Comparative Effectiveness of Hysteroscopic Endometrial Resection Versus the 52-mg Levonorgestrel-Releasing Intrauterine System for Heavy Menstrual Bleeding: A Retrospective Cohort Study

Background and Objectives: To compare the effectiveness, durability, and patient-reported outcomes of hysteroscopic endometrial resection (ER) and the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) in women with medically refractory heavy menstrual bleeding (HMB) without structural uterine pathology. Materials and Methods: This retrospective cohort study included 242 women treated between January 2021 and December 2024, of whom 117 underwent ER and 125 received a 52 mg LNG-IUS. The primary outcome was hysterectomy during follow-up. Secondary outcomes included bleeding-related symptoms, treatment satisfaction, the change in the Female Sexual Function Index-6 (FSFI-6) total score, LNG-IUS discontinuation/expulsion, and subsequent reintervention. Baseline bleeding severity was characterized using the Pictorial Blood Assessment Chart (PBAC), hemoglobin, and serum ferritin, and abnormal uterine bleeding etiologies were classified according to PALM–COEIN. To address non-randomized treatment allocation, inverse probability of treatment weighting (IPTW) was performed using prespecified baseline covariates. Hysterectomy was further evaluated using Firth penalized logistic regression, Kaplan–Meier analysis, and Cox proportional-hazards models.