Cochrane for Clinicians

Putting Evidence into Practice

Surgery vs. Medical Therapy for Heavy Menstrual Bleeding


Am Fam Physician. 2017 Jul 1;96(1):24-25.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is surgery more effective than medical treatment for heavy menstrual bleeding?

Evidence-Based Answer

In women of reproductive age with chronic heavy menstrual bleeding, hysterectomy is the most effective treatment for controlling symptoms. Conservative surgery is more effective for controlling bleeding symptoms at one and two years than oral medications or the levonorgestrel-releasing intrauterine system, but by five years there is no difference. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.) Patient acceptability of treatment and rates of adverse effects were similar among the various treatment options, although more severe adverse effects were associated with hysterectomy.1

Practice Pointers

Heavy menstrual bleeding, defined as a loss of 80 mL or more of menstrual blood per cycle, affects nearly one out of five women in the United States each year.2 Treatment options include complete hysterectomy, various endometrial ablation techniques, the levonorgestrel-releasing intrauterine system, and daily oral hormone medications. In this Cochrane review, the authors analyzed data from several studies to determine which treatment option is superior. The authors identified 15 randomized controlled trials including a total of 1,289 women 30 to 50 years of age who underwent surgery (hysterectomy or conservative surgery, including various methods of endometrial resection or ablation) or received medical therapy (oral contraceptives or levonorgestrel-releasing intrauterine system).

In the two studies evaluating surgery (i.e., hysterectomy and endometrial ablation) vs. oral medication, patients who chose surgery had greater satisfaction up to six months after. By two years, the higher level of satisfaction with endometrial ablation was still present, but by five years the satisfaction in both surgical groups was similar to that in patients treated with oral medication. By five years, though, more than 50% of the oral

Author disclosure: No relevant financial affiliations.


show all references

1. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2016;(1):CD003855....

2. Centers for Disease Control and Prevention. Blood disorders in women: heavy menstrual bleeding. Accessed August 2, 2016.

3. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. Accessed September 6, 2016.

4. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care: A Resource Manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2014.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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