61 The ISTH-BAT score and outcomes after EA in women with HMB Doherty et al. described that menorrhagia scores in BATs increase remarkably with aging in healthy women related to the procedure-specific accumulation in HMB management from medical treatment till surgical interventions. When assessed by age quartiles, the normal ISTH-BAT ranges are 0 to 4 (Q1, 18-30 years), 0 to 5 (Q2 and Q3, 31-41 years and 42-51 years, respectively), and 0 to 6 (Q4, 52-88 years). (21) In our study, we included 16 women in the ISTHBAT ≥6 group. Six of these patients (6/16) had an ISTH-BAT score of 6, all other participants >7 (range 7-10). The BAT score of these 6 participants, with age ranges at initial treatment: 42-47 years and age ranges at study visit 45-50 years, was due to obtaining the BAT score following the EA a point higher. However, we predefined in our study a BAT score of ≥6 as abnormal in our otherwise healthy participants because our study was performed after EA and secondly because of the mean age of 45.4 (range 34-57 years). In addition, Beelen et al. compared levonorgestrel-releasing intrauterine system and endometrial ablation strategies in women with HMB aged 34 years above and concluded that 1 out of 3 underwent accumulative EA after a levonorgestrel-releasing intrauterine system. (31) Also, von Willebrand factor (VWF) levels may be a determinant of IUD and endometrial ablation treatment success in heavy menstrual bleeding. (32) The rate of dysmenorrhea after EA varies. Literature describes that women who undergo EA at younger age, with preoperative diagnosed dysmenorrhea, are more likely to exhibit pain if bleeding frequency still occur post procedure. (33) Furthermore, Wyatt et al. described that 38% of all women obtained reduction of dysmenorrhea after EA and 7% of the women who underwent EA reported new-onset dysmenorrhea postoperatively. (34) Together with the observations in our current study, dysmenorrhea should not be neglected as potential risk factor in patients with a (suspected) bleeding disorder. HMB is associated with a negative effect on QoL. (30, 35) Several studies revealed social stress caused by all the hardships that accompany having a bleeding disorder before any treatment, and the radical choices they have to make as women. (30, 35, 36) Punt et al. described the substantial increase in QoL after medical or surgical treatment for HMB in women with (suspected) congenital platelet disorders. (35) Furthermore, Huq et al. described in a retrospective study a decreased PBAC score from 1208 preoperative to 0 post-ablation, and high QoL scores (median, 17-54) that significantly improved after endometrial ablation in 5 included VWD women with a median follow-up of 32 months after bipolar EA. (13) In our study, SF-36 profile data were not different between both ISTH-BAT score groups after treatment for HMB, despite higher rates of dysmenorrhea in the ISTH-BAT ≥6 group. This finding may suggest that for women with ISTH-BAT ≥6, the improvement in HMB symptoms after EA may be significant enough to offset any negative impact on QoL caused by dysmenorrhea. Future studies to improve care for women with VWD affected by HMB should be attentive to both QoL questionnaires and disease-specifiek items such as dysmenorrhea. 4
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