Endometrial resection / ablation techniques for heavy menstrual bleeding
Abstract
Background
Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First‐line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long‐term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of them must be considered to be still under development, requiring refinement and investigation.
Objectives
To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women.
Search methods
We searched MEDLINE, EMBASE, CINAHL, PsycInfo, the Cochrane Central Register of Controlled Trials and the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (from inception to August 2009). We also searched trial registers and other sources of unpublished or grey literature, reference lists of retrieved studies, experts in the field and made contact with pharmaceutical companies that manufactured ablation devices.
Selection criteria
Randomised controlled trials comparing different endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy.
Data collection and analysis
The two review authors independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.
Main results
In the comparison of the newer 'blind' techniques (second generation) with the gold standard hysteroscopic ablative techniques (first generation), there was no evidence of overall differences in the improvement in HMB or patient satisfaction.
Surgery was an average of 15 minutes shorter (weighted mean difference (WMD) 14.9, 95% CI 10.1 to 19.7), local anaesthesia was more likely to be employed (odds ratio (OR) 6.4, 95% CI 3.0 to 13.7) and equipment failure was more likely (OR 4.6, 95% CI 1.5 to 14.0) with second‐generation ablation. Women undergoing newer ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (OR 0.17, 95% CI 0.04 to 0.77; OR 0.32, 95% CI 0.1 to 1.0; OR 0.22, 95% CI 0.08 to 0.6 and OR 0.31, 95% CI 0.11 to 0.85, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (OR 2.4, 95% CI 1.6 to 3.9 and OR 1.8, 95% CI 1.1 to 2.8, respectively).
Authors' conclusions
Endometrial ablation techniques offer a less invasive surgical alternative to hysterectomy. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the 'gold standard' first generation techniques difficult. Most of the newer techniques are technically easier than hysteroscopy‐based methods to perform but technical difficulties with new equipment need to be ironed out. Overall, the existing evidence suggests that success rates and complication profiles of newer techniques of ablation compare favourably with hysteroscopic techniques.
PICOs
Plain language summary
Endometrial destruction techniques for heavy menstrual bleeding using the newer global ablation techniques and more established hysteroscopic techniques
Drugs or hysterectomy (removing the uterus) used to be the main option for women having problems with heavy menstrual bleeding (menorrhagia). In the last few decades, surgical techniques have been developed that remove only the lining of the uterus (endometrium). These techniques involve either cutting out the endometrium (resection) or destroying it with thermal energy from a laser, electric instruments or other devices. This review has not found that any of these procedures is better than any other in reducing heavy menstrual bleeding and satisfaction was high with all procedures. The more modern devices (second generation ablation) took less time to perform than the older first generation devices and were more likely to be performed under local anaesthesia when the woman is awake. Side effects were generally similar and mostly mild.
