Medical Research Council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia

Endometrial ablation and resection versus hysterectomy for heavy menstrual bleeding: an updated systematic review and meta-analysis of effectiveness and complications

To evaluate the clinical efficacy, safety, and cost-effectiveness of endometrial ablation or resection (E:A/R) compared to hysterectomy for the treatment of heavy menstrual bleeding. Literature search was conducted, and randomized control trials (RCTs) comparing (E:A/R) versus hysterectomy were reviewed. The search was last updated in November 2022. Twelve RCTs with 2,028 women (hysterectomy: n=977 vs. [E:A/R]: n=1,051) were included in the analyzis. The meta-analysis revealed that the hysterectomy group showed improved patient-reported and objective bleeding symptoms more than those of the (E:A/R) group, with risk ratios of (mean difference [MD], 0.75; 95% confidence intervals [CI], 0.71 to 0.79) and (MD, 44.00; 95% CI, 36.09 to 51.91), respectively. Patient satisfaction was higher post-hysterectomy than (E:A/R) at 2 years of follow-up, but this effect was absent with long-term follow-up. (E:A/R) is considered an alternative to hysterectomy as a surgical management for heavy menstrual bleeding. Although both procedures are highly effective, safe, and improve the quality of life, hysterectomy is significantly superior at improving bleeding symptoms and patient satisfaction for up to 2 years. However, it is associated with longer operating and recovery times and a higher rate of postoperative complications. The initial cost of (E:A/R) is less than the cost of hysterectomy, but further surgical requirements are common; therefore, there is no difference in the cost for long-term follow-up.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.

Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis

BACKGROUND

Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with women's quality of life, regardless of the absolute amount of bleeding. It is a very common condition in women of reproductive age, affecting 2 to 5 of every 10 women. Diverse treatments, either medical (hormonal or non-hormonal) or surgical, are currently available for HMB, with different effectiveness, acceptability, costs and side effects. The best treatment will depend on the woman's age, her intention to become pregnant, the presence of other symptoms, and her personal views and preferences.

OBJECTIVES

To identify, systematically assess and summarise all evidence from studies included in Cochrane Reviews on treatment for heavy menstrual bleeding (HMB), using reviews with comparable participants and outcomes; and to present a ranking of the first- and second-line treatments for HMB.

METHODS

We searched for published Cochrane Reviews of HMB interventions in the Cochrane Database of Systematic Reviews. The primary outcomes were menstrual bleeding and satisfaction. Secondary outcomes included quality of life, adverse events and the requirement of further treatment. Two review authors independently selected the systematic reviews, extracted data and assessed quality, resolving disagreements by discussion. We assessed review quality using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) 2 tool and evaluated the certainty of the evidence for each outcome using GRADE methods. We grouped the interventions into first- and second-line treatments, considering participant characteristics (desire for future pregnancy, failure of previous treatment, candidacy for surgery). First-line treatments included medical interventions, and second-line treatments included both the levonorgestrel-releasing intrauterine system (LNG-IUS) and surgical treatments; thus the LNG-IUS is included in both groups. We developed different networks for first- and second-line treatments. We performed network meta-analyses of all outcomes, except for quality of life, where we performed pairwise meta-analyses. We reported the mean rank, the network estimates for mean difference (MD) or odds ratio (OR), with 95% confidence intervals (CIs), and the certainty of evidence (moderate, low or very low certainty). We also analysed different endometrial ablation and resection techniques separately from the main network: transcervical endometrial resection (TCRE) with or without rollerball, other resectoscopic endometrial ablation (REA), microwave non-resectoscopic endometrial ablation (NREA), hydrothermal ablation NREA, bipolar NREA, balloon NREA and other NREA.

MAIN RESULTS

We included nine systematic reviews published in the Cochrane Library up to July 2021. We updated the reviews that were over two years old. In July 2020, we started the overview with no new reviews about the topic. The included medical interventions were: non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics (tranexamic acid), combined oral contraceptives (COC), combined vaginal ring (CVR), long-cycle and luteal oral progestogens, LNG-IUS, ethamsylate and danazol (included to provide indirect evidence), which were compared to placebo. Surgical interventions were: open (abdominal), minimally invasive (vaginal or laparoscopic) and unspecified (or surgeon's choice of route of) hysterectomy, REA, NREA, unspecified endometrial ablation (EA) and LNG-IUS. We grouped the interventions as follows. First-line treatments Evidence from 26 studies with 1770 participants suggests that LNG-IUS results 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; low certainty evidence); antifibrinolytics probably reduce MBL (mean rank 3.7, MD -80.32 mL/cycle, 95% CI -127.67 to -32.98; moderate certainty evidence); long-cycle progestogen reduces MBL (mean rank 4.1, MD -76.93 mL/cycle, 95% CI -153.82 to -0.05; low certainty evidence), and NSAIDs slightly reduce MBL (mean rank 6.4, MD -40.67 mL/cycle, -84.61 to 3.27; low certainty evidence; reference comparator mean rank 8.9). We are uncertain of the true effect of the remaining interventions and the sensitivity analysis for reduction of MBL, as the evidence was rated as very low certainty. We are uncertain of the true effect of any intervention (very low certainty evidence) on the perception of improvement and satisfaction. Second-line treatments Bleeding reduction is related to the type of hysterectomy (total or supracervical/subtotal), not the route, so we combined all routes of hysterectomy for bleeding outcomes. We assessed the reduction of MBL without imputed data (11 trials, 1790 participants) and with imputed data (15 trials, 2241 participants). Evidence without imputed data suggests that hysterectomy (mean rank 1.2, OR 25.71, 95% CI 1.50 to 439.96; low certainty evidence) and REA (mean rank 2.8, OR 2.70, 95% CI 1.29 to 5.66; low certainty evidence) result in a large reduction of MBL, and NREA probably results in a large reduction of MBL (mean rank 2.0, OR 3.32, 95% CI 1.53 to 7.23; moderate certainty evidence). Evidence with imputed data suggests hysterectomy results in a large reduction of MBL (mean rank 1.0, OR 14.31, 95% CI 2.99 to 68.56; low certainty evidence), and NREA probably results in a large reduction of MBL (mean rank 2.2, OR 2.87, 95% CI 1.29 to 6.05; moderate certainty evidence). We are uncertain of the true effect for REA (very low certainty evidence). We are uncertain of the effect on amenorrhoea (very low certainty evidence). Evidence from 27 trials with 4284 participants suggests that minimally invasive hysterectomy results in a large increase in satisfaction (mean rank 1.3, OR 7.96, 95% CI 3.33 to 19.03; low certainty evidence), and NREA also increases satisfaction (mean rank 3.6, OR 1.59, 95% CI 1.09 to 2.33; low certainty evidence), but we are uncertain of the true effect of the remaining interventions (very low certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests LNG-IUS is the best first-line treatment for reducing menstrual blood loss (MBL); antifibrinolytics are probably the second best, and long-cycle progestogens are likely the third best. We cannot make conclusions about the effect of first-line treatments on perception of improvement and satisfaction, as evidence was rated as very low certainty. For second-line treatments, evidence suggests hysterectomy is the best treatment for reducing bleeding, followed by REA and NREA. We are uncertain of the effect on amenorrhoea, as evidence was rated as very low certainty. Minimally invasive hysterectomy may result in a large increase in satisfaction, and NREA also increases satisfaction, but we are uncertain of the true effect of the remaining second-line interventions, as evidence was rated as very low certainty.

