Examining the Evidence
2 menorrhagia treatments: Which is better?
To compare outcomes, quality of life, and expenses for the levonorgestrel-releasing intrauterine system (LNG-IUS) versus hysterectomy in women with menorrhagia.
After 5 years, the LNG-IUS and hysterectomy groups did not differ substantially in health-related quality of life, psychosocial well-being, or satisfaction with treatment. The LNG-IUS group had significantly lower costs ($2,817 versus $4,660 per woman).
This well-executed study compared 119 women who received LNG-IUS with 117 participants who underwent hysterectomy. Follow-up visits took place at 6 months, 12 months, and 5 years after randomization. Enrollment details and 1-year follow-up data were published in 2001.1 At the time of that report, 24 women with the LNG-IUS had undergone hysterectomy (20%).
The current study presents 5-year follow-up data and reports that hysterectomy was ultimately performed in 50 women (42%) originally treated with the LNG-IUS. For comparison, note that 25% of women who undergo myomectomy and approximately 50% of those who undergo endometrial ablation present for hysterectomy within 5 years.
Unfortunately, Hurskainen et al provide no information on why the 236 women were enrolled in this protocol, except that they all had menorrhagia. Uterine fibroids and endometrial polyps, for example, cause anatomical abnormal bleeding, and thyroid dysfunction or acquired bleeding diathesis can cause functional bleeding. It would be important to learn that these conditions did not exist in the women prior to the study.
Assessing costs in practical terms
The authors translated medical and hysterectomy expenses into US dollars. However, the cost of hysterectomy in the United States is substantially higher than the figures quoted in the article. Thus, the cost-efficiency of medical therapy is even greater than this study suggests.
In assessing costs cited in the literature, each physician must decide how his or her patients compare to the study population. I suspect that only a few US populations (well-educated, non-obese) would match the women in this trial. Nevertheless, the authors offer an objective report that medical therapy is less expensive.
This study presents 3 novel facts: (1) Women who accept LNG-IUS must understand that there is a 42% chance they will need hysterectomy within 5 years; (2) the cost reduction with medical therapy in women with menorrhagia is a founded premise; and (3) health-related quality of life is improved during treatment with either medical therapy and hysterectomy.
1. Hurskainen R, Teperi J, Rissanen P, et al. Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomized trial. Lancet. 2001;357:273-277.