Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Abnormal Menstrual Bleeding Causes and Treatments
Guest Kelsey Kennedy, a dual-certified nurse practitioner at the Cleveland Clinic, joins Host Holly Thacker, MD on the Speaking of Women's Health Podcast for an in-depth discussion on managing abnormal menstrual bleeding.
Dr. Thacker and Kelsey explore the myriad causes behind abnormal bleeding, such as fibroids and endometrial polyps, and the comprehensive evaluations necessary before treatment. From hormonal therapies to non-hormonal alternatives and specialized surgical interventions, discover the individualized care approaches that ensure optimal outcomes for each patient.
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, and I am happy to be back in the Sunflower House for a new episode. And I'm with Kelsey Kennedy, who is a dedicated and highly skilled nurse practitioner and she works at the Cleveland Clinic in GYN subspecialty care and she spends a day a week in our Center for Specialized Women's Health. So some of our listeners and patients may have seen her and she's very well educated and is actually dual certified, first as a family nurse practitioner, so that's really a broad area of education. And then she has got her certification as a women's health nurse practitioner certification as a women's health nurse practitioner and so she focuses on women across the reproductive and lifespan.
Speaker 1:She completed her undergraduate education at St Louis University, so I was from. I went to school in Missouri, so you were at SLU. I was Hot summers Definitely Cleveland is so much nicer in the summer than St Louis and then she got her master's of science and nursing, with a specialization in family health, at Walsh University in Canton, ohio. And then, after working in women's health, she further advanced her healthcare by getting a post-master's certification in women's health from Kent State.
Speaker 1:Throughout her career she has been recognized for her compassionate approach, her clinical excellence and her leadership and her dedication to patient empowerment and education, which goes right along with our mission to be strong, be healthy and be in charge. She leads her team as an advanced practice provider coordinator. She focuses on leadership skills and fosters a collaborative, supportive environment for her colleagues and patients, and works closely with some of the other guests we've had, like Dana Leslie, a nurse practitioner. In addition to her clinical work, she advocates at health fairs, workshops, seminars and focuses on preventive care, chronic disease and reproductive health. So she brings a wealth of knowledge and passion.
Speaker 2:So welcome, kelsey. Yay, thank you. Thank you for having me.
Speaker 1:Excited to be here, so happy to have you. So what brought you from St Louis to Ohio? Is it that handsome?
Speaker 2:lacrosse coach husband of yours. That helped. But I'm actually originally from Ohio. I wanted to experience life outside of Ohio, which is how I ended up going to school in St Louis and then after graduation I just kind of wanted to be back with my family and my roots and that handsome lacrosse has been really yeah, he is really gorgeous, and so are your roots.
Speaker 1:are you Irish? Is that why you're going to Ireland?
Speaker 2:Yes, yes. So I think like 87.5% Irish. So going to Ireland this summer.
Speaker 1:Yes, that is great. Well, that'll be fun. You'll have to give us some pictures to post on social media. Our speaking of women's health folks who follow us on Facebook and Instagram and X and LinkedIn and on our website just you know love to know a little bit more personally about their clinicians. So tell us a little bit more about your specific role at Cleveland Clinic and why you got into this field.
Speaker 2:Okay. So I knew after a few years of being a bedside nurse, I didn't know exactly what I wanted to do, but I wanted to do more. After a while, when you're handling patient problems, working inpatient as a nurse, you start to know what you need and what you're going to be asking the physician for. And that made me think, okay, I can do this, I'm capable of more. So I went back for my family nurse practitioner degree. Because it's such a wide range, I knew I'd have a lot of options. I wasn't really sure where I was going to hone in, and during that master's program I actually had a clinical rotation with Mary Clarkin and with Dr Thacker's Center for Women's Health back in 2017. Thacker Center for Women's Health back in 2017.
Speaker 2:And I spent some time with Danielle Wen as well, upstairs in outpatient women's health, and between those two experiences I just really fell in love. I never expected myself to work in women's health. It was never something on my radar, but after you know spending that time and working with the patients, it just really clicked for me that it's just about connecting with women and that's it. It Like no one can understand how bad a yeast infection or a UTI can ruin your day better than a fellow woman.
Speaker 2:That's all it really is is connecting with women and, you know, providing them education, empowering them to, you know, be healthy and manage their lives. So that's kind of how I ended up in women's health in general.
Speaker 1:Yeah, that is just terrific.