Abnormal Uterine Bleeding in Perimenopausal Women: The Role of Hysteroscopy and Its Impact on Quality of Life and Sexuality

Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

Hysteroscopic endometrial resection vs. hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials

PURPOSE OF REVIEW

The aim of this systematic review is to summarize the current evidence regarding the effectiveness of hysterectomy and hysteroscopic endometrial resection in improving quality of life (QoL), sexual function and psychological wellbeing of women abnormal uterine bleeding.

RECENT FINDINGS

We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO 2019 CRD42019133632), using the terms 'endometrial ablation', 'endometrial destruction', 'endometrial resection', 'hysterectomy', 'menorrhagia', 'dysfunctional uterine bleeding', 'quality of life', 'sexuality' published up to April 2019. Our literature search produced 159 records. After exclusions, nine studies were included showing the following results: both types of treatment significantly improve QoL and psychological wellbeing; hysterectomy is associated with higher rates of satisfaction; hysterectomy is not associated with a significant deterioration in sexual function.

SUMMARY

Hysterectomy is currently more advantageous in terms of improving abnormal uterine bleeding and satisfaction rates than hysteroscopic endometrial destruction techniques. Furthermore, there is some evidence of a greater improvement in general health for women undergoing hysterectomy. However, high-quality prospective randomized controlled trials should be implemented to investigate the effectiveness of hysterectomy and endometrial ablation in the improvement of QoL outcomes in larger patient cohorts.

Systematic review, meta-analysis and statistical analysis of laparoscopic supracervical hysterectomy vs. endometrial ablation

Objective:

This meta-analysis aimed to compare the effect of laparoscopic supracervical hysterectomy (LSH) with endometrial ablation (EA) in terms of general and menstrual-related quality of life in women opting for surgical treatment for abnormal uterine bleeding.

Material and Methods:

Sources searched included PubMed, Cochrane library, Scopus, and Web of Science for relevant clinical trials. Main outcomes of interest included: quality of life assessed using medical outcomes survey short form-36 (SF-36), (SF-12), operation time, time from operation to discharge, pain, fever, and hemoglobin level. Screening and data extraction were performed independently and the analysis was conducted using Review Manager Software v5.4.1.

Results:

Four clinical trials were included. Results of SF-12 score showed that there was no significant difference between the LSH and EA groups for either mental or physical component score overall mean difference (MD): -4.15 (-16.01, 7.71; p=0.49) and MD: 2.67 (-0.37, 5.71; p=0.08), respectively. Subgroup analysis of the SF-36 showed that only two components, general health and social function, were significantly improved in the LSH group (p<0.01) while the other six sub-scores did not differ between groups. The overall MD significantly favored the EA group for: operation time [MD: 72.65 (35.48, 109.82; p=0.0001)], time from operation to discharge [MD: 13.61 (3.21, 24.01; p=0.01)], hemoglobin level outcome [MD: 0.57 (0.40, 0.74); p<0.01], and pain score [standardized MD: 0.46 (0.32, 0.60; p<0.01)].

Conclusion:

LSH has better outcomes for quality of life. This includes patient indicated responses to social health, general health, and superior hemoglobin levels at all measured points postoperatively. EA, however, was consistently associated with less operative time, a shorter hospital stay and is also considered by the authors to be a more minimally invasive technique which can also result in satisfying outcomes.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is common in otherwise healthy women of reproductive age, and can affect physical health and quality of life. Surgery is usually a second-line treatment of HMB. Endometrial resection/ablation (EA/ER) to remove or ablate the endometrium is less invasive than hysterectomy. Hysterectomy is the definitive treatment and can be via open (laparotomy) approach, or via minimally invasive approaches (vaginally or laparoscopically). Each approach has its own advantages and risk profile.

OBJECTIVES

To compare the effectiveness, acceptability and safety of endometrial resection or ablation versus different routes of hysterectomy (open, minimally invasive hysterectomy, or unspecified route) for the treatment of HMB.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase and PsycINFO (July 2020), and reference lists, grey literature and trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared techniques of endometrial resection/ablation with hysterectomy (by any technique) for the treatment of HMB in premenopausal women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 10 RCTs (1966 participants) comparing EA/ER to hysterectomy (open (abdominal), minimally invasive (laparoscopic or vaginal), or unspecified (or at surgeon's discretion) route of hysterectomy). The results were rated as moderate-, low- and very low-certainty evidence. Endometrial resection/ablation versus open hysterectomy We found two trials. Women having EA/ER are probably less likely to perceive an improvement in HMB compared to women having open hysterectomy (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.84 to 0.95; 2 studies, 247 women; moderate-certainty evidence) and probably have a 13% risk of requiring further surgery for treatment failure (compared to 0 on the open hysterectomy group; 2 studies, 247 women; moderate-certainty evidence). Both treatments probably lead to similar quality of life at two years (mean difference (MD) -5.30, 95% CI -11.90 to 1.30; 1 study, 155 women; moderate-certainty evidence) and satisfaction rate at one year (RR 0.91, 95% CI 0.82 to 1.00; 1 study, 194 women; moderate-certainty evidence). There may be no difference in serious adverse events (RR 1.29, 95% CI 0.32 to 5.20; 2 studies, 247 women; low-certainty evidence). EA/ER probably reduces time to return to normal activity compared to open hysterectomy (MD -21.00 days, 95% CI -24.78 to -17.22; 1 study, 197 women; moderate-certainty evidence). Endometrial resection/ablation versus minimally invasive hysterectomy We found five trials. The proportion of women with perception of improvement in HMB at two years may be similar between groups (RR 0.97, 95% CI 0.90 to 1.04; 1 study, 79 women; low-certainty evidence). Blood loss may be higher in the EA/ER group when assessed using the Pictorial Blood Assessment Chart (MD 44.00, 95% CI 36.09 to 51.91; 1 study, 68 women; low-certainty evidence). Quality of life is probably lower in the EA/ER group compared to the minimally invasive hysterectomy group at two years according to the 36-item Short Form (SF-36) (MD -10.71, 95% CI -15.11 to -6.30; 2 studies, 145 women; moderate-certainty evidence) and Menorrhagia Multi-Attribute Scale (RR 0.82, 95% CI 0.70 to 0.95; 1 study, 616 women; moderate-certainty evidence). EA/ER probably increases the risk of further surgery for HMB compared to minimally invasive hysterectomy (RR 7.70, 95% CI 2.54 to 23.32; 4 studies, 922 women; moderate-certainty evidence) and treatments probably have similar rates of any serious adverse events (RR 0.75, 95% CI 0.35 to 1.59; 4 studies, 809 women; moderate-certainty evidence). Women with EA/ER are probably less likely to be satisfied with treatment at one year (RR 0.90, 95% CI 0.85 to 0.94; 1 study, 558 women; moderate-certainty evidence). We were unable to pool data for time to return to work or normal life because of extreme heterogeneity (99%); however, the three studies reporting this all had the same direction of effect favouring EA/ER. Endometrial resection/ablation versus unspecified route of hysterectomy We found three trials. EA/ER may lead to a lower perception of improvement in HMB compared to unspecified route of hysterectomy (RR 0.89, 95% CI 0.83 to 0.95; 2 studies, 403 women; low-certainty evidence). Although EA/ER may lead to similar quality of life using the SF-36 General Health Perception at two years' follow-up (MD -1.90, 95% CI -8.67 to 4.87; 1 study, 209 women; low-certainty evidence), the proportion of women with improvement in general health at one year may be lower (RR 0.85, 95% CI 0.77 to 0.95; 1 study, 185 women; low-certainty evidence). EA/ER probably has a risk of 5.4% of requiring further surgery for treatment failure (compared to 0 with total hysterectomy; 2 studies, 374 women; moderate-certainty evidence) and reduces the proportion of women with any serious adverse event (RR 0.21, 95% CI 0.06 to 0.80; 2 studies, 374 women; moderate-certainty evidence). Both treatments probably lead to a similar satisfaction rate at one year' follow-up (RR 0.96, 95% CI 0.88 to 1.04; 3 studies, 545 women; moderate-certainty evidence). EA/ER may lead to shorter time to return to normal activity (MD -18.90 days, 95% CI -24.63 to -13.17; 1 study, 172 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

