Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis

First and second-generation endometrial ablation devices: A network meta-analysis

OBJECTIVE

First-generation and second-generation endometrial ablation (EA) techniques, along with medical treatment and invasive surgery, are considered successful lines of management for abnormal uterine bleeding (AUB). We set out to determine the efficacy of first and second-generation ablation techniques compared with medical treatment, invasive surgery and different modalities of the EA techniques themselves.

DESIGN

Systematic review and network meta-analysis using a frequentist network.

DATA SOURCES

We searched Medline (Ovid), PubMed, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science, EBSCO and Scopus for all published studies up to 1 March 2021 using relevant keywords.

ELIGIBILITY CRITERIA

We included all randomised controlled trials (RCTs) that compared premenopausal women with AUB receiving the intervention of second-generation EA techniques.

DATA EXTRACTION AND SYNTHESIS

49 high-quality RCTs with 8038 women were included. We extracted and pooled the data and then analysed to estimate the network meta-analysis models within a frequentist framework. We used the random-effects model of the netmeta package in R (V.3.6.1) and the 'Meta-Insight' website.

RESULTS

Our network meta-analysis showed many varying results according to specific outcomes. The uterine balloon ablation had significantly higher amenorrhoea rates than other techniques in both short (hydrothermal ablation (risk ratio (RR)=0.51, 95% CI 0.37; 0.72), microwave ablation (RR=0.43, 95% CI 0.31; 0.59), first-generation techniques (RR=0.44, 95% CI 0.33; 0.59), endometrial laser intrauterine therapy (RR=0.18, 95% CI 0.10; 0.32) and bipolar radio frequency treatments (RR=0.22, 95% CI 0.15; 0.31)) and long-term follow-up (microwave ablation (RR=0.11, 95% CI 0.01; 0.86), bipolar radio frequency ablation (RR=0.12, 95% CI 0.02; 0.90), first generation (RR=0.12, 95% CI 0.02; 0.90) and endometrial laser intrauterine thermal therapy (RR=0.04, 95% CI 0.01; 0.36)). When calculating efficacy based only on calculated bleeding scores, the highest scores were achieved by cryoablation systems (p-score=0.98).

CONCLUSION

Most second-generation EA systems were superior to first-generation systems, and statistical superiority between devices depended on which characteristic was measured (secondary amenorrhoea rate, treatment of AUB, patient satisfaction or treatment of dysmenorrhoea). Although our study was limited by a paucity of data comparing large numbers of devices, we conclude that there is no evidence at this time that any one of the examined second-generation systems is clearly superior to all others.

Endometrial ablation techniques in treating menorrhagia

Menorrhagia is a frequent gynecological problem that is clinically described as excessive blood loss of 80 mL per menstrual cycle. It has the potential to lower their quality of life and to induce anemia. Medical therapy has typically been the first line of treatment; however, it is frequently ineffectual. Hysterectomy, on the other hand, is clearly 100 percent effective in stopping bleeding, but it is more expensive and can cause serious problems. So, the endometrial ablation is preferred when the endometrial layer is destroyed or removed during the procedure. To "ablate" (remove) the endometrial lining, a variety of procedures has been devised. The gold standard resectoscopic procedures (laser, transcervical endometrial resection, and rollerball) require hysteroscopic visualization of the uterus and while safe, necessitate expert surgeons. Several innovative procedures have lately been developed, the majority of which may be conducted blindly and take less time. Many nonresectoscopic procedures are still in the process of being developed, refined, and investigated. This article discusses the various techniques and procedures used in endometrial ablation, the importance of the physician using endometrial thinning agents because success rates are higher when thinning agents are used, and the importance of women understanding the complications mainly related to pregnancy. Women should be helped to make informed management decisions by discussing the risks and benefits of each treatment with their consultant. Since there are many treatment options available, with no one option being superior in all respects, patient preference and treatment preferences should be considered when deciding on management.

Variation of outcome reporting in studies of interventions for heavy menstrual bleeding: a systematic review

Background: Heavy menstrual bleeding (HMB) detrimentally effects women. It is important to be able to compare treatments and synthesise data to understand which interventions are most beneficial, however, when there is variation in outcome reporting, this is difficult. Objectives: To identify variation in reported outcomes in clinical studies of interventions for HMB. Materials and methods: Searches were performed in medical databases and trial registries, using the terms ‘heavy menstrual bleeding’, menorrhagia*, hypermenorrhoea*, HMB, “heavy period „period“, effective*, therapy*, treatment, intervention, manage* and associated MeSH terms. Two authors independently reviewed and selected citations according to pre-defined selection criteria, including both randomised and observational studies. The following data were extracted- study characteristics, methodology and quality, and all reported outcomes. Analysis considered the frequency of reporting. Results: There were 14 individual primary outcomes, however reporting was varied, resulting in 45 specific primary outcomes. There were 165 specific secondary outcomes. The most reported outcomes were menstrual blood loss and adverse events. Conclusions: A core outcome set (COS) would reduce the evident variation in reporting of outcomes in studies of HMB, allowing more complete combination and comparison of study results and preventing reporting bias. What is new? This in-depth review of past research into heavy menstrual bleeding shows that there is the need for a core outcome set for heavy menstrual bleeding.