Speaker 1:And yeah, mary Clark and I think it was one of the areas first, women's health nurse practitioners and she followed me would come to different lectures and always wanted to get into the center, had moved around to you know she did REI, she was at different health institutions and in private practice and she retired in 2020.
Speaker 1:She still has a lot of great content, from self-defense to recipes, on our website and some patients who have seen her haven't seen any nurse practitioner since she retired and that was now four years ago. So, ladies, if you're out there and you haven't had your exam, at least every two or three years for sure, even if you have no symptoms, even if you don't need a pap smear. And we've done some great prior podcasts, like with Dr Sharon Sutherland in charge of cervical cancer prevention awareness, because we've really backslid in certain areas in women's health. There's been lots of advances but then some backsliding. So you work very closely with our minimally invasive gynecologic surgeons, migs and the so-called benign gynecology section, so tell us about that practice, how you interface with them, what some of the conditions are that are best seen by these kind of specialists.
Speaker 2:Yeah, so minimally invasive GYN surgery or the MIGS team is just really a group of highly trained surgeons that deal with all benign or non-cancer conditions in the GYN world. So our surgeons are doing laparoscopic, so minimally invasive, typically one to five small incisions on the belly surgeries for things like hysterectomies, removal of the uterus, for fibroid surgeries. We also do endometriosis surgeries as well as some kind of more niche groups like malaria anomaly clinics and ovarian cysts or masses that aren't cancerous but are causing problems. So there's a really wide variety of surgeries that our team does. That's all they do is these surgeries over and over and over. So they're highly trained and really good at what they do.
Speaker 2:And as a nurse practitioner myself and a couple of the other NPs on the MIGS team, we are really helping with teeing up some of the consults. So if a patient is, let's say, referred to see the MIG surgeons, we have a team of nurse coordinators that sort of reviews the chart. If the patient's ready to go, they'll have them schedule the consult with a physician. But if perhaps the patient is sent to us from an outside hospital or we're not really sure what the scoop is, or if they have their imaging up to date they might do their initial intake consult with the nurse practitioner to kind of get everything in order. And then we're also seeing these patients post-operatively. So usually about two weeks after their surgery we're seeing the nurse practitioners, are seeing all these patients virtually to check in and then we're managing a lot of that perioperative care too. So for a lot of the phone calls and my chart messages it's the nurse practitioner team that's managing those patients' concerns. So our surgeons can spend the long days in the OR helping as many people as they can.
Speaker 1:I know I frequently will put in a MIGS minimally invasive gynecologic surgery consult, and even if the woman isn't sure that she wants surgery.
Speaker 1:But I like to emphasize that if you do need surgery it's better to probably get your hysterectomy or your pelvic surgery from someone who does this all day long, not just one a month.
Speaker 1:And if you're one of our listeners across 80 plus countries and you're thinking about possibly needing a hysterectomy or having some gynecologic problems in many locations, a lot of OBGYNs are kind of a jack of all trades but really a master of none. And if you've got serious problems you've already been operated on or have endometriosis, then having the most experienced surgeon is important. And is it true that one of the roles that you and your colleagues do is see the patient first? Even if we do order a mixed consult just to make sure that the patient is in the right place, or if it's somebody internally who's a physician, like myself, who puts the consult in, they do get to see the surgeon if I've identified that they are a surgical candidate, as opposed to the patient just calling up and saying, hey, I want an appointment, which one of our most important podcasts was how to even get an appointment at the Cleveland Clinic.
Speaker 2:Right, it's so hard, any medical it's so hard. There's a little bit of nuance there. So we do have two nurse coordinators, sue and Michael, who kind of own scheduling all the consults. Sue and Michael kind of use their nursing judgment to triage and evaluate the patient chart and really it's different for every kind of consult we get.
Speaker 2:So some patients that are referred, even from an outside hospital. They have all their ducts in a row, all their records, all their imaging's up to date. They're ready to go. It's very clear that surgery's the next step. And some patients you know internal consults the patient's still trying to figure out goals. You know they don't exactly know what they want to do as far as pursue surgery, pursue medical management, what's out there, what are options. So if it's the latter, we typically start with a nurse practitioner visit just to try to explain to patients what's even out there, get their goals aligned, order any imaging medications that could help relieve some symptoms in the meantime. But other patients that are ready to rock like hey, I've tried six different things, nothing's helping my bleeding, I'm over it. Take this uterus out. Those would probably just go straight to the surgeon. But that's all managed by our nurses.
