Endometrial resection or endometrial ablation are recommended over total hysterectomy for heavy menstrual bleeding when non-surgical treatments do not offer enough relief. Hysterectomy is more invasive and carries a risk of urinary incontinence.
A Cochrane review [Abstract] 1 included 10 trials. A slight advantage in favour of hysterectomy in the improvement in heavy menstrual bleeding and satisfaction rates (up to 4 years post surgery) compared with endometrial ablation (table T1). Repeat surgery resulting from failure of the initial treatment was more likely to be needed after endometrial ablation than after hysterectomy. Most adverse events, both major and minor, were significantly more likely after hysterectomy and before discharge from hospital: sepsis, blood transfusion, pyrexia, vault haematoma, and wound haematoma. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection. 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.
| Outcome | Relative effect(95% CI) | Assumed risk - control=hysterectomy | Corresponding risk - intervention=endometrial ablation /resection (95% CI) | Number of participants (studies) |
|---|---|---|---|---|
| Improvement in bleeding at 1 year | RR 0.89 (0.83 to 0.95) | 965/1000 | 859/1000(801 to 917) | 403 (2) |
| Short term adverse events | RR 0.21 (0.06 to 0.80) | 59/1000 | 12/1000(4 to 47) | 374 (2) |
| Proportion requiring further surgery for HMB at 1 year | - | 0/1000 | Risk of having additional surgery was 5.4% | 374 (2) |
| Proportion satisfied with treatment at 1 year | RR 0.85(0.77 to 0.95) | 773/1000 | 812/1000 (735 to 907) | 185 (1) |
Another Cochrane review 2 (abstract , review [Abstract]) included 28 studies with a total of 4 287 premenopausal participants, mostly within the age range 30 to 50 years. In the comparison of the newer 'blind' techniques (second generation; e.g. balloon, microwave, Vesta system, cryoablation, thermal laser, bipolar electrode ablation and hydrothermal ablation) with the gold standard hysteroscopic ablative techniques (first generation) there was no evidence of overall differences in the improvement in heavy menstrual bleeding (HMB) (12 trials) or patient satisfaction (11 trials). Surgery was an average of 15 minutes shorter (WMD 13.52, 95% CI -16.90 to -10.13; 9 studies; n=1822), local anaesthesia was more likely to be employed (RR 2.8, 95% CI 1.8 to 4.4; 6 trials) and equipment failure was more likely (RR 4.3, 95% CI 1.5 to 12.4; 3 trials; moderate quality evidence) with second-generation ablation. There was no clear difference in perforation rates (RR 0.32, 95% CI 0.10 to 1.01; 8 trials, n=1885; I² = 0%) or in requirement for additional surgery (ablation or hysterectomy) at 1 year follow-up (RR 0.72, 95% CI 0.41 to 1.26; 6 studies: n=935 women). At 5 years, results showed probably little or no difference between groups in the requirement for hysterectomy (RR 0.85, 95% CI 0.59 to 1.22; 4 studies; n=758 women.
Primary/Secondary Keywords