13 General introduction and clinical pathways remain underdeveloped (2, 6). Also, the lived experiences of women with bleeding disorders are often normalized (7). Therefore, it is crucial to provide an overview of the existing globally available literature on the prophylactic and therapeutic strategies for intraoperative bleeding in women with von Willebrand disease and heavy menstrual bleeding. To investigate the patients’ preferences regarding the type of support from providers for treatment of HMB, it is necessary to explore the perspective of women with VWD and suffering from HMB. To optimize the route to diagnosis for women with bleeding disorders, specialist laboratory testing should be improved. Table 1: Challenges faced by women and girls with bleeding disorders worldwide. Challenges facing women and girls with bleeding disorders worldwide Diagnostic inequality Normalisation of HMB within families Stigmatization Poor awareness of bleeding among health-care providers Delay in referral and diagnosis Global inequities in specialist testing Suboptimal treatment Lack a culture of prophylaxis for women and girls with bleeding disorders Knowledge gaps on optimal treatments Poor representation in clinical trials Lack female care ways Adopted from: Doherty D, Lavin M. Challenges facing women and girls with bleeding disorders. Lancet Haematol. 2023; 10: e875-e6. 10.1016/S2352-3026(23)00302-2.) Besides a gynaecological evaluation to rule out other causes of HMB, such as uterine fibroids, polyps, or hormonal imbalances, gynaecologists should take a comprehensive medical history to assess the severity and impact of menstrual bleeding (9). They should recognize symptoms indicative of bleeding disorders, such as easy bruising, hematuria, sexual bleeding, or excessive bleeding after procedures or giving birth (8). If initial screening suggests a potential bleeding disorder, a hematologist or a specialized bleeding disorders clinic should be consulted for further specific diagnostic laboratory testing, evaluation and management to determine the most appropriate pathway for each individual case (10). The high prevalence of reduced thrombin generation and/or decreased platelet response in women with unexplained heavy menstrual bleeding should be evaluated. Tools to predict bleeding in women Treatment options for heavy menstrual bleeding due to underlying bleeding disorders vary depending on the cause and severity of the symptoms and the accessibility to medications or surgical treatments. The choice of treatment also depends on factors such as the woman’s age, desire for future fertility, and overall health. Medications, hormonal therapies (pills, devices), tranexamic acid (TXA) and surgical interventions like endometrial ablation or hysterectomy may be recommended by healthcare professionals. A bleeding disorder can contribute to excessive 1
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