Speaker 1:And I find some women who maybe aren't ready to take that next step. But if they're not connected and they don't have a care plan outlined, then it can be more difficult and they might have less choices. I think that's true with really any medical condition. Obviously we want to avoid surgery if we can and do medical options. So before I guess we get into all the different medical options, maybe you should elaborate just a little bit more on some of the conditions that can be treated with minimally invasive gynecologic surgery, even though of course our listeners, we know that you're not doing the surgery yourself, but you still work closely pre-op, post-op. You still see these women and kind of watch the whole spectrum of their care and also talk a little bit about those mullerian duct abnormalities. And is that primarily a pediatric gynecologic clinic? Or do you even see full-grown women that just weren't diagnosed, that still have those issues?
Speaker 2:Yeah, perfect that just weren't diagnosed, that still have those issues. Yeah, perfect. So I would say one of the biggest problems that the MIGS team helps manage is abnormal bleeding, abnormal uterine bleeding and sometimes abnormal bleeding. We really don't know what it's from. Sometimes there's not a cause, it's just there. Other times we very much know what abnormal bleeding is from and it could be from something like fibroids, which are a really common type of benign, so non-cancer, tumor in the uterus. By age 50, I think, around 70% of women have at least one fibroid. So sometimes fibroids are there and not problematic, and other times fibroids are there and, based on the size or location of the fibroids, they're causing problems, which is typically really heavy periods. We hear patients are, you know, having to wear a super plus tampon, plus an overnight pad, soaking their sheets, having to bring an extra change of clothes to work, that kind of thing. So fibroids are a big common cause of abnormal bleeding. Another cause of abnormal bleeding we treat often in MIGS with a hysterectomy is something called adenomyosis, which is where the lining of the uterus sort of migrates and grows these little pockets in the muscle of the uterus. So it makes the uterus a lot bigger in size, maybe even globular. It makes the uterus more tender. It kind of can feel a little bit more squishy when we're doing your bimanual exam and that can cause irregular bleeding, frequent periods. It can make periods more painful. So sometimes adenomyosis is, you know, maybe about one-third of the time it's just something we see on ultrasound, it doesn't really cause problems. But two-thirds of the time it's causing, you know, abnormal bleeding, painful periods, pain with intercourse, just because the uterus is more tender in general. Sometimes the adenomyosis is really responsive to things like medications. So sometimes people start medications. Their symptoms are better, they're happy with that, and other times it isn't. So if that's the case then the definitive treatment would be management with hysterectomy, surgical removal of that uterus. If you remove the uterus with the adenomyosis it's no longer an issue.
Speaker 2:Endometriosis is another really broad, interesting topic that we treat with minimally invasive GYN surgery and that is kind of blended with our CPP chronic pelvic pain and endometriosis center. So endometriosis the tissue of the lining, grows in other places outside of the uterus and basically when you have endometriosis that endometrial-like tissue during your period also gets really inflamed and it's famous for causing a ton of debilitating pain, especially pain during your periods. Patients are often fine the rest of their month and just completely out of commission during their periods. I'll hear like can't go to work or school, vomiting because of pain during my period, all these other things. So there's a couple of different kinds of endometriosis. It can be superficial, it can be deeply infiltrating, which are nodules in the intestines, and there can also be endometriomas, which are big cysts of endometriosis on either ovary.
Speaker 2:So it is really important, collaborating with my MIGS surgical colleagues, to see someone for endometriosis who's a high volume endometriosis surgeon. You want someone who's operating on endo all day because I'm not in the OR. But it can take many different forms and it can look very different. So we have a lot of patients who have unfortunately gotten surgery for endometriosis by an outside hospital Jack of all trades OBGYN they've been told they're fine, they see us. A couple months later Our surgeons open them up and do surgery and find endometriosis everywhere. So it can be really tricky to find and excise. You know, surgical management or surgery is the only way to formally diagnose endometriosis that we have right now. We have a lot of other ways to help give us clues, like ultrasound, MRI, but the formal way to diagnose endometriosis is to have a surgery with a highly trained surgeon. They see the endometriosis with their eyes, they remove it and then the pathologist confirms yes, in fact that was endometriosis.
