Abstract
Introduction
Menorrhagia (also known as heavy menstrual bleeding) limits normal activities, affects quality of life, and causes anaemia in two-thirds of women with objective menorrhagia (loss of 80 mL blood per cycle). Prostaglandin disorders may be associated with idiopathic menorrhagia and with heavy bleeding due to fibroids, adenomyosis, or use of intrauterine devices (IUDs). Fibroids have been found in 10% of women with menorrhagia overall and in 40% of women with severe menorrhagia; but half of women having a hysterectomy for menorrhagia are found to have a normal uterus.
Methods and outcomes
We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of surgical treatments for menorrhagia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2014 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review).
Results
At this update, searching of electronic databases retrieved 205 studies. After deduplication and removal of conference abstracts, 102 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 46 full publications. Of the 46 full articles evaluated, three systematic reviews and five RCTs were added at this update. We performed a GRADE evaluation for 30 PICO combinations.
Conclusions
In this systematic overview, we categorised the efficacy for three surgical interventions based on information about the effectiveness and safety of dilatation and curettage, endometrial destruction (resection or ablation), and hysterectomy.
Key Points
Menorrhagia (also known as heavy menstrual bleeding) limits normal activities, affects quality of life, and causes anaemia in two-thirds of women with objective menorrhagia (blood loss of 80 mL or more per cycle).
Prostaglandin disorders may be associated with idiopathic menorrhagia and with heavy bleeding caused by fibroids, adenomyosis, or use of IUDs.
Fibroids have been found in 10% of women with menorrhagia overall and in 40% of women with severe menorrhagia; but half of women having a hysterectomy for menorrhagia are found to have a normal uterus.
Hysterectomy reduces blood loss and the need for further surgery compared with medical treatments or endometrial destruction, but can lead to complications in up to one third of women. Fewer women reported overall treatment dissatisfaction with hysterectomy compared with endometrial destruction.
Endometrial destruction is more effective at reducing menorrhagia compared with medical treatment but complications can include infection, haemorrhage, and uterine perforation.
We don't know whether any one type of endometrial destruction is superior, or whether dilatation and curettage has any effect on menstrual blood loss.
Clinical context
General background
Menorrhagia (also known as heavy menstrual bleeding) is defined as excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms. Idiopathic ovulatory menorrhagia is regular, heavy bleeding in the absence of recognisable pelvic pathology or a general bleeding disorder.
Focus of the review
Menorrhagia is common and affects many women’s lives adversely. It is important to know which treatments are the most effective. This overview has concentrated on surgical treatments for menorrhagia, as little new evidence for first-line medical treatments is being generated. Previous overviews on medical interventions for menorrhagia are still available in the BMJ Clinical Evidence archive.
Comments on evidence
Many systematic reviews and RCTs exist that look at surgical interventions for menorrhagia; but when subject to GRADE evaluation, most of the evidence is of low to moderate strength only. We found no RCT evidence comparing surgical interventions with no treatment. For hysterectomy, none of the included systematic review or RCTs separated out whether ovaries were removed or conserved at the time of surgery, and this may have an effect on patient satisfaction and some of the postoperative emotional and functional outcomes.
Search and appraisal summary
The update literature search for this overview was carried out from the date of the last search, June 2011, to February 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 205 studies. After deduplication and removal of conference abstracts, 102 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 46 full publications. Of the 46 full articles evaluated, three systematic reviews and five RCTs were added at this update.
About this condition
Definition
Menorrhagia (also known as heavy menstrual bleeding) is defined as heavy, but regular, menstrual bleeding. Idiopathic ovulatory menorrhagia is regular heavy bleeding in the absence of recognisable pelvic pathology or a general bleeding disorder. Objective menorrhagia is taken to be a total menstrual blood loss of 80 mL or more in each menstruation. It is difficult to incorporate objective measurement of menstrual blood loss into everyday practice. Subjectively, menorrhagia may be defined as a complaint of regular excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms.
Incidence/ Prevalence
In the UK, 5% of women aged 30 to 49 years consult their general practitioners each year with menorrhagia. In New Zealand, 2% to 4% of primary-care consultations by premenopausal women are for menstrual problems. It is a common cause of referral to secondary care.
