14 Chapter 1 or prolonged bleeding during surgery, and significantly increasing the likelihood of requiring blood transfusions compared to women without a bleeding disorder (1, 11). Bipolar endometrial ablation using radiofrequency energy (Novasure) is a minimally invasive procedure to remove the uterine lining, used to treat HMB and is an effective alternative to hysterectomy (12, 13). It is a minimally invasive procedure that can be performed in an outpatient setting. Studies show that around 80% of women with HMB and bleeding disorders experience a significant reduction in menstrual flow after the procedure and significant improvement in quality of life (14). To reduce the time between making the decision to seek care and the initiation of an appropriate treatment, a standardized questionnaire for screening bleeding disorders is a valuable step worldwide to reduce diagnostic delay (15). Bleeding assessment tools (BAT) are free and can be easily used by health care providers or patients and are reliable and feasible to detect a bleeding tendency (9, 15-17). Because the BAT questionnaire is a reliable and easy to use tool, we wanted to investigate whether this BAT score also influences the choice of HMB treatment and the outcome of surgical treatment for HMB. Therefore, the results of ISTH-BAT scores and outcomes after endometrial ablation in women with heavy menstrual bleeding should be evaluated, along with comparing the total Self-BAT scores with the chosen treatment options for heavy menstrual bleeding. Communication between health care providers and women with heavy menstrual bleeding Besides failure to recognize bleeding symptoms in women with HMB among health care providers, family and social relationships may contribute to minimize the significance of bleeding symptoms or normalize symptoms which can prolong the delay in help-seeking (6, 8). To bridge this gap, this thesis introduces a narrative medicine (NM) approach to the obstetric-gynecological work floor using a co-created site-specific poem in a gynecological clinical setting. Narrative medicine (NM) approaches using the arts, is heralded by the WHO as a valuable means to improve clinical practice (18). A NM arts-based intervention in healthcare settings has proven to be a potent strategy for overcoming health care providers and patients’ discomfort when breaching sensitive topics like stigmatization (19). When considering how to optimize support for women with bleeding disorders and gynaecological conditions, it may be fruitful to focus on concepts and concerns that are independent of diagnoses, such as ‘distress’ or ‘shame’ (20). Guided reflection on workplace experiences and personal perspectives can help clinicians become more attuned to patients’ perspectives and support needs (21). AIM OF THIS THESIS This thesis describes a study to investigate and optimize the route to diagnosis in adult (above 18 years of age) women with bleeding disorders in gynaecology. We focus on women, but acknowledge that this term might not include the gender identity of all people with the potential to menstruate (22). Bleeding disorders are defined by a bleeding tendency, either caused by acquired or inherited primary (platelets disorders) or secondary (coagulation factor)
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