Background
Heavy menstrual bleeding affects up to one third of women in the United States, resulting
in a reduced quality of life and significant cost to the health care system. Multiple
treatment options exist, offering different potential for symptom control at highly
variable initial costs, but the relative value of these treatment options is unknown.
Objective
The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment
options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation,
nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine
system.
Study Design
We formulated a decision tree evaluating private payer costs and quality-adjusted
life years over a 5 year time horizon for premenopausal women with heavy menstrual
bleeding and no suspected malignancy. For each treatment option, we used probabilities
derived from literature review to estimate frequencies of minor complications, major
complications, and treatment failure resulting in the need for additional treatments.
Treatments were compared in terms of total average costs, quality-adjusted life years,
and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was
conducted to understand the range of possible outcomes if model inputs were varied.
Results
The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes
to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing
intrauterine system was cost-effective compared with hysterectomy in the majority
of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were
associated with reduced costs compared with hysterectomy but resulted in a lower average
quality of life. According to standard willingness-to-pay thresholds, resectoscopic
endometrial ablation was considered cost effective compared with hysterectomy in 44%
of scenarios, and nonresectoscopic endometrial ablation was considered cost effective
compared with hysterectomy in 53% of scenarios.
Conclusion
Comparing all trade-offs associated with 4 possible treatments of heavy menstrual
bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy
and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated
with a superior quality of life and fewer complications than either type of ablation
but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing
intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration
of cost, procedure-specific complications, and patient preferences can guide the decision
between hysterectomy and ablation.
Key words
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Article info
Publication history
Published online: July 25, 2017
Accepted:
July 18,
2017
Received in revised form:
July 12,
2017
Received:
April 8,
2017
Footnotes
Drs Louie, Schiff, and Moulder are consultants for Teleflex Medical. Dr Siedhoff is a consultant for Applied Medical and Olympus. Dr Wheeler and Ms Spencer receive grant funding for an unrelated study from Pfizer. None of the other authors has a financial interest to report.
Cite this article as: Spencer JC, Louie M, Moulder JK, et al. Cost-effectiveness of treatments for heavy menstrual bleeding. Am J Obstet Gynecol 2017;217:574.e1-9.
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