The levonorgestrel intrauterine system versus endometrial ablation for heavy menstrual bleeding: a cost‐effectiveness analysis

Abstract

Objective: To evaluate the costs and non-inferiority of a strategy starting with the LNG-IUS compared to endometrial ablation (EA) in the treatment of heavy menstrual bleeding (HMB).Design: Cost-effectiveness analysis from a societal perspective alongside a multicentre randomised noninferiority trial.Setting: General practices and gynaecology departments in the Netherlands.Population: 270 women with HMB, aged ≥34 years old, without intracavitary pathology or future child wish.Methods: Randomisation to a strategy starting with the LNG-IUS (n=132) or EA (n=138). The incremental cost-effectiveness ratio (ICER) was estimated.Main outcome measures: Direct medical costs and (in)direct non-medical costs were calculated. The primary outcome was menstrual blood loss after 24 months, measured with the mean Pictorial Blood Assessment Chart (PBAC)-score (non-inferiority margin 25 points). A secondary outcome was successful blood loss reduction (PBAC-score ≤75 points).Results: Total costs per patient were €2,285 in the LNG-IUS strategy and €3,465 in the EA strategy (difference: €1,180). At 24 months mean PBAC-scores were 64.8 in the LNG-IUS group (N=115) and 14.2 in the EA group (N=132); difference 50.5 points (95% CI: 4.3-96.7). In the LNG-IUS group, 87% of women had a PBAC-score ≤75 points versus 94% in the EA group (RR 0.93, 95% CI: 0.85-1.01). The ICER was €23 (95% CI: €5-€111) per PBAC-point. Conclusions:A strategy starting with the LNG-IUS was cheaper than starting with EA, but non-inferiority could not be demonstrated. The LNG-IUS is reversible and less invasive and can be a cost-effective treatment option, depending on the success rate women are willing to accept.

Nonsurgical treatment options for heavy menstrual bleeding

“…Few studies have been performed on patient preference and the treatment for HMB. Van den Brink et al evaluated patient preference for the LNG-IUS compared to the endometrial ablation (EA) (van den Brink et al, 2018). In a discrete choice experiment, a treatment without hormones had the most influence on women's decision.…”

“…Professionals should be aware of this and inform patients about hormone-related side effects (Dutton Kai, 2023). The treatment preferences of women in primary care seem to differ from those of women referred to the gynaecologist (van den Brink et al, 2018). The general practitioner (GP) is mostly the first professional with whom women share their complaints of HMB.…”

“…Most women received hormonal treatment (46%) within three months after diagnosis, but just as large a group (44%) received no medication at all. The LNG-IUS was prescribed only in 2.4% of the women (van den Brink et al, 2017).…”

“…In case of normal anatomy of the uterus, treatment options involve hormonal or nonhormonal drugs (including levonorgestrel releasing intra-uterine systems; LNG-IUS), endometrial ablation and hysterectomy. Hysterectomy seems to be most cost-effective treatment (Roberts et al, 2011;Spencer et al, 2017). Moreover, treatment of HMB starting with LNG-IUS seems to be cheaper but slightly less effective than endometrial ablation .…”

“…In general, the main advantage of pharmacological treatment is the reversibility and therefore the eligibility for women, independent of age and future child-wish. However, women seem to become more critical to take hormones for cycle regulation (van den Brink et al, 2018). From this perspective, following the scientific results of non-surgical treatment for HMB, the dilemmas experienced by women and doctors will be discussed.…”