Title: Patients’ motives and considerations on treatment decision-making for heavy menstrual
bleeding: a qualitative study
Version: 2 Date: 18 Jun 2024
Reviewer's report:
Thank you for the opportunity to review the revised manuscript, Patients’ motives and
considerations on treatment decision-making for heavy menstrual bleeding: a qualitative study.
The authors have carefully considered the previous feedback from both reviewers, and refined
the manuscript accordingly. In my opinion, several issues remain:
• The description of women for whom EA is a viable option (ln 74-5) should specify those who
do not wish to have (more) children.
• There are few places where the language of the paper is a little paternalistic. The reference
to confusion on line 80 is one example of this. I’m unconvinced that the issue is patients being
confused by too many options, and more likely not being aware of all the options and the benefits
and risks of each.
• The changes to line 107 re the NPF have introduced new ambiguity. It is unclear to me what the
role of the NPF was? Were they providing feedback on the design of the study? Or advertising
the study to their members? If it’s the latter, why was a different approach needed to recruit
through the MMC rather than the NPF? In the MMC who approached women to provide the
leaflet, and how did women express interest?
• The explanation of approach to translation on line 156 is insufficient. It needs to be clear that
interviews and analysis were conducted in Dutch, and that only illustrative quotations have been
translated (by the research team). It may still be problematic that there was no independent back-
translation undertaken (this should be acknowledged as a limitation of the study).
• Around line 160 It would be useful to have some literature to support this approach to member
checking, as well as additional data about how many participants responded, and of those how
many agreed vs clarified their comments.
• There is still a mismatch between the description of the analytical approach on Line 168
(as involving three authors, with confirmation by a fourth) and the previous description of the
approach (as mainly involving two authors). Please clarify.
• I am concerned about the reporting of individual descriptions in Table 1, as doing so risks
making individuals identifiable. I find descriptions of the group (frequencies, %) to be more
useful in understanding the sample.
• I’m still unclear about the role of the option grid in the interviews. The fact that it was sent to
participants prior to their interview needs to be clearly stated in the methods. I note the interview
guide asks only a very superficial question about the option grid. I do not believe that the option
grid is provided as supplementary materials? They are often  quite a complex thing for someone
to understand in the absence of a supportive conversation with a health care professional. While
I understand that the purpose of your study did not extend to evaluating the usefulness of the
option grid (although that makes your conclusion (on line 564 and again on line 619) about its
helpfulness difficult to justify), I’m not sure what if anything it adds to your results, especially
given that it was introduced part way through your interviews. Given your use of it as a checklist
during interviews, did participants indicate how many of the options had been considered in their
discussions with healthcare professionals? On Line 281, are you saying that only one participant
responded favourably to the options grid? If so, I’m not sure what, if anything this adds to your
results.
• I feel the illustrative quotation on Line 372 needs more unpacking. Is the participant saying
that a hysterectomy was perhaps not as bad as they anticipated or are they saying that having
tried everything else they accepted that it was ‘worth it’.
• There are still places where additional illustrative quotations are needed to support your points.
For example, line 293 says “In particular, there were numerous stories about side effects of the
LNG-IUD, hormone-related side effects and pain after EA.” But the following quotation only
addresses IUDs, not other hormonal medications or EA.
• I was surprised on in Subtheme 2.3 that it appears participants only searched online for lived
experience accounts of treatment options. Is that actually the case? Did they not seek out more
factual information about what options might be available to them, and what the risks and
benefits of each were?
• I’m much more interested in the reasons for the ‘long and confusing journey’ to effective
treatment – why does it take so long?
• I’m struggling to understand the implications for practice of these findings. At present, it is all
very descriptive – but how should this be considered in practice? Your recommendations would
surely describe what health care professionals already believe they do.
• Please review the paper for consistent use of past tense. Also, the sentence on line 289-290
does not make sense: In the interviewee's social environment, diverse opinions and experiences
regarding different treatments for HMB told.