134 Chapter 8 How do diagnostic BAT scores associate with treatment choices and outcomes after endometrial ablation in women with HMB? In 2010 the International Society for Thrombosis and Haemostasis (ISTH) has endorsed a new bleeding assessment tool (ISTH-BAT) [3]. This BAT was implemented in clinical practice to detect mild bleeding disorders and to assess the severity of bleeding symptoms. By completing this 14-domain questionnaire, a bleeding score is determined ranging from 0-56 points. Nowadays, the ISTH-BAT is recognized as a suitable screening tool for all types of congenital bleeding disorders and can be used to select patients for laboratory investigations [15, 16]. In 2015 the self-administered BAT (self-BAT) was introduced as a patient-friendly version of the ISTH-BAT that has been validated as a screening tool for inherited bleeding disorders [17]. In 2019, Punt et al. validated the self-BAT for the Dutch language in a (suspected) congenital platelet defect (CPD) population [18]. While there are limitations to the self-BAT format, such as its reliance on recall and risk of score saturation leading to under-reporting of bleeding symptoms, the selfBAT has been recommended in the clinic to support the healthcare professional in diagnosing underlying bleeding problems [17-19]. To assess the protentional use of the ISTH-BAT and the self-BAT as a screening tool for clinically relevant bleeding disorders in a gynecological care setting, we have evaluated the results of ISTH-BAT scores and outcomes after endometrium ablation in women with heavy menstrual bleeding (chapter 4) and we have evaluated the total self-BAT scores compared with choice of heavy menstrual bleeding treatment (chapter 5). In chapter 4 we describe a retrospective cohort study in HMB patients treated with EA. The median ISTH-BAT score of the total study group was 4 and the mean age was 45.4 years. Twentythree percent of women had an ISTH-BAT ≥6 score, suggesting a possible bleeding disorder. In our cohort, women with an ISTH-BAT score ≥6 had undergone EA at a significantly younger age than women with an ISTH-BAT score <6 (mean age 42.3 years versus 46.3, respectively) which may reflect the bleeding severity in this group and reveal HMB procedures at younger age. We observed a relatively high coexistence of dysmenorrhea after EA and lower amenorrhoe rate in ISTH-BAT ≥6 group compared to the ISTH-BAT <6 group. However, we concluded that EA remains an effective method to reduce HMB in women with both low and high ISTH-BAT scores. Despite the study is limited by its retrospective design, and a participation rate of 35% which limit the generalizability of this explorative study, our findings emphasize that gynecologists should be aware of impaired coagulation, which might influence the outcome of endometrium ablation. Following up on the results of Punt’s study we evaluated the total self-BAT scores compared with the choice of heavy menstrual bleeding treatment in women with HMB in a gynecological center in the Netherlands (chapter 5). In this selected cohort of patients with idiopathic heavy menstrual bleeding referred to a gynecological center, we found that at least 20% to 62% of the participants were classified as having abnormal self-BAT scores. This outcome underscores the importance of the self-BAT as a valuable screening tool, particularly in the context of patients
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