Title: Patients’ motives and considerations on treatment decision-making for heavy menstrual
bleeding: a qualitative study
Version: 1 Date: 13 May 2024
Reviewer's report:
Thank you for the opportunity to review this paper on women's experiences of decision making
in the context of heavy menstrual bleeding. The inclusion of patient perspectives on HMB
treatment is extremely important, addressing what has been an often neglected aspect of women's
health.  My feedback to the authors is all relatively minor:
The paper would benefit from close editing for English grammar and expression. Just a few
examples:
• Line 66-7, treatment used twice in same sentence;
• Line 60, should be “is now defined…”
• Line 70 ‘child wish’ is an unusual expression;
• Line 77 patients needs an apostrophe, but lives on line 400 does not;
• What is meant by ‘panel members’ on Line 100?
• Line 112, do you mean ‘attends’ rather than ‘presents’;
• Line 226, the expression to ‘take for granted’ is not quite right for this sentence.
• Line 398 does not show subject verb agreement  - ie ‘burden’ singular, vs ‘were’ plural
• Line 409 possibly should say ‘approximately’ (meaning about) rather than
‘proximally’ (meaning near).
• Line 454 – minor typographical error – in-depth.
Many of these are not actually wrong per se, but they do reduce the clarity of the writing.
Line 116: I’m unclear what contribution the OECD document made to the development of a
topic guide? It may also be useful to include the topic guide, or a summary of it either as a figure
or supplementary material? Was the topic guide piloted and refined in the early stages?
I presume the interviews were conducted in Dutch. Please clarify how translation of transcripts
was undertaken.
Line 130: Thematic analysis and content analysis are two different analytical approaches. By
your description of the analysis, it sounds like a descriptive thematic analysis? On line 150, it
sounds like three parallel version of the analysis were undertaken, but the para beginning on
Line 130 indicates a more collaborative consensus-based approach. Please clarify.
Line 146: there are many approaches to member checking. Please clarify what occurred here,
with reference to literature to justify this approach. See Birt et al (2016). Member Checking: A
Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res.
The concept of saturation (line 106) deserves more critical consideration and transparency. See
Braun & Clarke. (2021). To saturate or not to saturate? Questioning data saturation as a useful
concept for thematic analysis and sample-size rationales.
I’m unconvinced that the 14 subthemes have genuinely reached the level of being a subtheme.
Reconsidering these may assist with making the paper more concise. In some cases, the quotes
are unclear or don’t clearly link to the point being made (eg the quote on Line 362, doesn’t appear
to mention avoiding appointments?). Where patients had tried multiple options over time, how
did they experience this? Did they connect this to not being taken seriously, or to a supportive
process of trying less risky and less invasive treatments first?
Is tranexamic acid considered amongst treatment options for HMB in the Netherlands?
Given women's expressed preference for non-hormonal options, whether it might be regarded
favourably by patients.
The final para of the discussion needs to be better integrated with your argument. I note that an
options grid was introduced into latter interviews, but no further mention was made of this. Was
it used as a stimulus for further discussion and if so, with what findings?  It is unclear to me how
widely used a HMB options grid was in the study context, and how useful patients found it?
Overall the paper is quite long. Many of the quotes contain internal repetition and it may be
useful to ellipse repetitive utterances, or fillers like ‘um’, ‘eh’, ‘like’.