Endometrial resection/ablation (EA/ER) offers an alternative to hysterectomy as a surgical treatment for HMB. Effectiveness varies with EA/ER compared to different hysterectomy approaches. The perception of improvement in HMB with EA/ER is probably lower compared to open and unspecified route of hysterectomy, but may be similar compared to minimally invasive. Quality of life with EA/ER is probably similar to open and unspecified route of hysterectomy, but lower compared to minimally invasive hysterectomy. Further surgery for treatment failure is probably more likely with EA/ER compared to all routes of hysterectomy. Satisfaction rates also vary. EA/ER probably has a similar rate of satisfaction compared to open and unspecified route of hysterectomy, but a lower rate of satisfaction compared to minimally invasive hysterectomy. The proportion having any serious adverse event appears similar in all groups, but specific adverse events did reported difference between EA/ER and different routes. We were unable to draw conclusions about the time to return to normal activity, but the direction of effect suggests it is likely to be shorter with EA/ER.

Radiofrequency endometrial ablation with a novel endometrial tip for the management of heavy menstrual bleeding and abnormal uterine bleeding: a prospective study

Aim: To evaluate the safety and efficacy of a radiofrequency ablation system with a novel endometrial tip (RFA-EMT) for the management of heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB).Methods: This is a prospective study including a total of 38 premenopausal women with heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) that failed to respond to medical therapy. Hysteroscopic evaluation and curettage biopsy were performed just before the procedure. The procedure was timed to occur during the early proliferative phase (cycle days 4-10). RFA-EMT procedures were performed by a single surgeon with the patient under general anesthesia with a laryngeal mask airway. Primary outcome was reduction in bleeding, reported as amenorrhea, hypomenorrhea, and eumenorrhea, which were measured via hemoglobin level and pictorial blood assessment chart (PBAC) score. Secondary outcomes were adverse events, dysmenorrhea with numeric rating scale (NRS) score, and endometrial thickening in the early proliferative phase, as assessed by transvaginal ultrasonography.Results: There were no peri- or post-procedural complications. Combined amenorrhea, hypomenorrhea, and eumenorrhea rates at 3 and 6 months were 97.4% and 100%, respectively. The hemoglobin level was significantly increased, and the PBAC score, NRS score, and endometrial thickening were significantly decreased after 3 months. These trends were maintained for 6 months after the procedure.Conclusion: RFA-EMT, a new technique, is safe and effective for women with HMB or AUB for which medical therapy has failed.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important cause of ill health in women of reproductive age, causing them physical problems, social disruption and reducing their quality of life. Medical therapy has traditionally been first-line therapy. 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. Less invasive surgical techniques, such as endometrial resection and ablation, have been developed with the purpose of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.

OBJECTIVES

To compare the effectiveness, acceptability and safety of techniques of endometrial destruction by any means versus hysterectomy by any means for the treatment of heavy menstrual bleeding.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) targeted-but were not limited to-the following: the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, and the ongoing trial registries. We made attempts to identify trials by examining citation lists of review articles and guidelines and by performing handsearching. Searches were performed in 1999, 2007, 2008, 2013 and on 10 December 2018.

SELECTION CRITERIA

Any RCTs that compared techniques of endometrial resection or ablation (by any means) with hysterectomy (by any technique) for the treatment of heavy menstrual bleeding in premenopausal women.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed trials for risk of bias.

MAIN RESULTS

We identified nine RCTs that fulfilled our inclusion criteria for this review. For two trials, the review authors identified multiple publications that assessed different outcomes at different postoperative time points for the same women. No included trials used third generation techniques.Clinical measures of improved bleeding symptoms and satisfaction rates were observed in women who had undergone hysterectomy compared to endometrial ablation. A slightly lower proportion of women who underwent endometrial ablation perceived improvement in bleeding symptoms at one year (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.85 to 0.93; 4 studies, 650 women, I² = 31%; low-quality evidence), at two years (RR 0.92, 95% CI 0.86 to 0.99; 2 studies, 292 women, I² = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99; 2 studies, 237 women, I² = 79%). Women in the endometrial ablation group also showed improvement in pictorial blood loss assessment chart compared to their baseline (PBAC) score at one year (MD 24.40, 95% CI 16.01 to 32.79; 1 study, 68 women; moderate-quality evidence) and at two years (MD 44.00, 95% CI 36.09 to 51.91; 1 study, 68 women). Repeat surgery resulting from failure of the initial treatment was more likely to be needed after endometrial ablation than after hysterectomy at one year (RR 16.17, 95% CI 5.53 to 47.24; 927 women; 7 studies; I² = 0%), at two years (RR 34.06, 95% CI 9.86 to 117.65; 930 women; 6 studies; I² = 0%), at three years (RR 22.90, 95% CI 1.42 to 370.26; 172 women; 1 study) and at four years (RR 36.32, 95% CI 5.09 to 259.21;197 women; 1 study). The satisfaction rate was lower amongst those who had endometrial ablation at two years after surgery (RR 0.87, 95% CI 0.80 to 0.95; 4 studies, 567 women, I² = 0%; moderate-quality evidence), and no evidence of clear difference was reported between post-treatment satisfaction rates in groups at other follow-up times (1 and 4 years).Most adverse events, both major and minor, were more likely after hysterectomy during hospital stay. Women who had an endometrial ablation were less likely to experience sepsis (RR 0.19, 95% CI 0.12 to 0.31; participants = 621; studies = 4; I² = 62%), blood transfusion (RR 0.20, 95% CI 0.07 to 0.59; 791 women; 5 studies; I² = 0%), pyrexia (RR 0.17, 95% CI 0.09 to 0.35; 605 women; 3 studies; I² = 66%), vault haematoma (RR 0.11, 95% CI 0.04 to 0.34; 858 women; 5 studies; I² = 0%) and wound haematoma (RR 0.03, 95% CI 0.00 to 0.53; 202 women; 1 study) before hospital discharge. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection (RR 0.27, 95% CI 0.13 to 0.58; 172 women; 1 study).Recovery time was shorter in the endometrial ablation group, considering hospital stay, time to return to normal activities and time to return to work; we did not, however, pool these data owing to high heterogeneity. Some outcomes (such as a woman's perception of bleeding and proportion of women requiring further surgery for HMB), generated a low GRADE score, suggesting that further research in these areas is likely to change the estimates.

