Marjoribanks J, Lethaby A, Farquhar C
Cochrane Menstrual Disorders and Subfertility Group, Obstetrics and Gynaecology, University of Auckland, PO Box 92019, Auckland, New Zealand, 1003.
Cochrane Database Syst Rev. 2006 Apr 19(2):CD003855. doi: 10.1002/14651858.CD003855.pub2.
Heavy menstrual bleeding (HMB) significantly impairs the quality of life of many otherwise healthy women. Perception of HMB is subjective and management usually depends upon what symptoms are acceptable to the individual. Medical treatment options include oral medication 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 HMB.
In September 2005 we searched the Cochrane Menstrual Disorders and Subfertility Group trials register Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2005), MEDLINE EMBASE, Current Contents, Biological Abstracts, PsycINFO, and CINAHL. We also searched reference lists of articles retrieved and contacted pharmaceutical companies and experts in the field.
Controlled randomised trials comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials for quality and extracted data .
The eight included trials randomised 821 women. In comparisons of oral medication versus surgery, 58% of women randomised to medical treatment had received surgery by two years. Compared to oral medication, endometrial resection was significantly more effective in controlling bleeding (at four months: OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (at four months: OR 0.15, 95% CI 0.07 to 0.31) and hysterectomy resulted in significantly greater improvements in mental health (at six months p = 0.04). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates or quality of life, though adverse effects were significantly less likely with conservative surgery (OR 0.24, 95% CI 0.11 to 0.49). Two trials found conservative surgery significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38). Two other small trials with longer follow-up found no difference or favoured LNG-IUS - however in both these studies the data were skewed and fewer than two thirds of participants were analysed. Hysterectomy stopped all bleeding but caused serious complications for some women.
AUTHORS' CONCLUSIONS: Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. 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。对月经过多的认知是主观的，治疗通常取决于个体可接受的症状。药物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。
2005年9月，我们检索了Cochrane月经紊乱与生育力低下研究组试验注册库、Cochrane对照试验注册库（《Cochrane图书馆》2005年第3期）、MEDLINE、EMBASE、《现刊目次》、《生物学文摘》、PsycINFO和CINAHL。我们还检索了所获文章的参考文献列表，并联系了制药公司和该领域的专家。
比较保守手术或子宫全切术与药物治疗（口服或宫内治疗）月经过多的对照随机试验。数据收集与分析：两名评价员独立评估试验质量并提取数据。
纳入的8项试验将821名女性随机分组。在口服药物与手术的比较中，随机接受药物治疗的女性中有58%在两年内接受了手术。与口服药物相比，子宫内膜切除术在控制出血方面显著更有效（4个月时：比值比10.62，95%置信区间5.30至21.27），且产生副作用的可能性显著更小（4个月时：比值比0.15，95%置信区间0.07至0.31），子宫全切术在改善心理健康方面有显著更大的改善（6个月时p = 0.04）。在LNG-IUS与保守手术或子宫全切术的比较中，1年时满意度或生活质量方面无统计学显著差异，尽管保守手术产生不良反应的可能性显著更小（比值比0.24，95%置信区间0.11至0.49）。两项试验发现保守手术在1年时控制出血方面显著比LNG-IUS更有效（比值比3.99，95%置信区间1.53至10.38）。另外两项随访时间更长的小型试验未发现差异或更倾向于LNG-IUS——然而在这两项研究中数据存在偏倚，且分析的参与者少于三分之二。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，尤其是子宫全切术，在1年时比药物治疗更能减少月经量，但LNG-IUS在改善生活质量方面似乎同样有效。长期比较的证据薄弱且不一致。口服药物长期适合少数女性使用。
