Hysterectomy is recommended for heavy menstrual bleeding as a permanent relief only when other options have failed, since surgery is associated with potential adverse effects such as urinary incontinence.
A Cochrane review (abstract [Abstract], review [Abstract]) included 15 studies with a total of 1 289 patients. Surgical interventions included hysterectomy and endometrial resection or ablation. In comparisons of oral medication versus surgery, 58% of women randomised to medical treatment had received surgery by two years. Compared to oral medication, endometrial resection was significantly more effective in controlling bleeding (at 4 months: RR 2.66, 95% CI 1.94 to 3.64, 1 study; n= 186; NNT = 2, 95% CI 2 to 3) and hysterectomy resulted in significantly greater improvements in mental health (at 6 months: P = 0.04, 1 study).
In comparisons of levonorgestrel-releasing intrauterine device (LNG-IUS) versus conservative surgery or hysterectomy, there was no statistically significant difference in satisfaction rates or quality of life at one year, though adverse effects were significantly less likely with conservative surgery (RR 0.51, 95% CI 0.36 to 0.74, 3 studies; NNT = 4, 95% CI 3 to 7). Conservative surgery was significantly more effective than LNG-IUS in controlling bleeding at one year (objective control: RR 1.11(1.05 to 1.19); 1 trial, n=223 and subjective control or PBAC: RR 1.19, 95% CI 1.07 to 1.32, 5 studies; n=281; NNT = 7, 95% CI 5 to 19). Two other small trials with longer follow-up found no difference or favoured LNG-IUS, but trials had methodological shortcomings. Hysterectomy stopped all bleeding but caused serious complications for some women.
Another Cochrane review [Abstract] 2 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[Abstract]3assessed interventions for heavy menstrual bleeding. For first line treatments, meta-analysis included 26 studies with 1770 participants. LNG-IUS resulted in a large reduction of menstrual blood loss (MBL; mean rank 2.4, MD −105.71 mL/cycle, 95% CI −201.10 to −10.33) and was the best option. Antifibrinolytic agents reduced MBL (mean rank 3.7, MD −80.32 mL/cycle, 95% CI −127.67 to −32.98); long-cycle progestogen reduced MBL (mean rank 4.1, MD −76.93 mL/cycle, 95% CI −153.82 to −0.05), and NSAIDs slightly reduced MBL (mean rank 6.4, MD −40.67 mL/cycle, −84.61 to 3.27). For second line treatments, hysterectomy was the best and endometrial ablation the second best option.
The following decision support rules contain links to this evidence summary:
Primary/Secondary Keywords