433 Endometrial resection/ablation as effective as hysterectomy for heavy menstrual bleeding

July 09, 2014

PEARLS 433, June 2014, written by Brian R McAvoy

Clinical question
Compared with hysterectomy, how effective is endometrial resection/ablation for heavy menstrual bleeding?

Bottom line
Both endometrial resection/ablation and hysterectomy were effective, and satisfaction rates were high. Duration of surgery, hospital stay, time to return to normal activities and time to return to work were shorter for those who had transcervical resection of the endometrium (TCRE)/ablation when compared with those who underwent hysterectomy. Hysterectomy is more effective at reducing bleeding symptoms and improving quality of life and is associated with less repeated surgery than endometrial ablation, but considerable short-term benefits are associated with endometrial ablation techniques when compared with hysterectomy, mainly in the areas of recovery time and cost. Both surgical treatments were considered to be safe, with low complication rates reported. However, hysterectomy was associated with higher rates of sepsis, pyrexia, requirement for blood transfusion, vault haematoma and wound haematoma. It is recommended women be encouraged to play an active role in selecting the type of surgery, based on the personal value they place on the advantages and disadvantages of each surgical approach.

Caveat
All studies were at high risk of performance/detection bias, as it was not feasible to blind women or the surgeon against the type of operation performed. Several older studies were at high risk of selection bias. As the studies used many different measurements for outcomes (particularly for effectiveness of treatment), it was not possible to pool data for every outcome. Only 3 studies included laparoscopic hysterectomy in their comparison.

Context
Heavy menstrual bleeding (HMB), which includes heavy and irregular bleeding, is an important cause of ill health. Surgical treatment of HMB often follows failed or ineffective medical therapy. The definitive treatment is hysterectomy, but this is a major surgical procedure with significant physical and emotional complications, as well as social and economic costs. Several less-invasive surgical techniques (eg, TCRE, laser approaches) and various methods of endometrial ablation have been developed with the aim of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.

Cochrane Systematic Review
Fergusson RJ et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Reviews, 2013, Issue11. Art. No.: CD000329.DOI: 10.1002/14651858. CD000329.pub2. This review contains 8 studies involving 1260 participants.

Pearls are an independent product of the Cochrane primary care group and are meant for educational use and not to guide clinical care.