75 Total Self-BAT scores associated with choice of heavy menstrual bleeding treatment reflected on the self-BAT questionnaire. They were satisfied with the self-administration process and completion of the questionnaire improved self-reflection in some cases. As one participant described: ‘After reading the questionnaire, I also presented it to my grandmother and mother, and they experience the same heavy menstruation and other complaints of blood loss! We looked at each other and realized ‘Could it be hereditary?’ However, most reflections considered low awareness on the impact of heavy blood loss as another participant wrote: ‘I’ve had HMB since my menarche. Now, after years of struggling through anemia, I have had a hysterectomy which is a huge relief. The 15-year period before with trying all kinds of things because, according to the doctors, the uterus had to be spared, has been too long for me versus all the bleeding complaints.’ Or as another participant put it: ‘I continued to have blood loss under levonorgestrel-device use. Finally, after an intake in the gynecological outpatient clinic, the gynecologist had my blood tested. I turned out to have VWD type 1.’ Participants expressed also the need for patient empowerment: ‘I have thalassemia as a carrier. My periods were always very heavy with anemia, but I thought everyone had that. When I started using a menstrual cup, I was able to keep track of how much it was. It turned out that I had more than 250cc of blood loss every week.’ Or as another participant put it: ‘After more or less permanent continuous blood loss the endometrium ablation procedure turned out to be the ideal solution. I should have known and done it much earlier. I am glad that more attention is now being paid to HMB and (bleeding) problems that can occur with it.’ DISCUSSION The current study reflects the raised concerns that in women who underwent a hysterectomy an underlying bleeding tendency is more prevalent [5]. Therefore, thoughtful and structured bleeding assessment during HMB work-up should be implemented to timely diagnose this disorder and prevent needless hysterectomy [5, 17]. With application of BATs being an important protective factor for missing bleeding tendencies, the role of educating gynecologist and patients to use the self-BAT screening tool and to incorporate it in the HMB work-up to increase awareness on underlying bleeding disorders in patients with HMB is crucial [10]. In the study from the online awareness project ‘Let’s Talk Period!’(www.letstalkperiod.ca) to increase awareness of the signs and symptoms of bleeding disorders, 44% of the general public responders have a self-BAT scores above the cut-off levels [18]. Both hormonal therapy and TXA are effective in reducing the mean blood loss among women with HMB, especially in younger age groups [19]. Also in this study, the common approach to 5
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