Clinical Question

Is surgery more effective than medical treatment for heavy menstrual bleeding?

Evidence-Based Answer

In women of reproductive age with chronic heavy menstrual bleeding, hysterectomy is the most effective treatment for controlling symptoms. Conservative surgery is more effective for controlling bleeding symptoms at one and two years than oral medications or the levonorgestrel-releasing intrauterine system, but by five years there is no difference. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.) Patient acceptability of treatment and rates of adverse effects were similar among the various treatment options, although more severe adverse effects were associated with hysterectomy.¹

Practice Pointers

Heavy menstrual bleeding, defined as a loss of 80 mL or more of menstrual blood per cycle, affects nearly one out of five women in the United States each year.² Treatment options include complete hysterectomy, various endometrial ablation techniques, the levonorgestrel-releasing intrauterine system, and daily oral hormone medications. In this Cochrane review, the authors analyzed data from several studies to determine which treatment option is superior. The authors identified 15 randomized controlled trials including a total of 1,289 women 30 to 50 years of age who underwent surgery (hysterectomy or conservative surgery, including various methods of endometrial resection or ablation) or received medical therapy (oral contraceptives or levonorgestrel-releasing intrauterine system).

In the two studies evaluating surgery (i.e., hysterectomy and endometrial ablation) vs. oral medication, patients who chose surgery had greater satisfaction up to six months after. By two years, the higher level of satisfaction with endometrial ablation was still present, but by five years the satisfaction in both surgical groups was similar to that in patients treated with oral medication. By five years, though, more than 50% of the oral medication group had crossed over into the surgical groups, which may explain why the difference did not hold.

In the study that compared endometrial ablation with oral contraceptives, patient-reported control of bleeding after endometrial ablation was better than that with oral contraceptives in the first four months following initiation of treatment (relative risk [RR] = 2.66; 95% confidence interval [CI], 1.94 to 3.64), but the difference in patient-rated control of bleeding decreased at two years and was no longer present at five years.

One study found that hysterectomy controlled objectively measured bleeding better than the levonorgestrel-releasing intrauterine system at one year (RR = 1.11; 95% CI, 1.05 to 1.19). However, there was no difference in quality of life between the groups at five or 10 years. The percentage of women who initially received the levonorgestrel-releasing intrauterine system and eventually had a hysterectomy was 42% by five years and 46% by 10 years.

Five studies (N = 281) that compared conservative surgeries with the levonorgestrel-releasing intrauterine system measured the proportion of women who self-reported that their bleeding was well controlled by their initial treatment at one year. Pooled effectiveness data, measured by subjective control of bleeding symptoms, favored surgical interventions at the one-year interval (RR = 1.19; 95% CI, 1.07 to 1.32).

The overall risk of adverse effects was lower in the surgical groups vs. the medical therapy groups. Patients treated with conservative surgery had fewer adverse effects than those treated with oral contraceptives at four months (RR = 0.26; 95% CI, 0.15 to 0.46), and those who underwent conservative surgery had fewer adverse effects than those treated with the levonorgestrel-releasing intrauterine system at one year (RR = 0.51; 95% CI, 0.36 to 0.74). However, the adverse effects in the medical therapy group were less severe (e.g., nausea, irregular bleeding) than those in patients who underwent surgery (e.g., postoperative wound infection, bowel or bladder perforation). One study reported operative complications in 3.7% of patients (four out of 109) and postoperative/late complications in 30% of patients (33 out of 109).

In patients with heavy menstrual bleeding, guidelines from the National Institute for Health and Care Excellence state that “pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity.”³ The American College of Obstetricians and Gynecologists concurs that many causes of heavy menstrual bleeding are amenable to medical management, and that surgical options can be considered if medical management is ineffective or contraindicated.⁴ Family physicians should inform patients that surgical interventions (hysterectomy or conservative surgeries) are initially more effective and satisfactory than medical treatments, but that the levonorgestrel-releasing intrauterine system yields similar long-term results and patient satisfaction compared with conservative surgical interventions.

The practice recommendations in this activity are available at http://www.cochrane.org/CD003855.