Beelen P, van den Brink MJ, Herman MC, et al. - Researchers conducted a multicenter, randomized controlled, noninferiority trial comparing the effectiveness of the levonorgestrel-releasing intrauterine system with endometrial ablation in women with heavy menstrual bleeding. They performed allocation of women with heavy menstrual bleeding, aged 34 years and older, without a pregnancy wish or intracavitary pathology, to either the levonorgestrel-releasing intrauterine system (baseline Pictorial Blood Loss Assessment Chart score, 616) (n = 132) or to endometrial ablation (baseline Pictorial Blood Loss Assessment Chart score, 630) (n = 138 ). Outcomes revealed a large reduction in menstrual blood loss in women with heavy menstrual bleeding in correlation with both the levonorgestrel-releasing intrauterine system and endometrial ablation strategies; quality of life scores after treatment were comparable between groups. Nevertheless, menstrual blood loss differed significantly in favor of endometrial ablation, and noninferiority could not demonstrated for starting with the levonorgestrel-releasing intrauterine system. Risk of requiring additional treatment was higher among women who start with the levonorgestrel-releasing intrauterine system, a reversible and less invasive treatment, vs women who start with endometrial ablation.