessed heterogeneity with the I(2) statistic and evaluated the quality of the evidence using GRADE methods.

Main results: We included 15 parallel-group RCTs (1289 women). Surgical interventions included hysterectomy and endometrial resection or ablation. Medical interventions included oral medication and the levonorgestrel-releasing intrauterine device (LNG-IUS). The overall quality of the evidence for different comparisons ranged from very low to moderate. The main limitations were lack of blinding, attrition and imprecision. Moreover, it was difficult to interpret long-term study findings as many women randomised to medical interventions subsequently underwent surgery. Surgery versus oral medicationSurgery (endometrial resection) was more effective in controlling bleeding at four months (RR 2.66, 95% CI 1.94 to 3.64, one RCT, 186 women, moderate quality evidence) and also at two years (RR 1.29, 95% CI 1.06 to 1.57, one RCT, 173 women, low quality evidence). There was no evidence of a difference between the groups at five years (RR 1.14, 95% CI 0.97 to 1.34, one RCT, 140 women, very low quality evidence).Satisfaction with treatment was higher in the surgical group at two years (RR 1.40, 95% CI 1.13 to 1.74, one RCT, 173 women, moderate quality evidence), but there was no evidence of a difference between the groups at five years (RR 1.13, 95% CI 0.94 to 1.37, one RCT, 114 women, very low quality evidence). There were fewer adverse events in the surgical group at four months (RR 0.26, 95 CI 0.15 to 0.46, one RCT, 186 women). These findings require cautious interpretation, as 59% of women randomised to the oral medication group had had surgery within two years and 77% within five years. Surgery versus LNG-IUSWhen hysterectomy was compared with LNG-IUS, the hysterectomy group were more likely to have objective control of bleeding at one year (RR 1.11, 95% CI 1.05 to 1.19, one RCT, 223 women, moderate quality evidence). There was no evidence of a difference in quality of life between the groups at five or 10 years, but by 10 years 46% of women originally assigned to LNG-IUS had undergone hysterectomy. Adverse effects associated with hysterectomy included surgical complications such as bladder or bowel perforation and vesicovaginal fistula. Adverse effects associated with LNG-IUS were ongoing bleeding and hormonal symptoms.When conservative surgery was compared with LNG-IUS, at one year the surgical group were more likely to have subjective control of bleeding (RR 1.19, 95% CI 1.07 to 1.32, five RCTs, 281 women, low quality evidence, I(2) = 15%). Satisfaction rates were higher in the surgical group at one year (RR 1.16, 95% CI 1.04, to 1.28, six RCTs, 442 women, I(2) = 27%), but this finding was sensitive to the choice of statistical model and use of a random-effects model showed no conclusive evidence of a difference between the groups. There was no evidence of a difference between the groups in satisfaction rates at two years (RR 0.93, 95% CI 0.81 to 1.08, two RCTs, 117 women, I(2) = 1%).At one year there were fewer adverse events (such as bleeding and spotting) in the surgical group (RR 0.36, 95% CI 0.15 to 0.82, three RCTs, moderate quality evidence). It was unclear what proportion of women assigned to LNG-IUS underwent surgery over long-term follow-up, as there were few data beyond one year.

Authors' conclusions: Surgery, especially hysterectomy, reduces menstrual bleeding more than medical treatment at one year. There is no conclusive evidence of a difference in satisfaction rates between surgery and LNG-IUS, though adverse effects such as bleeding and spotting are more likely to occur with LNG-IUS. Oral medication suits a minority of women in the long term, and the LNG-IUS device provides a better alternative to surgery in most cases. Although hysterectomy is a definitive treatment for heavy menstrual bleeding, it can cause serious complications for a minority of women. Most women may be well advised to try a less radical treatment as first-line therapy. Both LNG-IUS and conservative surgery appear to be safe, acceptable and effective.

PubMed Disclaimer

Conflict of interest statement

None known.

Cindy Farquhar and Anne Lethaby are authors of one of the included trials (Talis 2006). However they have no present or past affiliations or other involvement in any organization or entity with an interest in the review’s findings that might lead to a real or perceived conflict of interest.

Jane Marjoribanks has no present or past affiliations or other involvement in any organization or entity with an interest in the review’s findings that might lead to a real or perceived conflict of interest.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Surgery versus oral medication, outcome: 1.1 Control of bleeding (cure or improvement to acceptable level).
5
5
Forest plot of comparison: 2 Surgery versus LNG‐IUS, outcome: 2.2 Subjective control of bleeding at up to one year: PBAC =/< 75 per cycle with primary treatment.
6
6
Forest plot of comparison: 2 Surgery versus LNG‐IUS, outcome: 2.7 Proportion of women with adverse events at one year.
1.1
1.1. Analysis
Comparison 1 Surgery versus oral medication, Outcome 1 Control of bleeding (cure or improvement to acceptable level).
1.2
1.2. Analysis
Comparison 1 Surgery versus oral medication, Outcome 2 Bleeding score.
1.3
1.3. Analysis
Comparison 1 Surgery versus oral medication, Outcome 3 Overall satisfaction with treatment.
1.4
1.4. Analysis
Comparison 1 Surgery versus oral medication, Outcome 4 Proportion reporting adverse effects at four months.
1.5
1.5. Analysis
Comparison 1 Surgery versus oral medication, Outcome 5 Additional surgery for HMB received.
2.1
2.1. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 1 Objective control of bleeding at one year: menstrual loss < 80 ml per cycle.
2.2
2.2. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 2 Subjective control of bleeding at up to one year: PBAC =/< 75 per cycle with primary treatment.
2.3
2.3. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 3 PBAC score at one year.
2.4
2.4. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 4 PBAC score at two years.
2.5
2.5. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 5 Satisfaction rate at one year: surgery versus LNG‐IUS.
2.6
2.6. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 6 Satisfaction rate at two years: surgery versus LNG‐IUS.
2.7
2.7. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 7 Proportion of women with adverse events at one year.
2.8
2.8. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 8 Adverse effects: bone mineral density decrease at five years (g/cm2).
2.9
2.9. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 9 Change in EQ‐5D score: surgery (hysterectomy) versus LNG‐IUS.
2.10
2.10. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 10 Final PGWBI score: thermal balloon ablation versus LNG‐IUS.
2.11
2.11. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 11 SF36 score at one year: surgery versus LNG‐IUS.
2.12
2.12. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 12 SF 36 score at 2 years: surgery versus LNG‐IUS.
2.13
2.13. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 13 Additional surgery for HMB received by one year.
2.14
2.14. Analysis
Comparison 2 Surgery versus LNG‐IUS, Outcome 14 Additional surgery for HMB received by two years.
See this image and copyright information in PMC

Update of

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