57 The ISTH-BAT score and outcomes after EA in women with HMB and presence of intramural fibroids (>10 cm). Transvaginal ultrasound (TVU) or diagnostic hysteroscopy was performed before the EA to confirm a normal uterine cavity with histological benign endometrium and a cavity length between 6–10 cm. EA was mostly performed in office-based surgery under local anesthetics. No prophylactic treatments (i.e. tranexamic acid) were prescribed. When a permanent method of contraception was desired, EA was combined with a laparoscopic sterilization procedure (i.e., clipping, cutting and removing the fallopian tubes) in the operating room under general anesthetics. All procedures were performed by experienced gynecologists or gynecological residents. Definitions Self-reported HMB was clinically defined as PBAC 120, passing of clots, or a duration of menstrual bleeding > days. (17) Dysmenorrhea is standard categorized into two distinct types: primary and secondary. Primary dysmenorrhea is defined as painful menses in women with normal pelvic anatomy. Secondary dysmenorrhea is menstrual pain associated with underlying pathology, it can be caused by many factors such as endometriosis, pelvic inflammatory disease, irregular cycles or ovarian cysts, perimenstrual somatic complaints, a history of sexual assault, adenomyosis, uterine myomas, intra-uterine adhesions (par example after EA), or cervical stenosis. (18-20)An abnormal ISTH-BAT was defined as a score of ≥6 in these healthy females because of the mean age of 45.4 (range 34-57 years) and secondly because our study was performed after surgical intervention. (21) A major clinical bleeding complication was determined according to the criteria of ISTH: (a) a fall in hemoglobin level of 2 g/dL or more or documented transfusion of at least 2 units of packed red blood cells (b) involvement of a critical anatomical site (intracranial, spinal, ocular, pericardial, articular, intramuscular with compartment syndrome, retroperitoneal)) (22) The SF-36 scores are standardized scales with a scoring algorithm implying a health status (ranging: 0-100) in which a mean score of 50 has been expressed as a normative value for all scales. (14) Statistical Analysis All data were checked for completeness before analysis. In case of missing data, patients were excluded from further analyses. Categorical variables are presented as numbers (n) and percentages (%) and were analyzed with the chi-square test or Fischer’s exact test in case of small, expected counts (i.e., n≤5) in one or more cells of a contingency table. Continuous variables with a normal distribution are presented as the mean (±) and standard deviation (SD), in case of skewed distribution as median and interquartile range (IQR). Depending on their distribution continuous variables were analyzed with the student t or Mann–Whitney U-test for non-paired data in ISTH-BAT ≥6 group compared with ISTH-BAT <6 group. Eta squared (η2) was calculated to express the effect size of differences in SF-36 scores between the two groups. (23) Odds ratios (ORs) and their 95% confidence intervals (CI) were calculated to compare dichotomous outcomes between the two groups. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS®) version 28.0 (IBM Corp., Armonk, NY, USA). Statistical significance level was set at p < 0.05. 4
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