AUTHORS' CONCLUSIONS

Endometrial resection and ablation offers an alternative to hysterectomy as a surgical treatment for heavy menstrual bleeding. Both procedures are effective, and satisfaction rates are high. Although hysterectomy offers permanent and immediate relief from heavy menstrual bleeding, it is associated with a longer operating time and recovery period. Hysterectomy also has higher rates of postoperative complications such as sepsis, blood transfusion and haematoma (vault and wound). The initial cost of endometrial destruction is lower than that of hysterectomy but, because retreatment is often necessary, the cost difference narrows over time.

Endometrial ablation

Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.

[Operative hysteroscopy for myoma removal: Morcellation versus bipolar loop resection]

OBJECTIVE

To evaluate the results associated with hysteroscopic morcellation for submucous myomas removal, and to compare with those observed associated with bipolar loop resection.

MATERIELS AND METHODS

A retrospective comparative study was conducted in two universitary centers from January 2012 to December 2013. A total of 83 patients, who presented with submucous myomas type 0,1 and 2, were included. The number of myomas type 0,1 was 36 (71 %) and 15 (29 %) myomas type 2 in morcellation group versus 44 (59 %) myomas type 0,1 and 31 (41 %) type 2 in electrosurgical resection group (P=0.17). Hysteroscopic morcellation or electrosurgical resection with bipolar loop for removal submucous myomas were performed.

RESULTS

Thirty-four patients underwent hysteroscopic morcellation using MyoSure(®), and 49 had hysteroscopic resection using Versapoint-24F(®) bipolar loop. The mean operative duration was 30minutes in morcellation group, compared to 31minutes in bipolar resection group (P=0.98). Complete myoma removal was achieved in 22 (64 %) patients in morcellation group, and in 34 (69 %) in bipolar resection group (P=0.65). There were no difference in the occuring of adverse events between the two. The prevalence of postoperative intra-uterine adherence was 10 % in morcellation group and 13.8 % in bipolar resection group (P=0.69).

CONCLUSION

In the current short comparative series, hysteroscopic morcellation and bipolar loop resection were associated with comparable results for removal of submucous myomas.

Tranexamic acid: a potential adjunct to resectoscopic endometrial ablation

Abnormal uterine bleeding (AUB) is a substantial cause of ill health in women worldwide. In this study, our aim was to evaluate the effectiveness of endometrial ablation using a modified urologic resectoscope along with tranexamic acid in AUB. Sixty patients were enrolled in this study. All patients underwent resectoscopic surgery. Patients were randomly divided into two groups. Group 1 (n = 30) received 500 mg of tranexamic acid. Group 2 (n = 30) served as the control group and underwent surgery without the administration of tranexamic acid. Total pictorial blood loss assessment chart (PBAC) scores were significantly lower postoperatively (152.14 ± 9.65 versus 6.6 ± 0.90; P < 0.001). When stratified by the administration of tranexamic acid, the number of patients with a postoperative day 1 PBAC score ≤15 was higher in the tranexamic group (19 versus 13), whereas the number of patients with a post operative day 1 PBAC score >15 was lower in the tranexamic group (11 versus 17), but the differences were not statistically significant (P > 0.05). AUB is a complex disease that may need repeated treatments. In expert hands, the treatment rate of resectoscopic surgery seems acceptable. However, some patients may require additional interventions, like repeated surgery, hysterectomy, or a drug therapy in the long run. Introduction of tranexamic acid as a potential adjunct to rollerball endometrial ablation may present an interesting option that requires additional well-designed studies before firm conclusions can be made.

Impact of myomas on the results of transcervical resection of the endometrium

STUDY OBJECTIVE

To investigate long-term hysterectomy rates after transcervical resection of the endometrium (TCRE) performed by experienced surgeons in the presence and absence of intracavitary myomas.

DESIGN

Multicenter case-control study (Canadian Task Force classification II-2).

PATIENTS

The study group comprised 456 women with myomas who met the inclusion criteria, and of these, 82 (17.98%) later underwent hysterectomy. The control group comprised 1438 women without myomas, and of these, 284 (19.75%) later underwent hysterectomy.

METHODS

From 2001 to 2004, standardized results were extracted from Hyskobase on the basis of a total of 1894 women aged 23 to 59 years. The women were identified as having or not having myomas, and data from both groups were statistically analyzed. Detailed information on myoma size and intramural involvement (type 0, 1, and 2) was collected.

MEASUREMENTS AND MAIN RESULTS

After TCRE, women with type 2 myomas, compared with those with type 0 myomas, were found to have a significantly higher risk of undergoing hysterectomy (p = .04), and women, including controls, with myomas >3.6 cm in greatest diameter were found to have a significantly higher risk of undergoing hysterectomy than were those with smaller myomas (p = .01). There was no statistically significant difference in risk of hysterectomy between type 0 and type 1 myomas or between type 1 and type 2 myomas. When hysterectomy rates between the myoma and control groups were compared, there was an increased risk of hysterectomy in the control group (p = .008). Multiple-step multivariate regression analysis of uterine and procedural characteristics of TCRE demonstrated that factors that were positive predictors of hysterectomy within 66 months after resection were younger age, inaccessible uterine corners, enlarged uterus, and pretreatment using gonadotropin-releasing hormone agonists.

CONCLUSION

When performing TCRE in women with intracavitary myomas, the chance of treatment success is worsened if they are of type 2 or their diameter is >3.5 cm. In addition, younger age increases the risk of hysterectomy and the need for pretreatment with gonadotropin-releasing hormone agonists, or if the uterus is enlarged or the uterine corners are difficult to access during the procedure.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB), which includes both menorrhagia and metrorrhagia, is an important cause of ill health in women. 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 (e.g. transcervical resection of the endometrium (TCRE), laser approaches) and various methods of endometrial ablation have been developed with the purpose of improving menstrual symptoms by removing or ablating the entire thickness of the endometrium.

OBJECTIVES

The objective of this review is to compare the effectiveness, acceptability and safety of techniques of endometrial destruction by any means versus hysterectomy by any means for the treatment of heavy menstrual bleeding.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) targeted but were not limited to the following: the Cochrane Menstrual Disorders and Subfertility Group Register of Trials, MEDLINE, EMBASE, PsycINFO and the Cochrane CENTRAL register of trials. Attempts were made to identify trials by examining citation lists of review articles and guidelines and by performing handsearching. Searches were performed in 2007, 2008 and 2013.

SELECTION CRITERIA

Included in the review were any RCTs that compared techniques of endometrial destruction by any means with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched for studies, extracted data and assessed risk of bias. Risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) 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 requirements for repeat surgery due to failure of the initial surgical treatment.

