The Combined Use of Endometrial Ablation or Resection and Levonorgestrel-Releasing Intrauterine System in Women With Heavy Menstrual Bleeding: A Systematic Review

Heavy menstrual bleeding (HMB) affects approximately 10% to 30% of women of reproductive age and is often treated conservatively with insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) or endometrial ablation/ resection (EA). The LNG-IUS induces atrophy of endometrial tissue, whereas EA is a minimally invasive, uteruspreserving procedure that destroys endometrial tissue and superficial myometrium. Approximately 12% to 25% of the women require reintervention with additional surgery 2 to 5 years after EA treatment. Treatment failure after EA presents with persistent or recurrent vaginal bleeding thought to occur because of ongoing bleeding from areas of untreated or regenerated endometrium and can require hysterectomy. Introduction of an LNG-IUS after EA could suppress regeneration and nonablated endometrial tissue resulting in a reduction of symptoms and lower hysterectomy rate. This systematic review aimed to determine whether combined treatment with LNG-IUS insertion immediately after EA can lower the reintervention rate among women with HMB. A systematic search was conducted using the Medline, EMBASE, and Cochrane Library databases from inception through September 16, 2020. Studies reporting the results of this combined treatment with orwithout a control group were included. The primary study outcome was hysterectomy rate after treating with EA and LNG-IUS. Secondary outcomes included reintervention rate, reasons why women required additional treatment, removal rate of LNG-IUS, bleeding pattern, patient satisfaction, and adverse events. Included studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for nonrandomized cohort studies. A total of 7 studies were included in this systematic review, of which 4 were historic cohort studies with a control group, 2 were historic cohort studies without a control group, and 1 was case series. A total of 747 women were included, 472 of whom were treated withEA and LNG-IUS, with a follow-up duration between 6 and 55.2 months. The 4 controlled studies showed a hysterectomy rate in the combined treatment group between 0% and 11%, whereas treatment with EA alone showed a rate between 9.4% and 24%. The 4 studies investigating nonhysteroscopic EA plus LNG-IUS showed hysterectomy rates between 0% and 1%. Four studies reported reintervention rates, with 3 controlled studies showing a lower reintervention rate among the combined treatment cohort (0%8.7%) compared with the EA alone cohort (19%-29.2%). Reintervention rate was significantly lower at 12 and 24 months after combined treatment compared with EA alone. Patient satisfaction was reported in 3 studies, with satisfaction rates in favor of the combined treatment group. The adverse event rate associated with LNG-IUS after combined treatment resulting in removal was 1.6%. The results of this review show that hysterectomy rate after combined treatment with EA and LNG-IUS seems to vary between 0% and 11% compared with a rate between 9.4% and 24% associated with EA alone. The complication rate between the 2 management options seemed the same, whereas the bleeding profile and patient satisfaction both favored the combined treatment group. The data from included studies are limited by its observational nature with low methodological quality, and high-quality prospective research is necessary to guide clinical decision-making regarding HMB management.