Marjoribanks J, Lethaby A, Farquhar C
Obstetrics and Gynaecology, University of Auckland, National Women's Hospital, Claude Road, Epsom, Auckland, New Zealand.
Cochrane Database Syst Rev. 2003(2):CD003855. doi: 10.1002/14651858.CD003855.
Heavy menstrual bleeding significantly impairs the quality of life of many otherwise healthy women. Perception of heavy bleeding is highly subjective and management of the condition usually depends upon the degree of bleeding and discomfort found acceptable by the individual woman. Medical treatment options include oral medications and a hormone-releasing intrauterine system (LNG-IUS). Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy.
To compare the effectiveness, safety and acceptability of surgery versus medical therapy for heavy menstrual bleeding.
We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (October 2002), Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (1966 to October 2002), EMBASE (1980 to October 2002), Current Contents (1993 to week 45, 2002), Biological Abstracts (1969 to September 2002), PsycINFO (1985 to October 2002), CINAHL (1982 to October 2002), and reference lists of articles. We also contacted pharmaceutical companies and experts in the field.
Controlled randomised trials comparing surgery (conservative surgery and hysterectomy) versus medical therapy (both oral and intrauterine) for heavy menstrual bleeding
Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes.
Five trials met the inclusion criteria. They randomised 625 women, 311 to receive surgery and 314 to receive medical treatment. One trial compared endometrial resection with oral medication: surgery proved significantly more effective in controlling bleeding (OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (OR 0.15, 95% CI 0.07 to 0.31). In the other four trials the medical arms received LNG-IUS and the surgical arms received conservative surgery or hysterectomy. At one year no statistically significant difference was shown between LNG-IUS and any surgical treatment in satisfaction rates or quality of life, though conservative surgery was significantly less likely to cause adverse effects (OR 0.24, 95% CI 0.11 to 0.49). Although conservative surgery was significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38), a small trial showed no significant difference between the treatments at two and three years. Hysterectomy stopped all bleeding but caused serious complications for some women.
REVIEWER'S CONCLUSIONS: Surgery reduces menstrual bleeding at one year more than medical treatments, but LNG-IUS appears equally beneficial in improving quality of life and may control bleeding as effectively as conservative surgery over the long term. Oral medication suits a minority of women long term.
月经过多严重影响许多健康女性的生活质量。对月经过多的认知高度主观，该病的治疗通常取决于个体女性所能接受的出血程度和不适程度。医学治疗选择包括口服药物和激素释放宫内节育系统（LNG-IUS）。手术选择包括保守手术（子宫切除术或消融术）和子宫全切术。
比较手术与药物治疗月经过多的有效性、安全性和可接受性。
我们检索了Cochrane月经失调与生育力低下研究组试验注册库（2002年10月）、Cochrane对照试验注册库（2002年第3期）、MEDLINE（1966年至2002年10月）、EMBASE（1980年至2002年10月）、《现刊目次》（1993年至2002年第45周）、《生物学文摘》（1969年至2002年9月）、PsycINFO（1985年至2002年）、CINAHL（1982年至2002年）以及文章的参考文献列表。我们还联系了制药公司和该领域的专家。
比较手术（保守手术和子宫全切术）与药物治疗（口服和宫内用药）治疗月经过多的对照随机试验
两名评价员独立评估试验质量并提取数据，计算二分变量结果的比值比和连续变量结果的加权平均差。
五项试验符合纳入标准。他们将625名女性随机分组，311名接受手术，另314名接受药物治疗。一项试验比较了子宫内膜切除术与口服药物：手术在控制出血方面明显更有效（比值比10.62，95%置信区间5.30至21.27），且引起副作用的可能性明显更小（比值比0.15，95%置信区间0.07至0.31）。在其他四项试验中，药物治疗组接受LNG-IUS，手术组接受保守手术或子宫全切术。一年时，LNG-IUS与任何手术治疗在满意率或生活质量方面均未显示出统计学上的显著差异，不过保守手术引起不良反应的可能性明显更小（比值比为0.24，95%置信区间0.11至0.49）。虽然保守手术在一年时控制出血方面比LNG-IUS明显更有效（比值比3.99，95%置信区间1.53至10.38），但一项小型试验显示，两年和三年时两种治疗方法之间没有显著差异。子宫全切术可止住所有出血，但对一些女性会引起严重并发症。
手术在一年时减少月经出血比药物治疗更有效，但LNG-IUS在改善生活质量方面似乎同样有益，从长期来看，其控制出血的效果可能与保守手术一样有效。口服药物长期来看只适合少数女性。
