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When surgical treatment was needed, almost all women with heavy menstrual bleeding were satisfied and had a good quality of life following keyhole surgery to remove the uterus. Slightly fewer achieve this with ablation to remove the uterine lining.
In a UK randomised trial, women given one or other treatment in NHS hospitals reported good benefits after both interventions, which also had similar, low rates of adverse effects. In total, 97% were satisfied with the effects a year after laparoscopic supracervical hysterectomy (which retains the cervix). However, 87% were also satisfied after endometrial (uterine lining) ablation, which was quicker to perform and had a faster recovery.
The study suggests that both options have advantages and could be appropriate choices for women, based on their personal preferences. While more women were satisfied with the results of their hysterectomy a year after surgery, some women may prefer to try a less invasive treatment with a quicker recovery time first.
Why was this study needed?
Surgical options for women with heavy menstrual bleeding are normally only offered after insertion of a progesterone releasing coil or other medical treatment. However, many women find that surgery is necessary.
Choices for surgery include different types of endometrial ablation, aimed at destroying the uterine lining that causes heavy menstrual bleeding, removal of fibroids if present, and hysterectomy.
Techniques available for ablation and hysterectomy have advanced in recent years. While open hysterectomy is still widely used, laparoscopic supracervical hysterectomy (which removes only the body of the uterus, leaving the cervix in place) is an option that is becoming easier to perform, avoids some of the risks to the bladder and offers quicker post-op recovery. The technology for ablation has also become simpler to use.
There have been few large-scale studies comparing newer therapies. This study was intended to compare laparoscopic supracervical hysterectomy with second-generation endometrial ablation.
What did this study do?
Researchers recruited 660 women in 31 UK hospitals into a randomised controlled trial (the HEALTH trial). Women were aged less than 50 years and had been referred for surgical treatment of heavy menstrual bleeding. All were eligible for endometrial ablation.
After randomisation, women were added to the local waiting lists for their allocated procedure. They were assessed 15 months after randomisation for satisfaction with treatment and with a condition-specific quality of life measure.
The researchers reported treatment-associated adverse events, length of procedure, time to discharge from hospital and to return to everyday activities.
Because of the nature of the treatments, the surgeons and the participants were aware of their treatment allocation. The trial was carefully conducted and biases minimised, making the results reliable. The treatments and settings were not adapted for this trial, so the results should be applicable in normal NHS practice.
What did it find?
- About 12 months after the procedure, 97% of women allocated to hysterectomy and 87% of women allocated to ablation were satisfied with their treatment (adjusted difference 9.8%, 95% confidence interval 5.1 to 14.5).
- The maximum score possible on the menorrhagia quality of life scale used (MMAS) is 100, and this was achieved in 69% of women allocated to hysterectomy and 54% of women allocated to ablation 12 months after the procedure.
- An adverse event such as infection, pain or catheterisation for longer than 72 hours affected 5% of women allocated to hysterectomy and 4% of women allocated to ablation. A further operation was necessary for 6% of women who had ablation by 15 months post-randomisation, and this was mostly hysterectomy. There was no evidence of bladder damage or complications for women having a hysterectomy.
- Women in the ablation group returned to paid work after a median of 10 days, compared with 42 days for women in the hysterectomy group.
- Women in the ablation group were discharged after an average of 3.2 hours, compared with 21.5 hours for women in the hysterectomy group.
What does current guidance say on this issue?
In a 2019 guideline, NICE says that women with heavy menstrual bleeding should first be offered a progesterone-releasing intrauterine system or other medical therapy.
Surgical options to consider if required include second-generation endometrial ablation or hysterectomy. The guideline says: “When discussing the route of hysterectomy (laparoscopy, laparotomy or vaginal) with the woman, carry out an individual assessment and take her preferences into account”.
The guidance continues: “Discuss the options of total hysterectomy (removal of the uterus and the cervix) and subtotal hysterectomy (removal of the uterus and retention of the cervix) with the woman”.
What are the implications?
The study suggests that either supracervical laparoscopic hysterectomy or endometrial ablation could be appropriate for women with heavy menstrual bleeding who require surgical intervention.
While hysterectomy provided the greatest satisfaction and a lower rate of reoperation within 12 months, it may not be the preferred first choice of all women because of the longer recovery time and duration of hospital stay.
The comparable and low rate of complications suggests a similar level of risk for the two procedures, in contrast to previous studies which found more complications after hysterectomy.
Citation and Funding
Cooper K, Breeman S, Scott NW et al. Laparoscopic supracervical hysterectomy versus endometrial ablation for women with heavy menstrual bleeding (HEALTH): a parallel-group, open-label, randomised controlled trial. Lancet. 2019;394:1425-36.
The study was funded by the NIHR Health Technology Assessment Programme (project number 12/35/23).
Bibliography
NICE. Heavy menstrual bleeding: assessment and management. NG88. London: National Institute for Health and Care Excellence; updated November 2018.
Singh S and Bougie O. HEALTH for heavy menstrual bleeding: real-world implications. Lancet. 2019;394:1390-92.
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