Key results
Evidence suggests that the levonorgestrel-releasing intrauterine system (LNG-IUS) is the best first-line option for reducing menstrual bleeding, while antifibrinolytics are probably the second best, and long-cycle progestogens are the third best. Because of some limitations in the evidence, we are not sure what the true effect of these first-line treatments is for the perception of improvement and satisfaction.
For second-line treatments, evidence suggests any type of hysterectomy is the best treatment for reducing bleeding, even though this is a major surgery, and resectoscopic endometrial ablation (REA) and non-resectoscopic endometrial ablation (NREA) are second and third best. We are uncertain of the true effect of the second-line treatments on amenorrhoea (absence of menstrual blood loss). Evidence suggests that minimally invasive hysterectomy results in a large increase in satisfaction, and NREA increases satisfaction, but we are uncertain of the true effect of the remaining interventions.
What is heavy menstrual bleeding?
Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with the quality of life of people who menstruate. It is very common and can affect 20% to 50% of people who menstruate during their reproductive years. There are different treatments available, each with their own pros and cons. The best treatment depends on the person's age, whether they have or want to have children, their personal preferences, and their medical history, among other things.
What did we want to find out?
We wanted to get an overview of all the published evidence on different treatments for heavy menstrual bleeding. We were most interested in finding out if the treatments were effective for reducing menstrual bleeding and for improving women's satisfaction. We also wanted to know how the treatment affected quality of life, what side effects it caused, and whether women required further treatment.
What did we do?
This study is an overview of reviews, which means we looked for published studies that synthesised the results of other studies on different treatments for heavy menstrual bleeding. Then we tried to give a broad overview of all that evidence. We analysed the certainty of the evidence based on factors like study size and methodological rigour. We categorised the treatments based on patient characteristics, including the desire (intention) for future pregnancy, failure of previous treatment or having been referred for surgery. First-line treatment included medical interventions and second-line treatment included the LNG-IUS plus surgical interventions; thus, the LNG-IUS was included in both first- and second-line treatments. We used network meta-analysis, a statistical method that compares all the interventions at the same time, to find out which treatments produced the best results for patients.
What did we find?
We found nine reviews with 104 studies, involving a total of 11,881 participants. Altogether, the data we analysed came from 85 trials and 9950 participants. The medical interventions included were: non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics (tranexamic acid), combined oral contraceptives (COC), combined vaginal ring (CVR), long-cycle and luteal oral progestogens, the LNG-IUS, ethamsylate and danazol (included only to provide indirect evidence). These were compared to placebo (sham treatment). The surgical interventions included were: open (abdominal), minimally invasive (vaginal or laparoscopic) and unspecified (or surgeon's choice of) route of hysterectomy, REA, NREA and unspecified endometrial ablation (EA).
What are the limitations of the evidence?
Our confidence in some evidence is moderate, but for most of it, our confidence is low to very low. The main reasons were because the studies were often not blinded, which means the participants knew which treatment they were receiving, and that could have changed their perception; the direct and indirect evidence was not similar enough to compare in the network; and the range of the results was too wide.
How up to date is this evidence?
The last search for reviews was in July 2021.