Title: Navigating Treatment Options: A Qualitative Study Exploring Australian Women’s
Decision-making Experiences and Satisfaction with Treatment of Heavy Menstrual Bleeding
Version: 2 Date: 26 May 2025
Reviewer:  Marian J. van Den Brink
Reviewer's report:
The paper is technically sound.
Method section:
+ The authors used the QOREC checklist reporting qualitative research.
+ there was patient involvement at each stage of the study’s design through the Consumer
Advisory Group.
- Identifying initial topics and themes was done by multiple researchers; however only 10% of
data was coded by more than one researcher, this researcher (and the interviewer) was quite
unexperienced in interviewing / qualitative research.
- Transcripts (or a summary) were not returned to participants for comments and correction.
Minor points to make the manuscript more clear/improve the quality of the paper:
Introduction:
A bit more background information of which treatments for HMB are offered by the GP and
when referral to the gynaecologist is needed in Australia would be useful to interpret the
result section about waiting list to specialist care and would place the information in a broader
international perspective.
For example, in the Netherlands, most treatment options for HMB (excluding myoma treatment,
endometrial ablation and of course hysterectomy) can be offered in general practice. Also, an
ultrasound can be requested without referral to the gynaecologist.
Methods:
Discrepancy between the main text (“Interviews were conducted by JR, under the guidance
of BJ and TC) and Supplementary Table 1, question 15 of the QOREC guideline: “For most
interviews, only the participant and researcher (JR) were present during the interview. One
interview was conducted by a senior researcher (BJ), as an opportunity to provide feedback on
interview techniques.”
What did the guidance/supervision of BJ and TC involve? You would expect them to be
present during more than one interview, or review the interview technique afterwards to provide
feedback (and not conduct the interview by the senior researcher, this gives less possibility to
for JR to practice herself)
Purposive sampling: where are the chosen characteristics based on? For example ‘whether the
participant was living with a disability or chronic condition’ please explain what would be the
expected effect of having a chronic condition on treatment choise/SDM? Why is not chosen for
more basic characteristics such as a diversity in age and SES?
Reflexivity: the authors only reflect on educational background of the interviewer, but this
section can be described in a broader view: for example cultural background en ethnicity can
also influence what is discussed in the in-depth interviews and the interpretation of the data by
the individual researchers.
Method of approach: could there be patient selection via social media? E.g. especially women
with persistent HMB or perhaps negative experiences with SDM/clinician advices? (The authors
already mention the latter in the discussion section)
Results:
48 women were contacted, 24 were interviewed, how was this selection made? This is not clear
in the text.
Table 1: duration of HMB: >10 years; does this mean these women did not have a successful
treatment yet, despite of this long duration of HMB symptoms? This will probably colour the
respondents' answers, if >40% have had HMB for so long, instead of a group of women who
go to their GP with this 'new' complaint and make a treatment choice together. Please explain
in your methods and/or describe in the discussion section.
Discussion:
“up to 30% of women remained untreated even after having their HMB confirmed by a clinician”
--> this doesn’t imply that this is because of women remain uncertain whether it was a problem
worth addressing; some women may decide (after SDM) not to start a treatment yet.
Conclusion:
“Moreover, women are frequently not informed about the full range of options for HMB” # I
would rewrite this sentence because of 2 reasons:
1. From a qualitative research it is difficult to conclude that women are ‘frequently’ not informed.
2. If I read the results, I would conclude that the counselling of the clinician was not always
neutral due to a preference for the less invasive treatment option by the clinician (but this is also
in line with the current treatment guidelines). If I read the quotes, a hysterectomy was not totally
neglected, it was discussed during the consultation but not recommended by the clinician.