MAIN RESULTS

Eight RCTs that fulfilled the inclusion criteria for this review were identified. For two trials, the review authors identified multiple publications that assessed different outcomes at different postoperative time points for the same women.An advantage in favour of hysterectomy compared with endometrial ablation was observed in various measures of improvement in bleeding symptoms and satisfaction rates. A slightly lower proportion of women who underwent endometrial ablation perceived improvement in bleeding symptoms at one year (RR 0.89, 95% confidence interval (CI) 0.85 to 0.93, four studies, 650 women, I(2) = 31%), at two years (RR 0.92, 95% CI 0.86 to 0.99, two studies, 292 women, I(2) = 53%) and at four years (RR 0.93, 95% CI 0.88 to 0.99, two studies, 237 women, I(2) = 79%). The same group of women also showed improvement in pictorial blood loss assessment chart (PBAC) score at one year (MD 24.40, 95% CI 16.01 to 32.79, one study, 68 women) and at two years (MD 44.00, 95% CI 36.09 to 51.91, one study, 68 women). Repeat surgery resulting from failure of the initial treatment was more likely to be needed after endometrial ablation than after hysterectomy at one year (RR 14.9, 95% CI 5.2 to 42.6, six studies, 887 women, I(2) = 0%), at two years (RR 23.4, 95% CI 8.3 to 65.8, six studies, 930 women, I(2) = 0%), at three years (RR 11.1, 95% CI 1.5 to 80.1, one study, 172 women) and at four years (RR 36.4, 95% CI 5.1 to 259.2, one study, 197 women). Most adverse events, both major and minor, were significantly more likely after hysterectomy during hospital stay. Women who had a hysterectomy were more likely to experience sepsis (RR 0.2, 95% CI 0.1 to 0.3, four studies, 621 women, I(2) = 62%), blood transfusion (RR 0.2, 95% CI 0.1 to 0.6, four studies, 751 women, I(2) = 0%), pyrexia (RR 0.2, 95% CI 0.1 to 0.4, three studies, 605 women, I(2) = 66%), vault haematoma (RR 0.1, 95% CI 0.04 to 0.3, five studies, 858 women, I(2) = 0%) and wound haematoma (RR 0.03, 95% CI 0.00 to 0.5, one study, 202 women) before hospital discharge. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection (RR 0.2, 95% CI 0.1 to 0.5, one study, 172 women).For some outcomes (such as a woman's perception of bleeding and proportion of women requiring further surgery for HMB), a low GRADE score was generated, suggesting that further research in these areas is likely to change the estimates.

AUTHORS' CONCLUSIONS

Endometrial resection and ablation offers an alternative to hysterectomy as a surgical treatment for heavy menstrual bleeding. Both procedures are effective, and satisfaction rates are high. Although hysterectomy is associated with longer operating time (particularly for the laparoscopic route), a longer recovery period and higher rates of postoperative complications, it offers permanent relief from heavy menstrual bleeding. The initial cost of endometrial destruction is significantly lower than that of hysterectomy, but, because retreatment is often necessary, the cost difference narrows over time.

Rates of subsequent surgery following endometrial ablation among English women with menorrhagia: population-based cohort study

OBJECTIVE

To assess the risk of further surgery amongst women who had an initial endometrial ablation (EA) for the treatment of heavy menstrual bleeding (HMB).

DESIGN

A retrospective cohort study using a national administrative database.

SETTING

Population-based study of hospital care in the English National Health Service.

POPULATION

A cohort of 114,910 women who had EA for HMB between January 2000 and December 2011.

METHODS

Multiple Cox regressions were performed to identify the risks of a further procedure, adjusted for age, social deprivation, year and type of initial EA, and presence of fibroids/polyps.

MAIN OUTCOME MEASURES

Time to repeat EA or hysterectomy after initial surgery.

RESULTS

Of 114,910 women undergoing EA, 16.7% had at least one subsequent procedure within 5 years. Higher rates of subsequent surgery were associated with younger age at initial EA, with women aged under 35 years having an adjusted hazard ratio of 2.83 (95% CI 2.67-2.99), compared with women aged over 45 years. Women who had radiofrequency ablation were less likely to have subsequent surgery as compared with first-generation techniques (HR 0.69, 95% CI 0.63-0.76). The rate of a subsequent hysterectomy within 5 years was 13.5%. Younger women (OR 0.59, 95% CI 0.51-0.69) and those who had balloon, microwave, or radiofrequency ablation were less likely to have a second EA procedure, rather than a hysterectomy.

CONCLUSIONS

One in six women have further surgery after EA for HMB, which is a higher rate than reported in clinical trials. This risk of further surgery decreases with age.

Effect of myoma size on failure of thermal balloon ablation or levonorgestrel releasing intrauterine system treatment in women with menorrhagia

Objective

The aim of the present study was to identify variables associated with treatment failure in women with menorrhagia who were treated with thermal balloon ablation (TBA) or levonorgestrel releasing intrauterine system (LNG-IUS), and to determine if there are subgroups where one treatment type is more effective than the other.

Methods

The study included 106 women with menorrhagia who were treated with TBA or LNG-IUS at the study institute between January 2003 and December 2007, with a follow-up period greater than 12 months. Data were collected by retrospective review of medical records. Treatment failure was defined as persistent or recurrent menorrhagia within one year after treatment or hysterectomy at any time during follow-up. The relationships between variables and treatment outcome were analyzed using the chi-square or Fisher's exact test. The treatment outcome of TBA was compared with LNG-IUS.

Results

Sixty-seven women were treated with TBA and 39 women were managed with LNG-IUS. Fifty-two women had a myoma ≥2.5 cm. Treatment failure was observed in 24 women (2 recurrent or persistent menorrhagia and 22 hysterectomies) and myoma size (≥2.5 cm vs. <2.5 cm) was associated with treatment outcome. TBA and LNG-IUS showed similar treatment outcomes.

Conclusion

A large myoma is a risk factor for treatment failure in women with menorrhagia treated with TBA or LNG-IUS.

Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy

STUDY OBJECTIVE

To develop recommendations in selecting treatments for abnormal uterine bleeding (AUB).

DESIGN

Clinical practice guidelines.

SETTING

Randomized clinical trials compared bleeding, quality of life, pain, sexual health, satisfaction, the need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.

PATIENTS

Women with AUB, predominantly from ovulatory disorders and endometrial causes.

INTERVENTIONS

On the basis of findings from a systematic review, clinical practice guidelines were developed. Rating the quality of evidence and the strength of recommendations followed the Grades for Recommendation Assessment, Development, and Evaluation system.

MEASUREMENTS AND MAIN RESULTS

This paper identified few high-quality studies that directly compared uterus-preserving treatments (endometrial ablation, levonorgestrel intrauterine system and systemically administered medications) with hysterectomy. The evidence from these randomized clinical trials demonstrated that there are trade-offs between hysterectomy and uterus-preserving treatments in terms of efficacy and adverse events.

