STUDY QUESTION Which of first or second generation endometrial ablative techniques, hysterectomy or the levonorgestrel intrauterine system (Mirena) is the relatively more cost effective first line intervention in the treatment of heavy menstrual bleeding? SUMMARY ANSWER The strategy that adopts hysterectomy as the first and only intervention produces the most quality adjusted life years (QALYs) and is likely to be considered the most cost effective strategy WHAT IS KNOWN AND WHAT THIS PAPER ADDS Less invasive alternatives to hysterectomy for the treatment of heavy menstrual bleeding, such as endometrial ablation and Mirena, have become increasing popular. Based on all available evidence on effectiveness, cost, and utility values, hysterectomy is both more costly and produces more QALYs than the available alternatives and produces cost effectiveness ratios that are likely to be accepted by decision makers.