Speaker 1:Now you have been listening to the Speaking of Women's Health podcast and I'm your host, dr Holly Thacker, and we are talking with Kelsey Kennedy, a well-trained women's health nurse practitioner who works with minimally invasive gynecologic surgeons as well as spends some time in our specialty women's health center, which focuses on midlife women's health, and there's this overlap and issue that of course women have with painful periods, abnormal bleeding pain, the vexing problem of endometriosis.
Speaker 1:In fact, when you were talking about those symptoms, I remember when I was a very young adolescent and having horrible painful periods and I wanted to sign up for a hysterectomy right away.
Speaker 1:Now thank goodness I didn't because I wouldn't have my three sons or my three grandchildren, but it is so painful and even after a lot of research and surgery and intervention it's still a very complicated problem. We do have a lot of information on our website, including free treatment guidebooks on abnormal bleeding and fibroids that anyone can go on speakinginwomenshealthcom and download. We're going to have some content up on our website by nurse practitioner Kennedy and the head of our MIGS section, dr Kara King, who has her own podcast and does a lot of coaching of surgeons. She has a column on what is MIGS and surgery. So the one thing I say from a medical perspective is anyone who's considering a hysterectomy for heavy bleeding should be treated for, or evaluated rather for, bleeding disorders and von Willebrands, because I have seen some women get hysterectomies who are bleeders and they have a bleeding disorder as opposed to a gynecologic anatomic problem. So I don't know if you want to expound on abnormal bleeding.
Speaker 1:Talk about the use of IUDs which you insert and remove in your office and the different kinds of IUDs for bleeding.
Speaker 2:Yeah, yeah, that'd be great. So I always tell patients abnormal bleeding is really anything that's not normal. So a normal period cycles anywhere from every 21 to 35 days. On average, women bleed for about five days at a time. So abnormal bleeding can mean your cycles are irregular, you're bleeding in between your cycles, or the amount of bleeding you're having can be abnormal. So bleeding can be from a bunch of things. First off, if anyone is of a reproductive age, meaning they're having monthly periods and there's even a chance of pregnancy we're always going to make sure that the pregnancy test is negative and this isn't some sort of first trimester bleeding or a miscarriage or something like that. So that's really important. To check off the list. I always tell patients if you're having weird bleeding or spotting at home, just do a pregnancy test at home just to rule that out, even if you think the chances are very slim.
Speaker 2:We talked a little bit about fibroids. There's also endometrial polyps, which are teeny little polyps inside the uterus. 99% of the time they're benign or non-cancerous, but those are an extremely common cause of abnormal bleeding, typically polyps. We remove them hysteroscopically in the OR with one of our surgeons. Remove them hysteroscopically in the OR with one of our surgeons and hysteroscopically means we just do a teeny tiny camera through your cervix, so there's no cuts in the skin. It's a very quick recovery. You can be back in your Orange Theory workout class like two days after surgery. I mean, it's quick, it's in and out and typically when we remove those polyps the abnormal bleeding is gone.
Speaker 2:So managing abnormal bleeding, we do have quite a few options. So one of the tried and true bread and butter options is something like birth control pills, because those are going to regulate periods, they're going to make heavy periods lighter and typically they take care of any irregular bleeding that might be from an unknown cause, like or if you're not ovulating regularly something like that we also have for heavier bleeding. That's maybe birth control pills aren't cutting it. We have things like progestin therapies, which are progesterone only medications. Typically we're using ones called Agestin and Provera and you're taking those medications every day.
Speaker 1:Yeah, those are the brand names medroxyprogesterone acetate.
Speaker 2:Yes, yes, and those can really reduce the amount of bleeding that some women are having. I even have some women that I've seen for abnormal bleeding. We start them on a progestin and they completely stop bleeding and they're like this is great, as long as I'm not bleeding, I'm fine. So sometimes we can avoid surgery with those medications.
Speaker 1:One of the, in fact, the only hormonal contraceptive at this time in 2024, which is when we're doing this podcast, taping it that is FDA approved to treat abnormal bleeding, after, of course, an evaluation, because you always have to rule out cancer and infection and structural problems is the brand name is Natasia, which is bioidentical estradiol and different doses of a progestin, with only two days of placebos.
