Selected Podcast
Why You’re Bleeding When It’s Not Your Period
One of the easier ways to gauge reproductive health is the consistency of menstruation but when you're bleeding outside of your period, that can indicate a more serious issue in some cases. Dr. Assaad Semaan discusses endometrial cancer, risk factors, and what symptoms to look out for.
Featuring:
Assaad Semaan, MD
Dr. Semaan has been practicing gynecology for eight years, three of which have been at AMITA Health. His special interests include robotic surgery and technological advances within general surgery. Outside of work, Dr. Semaan is an avid runner and spends most of his time with his wife and three kids. He is a big believer in an individualized approach for treatment and involving patients in decision making. Transcription:
Prakash Chandran (Host): One of the easier ways to gauge reproductive health in women is the consistency of menstruation. But when you're bleeding outside of your period, that can, in some cases indicate a more serious issue. Today, Dr. Assaad Semaan, a Gynecologic Oncologist for AMITA Health is going to teach us about endometrial cancer, risk factors and what to look out for.
This is AMITA Health Cast, the podcast from AMITA Health. I'm your host Prakash Chandran. And so Dr. Semaan, really great to have you here today. Thank you so much for being here. I wanted to get started by asking why might a woman bleed when it is not her period.
Assaad Semaan, MD (Guest): First of all, thank you for having me you know, this is a very common question that we get as gynecologists, but also as, you know, gynecologic oncologist you know, not every single abnormal bleeding or bleeding outside of the period is a cause of, you know, worry for a cancer. But, you know, this is something that always needs to be investigated, especially when it is a recurring issue.
We usually you know, divide patients into patients before menopause and patients after menopause. Women before menopause tend to have a lot of benign reasons why they're bleeding in between periods. While women after menopause should never have any bleeding after they fully go into that menopause. So the suspicion for any you know, cancerous lesion or precancerous lesion is much higher in a woman who's passed the age of menopause. And that also depends on the risk factors. So some certain women before menopause do have risk factors for these cancers and they should be aware of these risk factors. And in these women bleeding outside of the period, even before menopause is a cause of worry.
Host: Okay, understood. So you mentioned some of those risk factors. Maybe you can unpack what they are for us.
Dr. Semaan: Yeah. The, the main risk factors that we're seeing more and more these days is obesity. We know that obesity is associated with, with endometrial cancer and with endometrial precancers or what we refer to as hyperplasia. And the reason that happens is that the fat in the body can actually produce estrogen and lead to an imbalance between the female hormones, estrogen, and progesterone, and that can secondarily lead to the formation of a pre-cancer that can become a cancer. So obesity is a huge one. You know, another one is we tend to see these cancers more in women who have not had kids, in women who have diabetes, in women who have a strong family history of colon cancer and endometrial cancer, in women who you know, went or started having periods very early. And in women who have ovulation issues like women with polycystic ovarian syndrome, these are the main risk factors where even if the abnormal bleeding is happening before the age of menopause, we do, you know, pause and investigate looking for a potential cancer.
Host: So just focusing in on women that are pre-menopausal, how can they distinguish between less severe reasons for bleeding and spotting outside of their period and bleeding that might be caused by something more serious, like endometrial cancer?
Dr. Semaan: That's a very good question. You know, not every single abnormal bleeding is a source of worry, but you know, what I would say is one, you know, how much bleeding is happening even if it's within the period, it's very heavy. It's been going for, you know, several days and having to use a lot of, you know, tampons or, or sanitary pads, more so than they are used to, that's a cause of worry, if they see bleeding after intercourse, that's a cause of worry. If the problem gets repeated one cycle after another, that's a cause of worry. And you know, if unsure, it's always good to reach out to your obstetrician and gynecologist or to your primary care and discuss the situation. The work up, you know, it's very easy. So, you know, if we are unsure, we go through the workup to make sure that we are not missing anything.
Host: Okay, that makes a lot of sense. So one of the things we're focusing on today is endometrial cancer. Maybe talk a little bit about what it is and why it's important for patients to know about it.
Dr. Semaan: Excellent. So, you know, endometrial cancer is the fourth most common cancer that we see in the United States in women. So it's a, it's a very common cancer. It's the most common gynecologic cancer. And we diagnose around 60 to 70,000, you know, women in the United States every year. And one of the reason why we're seeing the incidence or the occurrence of that cancer increase one year after the other is we, as a population are gaining weight and our average body mass index or weight is increasing.
