What happened
A multicentre randomized trial in the Netherlands found that inserting a 52 mg levonorgestrel-releasing intrauterine system immediately after endometrial ablation reduced subsequent hysterectomy among women treated for heavy menstrual bleeding. At two years, 15 of 342 participants with outcome data in the combined-treatment group had undergone hysterectomy, compared with 34 of 331 in the ablation-only group. Serious adverse events were reported in 8% of both groups.
The trial tested whether two uterus-preserving treatments work better together
Endometrial ablation removes or destroys the uterine lining and can substantially reduce heavy menstrual bleeding, but symptoms can recur when untreated endometrium remains or regrows. The MIRA2 researchers tested whether placing a levonorgestrel-releasing intrauterine system immediately after ablation could suppress that residual tissue and reduce the need for later surgery.
The open-label trial enrolled 715 women younger than 60 across 34 Dutch hospitals. Participants were randomly assigned to ablation plus the intrauterine system or ablation alone. Among those with primary-outcome data at two years, hysterectomy occurred in 4% of the combined group and 10% of the ablation-only group: a relative risk of 0.43 and an absolute difference of six percentage points. Serious adverse events occurred in 27 of 346 and 26 of 327 participants respectively, with no treatment-related deaths.
A meaningful reduction, within a specific treatment pathway
The result supports discussing the combined option with patients who are already appropriate candidates for endometrial ablation. It does not mean that ablation or an intrauterine system is the right first treatment for every person with heavy bleeding. Endometrial ablation is generally intended for people who do not plan a future pregnancy, and individual causes of bleeding, contraceptive needs, preferences and contraindications still matter.
The study was open-label, so participants and clinicians knew which treatment was given. Forty-two participants, or 6%, lacked primary-outcome data at two years, and the trial was conducted within one national health system. Longer follow-up will help show whether the reduction in hysterectomy persists and how removal, bleeding patterns, pain, satisfaction and hormonal side effects shape the overall trade-off.
Why it matters
Heavy menstrual bleeding can disrupt daily life and sometimes leads to repeated procedures or hysterectomy. A six-percentage-point absolute reduction means the combined approach could help some women avoid major surgery, while preserving the need for informed, individualized counselling about benefits, side effects and reproductive plans.
What to watch
Longer-term hysterectomy and reintervention rates, IUD removals, patient-reported bleeding and pain outcomes, and replication outside the Netherlands. This report is educational news, not a recommendation for an individual treatment choice.
