Clinical Question: Which is preferred in the treatment of menorrhagia: hysterectomy or the levonorgestrel-releasing intrauterine system?

Setting: Outpatient (any)

Study Design: Randomized controlled trial (nonblinded)

Synopsis: Menorrhagia is a significant worldwide health problem and the major presenting symptom in women who undergo hysterectomy. The levonorgestrel-releasing intrauterine system slowly releases a steady amount of levonorgestrel. Currently, the levonorgestrel-releasing intrauterine system is being used in Finland for the treatment of menorrhagia but is approved in the United States as a contraceptive device only.

A total of 236 Finnish women (mean age: 43 years) with menorrhagia were assigned randomly (concealed allocation assignment) to treatment with the levonorgestrel-releasing intrauterine system or hysterectomy. Ninety-six percent of the patients were followed for five years. Outcomes were self-assessed by patients not blinded to treatment assignment using prevalidated health questionnaires and surveys.

Using intention-to-treat analysis, there were no significant differences in health outcomes or overall satisfaction with care reported by the two groups after five years. Although 42 percent of women initially assigned to the levonorgestrel-releasing intrauterine system eventually underwent hysterectomy, the direct and indirect costs were lower for patients assigned to the levonorgestrel-releasing intrauterine system group than for women in the assigned hysterectomy group ($2,817 versus $4,660 per participant, respectively). Since the introduction of the levonorgestrel-releasing intrauterine system in Finland in 1998, hysterectomy rates have fallen by 13 percent.

Bottom Line: Women with menorrhagia frequently require hysterectomy for symptom relief and health satisfaction. Placement of the levonorgestrel-releasing intrauterine system results in similar outcomes for many women and is more cost-effective as an initial treatment. (Level of Evidence: 1b–)