title: Second generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis.
abstract: OBJECTIVE
  To determine the relative effectiveness of second generation ablation techniques in the treatment of heavy menstrual bleeding.
  
  
  METHODS
  Network meta-analysis on the primary outcome measures of amenorrhoea, heavy bleeding, and patients' dissatisfaction with treatment.
  
  
  METHODS
  Nineteen randomised controlled trials (involving 3287 women) were identified through electronic searches of the Cochrane Library, Medline, Embase and PsycINFO databases from inception to April 2011. The reference lists of known relevant articles were searched for further articles. Two reviewers independently selected articles without language restrictions.
  
  
  METHODS
  Randomised controlled trials involving second generation endometrial destruction techniques for women with heavy menstrual bleeding unresponsive to medical treatment.
  
  
  RESULTS
  Of the three most commonly used techniques, network meta-analysis showed that bipolar radiofrequency and microwave ablation resulted in higher rates of amenorrhoea than thermal balloon ablation at around 12 months (odds ratio 2.51, 95% confidence interval 1.53 to 4.12, P<0.001; and 1.66, 1.01 to 2.71, P=0.05, respectively), but there was no evidence of a convincing difference between the three techniques in the number of women dissatisfied with treatment or still experiencing heavy bleeding. Compared with bipolar radio frequency and microwave devices, an increased number of women still experienced heavy bleeding after free fluid ablation (2.19, 1.07 to 4.50, P=0.03; and 2.91, 1.23 to 6.88, P=0.02, respectively). Compared with radio frequency ablation, free fluid ablation was associated with reduced rates of amenorrhoea (0.36, 0.19 to 0.67, P=0.004) and increased rates of dissatisfaction (4.79, 1.07 to 21.5, P=0.04). Of the less commonly used devices, endometrial laser intrauterine thermotherapy was associated with increased rates of amenorrhoea compared with all the other devices, while cryoablation led to a reduced rate compared with bipolar radio frequency and microwave.
  
  
  CONCLUSIONS
  Bipolar radio frequency and microwave ablative devices are more effective than thermal balloon and free fluid ablation in the treatment of heavy menstrual bleeding with second generation endometrial ablation devices.
authors.affiliation: University of Birmingham, Clinical Trials Unit, Birmingham B15 2TT, UK. j.p.daniels@bham.ac.uk
authors.forename: J P
authors.initials: JP
authors.lastname: Daniels
authors.forename: L J
authors.initials: LJ
authors.lastname: Middleton
authors.forename: R
authors.initials: R
authors.lastname: Champaneria
authors.forename: K S
authors.initials: KS
authors.lastname: Khan
authors.forename: K
authors.initials: K
authors.lastname: Cooper
authors.forename: B W J
authors.initials: BW
authors.lastname: Mol
authors.forename: S
authors.initials: S
authors.lastname: Bhattacharya
mesh_terms: D000465:Algorithms; D017115:Catheter Ablation; D016001:Confidence Intervals; D003452:Cryosurgery; D055356:Endometrial Ablation Techniques / Q000379:methods*; D004717:Endometrium / Q000601:surgery*; D005260:Female; D006801:Humans; D015907:Hysteroscopy; D017075:Laser Coagulation; D008595:Menorrhagia / Q000601:surgery*; D008872:Microwaves / Q000627:therapeutic use; D016017:Odds Ratio; D017060:Patient Satisfaction; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome