31 Systematic review for the comparison bleeding complications during or after EA to hysterectomy in women with VWD was judged to be low. Large studies or randomized clinical trials addressing outcome of EA and/or hysterectomy in women with VWD versus healthy controls are lacking. CONCLUSIONS In conclusion, this systematic review highlights the awareness of possible underlying bleeding disorders in women with HMB is of great importance before either EA or hysterectomy. Despite the limitations of the studies analyzed, our review suggests that both EA and hysterectomy are usable procedures for VWD women with HMB due to evolving surgical techniques. However, our review also revealed that none of the VWD patients who underwent EA experienced bleeding complications, in contrast to those who underwent hysterectomy despite of adequate medical prophylaxis. Therefore, this review contributes to the need to optimize prophylactic or therapeutic strategies for VWD women undergoing either EA or hysterectomy. Future considerations This review serves as a call to action to improve the quality of research and care for VWD women with HMB. Research agenda High-quality prospective studies are needed to optimize: 1) the diagnostic work up considering identifying underlying bleeding disorders before surgery and 2) the peri-operative prophylactic and therapeutic strategies for EA or hysterectomy in women with VWD to avoid the risk of over-dosing, leading to the administration and costs of unnecessary treatment versus risking under-dosing and consequently risking adverse bleeding events. Practice points - Both EA and hysterectomy are helpful procedures for VWD women with HMB. - Insufficient data is available from published studies for VWD women with HMB making the optimal prophylactic strategy for hysterectomy and EA uncertain in terms of agent and dosing. 2
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