132 Chapter 8 GENERAL DISCUSSION In 2021 heavy menstrual bleeding (HMB) was defined as menstrual bleeding meeting any of the following criteria [1]: • lasting ≥8 days • associated with repeated passing of blood clots • soaking through 1 or more pads/tampons every 2 hours on multiple days • requiring use of >1 pad/tampon at a time • needing to change a pad/tampon overnight • a pictorial blood loss assessment chart score of >100 (PBAC) [2] • International Society on Thrombosis and Haemostasis Bleeding Questionnaire bleeding assessment tool ([ISTH] BAT score >6 in adult women [3] However, a more pragmatic definition was established by The National Institute for Health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), and International Federation of Gynecology and Obstetrics (FIGO) whom define HMB as excessive blood loss which “interferes with a woman’s physical, emotional, social, and material quality of life and which can occur alone or in combination with other symptoms like iron deficiency anemia” [4-6]. HMB can lead to avoidance of school, work, sporting and leisure activities [4-6]. HMB causes 5% of menstruating women to seek medical attention each year [5]. In the Netherlands, HMB occurs in 80% of premenopausal women with a bleeding disorder [7]. The duration, impact and magnitude of menstrual bleeding is often greater in people with a bleeding disorder compared to those without [7, 8]. It is therefore imperative that we draw attention to the management of this common and often poorly treated condition to positively influence the quality of life of these women. The studies presented in this thesis focus on several interventions aimed at optimizing the route for diagnosing women with bleeding disorders in gynecology [9, 10]. In the context of a gynecological setting, we explored current strategies to reduce bleeding during surgery for HMB in women with Von Willebrand disease (VWD), how bleeding assessment tools can optimize support in the route for HMB treatment in women with (undiagnosed) bleeding disorders, and how to create awareness about stigmatization [11, 12] by using a site-specific art-based approach in gynecology, We aimed to answer following questions: 1. What are the strategies to reduce intraoperative bleeding and what are patient preferences regarding surgical interventions for HMB in women with bleeding disorders? 2. How do diagnostic BAT scores associate with treatment choices and outcomes after endometrial ablation in women with HMB? 3. What impact does a narrative medicine approach using site-specific arts have on healthcare providers’ awareness of stigmatization, and how do women benefit from these initiatives?
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