And with that, you see an increase in incidence of endometrial cancer. Endometrial cancer in general, is divided into, into two. You have type one and type two. Type one cancers are the vast majority around 80 to 90% of cancers are type one and they tend to be associated with an imbalance in hormones and obesity. And we're seeing more and more of these in younger patients just also because of that weight gain early on in life. Type two cancers are cancers that are more aggressive and they tend to not be associated with things like hormonal imbalance and obesity, and they tend to happen later in life. They tend to happen moreso, you know, late sixties, early seventies, and they tend to be more aggressive. A lot of them, we really don't know what's, what's the cause of these cancers.
They tend to sometimes be genetic and sometimes not. And they tend to affect women who are older and their treatment is usually more extensive. So overall, you know, two types, one is most of hormone-related and in younger patients. And the other one is usually hormone independent in older patients and tends to have a worse prognosis.
Host: Okay. Understood. And so regardless of type one and type two, can you talk a little bit about how treatable these endometrial cancers are and how you go about doing it?
Dr. Semaan: So the first thing is to make the right diagnosis. You know, usually these cancers do present at an early stage because they cause bleeding. So that's the sign that, you know, anybody can, can figure out that there's something's wrong. And then they seek care. Once patients seek care, you know, we do use ultrasounds and biopsies to obtain tissue and to analyze the tissue under the microscope and make that diagnosis. Once you make the diagnosis, whether it's type one, or a type two cancer, you go through a workup to make sure that that cancer didn't spread or metastasize elsewhere. Sometimes that might include some blood testing and CT scan. Once that's done, then usually we move to the second phase of treatment, which has surgical staging.
So, all of these cancers are treated initially with few exceptions, surgically. And the information that we get from the surgery is what, what the next step would be.
Host: Okay. Understood. So, after that surgical staging and you're determining what the next steps are, what are the different pathways that you could take from there?
Dr. Semaan: So, you know, the, to talk a little bit about staging. Usually, you know, most of the, most of the surgeries we do for endometrial cancer are minimally invasive. So people are surprised these days to know that a lot of our patients leave the hospital the same day after the surgery. So surgeries are mostly done robotically. Robotic technology has been key in the last, I would say 10, 15 years., You know, in terms of getting these patients quick recovery, getting out of the hospital the same day and be ready for any additional treatment that might be needed very quickly, as opposed to the old ways of doing things, which was through an open incision.
So robotics staging or minimally invasive staging is usually the next step done through five small incisions where we do a full hysterectomy, remove the uterus, the cervix, the ovaries, and the fallopian tubes. And then we sample the lymph nodes from around the uterus to make sure that the cancer did not microscopically spread to the lymph nodes, patient leaves home, leaves the hospital the same day.
Usually they recover up to 80% of their physical abilities within the first two weeks. By week three or four, most of them are back to normal, with also a normal activity schedule. By then, we would have the report come back from the lab, looking at all these specimens that we removed and we categorize patients into risk factor for a reoccurence based on you know, certain pathologic findings. One, you want to see what stage that cancer is. The more advanced the stage, the more treatment is needed. You know, type two cancers that we mentioned tend to require more treatment after surgery than type one. A lot of type one patients can get by just with a hysterectomy or with, you know, minimal adjuvant or additional treatment. And if you want us to talk about what these additional treatments can be, I can give you an idea about that.
Host: Okay. Yeah, why don't, why don't we go ahead and get into that. What are the additional treatments?
Dr. Semaan: So usually the two modalities that are used in endometrial cancer, in case we need them, are chemotherapy and radiation. Radiation is split into what we call internal radiation or radiation in the vagina, which is usually a short course of treatment with very few side effects. Or external radiation, which has radiation that is a little bit more extensive and, you know, chemotherapy is sometimes needed in conjunction with radiation or even without the radiation.
It all depends on the stage and the agonisivity of that cancer and the chances that it might come back. So, you know, in a nutshell, radiation and chemotherapy are usually the mainstay of additional treatment or adjuvant treatment after surgery.
Host: Okay, understood. And you know, especially if you're younger and you do want to conceive and you don't, you don't want that full hysterectomy, do you see a lot of people taking the modalities of chemotherapy and you know, what does the success rate look like once it's discovered?
