First- versus second-generation endometrial ablation devices for treatment of menorrhagia: a systematic review, meta-analysis and appraisal of economic evaluations.

OBJECTIVE To estimate the clinical and economic effect of using second-generation endometrial ablation devices compared to first-generation devices for treatment of menorrhagia in pre-menopausal women. The secondary objective was to compare the second-generation devices with one another. DATA SOURCES We searched Medline and EMBASE, and other sources of unpublished literature, and screened references from relevant articles. STUDY SELECTION We included only randomized controlled trials or full economic evaluations of premenopausal women with menorrhagia undergoing endometrial ablation using first-generation compared with second-generation devices. DATA EXTRACTION AND DATA SYNTHESIS Data extraction and risk of bias assessment was carried out for all clinical studies, and data were pooled using the random effects model. A qualitative narrative synthesis was used to combine results from the economic review. Eleven studies met eligibility criteria (n = 1679). There was no difference in the rate of amenorrhea between first- and second-generation ablation (5 studies with 998 patients, rate ratio 1.15, 95% CI 0.96 to 1.38; P = 0.14), but second-generation devices had a lower complication rate (7 studies with 1272 patients, rate ratio 0.52, 95% CI 0.35 to 0.76; P < 0.001), decreased operating time by 16.6 minutes (3 studies with 486 patients, 95% CI 12.1 to 21.2 minutes; P < 0.001), and could more commonly be used with local anaesthesia (3 studies with 558 patients, rate ratio 1.87, 95% CI 1.04 to 3.37; P = 0.04). There was a higher rate of amenorrhea in patients treated with Novasure than with other second-generation devices (4 studies with 407 patients, rate ratio 2.60, 95% CI 1.63 to 4.14; P < 0.001). Three European studies were included in the economic synthesis, which found that second-generation devices were more cost-effective than first-generation devices. CONCLUSION Second-generation endometrial ablation devices seem to be as effective as first-generation devices but likely reduce operating time, can be used more often with local anaesthesia, and have fewer complications. They also seem to be more cost-effective than first-generation devices, but further economic evaluations need to be carried out in Canada.