144 Chapter 9 SUMMARY Chapter 1 describes the general introduction of this thesis, containing the main lines and objectives. In order to recognize women with a coagulation disorder and heavy menstruation in a gynecological setting more quickly and to optimize the treatment process, we built this dissertation on the basis of the following questions: 1. Strategy: Which surgical procedure (uterine removal versus endometrial ablation) to reduce heavy menstrual bleeding (HMB) is preferred in women with bleeding disorder? What are strategies to reduce intraoperative bleeding in women with bleeding disorders? 2. Screening tools: How do BAT (bleeding assessment tools) scores relate to the choice of treatment for HMB? Is there a relationship between a BAT score and the treatment outcome after endometrial ablation for HMB? 3. Communication: How to discuss taboo topics such as HMB and impact on quality of life in the gynaecological consultation room? What contribution can a narrative medical approach with the using specific art make to this? We conducted this study to draw more attention to optimizing care for women with bleeding disorders and gynecological disorders. The aim was to contribute to improving the diagnostic care pathways. We examined in the literature the current strategies to reduce bleeding during surgery for HMB in women with Von Willebrand disease (VWD) in a gynecological setting. In addition, we investigated how screening instruments for assessment of bleeding propensity can be used during the diagnosis of HMB in a gynaecological setting. Finally, we investigated how narrative medicine can use specific art to make stigmatization and taboo subjects such as the impact of HMB on the gynaecological workplace more open to discussion. In chapter 2, we discuss the question: “what are the current prophylactic and therapeutic strategies for intraoperative bleeding in women with von Willebrand disease?” through a systematic review. Our review evaluates the (pre)operative treatment in relation to (post) operative bleeding after endometrial ablation (EA) and hysterectomy in VWD women with HMB. A literature search was conducted between 1994 and 2023. After screening, 11 cohort studies and 1 case report were reviewed, describing a total of 691 operative procedures. Prophylaxis (desmopressin, coagulation factor concentrates, or tranexamic acid) to prevent bleeding was described in all EA procedures and in 4% of hysterectomies. Bleeding complications despite prophylaxis did not occur in EA but were described in 13% of hysterectomies. Our conclusion was that VWD women often seem to experience bleeding complications during a hysterectomy, even despite prophylaxis. The fact that all women with a known VWD received hemostatic prophylaxis during an EA indicates on the one hand possible negotiation of these women in a gynecological setting - where there is generally low screening for women with an underlying coagulation problem prior to an EA - or on the other hand an overtreatment with standard prophylaxis of women with a known VWD in such minimally invasive procedures with a low bleeding risk. Our main conclusion was that both EA and hysterectomy are useful
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