Aetiology/ Risk factors
Idiopathic ovulatory menorrhagia is thought to be caused by disordered prostaglandin production within the endometrium. Prostaglandins may also be implicated in menorrhagia associated with uterine fibroids, adenomyosis, or the presence of an IUD. Fibroids have been reported in 10% of women with menorrhagia (80–100 mL/cycle) and in 40% of women with severe menorrhagia (at least 200 mL/cycle).
Prognosis
Menorrhagia limits normal activities, affects quality of life, and causes iron-deficiency anaemia in two-thirds of women shown to have objective menorrhagia. One in five women in the UK, and one in three in the US, have a hysterectomy before the age of 60 years; menorrhagia is the main presenting problem in at least half of these women. About half of women who have a hysterectomy for menorrhagia are found to have an anatomically normal uterus, although this does not mean intervention was not warranted. Data suggest that hysterectomy rates are falling, perhaps due to the widespread introduction of endometrial destruction procedures or intrauterine progestogens.
Aims of intervention
To reduce menstrual bleeding; improve quality of life; and prevent or correct iron-deficiency anaemia with minimal adverse effects.
Outcomes
Menstrual blood loss (assessed objectively [mL/cycle] or subjectively), including rates of amenorrhoea; anaemia, primarily measured by haemoglobin concentration; patient satisfaction; quality of life; need for re-treatment; intraoperative and postoperative complications; postoperative recovery; and adverse effects. Whether a particular percentage reduction in menstrual blood loss is considered clinically important will depend on pretreatment menstrual loss and on individual women's perceptions of acceptable menstrual loss. Women may regard amenorrhoea as a benefit or a harm of treatment, depending on their perspective.
Methods
Search strategy BMJ Clinical Evidence search and appraisal February 2014. Databases used to identify studies for this systematic review include: Medline 1966 to February 2014, Embase 1980 to February 2014, The Cochrane Database of Systematic Reviews 2014, issue 1 (1966 to date of issue), the Database of Abstracts of Reviews of Effects (DARE), and the Health Technology Assessment (HTA) database. Inclusion criteria Study design criteria for inclusion in this review were systematic reviews and RCT published in English, at least single-blinded (where possible, because blinding is difficult when comparing different modalities, such as surgical versus medical, and therefore open studies were included in these scenarios), and studies containing 10 or more individuals in each treatment arm, of whom more than 80% were followed up. There was no minimum length of follow-up. BMJ Clinical Evidence does not necessarily report every study found (e.g., every systematic review). Rather, we report the most recent, relevant and comprehensive studies identified through an agreed process involving our evidence team, editorial team, and expert contributors. Evidence evaluation A systematic literature search was conducted by our evidence team, who then assessed titles and abstracts, and finally selected articles for full text appraisal against inclusion and exclusion criteria agreed a priori with our expert contributors. In consultation with the expert contributors, studies were selected for inclusion and all data relevant to this overview extracted into the benefits and harms section of the overview. In addition, information that did not meet our predefined criteria for inclusion in the benefits and harms section, may have been reported in the 'Further information on studies' or 'Comment' section. Adverse effects All serious adverse effects, or those adverse effects reported as statistically significant, were included in the harms section of the overview. Pre-specified adverse effects identified as being clinically important were also reported, even if the results were not statistically significant. Although BMJ Clinical Evidence presents data on selected adverse effects reported in included studies, it is not meant to be, and cannot be, a comprehensive list of all adverse effects, contraindications, or interactions of included drugs or interventions. A reliable national or local drug database must be consulted for this information. Comment and Clinical guide sections In the Comment section of each intervention, our expert contributors may have provided additional comment and analysis of the evidence, which may include additional studies (over and above those identified via our systematic search) by way of background data or supporting information. As BMJ Clinical Evidence does not systematically search for studies reported in the Comment section, we cannot guarantee the completeness of the studies listed there or the robustness of methods. Our expert contributors add clinical context and interpretation to the Clinical guide sections where appropriate. Data and quality To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). BMJ Clinical Evidence does not report all methodological details of included studies. Rather, it reports by exception any methodological issue or more general issue that may affect the weight a reader may put on an individual study, or the generalisability of the result. These issues may be reflected in the overall GRADE analysis. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table.