Dr. Semaan: That's an excellent question. You know, the more we're seeing that you know, increase in body mass index and weight with our population, we're seeing these cancers at an early age. So, women in their even late twenties, you know, mid thirties, forties are showing up with these low-grade cancers.
Now fortunately, most of these cancers in that younger population are type one cancers, you know, the vast majority and fortunately these type one cancer can sometimes respond to hormonal treatment. So what we do is we try to reestablish that balance between estrogen and progesterone, by giving these patients excess progesterone, and that can be given by mouth, or it can be done through inserts or intrauterine devices that we place that can secrete progesterone and reverse these changes. So the two things we do most of the time is we initiate hormonal treatment and we follow these patients up with multiple samplings to make sure that the changes in the uterus are getting reversd and going back to normal. The other thing is we hook them up with an infertility physician early on to have a plan in case, you know, we end up having to do something more substantial.
You know, there are a lot of things that can be done. One of them would be egg freezing so that they maintain the ability to have their genetic children and the future, and that collaboration with an infertility physician early on is very important.
Host: Okay. Yeah, that makes a lot of sense. You know, one of the things that you touched on before is how most of these surgeries were done, minimally invasively or with robotics, maybe talk a little bit more about recent advancements in the treatment of endometrial cancer.
Dr. Semaan: So, you know, robotic staging is, is is a huge addition to our armamentarium, you know, in terms of treatment of these cancers another you know, main advancement is doing what we call sentinel lymph nodes. You know, women who've had breast cancer or people who are aware of how breast cancer is treated know that this has been done for years for breast cancer. We've started over the last few years, applying it for endometrial cancer. You know, one of the things we want to know, in endometrial cancer is whether any of the lymph nodes that are around the uterus are involved. The old way of doing that was to harvest a lot of these lymph nodes with potential side effects, including swelling of the lower extremities, you know, chronic lymphedema and things like that.
More recently, we've been injecting a dye in the cervix and the uterus and following the dye to the sentinel or first lymph nodes that drain the uterus and sampling that lymph node and making sure that that lymph node is clean. If it is, the likelihood of any other lymph nodes being involved, is very, very small and that is making the surgery shorter, you know, less complications and then preventing that lymphedema or chronic swelling of the lower extremities. The other, I would say advancement is we understand more, the molecular makeup of these tumors. And we understand more and more about some of the genetic predispositions that patients might have to develop these tumors.
And a secondary improvement in knowing how these tumors work molecularly is we've developed certain drugs that can target these molecular changes and you know, targeted treatment and immunotherapy are becoming more and more available in difficult cases or cases where these cancers come back. So the more we know at the molecular level, the more we can design treatments that specifically target that cancer, rather the way usual chemotherapy works and you know, the side effects that we see with chemo. So there's a lot that is exciting. And that is spanning out of all of these molecular studies and targeted treatments that we're seeing come on the market from years of studying these cancers and knowing more about them.
Host: Yeah, it's absolutely fascinating to hear about all the advancements. You know, just before we close here today, one thing I always like to ask is, you know, Dr. Semaan, you have so much experience dealing with women that might unfortunately have been affected by endometrial cancer. You know, out of all that experience, if there's one thing that you know to be true or you just wish more women knew before they came to see you, what might that be?
Dr. Semaan: I think the most important thing is to be aware of your body and listen to signals that your body is giving. If you develop anything that is out of the usual for you, you, know, the period is not what it used to be. The changes are getting worse. If you are unsure about any of these signs or symptoms that you develop, reach out to your OB GYN, it might be these days, a Telehealth visit or a phone visit where you ask about these symptoms and you know, the investigation has become, you know, more available you know, the, the amount of discomfort, or you're going to go through to investigate that it's so minimal and so worthwhile. So when in doubt, always reach out to your primary care, always reach out to your OB GYN. Doing things early on means, you know, you're going to go through a much shorter treatment. We're going to address the issue and you're going to most likely have to you know, get much less treatment than if we wait for things to progress. So be aware of any unusual sign or symptom that your body is giving you.
Host: Dr. Semaan, I think that's wonderful advice and the perfect place to end. Thank you so much for your time.
Dr. Semaan: Thank you for having me.
Host: That was Dr. Assaad Semaan, a Gynecologic Oncologist for AMITA Health. Thanks for listening to the AMITA Health Cast, the podcast from AMITA Health. For more information, you can visit Amitahealth.org/care.
My name is Prakash Chandran. Thank you so much for listening and we'll talk again soon.