Speaker 1:And I was in clinic the other day with one of our specialized women's health fellows, dr Madeline Cohn, and I said okay, so what do you think you should offer to this woman who's already been evaluated, is perimenopausal, has abnormal bleeding, has already tried a lot of different things and she has like a mental block about remembering the name Natassia, and I said you have to name your firstborn daughter Natassia and that's how she's going to remember it. But we do have this content on, and so some generic, cheaper contraceptives can do it. Not all women, of course, can take oral synthetic estrogen or even oral estrogen if they have blood clots or other issues or over 35 and smoke cigarettes, but it's nice to do those. You want to talk about some non-hormonal treatments or mixed hormonal treatments that I know are very expensive with endometriosis like Orlissa and well, lysteta, transdynamic acid yeah, Lysteta.
Speaker 2:I use a lot Lysteta, or transdsexamic acid, is. I describe it like a cousin of ibuprofen and it kind of makes your blood less clotty or less oozy is how I've heard it described to patients. So you know, if you can take ibuprofen and you don't have kidney disease, really you can take Listeria and the nice thing about that is it's non-hormonal and women like it because you only take it during your period. So you take two pills every eight hours for up to five days during your period and for the women it works for it can really reduce their bleeding by about 30 to 40 percent, which sometimes that's all we need. Um, so for people that are having heavier periods or you know, the amount of bleeding they're having is picked up, let's say, as part of perimenopause, but they're otherwise fine, that can be a really nice option.
Speaker 1:But if they're on that Lystata. They cannot be on a concurrent hormone. I've seen some clinicians try to prescribe both at the same time, which would not be recommended.
Speaker 2:Yeah, I have seen some studies that show if they're like otherwise healthy, it can be okay. But generally I don't see it done Because if you're going to need both, there's just better options. Like we should probably be thinking about an IUD or something. So IUDs, there's two main kinds of IUDs the non-hormonal Paragard that's not going to help your bleeding, so if you have heavy periods, painful periods, the Paragard is actually probably going to make that a little bit worse. So that's not your answer if you're having abnormal bleeding. Of the hormonal IUDs, there's three levels. I tell patients to think of them as big sister, little sister, mirena, kylena. There's another one that's Skyla. That's good for three years, but really out of the Mirena and Kylena, the Mirena, the big sister one that one is FDA approved to treat heavy menstrual bleeding.
Speaker 1:For five years, right, even though for contraception it's eight years, correct, although we've seen some decidual tissue in the eight years. So I don't know that I personally would ever rely on a Mirena for eight years. But I think women need to pay attention or write down in their phone or their book exactly when they got their device, because it's amazing, I see a lot of people who can't tell me the exact date, and that does, you know, have importance.
Speaker 2:Agree, yeah, it totally does. Yeah, so I always, when I meet patients, I'm really I'm digging through their charts to try to find the month and the year that that IUD was put in, because the further away you get from insertion, the harder it is to remember and all the years blur together and I've definitely had patients that are like, yeah, I've had it for about six or seven years. Then we find the date and they've had it for like 10. Is when we find the date and they've had it for like 10. Oh no, the time flies by.
Speaker 1:I remember having a conversation in clinic with you and you were saying how you know, the patient says, just look in the chart. And you're like there's a thousand different places to look in the chart.
Speaker 2:You know, and you want to really I can probably look in the average patient's chart for maybe like six hours and still not cover everything that's in there.
Speaker 2:So everything's in your chart. But it can also be a firehose of information, which is why it's so important for us clinicians and patients to have that conversation, because who knows their health better than the patient? You know, absolutely I don't prescribe Orlissa as much to treat endometriosis. I typically am referring to our chronic pelvic pain team, who does all medical management of endometriosis, to prescribe that if it's an option. Basically it's kind of shutting down everything to put your body into a medical menopause, because then the endometriosis tissue can't be active, it can't be causing pain and flares and problems. We also do something called Lupron rarely which is an injection that kind of throws your body into menopause to keep that endometriosis from becoming a problem. That can be helpful in the MIGS chronic pelvic pain world too.
Speaker 2:If a patient's having a bunch of pain, pain is really tricky, it can be from many things at once. So sometimes we'll put patients on Lupron, because if they're on Lupron and their pain completely goes away, we can be more suspicious that yes, this is probably endometriosis instead of something else. So that can kind of help our team decide. You know, is surgery the answer? Because some patients with chronic pelvic pain they've had it for, you know decades and sometimes they have endometriosis and surgery doesn't help the pain because the pain's also from something else GI, musculoskeletal, high-tone pelvic floor. There can be a high association with pelvic pain and things like PTSD or history of trauma. So it's very complex and gnarly to try to untangle what the pain is from and it's not always a thing we can see on imaging or remove in surgery or measuring in blood work. It's really complex.