GRADE Evaluation of interventions for Menorrhagia.
| Important outcomes | Anaemia, Intraoperative and postoperative complications, Menstrual blood loss, Need for re-treatment, Patient satisfaction, Postoperative recovery, Quality of life | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of surgical treatments for menorrhagia? | |||||||||
| 1 (72) | Menstrual blood loss | Hysterectomy versus intrauterine progestogens | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for unclear clinical importance |
| 3 (536) | Anaemia | Hysterectomy versus intrauterine progestogens | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for high switch rates to surgery |
| 1 (232) | Patient satisfaction | Hysterectomy versus intrauterine progestogens | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for high switch rates to surgery |
| 3 (at least 308) | Quality of life | Hysterectomy versus intrauterine progestogens | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting; directness point deducted for high switch rates to surgery |
| at least 4 (at least 650) | Menstrual blood loss | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 5 (at least 836) | Patient satisfaction | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 4 (at least 513) | Quality of life | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods; directness point deducted for inconsistent results depending on analysis undertaken |
| at least 6 (at least 930) | Need for re-treatment | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | 0 | 0 | +2 | High | Quality point deducted for weak methods. Effect size points added for RR 11 to 36 |
| at least 5 (at least 858) | Intraoperative and postoperative complications | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods. |
| at least 7 (at least 1066) | Postoperative recovery | Hysterectomy versus endometrial destruction (resection or ablation) | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for weak methods; consistency point deducted for statistical heterogeneity |
| at least 6 (at least 385) | Menstrual blood loss | Endometrial destruction (resection or ablation) versus intrauterine progestogens | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for incomplete reporting of results; consistency point deducted for conflicting results; directness point deducted for study involving mainly women <40 years |
| 1 (33) | Anaemia | Endometrial destruction (resection or ablation) versus intrauterine progestogens | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| at least 6 (at least 378) | Patient satisfaction | Endometrial destruction (resection or ablation) versus intrauterine progestogens | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and weak methods (baseline differences, lack of standardisation of outcome) |
| 3 (210 at most) | Quality of life | Endometrial destruction (resection or ablation) versus intrauterine progestogens | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results; consistency point deducted for conflicting results |
| at least 3 (at least 194) | Need for re-treatment | Endometrial destruction (resection or ablation) versus intrauterine progestogens | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (187) | Menstrual blood loss | Endometrial destruction (resection or ablation) versus oral medical treatments (NSAIDs, tranexamic acid, combined oral contraceptive, oral progestogens) | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for range of drugs in comparison |
| at least 12 (at least 1985) | Menstrual blood loss | First-generation versus second-generation techniques | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for weak methods; consistency point deducted for statistical heterogeneity |
| at least 11 (at least 1690) | Patient satisfaction | First-generation versus second-generation techniques | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for weak methods; consistency point deducted for statistical heterogeneity |
| at least 7 (at least 1028) | Need for re-treatment | First-generation versus second-generation techniques | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 8 (at least 1885) | Intraoperative and postoperative complications | First-generation versus second-generation techniques | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 3 (at least 398) | Menstrual blood loss | Different first-generation techniques versus each other | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods; directness point deducted for small number of comparators |
| 3 (462) | Patient satisfaction | Different first-generation techniques versus each other | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods; directness point deducted for small number of comparators |
| at least 3 (at least 438) | Need for re-treatment | Different first-generation techniques versus each other | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods; directness point deducted for small number of comparators |
| 2 (486) | Intraoperative and postoperative complications | Different first-generation techniques versus each other | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods; directness point deducted for small number of comparators |
| at least 6 (at least 758) | Menstrual blood loss | Different second-generation techniques versus each other | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 4 (at least 658) | Patient satisfaction | Different second-generation techniques versus each other | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 3 (at least 438) | Quality of life | Different second-generation techniques versus each other | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 5 (at least 495) | Need for re-treatment | Different second-generation techniques versus each other | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| at least 3 (at least 329) | Intraoperative and postoperative complications | Different second-generation techniques versus each other | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for weak methods |
| 2 (181) | Postoperative recovery | Different second-generation techniques versus each other | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and weak methods |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
- European Quality of Life (Euroqol)–5 Dimensions (EQ–5D)
A descriptive system of health-related quality of life states, consisting of 5 dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each of which allows one of 3 (or 5) responses. The responses record 3 (no problems, some or moderate problems, extreme problems) or 5 (no problems, slight problems, moderate problems, severe problems, or extreme problems) levels of severity.