Menstrual problems in chronic immune thrombocytopenia: A monthly challenge ‐ a cohort study and review

Immune thrombocytopenia (ITP) may cause menstrual problems. This cross‐sectional study assessed menstrual problems in premenopausal chronic ITP women by several questionnaires, including the pictorial bleeding assessment calendar (PBAC; score ≥100 indicates heavy menstrual bleeding [HMB]), and the menorrhagia multiattribute scale (MMAS). Spearman was used for assessing correlations. A literature review was performed in Pubmed. The cohort comprised 37 women (mean age 31 ± 9). A total of 29/37 (78%) had experienced clinical menstrual problems in the present or past. Of the 33 patients who returned the PBAC, 13 (39%) had a score of ≥100. The median MMAS score was 79 (IQR 60–95). The PBAC scores correlated with the MMAS. Both questionnaires were unrelated to the platelet count. Patients with a levonorgestrel intrauterine device (LNG‐IUD) had lower PBAC scores than patients with other or no hormonal therapy. MMAS scores were correlated with fatigue. The review identified 14 papers. HMB occurred in 6%–55% at ITP diagnosis and 17%–79% during disease. Menstrual symptoms influenced the quality of life, particularly in patients with a low platelet count. This explorative study suggested that HMB is frequent in women with chronic ITP despite management and platelet counts >50 *10⁹/l. An LNG‐IUD seemed to reduce blood loss significantly.

Pictorial methods to assess heavy menstrual bleeding in research and clinical practice: a systematic literature review

Background

Pictorial blood loss assessment charts (PBACs) represent the most widely used method to assess menstrual blood loss (MBL) in clinical trials. The aims of this review were to: (1) determine the diagnostic accuracy of PBACs that have been validated against the reference alkaline hematin technique; (2) categorize the pitfalls of using obsolete and nonvalidated charts; (3) provide guidelines for development of a new PBAC or use of an existing chart to measure MBL in clinical trials; and (4) consider the feasibility of using pictorial charts in primary care.

Methods

A literature review was conducted using Embase and MEDLINE databases. The review identified reports of women with self-perceived or actual heavy menstrual bleeding (HMB), bleeding disorders, abnormal uterine bleeding, leiomyomata (uterine fibroids) or endometriosis, and women undergoing treatment for HMB, as well as those with normal menstrual periods. Data were reviewed from studies that focused on the development and validation of PBACs and from those that used derivative noncertified charts to assess HMB.

Results

Nine studies reported validation of PBAC scoring systems against the alkaline hematin technique. Across these studies, the sensitivity was 58–97%, the specificity was 7.5–95.5%, the positive and negative likelihood ratios were 1.1–13.8 and 0.14–0.56, respectively, and the diagnostic odds ratio was 2.6–52.4. The cut-off score above which the diagnosis of HMB was made ranged from 50 to 185. Several modifications of these PBACs were used in other studies; however, objective confirmation of their validity was not reported. Overall, there was widespread inconsistency of chart design, scoring systems, diagnostic cut-off limits and post-treatment outcome measures.

Conclusions

PBACs are best suited to the controlled and specific environment of clinical studies, where clinical outcome parameters are defined. The current lack of standardization precludes widespread use of the PBAC in primary care.

Review registration number

PROSPERO international prospective register of systematic reviews: CRD42016030083.

Employer-perspective cost comparison of surgical treatments for abnormal uterine bleeding

Aim: To estimate direct and indirect costs of surgical treatment of abnormal uterine bleeding (AUB) from a self-insured employer's perspective. Methods: Employer-sponsored insurance claims data were analyzed to estimate costs owing to absence and short-term disability 1 year following global endometrial ablation (GEA), outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH). Results: Costs for women who had GEA are substantially less than costs for women who had either OPH or IPH, with the difference ranging from approximately $7700 to approximately $10,000 for direct costs and approximately $4200 to approximately $4600 for indirect costs. Women who had GEA missed 21.8-24.0 fewer works days. Conclusion: Study results suggest lower healthcare costs associated with GEA versus OPH or IPH from a self-insured employer perspective.

Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important cause of ill health in premenopausal women. Although surgery is often used as a treatment, a range of medical therapies are also available. Non-steroidal anti-inflammatory drugs (NSAIDs) reduce prostaglandin levels, which are elevated in women with excessive menstrual bleeding and also may have a beneficial effect on dysmenorrhoea.

OBJECTIVES

To determine the effectiveness, safety and tolerability of NSAIDs in achieving a reduction in menstrual blood loss (MBL) in women of reproductive years with HMB.

SEARCH METHODS

We searched, in April 2019, the Cochrane Gynaecology and Fertility specialised register, Cochrane Central Register of Studies Online (CENTRAL CRSO), MEDLINE, Embase, PsycINFO, the clinical trial registries and reference lists of articles.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of individual NSAIDs or combined with other medical therapy with each other, placebo or other medical treatments in women with regular heavy periods measured either objectively or subjectively and with no pathological or iatrogenic (treatment-induced) causes for their HMB.

DATA COLLECTION AND ANALYSIS

We identified 19 randomised controlled trials (RCTs) (759 women) that fulfilled the inclusion criteria for this review and two review authors independently extracted data. We estimated odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes from the data of nine trials. We described in data tables the results of the remaining seven cross-over trials with data unsuitable for pooling, one trial with skewed data, and one trial with missing variances. One trial had no data available for analysis.

MAIN RESULTS

As a group, NSAIDs were more effective than placebo at reducing HMB but less effective than tranexamic acid, danazol or the levonorgestrel-releasing intrauterine system (LNG IUS). Treatment with danazol caused a shorter duration of menstruation and more adverse events than NSAIDs, but this did not appear to affect the acceptability of treatment, based on trials from 1980 to 1990. However, currently danazol is not a usual or recommended treatment for HMB. There was no clear evidence of difference between NSAIDs and the other treatments (oral luteal progestogen, ethamsylate, an older progesterone-releasing intrauterine system and the oral contraceptive pill (OCP), but most studies were underpowered. There was no evidence of a difference between the individual NSAIDs (naproxen and mefenamic acid) in reducing HMB. The evidence quality ranged from low to moderate, the main limitations being risk of bias and imprecision.

AUTHORS' CONCLUSIONS

NSAIDs reduce HMB when compared with placebo, but are less effective than tranexamic acid, danazol or LNG IUS. However, adverse events are more severe with danazol therapy. In the limited number of small studies suitable for evaluation, there was no clear evidence of a difference in efficacy between NSAIDs and other medical treatments such as oral luteal progestogen, ethamsylate, OCP or the older progesterone-releasing intrauterine system.

Endometrial ablation; less is more? Historical cohort study comparing long-term outcomes from two time periods and two treatment modalities for 854 women

Background

Abnormal uterine bleeding needs surgical treatment if medical therapy fails. After introduction of non-hysteroscopic endometrial ablation as alternative to hysteroscopic endometrial resection, we aimed to compare short and long-term outcomes for women treated with these two minimally-invasive procedures. A secondary goal was comparing the present cohort to a previous cohort of women treated with hysteroscopic resection only.

Materials and methods

Historical cohort study of women treated for abnormal uterine bleeding with hysteroscopic resection or endometrial ablation at Haukeland University Hospital during 2006–2014. Similar patient file and patient-reported outcome data were collected from 386 hysteroscopic resections in a previous cohort (1992–1998). Categorical variables were compared by Chi-square or Fisher´s Exact-test, linear variables by Mann-Whitney U-test and time to hysterectomy by the Kaplan-Meier method.

Results

During 2006–2014, 772 women were treated with endometrial resection or ablation, 468 women (61%) consented to study-inclusion; 333 women (71%) were treated with hysteroscopic resection and 135 (29%) with endometrial ablation.

Preoperative characteristics were significantly different for women treated with hysteroscopic resection compared to endometrial ablation in the 2006-2014-cohort and between the two time-cohorts regarding menopausal, sterilization and myoma status (p≤0.036). The endometrial ablation group had significantly shorter operation time, median 13 minutes (95% Confidence Interval (CI) 12–14) and a lower complication rate (2%) versus operation time, median 25 minutes (95% CI 23–26) and complication rate (13%) in the hysteroscopy group, all p ≤0.001. The patient-reported rate of satisfaction with treatment was equivalent in both groups (85%, p = 0.955). The endometrial ablation group had lower hysterectomy rate (8% vs 16%, p = 0.024). Patient-reported satisfaction rate was higher (85%) in the 2006-2014-cohort compared with the 1992-1998-cohort (73%), p<0.001.

Conclusions

Endometrial ablation has similar patient satisfaction rate, but shorter operation time and lower complication rate and may be a good alternative to hysteroscopic resection for treatment of abnormal uterine bleeding.