Speaker 1:Our colleague who has been on this podcast, dr Sobia Khan, in functional medicine, has looked at using low dose naltrexone or the brand name Narcan, which in high doses is used to reverse opiate overdose, but in really low doses, LDN is used to potentiate our natural opiate receptors and she's doing a study on patients with endometriosis and using that. Because anytime someone gets into a chronic pain situation, even if you can identify what part of it was that initiated it and take care of that, if the nerve fibers and everything are reverberating and the body and the response is set in, it can really need a multidisciplinary, very comprehensive approach. And do you want to talk about how you interface with the chronic pelvic pain team?
Speaker 2:Yeah, so the chronic pelvic pain team at the Cleveland Clinic. It's two physicians, dr Ashley Goobles and Dr Jessica Strasberg, and then one nurse practitioner, erin Reaper. So Erin Reaper is part of our benign MIGS you know CPP nurse practitioner team. So it's really quite an honor to be able to work so close with Erin, because I feel I peripherally get to learn a lot about pelvic pain team and not every hospital system has a dedicated chronic pelvic pain center. So we have patients coming to see these providers from all over the country. It's really quite amazing what they do. So Erin does some minimally invasive GYN surgery. She sees some benign annuals and then she has a lot of chronic pelvic pain.
Speaker 2:So when people are referred patients are referred to see the chronic pelvic pain team. There's a very extensive form that they need to fill out before they can actually schedule. But I always tell patients don't get weirded out if you don't feel that these questions apply to you, because this is for the clinician to try to figure out where you're coming from. Some people come to see them and they've been having chronic pain for six months. Some people have been having this pain for 10 years. Some people have never seen a specialized pain provider. Other people have already seen three or four.
Speaker 2:So it's really to help you know the provider you're seeing, see where you are, so they can meet you where you are. And then the first appointment with the chronic pelvic pain team is actually an hour long. So it's very in-depth, it's very kind of you know, explores a lot and kind of goes over a lot. And then I pretty much help support some of the in-between care. So, for example, if a patient is seeing Aaron Reaper, dr Strasberg and needs refills or has a quick question in between appointments, that's where my nurse practitioner team is helping kind of fill in to kind of keep that care going smoothly and cohesively in between follow-ups and things like that.
Speaker 1:And Dr Jessica Strausberg, who's trained in family medicine and had extra training in women's health, who's part of the chronic pelvic pain team. From the medical perspective as opposed to the surgical perspective, she has provided content for us on speaking of women's health and I am certainly not a surgeon and I tell patients that who sometimes get scheduled and think that I can do their surgery. But I do have some opinions about surgery. As I mentioned, getting the most experienced surgeon, especially if there's complications or difficult diseases like endometriosis, and if you're having a tubal ligation, um, you want all the tubes taken out because that reduces ovarian cancer, and so I think that's a little bit better known in the last few years. But still there may be some surgeons who are not doing that.
Speaker 1:We're no longer doing Assure devices. Those have been pulled off the market. Those were coils put in the tubes and I see a lot of women at high risk for breast and ovarian cancer that need surgery. If they're very young and they want to keep their ovaries still, they may just get a complete tubal ligation. But when they go after age 40 to remove the ovaries, I'm pretty much a stickler, even though it's not standard of care to remove the uterus at the same time, because once the ovaries are completely removed, a woman is surgically menopausal and even if they have a gene, that increases cancer risk. We know that estrogen therapy reduces cancer rates of the breast and prolongs lifespan and reduces lots of disease. But we can't just give estrogen if you still have an endometrium or a uterus and so a lot of women aren't even given that option.
Speaker 1:They just think they need their ovaries and tubes out and they keep their uterus. And so a lot of women aren't even given that option. They just think they need their ovaries and tubes out and they keep their uterus, which has some mechanisms for support, but it does make managing that surgical menopause much more difficult. So I don't know if you're involved in any of those discussions or if that's primarily the GYN oncology nurse practitioner, since usually it's GYN who's doing those surgeries.
Speaker 2:Yeah, most of my discussions are just with you about that, dr.
Speaker 1:Thacker.
Speaker 2:Yeah, that's more a, that's more a GYN. So I don't, I don't work with that team as much.
