Intended for healthcare professionals

CCBYNC Open access

Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system (Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis

BMJ 2011; 342 doi: (Published 26 April 2011) Cite this as: BMJ 2011;342:d2202
  1. T E Roberts, professor of health economics1,
  2. A Tsourapas, research fellow1,
  3. L J Middleton, statistician2,
  4. R Champaneria, research associate2,
  5. J P Daniels, senior research fellow2,
  6. K G Cooper, consultant gynaecologist3,
  7. S Bhattacharya, professor of obstetrics and gynaecology4,
  8. P M Barton, senior lecturer in mathematical modelling1
  1. 1Health Economics Unit, School of Health and Population Sciences, Public Health Building, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Birmingham Clinical Trials Unit, University of Birmingham, Birmingham
  3. 3Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN
  4. 4Section of Applied Clinical Sciences, Division of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen Maternity Hospital, Foresterhill, Aberdeen
  1. Correspondence to: T E Roberts T.E.Roberts{at}
  • Accepted 16 February 2011


Objective To undertake a cost effectiveness analysis comparing first and second generation endometrial ablative techniques, hysterectomy, and the levonorgestrel releasing intrauterine system (Mirena) for treating heavy menstrual bleeding.

Design Model based economic evaluation with data from an individual patient data meta-analysis supplemented with cost and outcome data from published sources taking an NHS (National Health Service) perspective. A state transition (Markov) model was developed, the structure being informed by the reviews of the trials and clinical input. A subgroup analysis, one way sensitivity analysis, and probabilistic sensitivity analysis were also carried out.

Population Four hypothetical cohorts of women with heavy menstrual bleeding.

Interventions One of four alternative strategies: Mirena, first or second generation endometrial ablation techniques, or hysterectomy.

Main outcome measures Cost effectiveness based on incremental cost per quality adjusted life year (QALY).

Results Hysterectomy is the preferred strategy for the first intervention for heavy menstrual bleeding. Although hysterectomy 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 (€1633, $2350) per additional QALY. The incremental cost effectiveness ratio for hysterectomy compared with second generation ablation is £970 per additional QALY.

Conclusion In light of the acceptable thresholds used by the National Institute for Health and Clinical Excellence, hysterectomy would be considered the preferred strategy for the treatment of heavy menstrual bleeding. The results concur with those of other studies but are highly sensitive to utility values used in the analysis.


  • Contributors: TER, PB, SB, and JD contributed to the design of the whole project and obtained funding. TER and PB designed the model based cost effectiveness analysis. TER prepared the manuscript as lead writer. AT under the supervision of PB constructed the model with advice from KC and SB. AT under the supervision of TER and PB identified and collected the required data on costs and effectiveness for the model and carried out the analysis. LM, JD, KC, RC, and SB provided the relevant data from the individual patient data meta-analysis. TR, PB, and AT interpreted the results with assistance from KC and SB. TR is guarantor.

  • Funding: This study was funded by the National Institute for Health Research Health Technology Assessment Programme (05/45/02).

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text