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.