77 Total Self-BAT scores associated with choice of heavy menstrual bleeding treatment as frequently occurs in qualitative studies [35], our study design relied on self-reporting, which may be prone to selection bias or social desirability bias, leading to overestimation of bleeding tendency in our data. Additionally, age groups (18-30, 31-41, 42-52) were rather broad and possibly included persons in different life stages, characterized by different stressors and biological processes [36-38]. Implications and recommendations Implications of this study concern informing clinicians and patients about different outcomes following surgical HMB treatment in context of bleeding tendency. If supported by future evidence, the results of our and other recent studies [39] could be utilized for organizing diagnostic work up care to recognize bleeding disorders in women, for instance scheduling earlier or more frequent appointments for women with (history of) bleeding tendencies at the gynecological outpatient clinic. Furthermore, other potential interdisciplinary communications mechanism should be measured and explored in upcoming research to reduce delays of diagnosis bleeding disorders in women. For future research and clinical care, we suggest that adding a free-text section to the selfBAT questionnaire allows respondents to reflect on their treatment and to encourage patient empowerment. Lastly, we suggest further evaluation of the optimal self-BAT cut-off levels per age group in women with HMB. An evaluation of the self-BAT questionnaire incorporated in daily practice can increase awareness of underlying bleeding disorders in patients with HMB among gynecologists. Conclusion Our findings imply that there is a substantial group of patients with HMB who experience a bleeding tendency according to self-BAT measurement. This bleeding tendency may influence the choice of HMB treatment like a hysterectomy over more minimal invasive treatments. Implementing structured bleeding assessment tools could guide optimal diagnostics and treatment for women with HMB. 5
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