145 English summary procedures for VWD women with HMB. However, there is insufficient data available from published studies for VWD women with HMB, so the optimal prophylactic strategy before and during a hysterectomy or EA is still unclear. Prospective studies are needed to determine the optimal (pre)operative strategy for gynecologic surgical procedures in women with VWD. To improve diagnostics for women with HMB and underlying bleeding disorders, specialist laboratory tests may be performed. In chapter 3 we discuss the high prevalence of reduced thrombin production and/or reduced platelet response in women with HMB in a gynecological setting. In this study, we used thrombin generation (TG), a flow cytometry-based platelet function test, and a flow cytometry-based VWF (Von Willebrand Function) function test to study hemostasis in 58 women with HMB. In addition, we determined VWF antigen levels and VWF ristocetin cofactor activity in platelet-poor plasma. With this study, we showed that 24% of these patients with HMB had impaired platelet function and 29% of the participating patients had impaired coagulation. Five patients (9%) had both impaired platelet function and impaired clotting and 3% had impaired VWF function. We concluded that in women with HMB in a general gynecological population where an accurate platelet function test in combination with thrombin generation was used, impaired coagulation or platelet function was found in approximately 1 in 3 patients. In 2010, the International Society for Thrombosis and Haemostasis (ISTH) approved a new bleeding assessment tool (ISTH-BAT). This BAT was implemented in clinical practice worldwide to detect mild congenital bleeding disorders and assess the severity of bleeding symptoms. By completing this questionnaire with 14 domains, a bleeding score will be determined. The instrument can also be used to select patients for whom further laboratory testing is required. We examined the postoperative incidence of amenorrhea, dysmenorrhea, re-intervention after EA in relation to the overall ISTH-BAT score in women with HMB in a gynecological setting (chapter 4). This study describes 71 women who underwent EA because of HMB. During a period of 2-5 years after the initial intervention, ISTH-BAT questionnaires were administered. Ten years after the initial procedure, surgical re-interventions were evaluated through screening of the medical records. The results showed that 77% of the women included had an ISTHBAT score <6, vs. 23% ISTH-BAT score ≥6. In the ISTH-BAT ≥6 group vs. <6 group, amenorrhea occurred in 63% vs. 82%, dysmenorrhea in 38% versus 18%, and surgical re-intervention in 19% vs. 25%. We concluded that an ISTH-BAT score ≥6 may be related to a worse outcome (less amenorrhoea, more dysmenorrhoea) after an EA. In 2018, Punt et al. converted the international ISTH-BAT to a Dutch ‘self-BAT’ version in which patients complete the BAT at home without assistance. They sent the self-BAT to all 201 adult patients who participated in the “Thrombocytopathy in the Netherlands” (TIN) study. Punt et al. recommended implementing the self-BAT in the clinic to support the caregiver in diagnosing bleeding problems. Following the results of Punt’s study, we evaluated the total self-BAT scores compared to the choice of treatment of heavy menstrual bleeding in a general gynecological setting (chapter 5). In this study, a self-BAT questionnaire was sent to adult
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