A cost-effectiveness analysis comparing four alternative strategies for heavy menstrual bleeding concludes that hysterectomy is the most cost-effective; however the authors caution that the analysis is very sensitive to the utility values used.

Heavy menstrual bleeding is a common problem that accounts for 20% of referrals to gynaecology outpatients in the UK. First line treatments are oral therapies including NSAID and combined oral contraceptives; however more invasive treatment may be required. This analysis was intended to study the cost-effectiveness of the four main interventions used: the levonorgestrel-releasing IUD (Mirena), first or second generation endometrial ablation techniques, or hysterectomy. The authors used published patient-level clinical trial data and 2008 UK costs to construct a Markov model and estimate cost effectiveness from an NHS perspective, based on incremental cost per quality adjusted life year (QALY).

The model indicated that Mirena is the least and hysterectomy the most expensive strategy as the first intervention for heavy menstrual bleeding.  Overall, however, hysterectomy is the preferred strategy: although it is more expensive, it produces more QALYs relative to other remaining strategies and is likely to be considered cost effective. The incremental cost effectiveness ratio for hysterectomy compared with Mirena is £1440 per additional QALY. The incremental cost effectiveness ratio for hysterectomy compared with second generation ablation is £970 per additional QALY. First generation ablation used first-line was the most expensive option: it is overall more expensive and less effective.

The authors conclude that according to this analysis, hysterectomy would be considered the preferred strategy for treatment of heavy menstrual bleeding. They caution, however, that the model was very sensitive to utility values used, and there are considerable uncertainties over those available. Limitations are discussed: they were not, for example, able to capture measures of the anxiety before hysterectomy or the costs of convalescence or long-term adverse effects. They discuss in some detail areas where the data are limited, and comment that the model cannot reflect resource constraints in terms of skills and capacity. More research is needed to clarify utility values, and a large trial of Mirena that will produce such data is in progress.