CONCLUSION

Selecting an appropriate treatment for AUB requires identifying a woman's most burdensome symptoms and incorporating her values and preferences when weighing the relative benefits and harms of hysterectomy versus other treatment options.

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding

STUDY OBJECTIVE

To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains.

DESIGN

Systematic review.

SETTING

Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.

PATIENTS

Women with AUB, predominantly from ovulatory disorders and endometrial causes.

INTERVENTIONS

Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system.

MEASUREMENTS AND MAIN RESULTS

Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found.

CONCLUSION

Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Thermal balloon ablation versus laparoscopic supracervical hysterectomy for the surgical treatment of heavy menstrual bleeding: a randomized study

AIM

To compare postoperative outcomes and effects on quality of life following thermal balloon ablation (TBA) or laparoscopic supracervical hysterectomy (LSH) in women with heavy menstrual bleeding (HMB).

MATERIAL AND METHODS

Sixty-eight women requiring surgical treatment for HMB were randomly allocated into two treatment arms: TBA (n = 34) and LSH (n = 34). The randomization procedure was based on a computer-generated list. The primary outcome was a comparison of the effects on menstrual bleeding (Pictorial Blood Loss Assessment Chart [PBAC]) between the two procedures. The secondary outcome measures were quality of life, improvement of bleeding patterns, intensity of postoperative pain, and early postoperative complications. Continuous outcome variables were analyzed using Student's t-test. Discrete variables were analyzed with the χ2 test or Fisher's exact test. P < 0.05 was considered statistically significant.

RESULTS

The PBAC score was significantly reduced in both treatment groups. After LSH all women had amenorrhea. After TBA there was a significant improvement of bleeding frequency and length. The postoperative pain intensity at 24 h was significantly minor in women treated with TBA rather than with LSH. The Medical Outcomes Survey Short Form 36 (SF-36) score improved in both groups. However, LSH showed a negative impact on the emotional state. No intraoperative complications occurred, and no case was returned to the theatre in either group.

CONCLUSION

The effectiveness of TBA as a possible treatment of HMB is confirmed. However, LSH showed a definitive improvement of the symptoms, and a better life quality profile. Further controlled prospective studies are required for identifying the best surgical approach in women with HMB.

Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland

OBJECTIVE

To determine the risk of further gynaecological surgery and gynaecological cancer following hysterectomy and endometrial ablation in women with heavy menstrual bleeding.

DESIGN

Population-based retrospective cohort study.

SETTING

Scottish hospitals between 1989 and 2006. Population or sample Scottish women treated with hysterectomy or endometrial ablation for heavy menstrual bleeding between 1989 and 2006.

METHODS

Anonymised data collected by the Scottish Information Services Division were analysed using appropriate methods across the hysterectomy and endometrial ablation groups. Cox proportional hazards regression analysis was used to examine the survival experience for different surgical outcomes after adjustment for age, year of primary operation and Carstairs quintile.

MAIN OUTCOME MEASURES

Further gynaecological surgery and gynaecological cancer in women.

RESULTS

A total of 37,120 women had a hysterectomy, 11,299 women underwent endometrial ablation without a subsequent hysterectomy and 2779 women underwent endometrial ablation followed by a subsequent hysterectomy. The median (interquartile range) duration of follow-up was 11.6 years (7.9, 14.8) and 6.2 years (2.7, 10.8) in the hysterectomy and endometrial ablation (without hysterectomy) cohorts, respectively. Compared with women who underwent hysterectomy, those who underwent ablation were less likely to need pelvic floor repair [adjusted hazards ratio, 0.62; 95% confidence interval (95% CI), 0.50, 0.77] or tension-free vaginal tape surgery for stress urinary incontinence (adjusted hazards ratio, 0.55; 95% CI, 0.41, 0.74). Abdominal hysterectomy was associated with a lower chance than vaginal hysterectomy of pelvic floor repair surgery (hazards ratio, 0.54; 95% CI, 0.45, 0.64). Overall, the number of women diagnosed with cancer was small, the largest group being breast cancer (n = 584, 1.57% and n = 130, 1.15% in the hysterectomy and endometrial ablation groups respectively; adjusted hazards ratio, 1.14; 95% CI, 0.93-1.39).

CONCLUSIONS

Hysterectomy is associated with a higher risk than endometrial ablation of surgery for pelvic floor repair and stress urinary incontinence. Surgery for pelvic floor prolapse is more common after vaginal than abdominal hysterectomy.

Modified thermal balloon endometrial ablation in low resource settings: a cost-effective method using Foley's catheter

OBJECTIVE

To assess the efficacy of a modified Foley's catheter endometrial ablation in the treatment of abnormal uterine bleeding in low resource settings.

METHODS

Four hundred and thirty premenopausal women with abnormal uterine bleeding were subjected to thermal balloon endometrial ablation using modified Foley's catheter. The primary outcome measure was patient satisfaction regarding menstrual blood loss. Secondary measures included improvement in quality of life scores and failure rates.

RESULTS

Three hundred and three patients were available for evaluation at 3-year follow up. 270/303 (89.1%) reported their satisfaction as indicated by reduction in days of menstrual flow per cycle (4.2 vs. 8.8 days, p < 0.0001). There was a significant improvement in quality of life scores (p < 0.0001). The rate of failure varies according to the interval of follow up from 15.6% at 6 months to 10.9% at 3 years.

CONCLUSION

Modified Foley's catheter endometrial ablation is a cost effective alternative to other thermal endometrial ablation techniques in the treatment of abnormal uterine bleeding in low resource settings.

Hysterectomy or a minimal invasive alternative? A systematic review on quality of life and satisfaction

Nowadays, an increasing number of minimal invasive treatment alternatives to hysterectomy may be offered to the patient. In determining the appropriate treatment option, the patient has a distinct dilemma if a minimal invasive treatment with lesser effect than hysterectomy should be chosen or if a hysterectomy should be chosen which is a major surgery and requires longer recovery than the minimal invasive alternative. Quality-of-life (QoL) questionnaires that take subjective health perception into account are currently used to assess the treatment effects. The objective of this literature study is to determine and discuss the role of QoL as an outcome in randomized controlled trials (RCT) or systematic reviews of RCTs that study the treatment effect of hysterectomy compared to that of minimal invasive alternatives. A systematic literature search was performed in the PubMed database and in the Cochrane database to find randomized trials and systematic reviews of randomized trials, comparing hysterectomy with minimal invasive or conservative treatment options with sufficient follow-up using satisfaction, health status, and quality of life as outcomes. The results were based on nine randomized trials and two systematic reviews. The differences are mostly in favor of hysterectomy. In two out of four studied treatment alternatives, the satisfaction or health status is different in favor of hysterectomy while the QoL is equivalent. After 2 years of follow-up, differences between both groups have disappeared, possibly because of the crossover effect. Possible reasons for the lesser response of QoL compared to satisfaction or health status are discussed. The fundamental question if patients have a better quality of life at all times if they choose for a minimal invasive alternative of hysterectomy remains unresolved. Information, individualization, and freedom of choice before surgery probably best serve the sense of well being and quality of life thereafter.

Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients

OBJECTIVE

To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding.

DESIGN

Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction.

DATA SOURCES

Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment.

RESULTS

At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis.

