Surgery versus medical therapy for heavy menstrual bleeding

Cindy Farquhar, Ann Lethaby

Almost a third of women are affected by heavy menstrual bleeding (menorrhagia), and this can seriously impair their quality of life. For women who have not completed their families, treatment needs to reduce blood flow without destroying fertility. Medical therapies that preserve fertility include LNG-IUS, a device placed inside the uterus that releases the hormone progestogen. As well as suppressing blood flow, LNG-IUS provides contraception, and fertility returns when the device is removed.

Oral medications such as antifibrinolytic drugs, non-steroid anti-inflammatory drugs, progestogen or danazol can also be used to reduce heavy menstrual bleeding, with no impact on fertility. However, potential side effects with most forms of oral medication make them more suitable as a short-term solution. Surgery to remove the uterus (hysterectomy) permanently stops menstrual bleeding, but results in infertility. Surgery to reduce the lining of the uterus (ablation) will also reduce blood flow, but fertility can be destroyed in the process.

A review of trials found that surgery or LNG-IUS are effective in reducing heavy menstrual bleeding, and suit most women better than oral medication. The LNG-IUS system improves the quality of life of women with menorrhagia as effectively as surgical treatment, but with the added benefit of preserving fertility. Although all treatments reviewed have potential side effects, hysterectomy is more likely to cause serious complications, and results in permanent loss of fertility.

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