Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.
Lethaby A., Shepperd S., Cooke I., Farquhar C.
BACKGROUND: Heavy menstrual bleeding (HMB) or menorrhagia 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 and laser ablation) have been developed with the purpose of removing the entire thickness of the endometrium. The benefits claimed for these therapies are reduced trauma and post-operative complications to the woman, reduced need for a general anaesthetic, direct cost savings to the health service due largely to a shift from inpatient to day case treatment and indirect cost savings to society as women return more quickly to their usual activities. However, endometrial hysteroscopic techniques are not always completely successful and additional surgical treatment is required in a proportion of cases. Although initially the resource and patient costs of these techniques are much cheaper than the cost of hysterectomy, the need for re treatment at a later stage may reduce the cost differential. Thus, the effectiveness of these techniques to improve a woman's perception of her own wellbeing long term has yet to be confirmed. 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, PsychLIT, Current Contents, Biological Abstracts, Social Sciences Index and CINAHL were performed. Attempts were also made to identify trials from citation lists of review articles and hand searching. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women. DATA COLLECTION AND ANALYSIS: Five 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 and satisfaction rates (up to 4 years post surgery) compared with endometrial destruction techniques. Although many quality of life scales reported no differences between surgery groups, there was some evidence of a greater improvement in general health for hysterectomy patients. Duration of surgery, hospital stay and recovery time were all shorter following endometrial destruction. 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. Repeat surgery because of failure of the initial treatment, either endometrial ablation or hysterectomy, was more likely after endometrial destruction than hysterectomy. (ABSTRACT TRUNCATED)