Comparative effectiveness of endometrial ablation techniques and the levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding: A systematic review and meta-analysis

Background: Heavy menstrual bleeding (HMB) is a common condition with substantial impact on quality of life. Although multiple minimally invasive treatment options are available, the relative effectiveness of different endometrial ablation techniques compared with the levonorgestrel-releasing intrauterine system (LNG-IUS) remains uncertain.

Objective: To compare the effectiveness of minimally invasive treatment modalities for HMB, focusing on amenorrhea rates at 3, 6, and 12 months, as well as changes in menstrual blood loss and subsequent hysterectomy rates.

Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines and registered in PROSPERO (CRD420261322761). PubMed, Embase, Scopus, Web of Science, and CENTRAL were searched from inception to February 2026. Randomized controlled trials and observational studies evaluating LNG-IUS, endometrial ablation (including radiofrequency, thermal balloon, hydrothermal, microwave, cryoablation, laser, and rollerball techniques), and hysteroscopic endometrial resection were included. Random-effects meta-analyses were performed to estimate pooled event rates and mean differences with 95% confidence intervals.

Results: Ninety-two studies including 14,039 patients were analyzed. At 12 months, pooled amenorrhea rates were higher following endometrial ablation (41%, 95% CI 33-48%) compared with LNG-IUS (22%, 95% CI 10-36%). Among ablative techniques, radiofrequency ablation demonstrated the highest amenorrhea rate (67%, 95% CI 52-80%). Hysterectomy rates were lower after ablation (approximately 2-5%) and endometrial resection (7%) compared with LNG-IUS (15%). All interventions were associated with substantial reductions in PBAC scores over time. However, considerable heterogeneity was observed across analyses.

Conclusion: Endometrial ablation, particularly radiofrequency-based techniques, was associated with higher amenorrhea rates and lower subsequent hysterectomy rates compared with LNG-IUS. These findings suggest that ablative and resective approaches may provide more durable symptom control in selected patients. However, given the substantial heterogeneity and inclusion of observational data, results should be interpreted with caution, and individualized treatment decisions remain essential.