135 General discussion and future perspectives with idiopathic HMB. However, it is important to note additional context, such as family history of bleeding disorders, medications being taken, or treatments applied, to provide a more complete picture and draw meaningful conclusions. Of the 231 included patients, 23 (10%) underwent a hysterectomy of which 20 patients (87%) had a self-BAT score ≥6 (total self-BAT score median 7, range 4-14). EA ablation was more often performed when the self-BAT score was ≥6. Also, all subsequent hysterectomies after EA (11%) were performed in women with a self-BAT score ≥6. Compared to literature, a Cochrane review (2021) showed that in the general population women with idiopathic heavy menstrual bleeding, endometrial ablation has a satisfaction rate exceeding 85% after 2 years and a subsequent hysterectomy rate of 19% from 2 to 5 years [20]. Interestingly, Vink et al. [21] published in April 2024 a register-based study that included 6 798 030 pre- and post-menopausal women aged ≥25 years to assess medical practice variation. Their analysis included women recorded for menstrual cycle disorders, menorrhagia or HMB (G11). The average age of women undergoing EA or hysterectomy in the Netherlands (2016-2020) was approximately 47 years. Consistent with the relevant literature, this study found no evidence of a negative relation between the number of hysterectomies and the number of endometrial ablations, indicating that endometrial ablation does not clearly act as a substitute for hysterectomy at the population level, suggesting that endometrial ablation does not clearly serve as a substitute for hysterectomy at the population level, which does not support the existence of a clear substitution effect for endometrial ablation at a population level. Vink et al. [21] attributed these results to two main factors: 1. women opt for a surgical intervention sooner than they might have otherwise, particularly if hysterectomy were the sole choice and 2. minimally invasive therapies might extend to broader indications than those for which their effectiveness has been demonstrated in comparative effectiveness studies. However, we argue that when considering the implementation of less invasive surgical techniques as an alternative to hysterectomy, the increased risk of abnormal bleeding symptoms should be a key factor in surgical counseling and decision-making. Despite the limited numbers of participants (n=239) in our study, we show that abnormal self-BAT scores were more prevalent among those who underwent hysterectomy, highlighting an important aspect for further discussion. This observation suggests a potential association between HMB severe enough to warrant hysterectomy and an increased likelihood of abnormal bleeding symptoms, as indicated by the self-BAT. In this case, thoughtful pre-operative evaluation for bleeding tendency or utilization of alternative surgical techniques should be implemented to reduce the risk of bleeding or re-surgery [22, 23]. Our focus group participants suggested that health care professionals should conduct a thorough review of the self-BAT results with patients to ensure effective and timely treatment. (chapter 6). Recent literature also shows that this review should be facilitated by a multidisciplinary, patient-centred approach .that includes clarification of relevant symptoms, appropriate laboratory tests, and patient education [13,15,19, 24, 25]. In addition to the self-BAT, we included a free-text response option. Of the participants 43% provided personal reflections on their experiences with HMB in the free-text section, identifying several areas for improvement: decrease lack of awareness, reduce delay in diagnosis and improve patient empowerment. According to the literature, getting an accurate diagnosis in 8
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