- First-generation endometrial destruction techniques
Procedures including rollerball ablation (a hysteroscopic procedure in which endometrium is destroyed under direct vision using cautery from a electrosurgical rollerball), laser ablation (a hysteroscopic procedure in which endometrium is destroyed under direct vision by a laser beam), and transcervical endometrial resection (a hysteroscopic procedure in which endometrium is removed under direct vision by using an electrosurgical loop). All these techniques involve hysteroscopy and fluid distension of the uterus.
- High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Research and Development (RAND)-36
A widely used survey instrument designed to assess health-related quality of life. The RAND-36 comprises 36 items that assess 8 health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from 8 RAND-36 scales.
- Second-generation endometrial destruction techniques
These techniques do not require hysteroscopy and in general are techniques that are easier to learn and perform. Destruction of the endometrium is achieved via various devices using different energies, such as bipolar radiofrequency electrical energy (NovaSure); balloon ablation, which uses high-temperature fluid at high pressure within an intrauterine balloon (Thermachoice, Thermablate, and Cavaterm); hydrothermal ablation using free fluid within the uterus at high temperature (Hydro ThermAblator); microwave energy (Microsulis); and cryoablation (Her Option).
- Short Form (SF)-12
A generic, multi-purpose short form survey with 12 questions selected from the SF-36 Health Survey; the responses, when combined, scored, and weighted, result in 2 scales of mental and physical functioning and overall health-related quality of life.
- Short Form (SF)-36
A health-related quality-of-life scale across 8 domains: limitations in physical activities (physical component), limitations in social activities, limitations in usual role activities owing to physical problems, pain, psychological distress and wellbeing (mental health component), limitations in usual role activities because of emotional problems, energy and fatigue, and general health perceptions.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Fibroids (uterine myomatosis, leiomyomas)
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
References
- 1.Hallberg L, Högdahl A, Nilsson L, et al. Menstrual blood loss – a population study: variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966;45:320–351. [DOI] [PubMed] [Google Scholar]
- 2.National Institute for Health and Care Excellence. Heavy menstrual bleeding: NICE clinical guideline CG44. January 2007. Available at https://www.nice.org.uk/guidance/cg44 (last accessed 6 August 2015). [Google Scholar]
- 3.Vessey MP, Villard-Mackintosh L, McPherson K, et al. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynaecol 1992;99:402–407. [DOI] [PubMed] [Google Scholar]
- 4.Working Party of the National Health Committee New Zealand. Guidelines for the management of heavy menstrual bleeding. Wellington, New Zealand: Ministry of Health, 1998. [Google Scholar]
- 5.Bradlow J, Coulter A, Brooks P. Patterns of referral. Oxford, UK: Health Services Research Unit, 1992. [Google Scholar]
- 6.Smith SK, Abel MH, Kelly RW, et al. A role for prostacyclin (PGI2) in excessive menstrual bleeding. Lancet 1981;1:522–524. [DOI] [PubMed] [Google Scholar]
- 7.Rybo G, Leman J, Tibblin R. Epidemiology of menstrual blood loss. In: Baird DT, Michie EA, eds. Mechanisms of menstrual bleeding. New York: Raven Press, 1985:181–193. [Google Scholar]
- 8.Alexander DA, Naji AA, Pinion SB, et al. Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects. BMJ 1996;312:280–284. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Coulter A, Peto V, Jenkinson C. Quality of life and patient satisfaction following treatment for menorrhagia. Fam Pract 1994;11:394–401. [DOI] [PubMed] [Google Scholar]
- 10.Lukes AS, Baker J, Eder S, et al. Daily menstrual blood loss and quality of life in women with heavy menstrual bleeding. Womens Health (Lond Engl) 2012;8:503–511. [DOI] [PubMed] [Google Scholar]
- 11.Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988;27:987–994. [DOI] [PubMed] [Google Scholar]