CONCLUSIONS

More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

Microwave endometrial ablation for menorrhagia

Sixteen women requesting surgical treatment of menorrhagia were recruited for a study on microwave endometrial ablation. The mean age at treatment was 41.4 years and all patients had completed their family and were pre-menopausal. Average treatment time was 2 minutes 6 seconds. All patients reported a reduction in their menstrual loss and 87.5% were satisfied with their treatment after 1 year follow-up. One patient required overnight admission for analgesia while 15 patients were treated on a day case basis using light general anaesthesia. Sixty-seven per cent of patients reported a reduction in dysmenorrhoea scores at 1 year, two patients reported no change in symptoms and one patient reported a modest increase. One patient had a hysterectomy 10 months after treatment despite being amenorrhoeic. The indication for hysterectomy was pelvic pain (which was present before endometrial ablation). There were few minor complications but no uterine perforation or emergency hysterectomies.

Clinical outcomes from a randomised comparison of Microwave Endometrial Ablation with Thermal Balloon endometrial ablation for the treatment of heavy menstrual bleeding

OBJECTIVE

To compare the clinical outcomes of microwave endometrial ablation and thermal balloon ablation for the treatment of heavy menstrual bleeding.

DESIGN

A double blind randomised controlled trial.

SETTING

A UK teaching hospital.

POPULATION

Three hundred and twenty women requesting endometrial ablation.

METHODS

Operative data collection and patient completed postal questionnaires were used to ascertain women's satisfaction with outcome, acceptability of each procedure, changes in menstrual symptoms and health related quality of life and additional treatments received.

MAIN OUTCOME MEASURES

Primary outcomes were satisfaction and menstrual scores 1 year. Secondary outcomes were operative differences, acceptability of treatment and changes in health related quality of life.

RESULTS

Both technologies achieved high levels of satisfaction (-1%, 95% CI (-11, 9)). Menstrual scores were also similar (4%, 95% CI (-7, 19)) Microwave had a significantly shorter operating time, reduced usage of antiemetics and opiate analgesia, increased discharge by 6 hours and fewer device failures.

CONCLUSIONS

Both treatments are acceptable to women, with high levels of satisfaction. Microwave is quicker to perform with faster hospital discharge.

A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium: follow up at a minimum of 10 years

OBJECTIVE

To compare outcomes and further operations at a minimum of 10 years following microwave endometrial ablation (MEA) or transcervical resection of the endometrium (TCRE).

DESIGN

Follow up of a randomised controlled trial using postal questionnaires and operative databank review.

SETTING

Gynaecology department of a large UK teaching hospital.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, menstrual symptoms, changes in health-related quality of life, and additional treatments received.

RESULTS

One-hundred and eighty-nine of the original 263 women returned questionnaires (72%) after a minimum of 10 years post-treatment. Those totally or generally satisfied with treatment numbered 77/129 (60%) in the microwave arm and 70/134 (52%) in the resection arm, the difference is not statistically significant. Bleeding and pain scores were highly significantly reduced and similar following both MEA and TCRE, achieving amenorrhoea rates of 83 and 88% respectively. The hysterectomy rate after 10 years was significantly different with 22 (17%) in the MEA and 38 (28%) in the TCRE arm (95% CI: -0.21, -0.13).

CONCLUSIONS

Both techniques achieve significant and comparable improvements in menstrual symptoms, health-related quality of life and high rates of satisfaction. With the known operative advantages, lower costs and fewer hysterectomies, it is clear that MEA is a more effective and efficient treatment for heavy menstrual loss than TCRE.

Prediction of treatment outcomes after global endometrial ablation

OBJECTIVE

To report rates of amenorrhea and treatment failure after global endometrial ablation and to estimate the association between patient factors and these outcomes by developing and validating prediction models.

METHODS

From January 1998 through December 2005, 816 women underwent global endometrial ablation with either a thermal balloon ablation or radio frequency ablation device; 455 were included in a population-derived cohort (for model development), and 361 were included in a referral-derived cohort (for model validation). Amenorrhea was defined as cessation of bleeding from immediately after ablation through at least 12 months after the procedure. Treatment failure was defined as hysterectomy or reablation for patients with bleeding or pain. Logistic and Cox proportional hazard regression models were used in model development and validation of potential predictors of outcomes.

RESULTS

The amenorrhea rate was 23% (95% confidence interval [CI] 19-28%) and the 5-year cumulative failure rate was 16% (95% CI 10-20%). Predictors of amenorrhea were age 45 years or older (adjusted odds ratio [aOR] 2.6, 95% CI 1.6-4.3); uterine length less than 9 cm (aOR 1.8, 95% CI 1.1-3.1); endometrial thickness less than 4 mm (aOR 2.7, 95% CI 1.2-6.3); and use of radio-frequency ablation instead of thermal balloon ablation (aOR 2.8, 95% CI 1.7-4.9). Predictors of treatment failure included age younger than 45 years (adjusted hazard ratio [aHR] 2.6, 95% CI 1.3-5.1); parity of 5 or greater (aHR 6.0, 95% CI 2.5-14.8); prior tubal ligation (aHR 2.2, 95% CI 1.2-4.0); and history of dysmenorrhea (aHR 3.7, 95% CI 1.6-8.5). After global endometrial ablation, 23 women (5.1%, 95% CI 3.2-7.5%) had pelvic pain, three (0.7%, 95% CI 0.1-1.9%) were pregnant, and none (95% CI 0-0.8%) had endometrial cancer.

CONCLUSION

Population-derived rates and predictors of treatment outcomes after global endometrial ablation may help physicians offer optimal preprocedural patient counseling.

LEVEL OF EVIDENCE

II.

Abnormal uterine bleeding: a review of patient-based outcome measures

OBJECTIVE

To summarize and evaluate the patient-based outcome measures (PBOMs) that have been used to study women with abnormal uterine bleeding (AUB).

DESIGN

Systematic review.

SETTING

Original articles that used at least one PBOM and were conducted within a population of women with AUB.

PATIENT(S)

Women with AUB.

INTERVENTION(S)

The titles, abstracts, and studies were systematically reviewed for eligibility. The PBOMs used in eligible studies were summarized. Essential psychometric properties were identified, and a list of criteria for each property was generated.

MAIN OUTCOME MEASURE(S)

"Quality" of individual PBOMs as determined using the listed criteria for psychometric properties.

RESULT(S)

Nine hundred eighty-three studies referenced AUB and patient-reported outcomes. Of these, 80 studies met the eligibility criteria. Fifty different instruments were used to evaluate amount of bleeding, bleeding-related symptoms, or menstrual bleeding-specific quality of life. The quality of each of these instruments was evaluated on eight psychometric properties. The majority of instruments had no documentation of reliability, precision, or feasibility. There was no satisfactory evidence that any one instrument completely addressed all eight psychometric properties.

CONCLUSION(S)

Studies of women with AUB are increasingly using PBOMs. Many different PBOMs were used; however, no single instrument completely addressed eight important measurement properties.

