76 Chapter 5 treatment of HMB is hormonal therapy [20] alone or combined with TXA [21]. Due to this common approach the prevalence of abnormal self-BAT scores did not appear to be associated with hormonal or TXA therapy in our study. In women aged 18-30 years hormonal + TXA therapy was even significantly more frequently prescribed in the normal self-BAT group. However, underlying bleeding disorders should be ruled out before prescribing medical therapy to optimize treatment [22, 23]. Iron supplements were not frequently prescribed in our population (36/231, 16%). This finding was not entirely unexpected, as this treatment has a poor compliance due to constipation or nausea [24]. Nevertheless, screening for iron deficiency in women with HMB should be standard care due the impact on quality of life [25]. Endometrial ablation offers an alternative to hysterectomy as a surgical treatment for HMB [26]. Although hysterectomy offers permanent relief from HMB [26] subsequent hysterectomy after EA is around 7% [27]. Our results show a link between abnormal self-BAT scores and hysterectomies or hysterectomies after EA. Literature describes that woman with moderate or severe VWD leads to hysterectomy due to HMB in 20% of cases [5]. During the diagnostic work up of HMB hormonal dysregulation, uterine pathology like polyps, myoma, adenomyosis should, of course, be investigated besides bleeding tendency [28, 29]. Nowadays, intrauterine pathology can efficacy been ruled out combining diagnostic and therapeutic resectoscopes [30]. Additionally, bleeding patterns during the menopausal transition can be prolonged due to increased body mass index (BMI). Our study data showed also a slightly increased BMI in the in women aged 42-52 years with a median of 28 compared to 26 in the lower age categories. HMB has a profound effect on the quality of life due to the severe bleedings [27, 31]. In accordance with prior research, our respondents indicated a lack of awareness and delay in diagnosis of underlying bleeding tendency in patients with HMB and plead for improving patient empowerment [22, 32-34]. Parker et al., interviewed adolescents who describe the burden HMB gives on their identities and social quality of life, causing stress, anxiety and feelings of being ‘left out’ [33]. Given the greater impact HMB has on the quality of life of (young) women, obtaining an accurate and timely diagnosis can lead to identity building and empowerment [22]. Strengths and limitations The strength of this study was response rate of 36% which is, to our knowledge, a response rate that is considerably higher than in previous studies in adults with HMB (9–26%) [16]. Secondly, we also included a free-text section to gain insights into participants’ personal experiences with HMB health care. This study also has some limitations. We only had information on anonymous data collections of the study, so measurement of non-responders outcomes were not available. In addition, the cross-sectional nature of the study design and the relatively small sample size of 231 participants might have biased the observed associations. Further,
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