Speaker 1:So let's just back up, because we've talked about surgery, but let's go to some of the diagnostic tests that we do. When someone is over 40 and complains of abnormal bleeding, they might chart us in or they call us and they're like oh, it's because I skipped my pill, or oh, it's because I forgot something, or oh, whatever. But I don't want to undergo the evaluation. But, like once you're telling us about abnormal bleeding, we have to rule out cancer, even though we have to we have to look into it we just have to and I know it sucks but we just have to.
Speaker 2:So you know some of the I? I, if it's abnormal bleeding, I'm one of those that's like come on in, we need to do a good physical exam, we need to see what's going on. Um, you know, the workup I'm generally doing is I typically am doing a diagnostic pap. Um, even if a patient's had a normal pap history their whole life, less than 10% of cases of cervical cancer can kind of pop up out of nowhere in less than a year. So we always want to be doing a diagnostic pap to make sure the bleeding isn't from abnormal cells on the cervix. Um, I'm typically doing an infection swab just to make sure there's no infection causing this abnormal bleeding, like bacterial imbalance, yeast, even a sexually transmitted infection.
Speaker 2:And then we're typically looking for some imaging. So there's pelvic ultrasound, which is the wound in the vagina. The jelly on your belly looks at your uterus and your ovaries, at your uterus and your ovaries. That's okay. But the best ultrasound for an abnormal bleeding evaluation is the saline infusion ultrasound or the SIS, and that's what the GYN physician and they put a teeny, tiny straw through your cervix into your uterus because the uterus without a baby in it lies flat and collapsed. So the saline in your uterus kind of pops it open and then we can see crystal clear what the heck is going on in that uterus. Is there anything in there that could be causing bleeding?
Speaker 2:So often that's how we find endometrial polyps. We can also find a thickened endometrial lining which is concerning for a cancer or a pre-cancer of the uterus that could be causing bleeding. And sometimes we do find submucosal fibroids, which can even sometimes be small fibroids. But if they're sort of poking into the cavity of the uterus, even though they're small, they can cause bleeding drama, lots of big bleeding drama even for a small fibroid. I really prefer to order the SIS because at the same time we can do an endometrial biopsy, which is very important to have a sample of the cell tissue from the endometrium inside the uterus that we send off to the lab just to make sure there's no cancer or pre-cancer cells going on. It's nice because with the SIS you're kind of already getting that procedure done anyways. So if you have abnormal bleeding over 40, we really need an endometrial biopsy to definitively rule out this isn't from a cancer, a pre-cancer of the uterus.
Speaker 1:Absolutely. I have had a subucosal fibroid that I had to have removed by an in and out DNC, like I send women almost every day for.
Speaker 1:It's so common and ended up having a polyp that wasn't even identified. So there can be these little minor, annoying structural problems that cause problems. Tissue is always queen. Even if you have an ultrasound that seems normal, you still want to get the tissue. If someone has had an SIS and an endometrial biopsy and they're still bleeding, I usually recommend that they go in for an office hysteroscopy which a lot of gynecologists can't do, but we certainly have several who have that ability a tiny little three millimeter lighted scope, because then you can see at the opening of the tubes, because I have seen some women who've had tubal disease or early cancer with abnormal bleeding or discharge. So you just don't want to ignore these problems. Most of the time it's going to be fine, but it may not be and we'd much rather treat these problems sooner rather than later. And it's so wonderful to have someone like you and your colleagues on the team because it really does help patients. So thanks so much for joining me.
Speaker 1:How can people follow you or reach you or see you?
Speaker 2:clinically, yeah, so so to follow me, my professional Instagram is Kelsey Kennedy NP one word NP for nurse practitioner that's. That's really where you can follow me and to see me as a patient. You can look me up on Cleveland Clinic. Find a doc website called the Cleveland Clinic Women's Health Appointment to schedule an appointment. I have good availability. I love meeting new patients and I love seeing new patients and getting referrals. There's no better feeling. I do virtual visits on Wednesdays for people who don't want to drive downtown and fight the downtown traffic to see me. We can typically get a lot done that way, but that's basically where you can find me IRL and online.
Speaker 1:Well, thank you so much and thanks to our listeners for joining us for another podcast. We're grateful for your support. Please share this with others and, if you don't already subscribe, hit the follow or subscribe button on Apple Podcasts, spotify, tune in or wherever you listen to podcasts. Thanks again for listening and we'll see you next time in the Sunflower House.