First-generation endometrial ablation: roller-ball vs loop vs laser

Hysteroscopic guided or first generation endometrial ablation methods include transcervical endometrial resection, and rollerball and laser ablation. These techniques have been shown to be effective and safe alternatives to hysterectomy for dysfunctional uterine bleeding resulting in reduction in menstrual blood loss and dysmenorrhoea, correction of anaemia and improvement in quality of life. Compared with hysterectomy, treatment is associated with lower morbidity, shorter hospitalisation and faster recovery, and reduced treatment costs. As a result, the 1st generation ablation techniques are recognized as the "gold standard" ablation methods. There are many similarities between the three techniques with respect to surgical principles and effectiveness. Certainly, menstrual improvement and patient satisfaction are similar with all three methods. In contrast, the complication profile of the three techniques is different, but surgical experience is arguably a much more important arbiter of patient safety than the technique itself.

Current treatment options for abnormal uterine bleeding: an evidence-based approach

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.

Second-generation endometrial ablation – an overview

Various methods exist to destroy the endometrium as a treatment for menorrhagia. This chapter discusses the rationale, evidence, indications, and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with the existing alternative treatments.

Long-term outcome of hysteroscopic endometrial ablation without endometrial preparation

OBJECTIVE

To describe the three-step hysteroscopic endometrial ablation (EA) technique without endometrial preparation, and its long-term outcomes.

STUDY DESIGN

Four hundred and thirty-eight premenopausal women with menorrhagia or menometrorrhagia underwent three-step hysteroscopic EA, which consists of rollerball ablation of the fundus and cornual regions, a cutting loop endomyometrial resection of the rest of the cavity, and rollerball redessication of the whole pre-ablated uterine cavity. The main outcome measures were menstrual status, level of satisfaction with the procedure, and the need for repeat ablation or hysterectomy. Questionnaires were completed for 385 women (87.9%) with a mean follow-up of 48.2 months.

RESULTS

One hundred and eighty-four responders (47.8%) reported amenorrhea; 177 (46%) had light to normal flow. One patient (0.3%) underwent repeat ablation and 20 (5.2%) underwent hysterectomy: 15 (3.9%) because of endometrial ablation failure and 5 (1.3%) because of indications unrelated to the ablation (three cases of atypical endometrial hyperplasia and two cases of fibroids). Two hundred and ninety-two patients (75.8%) were very satisfied, and 78 (20.3%) satisfied with the results. No major complications occurred and three women (0.8%) became pregnant during the follow-up period.

CONCLUSIONS

EA is safe and effective means of treating of menorrhagia and menometrorrhagia in premenopausal women, and helps avoid hysterectomy in 95% of patients suffering from heavy bleeding, with or without uterine fibroids. Women should be informed that the procedure is not contraceptive and that pregnancy is possible after treatment.

Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.

Health technology assessment of surgical therapies for benign gynaecological disease

This chapter summarises the evidence of the benefits and harm of surgical therapies for benign gynaecological disease. We have limited the discussion in this chapter to three gynaecological conditions - menorrhagia, endometriosis and benign ovarian tumours - with a further section on the different surgical approaches for performing a hysterectomy for menorrhagia due to dysfunctional uterine bleeding and pelvic masses such as fibroids and benign adnexal masses. The currently available evidence suggests that there is little to choose between the four first-generation endometrial destruction techniques - laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards to the comparison of the different second-generation endometrial-destruction techniques but current evidence suggests that bipolar radiofrequency ablation is more effective than thermal balloon ablation for treating menorrhagia. Overall, the second-generation techniques are at least as effective as first-generation methods but are easier to perform and can be done under local rather than general anaesthesia in some circumstances. Hysteroscopic endometrial ablation is an alternative to hysterectomy and should be offered to women with menorrhagia because of its high satisfaction rates, shorter operation time, shorter hospital stay, earlier recovery and reduced postoperative complications; hysterectomy remains the surgical option of choice for women with intractable menorrhagia despite repeated endometrial ablations and for those who do not wish under any circumstances to continue to have menstrual bleeding. The combined use of laparoscopic laser ablation, adhesiolysis and uterine nerve ablation has been shown to have a beneficial effect on pelvic pain associated with mild to moderate endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal and mild endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The current available evidence suggests that the laparoscopic approach is superior to laparotomy for the surgical management of benign ovarian cysts. It results in less postoperative pain and a shorter postoperative hospital stay; it also costs less. With regards to the surgical approach for performing a hysterectomy for menorrhagia and benign pelvic masses, vaginal hysterectomy should be performed over laparoscopic and abdominal hysterectomy when possible. Where it is not possible to perform the hysterectomy vaginally, then laparoscopic hysterectomy can be employed instead of abdominal hysterectomy to avoid a laparotomy scar. There appears to be no significant advantage in performing a subtotal hysterectomy instead of the total removal of the uterine corpus and cervix.

Endometrial Ablation: Where Have We Been? Where Are We Going?

Endometrial ablation (EA) is targeted destruction of the endothelial surface of the uterine cavity. The procedure was originally designed as a less invasive alternative to hysterectomy for the symptom of heavy menstrual bleeding unrelated to structural pathology of the uterus, that was not responsive to medical therapy. More recently it has become apparent that the procedure can be performed in the presence of submucous leiomyomas, providing they meet a number of size and location criteria. The first EA serie as published in Germany in the 1930s, but the procedure did not attract much attention until the latter part of the 20th century. Currently, EA can be performed under endoscopic direction with the neodymium:yttrium alumnum garnet laser, with a radiofrequency resectoscope, or with an expanding array of nonresectoscopic EA systems. It is apparent that most but not all of the complications associated with resectoscopic endometrial ablation are eliminated with nonresectoscopic endometrial ablation, but serious morbidity has been reported with all of the newer systems to date. Success and patient satisfaction seem to be enduring in the majority of well-selected patients treated in clinical trials, but repeat surgery, usually hysterectomy, is performed in 25% to 40% by 5 years after surgery. Increased efficiencies should be realized if the procedure could be moved to an office setting.

Indications and options for endometrial ablation

Endometrial ablation is an effective therapeutic option for the management of menorrhagia in properly selected patients. Hysteroscopic and non-hysteroscopic techniques offer similar rates of symptom relief and patient satisfaction.

Managing drug-resistant essential menorrhagia without hysterectomy

Menorrhagia is a common disorder that requires plenty of resources. Rapid developments in medical technology have resulted in new management strategies, which are true alternatives to hysterectomy. In many countries the levonorgestrel-releasing intrauterine system (LNG-IUS) and endometrial destruction techniques are available for menorrhagia. Clinicians must answer questions about cost, effectiveness and quality of medical care when choosing the treatment option. This review integrates the results from the latest studies and review articles about LNG-IUS and endometrial destruction techniques by addressing the key clinical issues in menorrhagia. Both LNG-IUS and endometrial ablation seem to be good and effective alternative options to hysterectomy. Although these treatments have relatively high failure rates, the majority of women are satisfied and the cost-effectiveness of these treatments are better than that of hysterectomy. Both treatments have their advantages and disadvantages. Thus far LNG-IUS seems to be more cost-effective than endometrial resection or hysterectomy at 5 years follow-up. However, second generation ablation techniques may offer better cost-effectiveness than the first generation techniques, but the evidence is insufficient.