In May 2022, Cochrane published the first version of an overview and network meta-analysis of interventions for heavy menstrual bleeding, which can affect 20% to 50% of people who menstruate during their reproductive years. There are a variety of treatments available, each with its pros and cons, and the best treatment is likely to depend on several factors, including age, desire to have children, personal preferences and medical history.

I'm Mike Clarke, podcast editor for the Cochrane Library, and over the next four minutes, I'll outline the overview and what it found.
The overview summarises the evidence from nine Cochrane reviews of the effects of treatments on bleeding reduction, satisfaction, quality of life, side effects and treatment failure. It also used a network meta-analysis to combine the data because this statistical method allows all the interventions to be compared at the same time, to find out which produced the best results.
The nine reviews included a total of 104 studies and nearly 12,000 participants, and data from 85 trials with just under 10,000 participants could be used. The medical interventions compared were non-steroidal anti-inflammatory drugs, antifibrinolytics (tranexamic acid), combined oral contraceptives, combined vaginal ring, long-cycle and luteal oral progestogens, the levonorgestrel intrauterine releasing system, ethamsylate, danazol and placebo as sham treatment. The surgical interventions were open (abdominal), minimally invasive (vaginal or laparoscopic) and unspecified (or surgeon's choice of) route of hysterectomy, resectoscopic, non-resectoscopic and unspecified endometrial ablation.
The reviewers categorised the treatments based on the characteristics of the participants in the studies in the reviews, including their desire or intention for future pregnancy, failure of previous treatment or having been referred for surgery into first and second-line treatment. First line treatment included medical interventions and second line included the levonorgestrel intrauterine releasing system plus surgical interventions, which means that the levonorgestrel intrauterine releasing system was included in both first- and second-line treatments. 
From the network meta-analysis, the levonorgestrel-releasing intrauterine system appears to be the best first-line option for reducing menstrual bleeding, with antifibrinolytics second best, and long-cycle progestogens third. However, because of some limitations in the evidence, we are not sure what the true effect of these first-line treatments is on the perception of improvement and satisfaction.
For second-line treatments, even though it is major surgery, hysterectomy appears to be the best treatment for reducing bleeding, and resectoscopic endometrial ablation and non-resectoscopic endometrial ablation are second and third best. We are uncertain about the true effect of the second-line treatments on amenorrhoea (absence of menstrual blood loss) but the evidence suggests that minimally invasive hysterectomy results in a large increase in satisfaction, and non-resectoscopic endometrial ablation increases satisfaction, but we are uncertain of the true effect of the remaining interventions.

To conclude, although the reviewers' confidence in some of the evidence is moderate, it is low to very low for most of it. This is mainly because the studies were often not blinded, which means the participants knew which treatment they were receiving, which could have changed their perception; and the direct and indirect evidence was not similar enough to compare in the network, and the range of the results was too wide. However, bringing all the Cochrane evidence together into this single overview should help people making more informed decision and choices about the treatment of heavy menstrual bleeding and if you would like to read it in full, online at Cochrane Library dot com. If you search 'cochrane overview of heavy menstrual bleeding', you'll see a link to it.