- 12.Pokras R, Hufnagel VG. Hysterectomies in the United States. Vital Health Stat Series 13 1987;92:1–32. [PubMed] [Google Scholar]
- 13.Coulter A, Kelland J, Long A. The management of menorrhagia. Effective Health Care Bull 1995;9:1–14. [Google Scholar]
- 14.Clarke A, Black N, Rowe P, et al. Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study. Br J Obstet Gynaecol 1995;102:611–620. [DOI] [PubMed] [Google Scholar]
- 15.Reid PC, Mukri F. Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002–3. BMJ 2005;330:938–939. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Smith JJ, Schulman H. Current dilatation and curettage practice: a need for revision. Obstet Gynecol 1985;65:516–518. [PubMed] [Google Scholar]
- 17.Haynes PJ, Hodgson H, Anderson AB, et al. Measurement of menstrual blood loss in patients complaining of menorrhagia. Br J Obstet Gynaecol 1977;84:763–768. [DOI] [PubMed] [Google Scholar]
- 18.Lethaby AE, Cooke I, Rees M. Progesterone/progestogen intrauterine releasing systems for heavy menstrual bleeding. In: The Cochrane Library, Issue 1, 2014. Chichester, UK: John Wiley & Sons, Ltd. Search date 2005. [Google Scholar]
- 19.Kaunitz AM, Meredith S, Inki P, et al. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol 2009;113:1104–1116. [DOI] [PubMed] [Google Scholar]
- 20.Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. In: The Cochrane Library, Issue 1, 2014. Chichester, UK: John Wiley & Sons, Ltd. Search date 2010. [Google Scholar]
- 21.Heliövaara-Peippo S, Hurskainen R, Teperi J, et al. Quality of life and costs of levonorgestrel-releasing intrauterine system or hysterectomy in the treatment of menorrhagia: a 10-year randomized controlled trial. Am J Obstet Gynecol 2013;209:535.e1–535.e14. [DOI] [PubMed] [Google Scholar]
- 22.Sesti F, Piancatelli R, Pietropolli A,et al. Levonorgestrel-releasing intrauterine system versus laparoscopic supracervical hysterectomy for the treatment of heavy menstrual bleeding: a randomized study. J Womens Health (Larchmt) 2012;21:851–857. [DOI] [PubMed] [Google Scholar]
- 23.Fergusson RJ, Lethaby A, Shepperd S, et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. In: The Cochrane Library, Issue 1, 2014. Chichester, UK: John Wiley & Sons, Ltd. Search date 2013. [DOI] [PubMed] [Google Scholar]
- 24.Middleton LJ, Champaneria R, Daniels JP, et al. Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients. BMJ 2010;341:c3929. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Carlson KJ. Outcomes of hysterectomy. Clin Obstet Gynecol 1997;40:939–946. [DOI] [PubMed] [Google Scholar]
- 26.Silva-Filho AL, Pereira Fde A, de Souza SS, et al. Five-year follow-up of levonorgestrel-releasing intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: a randomized controlled trial. Contraception 2013;87:409–415. [DOI] [PubMed] [Google Scholar]
- 27.Ghazizadeh S, Bakhtiari F, Rahmanpour H, et al. A randomized clinical trial to compare levonorgestrel-releasing intrauterine system (Mirena) vs trans-cervical endometrial resection for treatment of menorrhagia. Int J Womens Health 2011;3:207–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Lethaby A, Penninx J, Hickey M, et al. Endometrial resection and ablation techniques for heavy menstrual bleeding. In: The Cochrane Library, Issue 1, 2014. Chichester, UK: John Wiley & Sons, Ltd. Search date 2013. [DOI] [PubMed] [Google Scholar]
- 29.Chang PT, Vilos GA, Abu-Rafea B, et al. Comparison of clinical outcomes with low-voltage (cut) versus high-voltage (coag) waveforms during hysteroscopic endometrial ablation with the rollerball: a pilot study. J Minim Invasive Gynecol 2009;16:350–353. [DOI] [PubMed] [Google Scholar]
- 30.Fürst SN, Philipsen T, Joergensen JC, et al. Ten-year follow-up of endometrial ablation. Acta Obstet Gynecol Scand 2007;86:334–338. [DOI] [PubMed] [Google Scholar]
- 31.Herman MC, Penninx JP, Mol BW, et al. Ten-year follow-up of a randomised controlled trial comparing bipolar endometrial ablation with balloon ablation for heavy menstrual bleeding. BJOG 2013;120:966–970. [DOI] [PubMed] [Google Scholar]
- 32.Overton C, Hargreaves J, Maresh M. A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study. Minimally invasive surgical techniques – laser, endothermal or endoresection. Br J Obstet Gynaecol 1997;104:1351–1359. [DOI] [PubMed] [Google Scholar]