Prakash Chandran (Host): One of the easier ways to gauge reproductive health in women is the consistency of menstruation. But when you're bleeding outside of your period, that can, in some cases indicate a more serious issue. Today, Dr. Assaad Semaan, a Gynecologic Oncologist for AMITA Health is going to teach us about endometrial cancer, risk factors and what to look out for.
This is AMITA Health Cast, the podcast from AMITA Health. I'm your host Prakash Chandran. And so Dr. Semaan, really great to have you here today. Thank you so much for being here. I wanted to get started by asking why might a woman bleed when it is not her period.
Assaad Semaan, MD (Guest): First of all, thank you for having me you know, this is a very common question that we get as gynecologists, but also as, you know, gynecologic oncologist you know, not every single abnormal bleeding or bleeding outside of the period is a cause of, you know, worry for a cancer. But, you know, this is something that always needs to be investigated, especially when it is a recurring issue.
We usually you know, divide patients into patients before menopause and patients after menopause. Women before menopause tend to have a lot of benign reasons why they're bleeding in between periods. While women after menopause should never have any bleeding after they fully go into that menopause. So the suspicion for any you know, cancerous lesion or precancerous lesion is much higher in a woman who's passed the age of menopause. And that also depends on the risk factors. So some certain women before menopause do have risk factors for these cancers and they should be aware of these risk factors. And in these women bleeding outside of the period, even before menopause is a cause of worry.
Host: Okay, understood. So you mentioned some of those risk factors. Maybe you can unpack what they are for us.
Dr. Semaan: Yeah. The, the main risk factors that we're seeing more and more these days is obesity. We know that obesity is associated with, with endometrial cancer and with endometrial precancers or what we refer to as hyperplasia. And the reason that happens is that the fat in the body can actually produce estrogen and lead to an imbalance between the female hormones, estrogen, and progesterone, and that can secondarily lead to the formation of a pre-cancer that can become a cancer. So obesity is a huge one. You know, another one is we tend to see these cancers more in women who have not had kids, in women who have diabetes, in women who have a strong family history of colon cancer and endometrial cancer, in women who you know, went or started having periods very early. And in women who have ovulation issues like women with polycystic ovarian syndrome, these are the main risk factors where even if the abnormal bleeding is happening before the age of menopause, we do, you know, pause and investigate looking for a potential cancer.
Host: So just focusing in on women that are pre-menopausal, how can they distinguish between less severe reasons for bleeding and spotting outside of their period and bleeding that might be caused by something more serious, like endometrial cancer?
Dr. Semaan: That's a very good question. You know, not every single abnormal bleeding is a source of worry, but you know, what I would say is one, you know, how much bleeding is happening even if it's within the period, it's very heavy. It's been going for, you know, several days and having to use a lot of, you know, tampons or, or sanitary pads, more so than they are used to, that's a cause of worry, if they see bleeding after intercourse, that's a cause of worry. If the problem gets repeated one cycle after another, that's a cause of worry. And you know, if unsure, it's always good to reach out to your obstetrician and gynecologist or to your primary care and discuss the situation. The work up, you know, it's very easy. So, you know, if we are unsure, we go through the workup to make sure that we are not missing anything.
Host: Okay, that makes a lot of sense. So one of the things we're focusing on today is endometrial cancer. Maybe talk a little bit about what it is and why it's important for patients to know about it.
Dr. Semaan: Excellent. So, you know, endometrial cancer is the fourth most common cancer that we see in the United States in women. So it's a, it's a very common cancer. It's the most common gynecologic cancer. And we diagnose around 60 to 70,000, you know, women in the United States every year. And one of the reason why we're seeing the incidence or the occurrence of that cancer increase one year after the other is we, as a population are gaining weight and our average body mass index or weight is increasing.
And with that, you see an increase in incidence of endometrial cancer. Endometrial cancer in general, is divided into, into two. You have type one and type two. Type one cancers are the vast majority around 80 to 90% of cancers are type one and they tend to be associated with an imbalance in hormones and obesity. And we're seeing more and more of these in younger patients just also because of that weight gain early on in life. Type two cancers are cancers that are more aggressive and they tend to not be associated with things like hormonal imbalance and obesity, and they tend to happen later in life. They tend to happen moreso, you know, late sixties, early seventies, and they tend to be more aggressive. A lot of them, we really don't know what's, what's the cause of these cancers.
They tend to sometimes be genetic and sometimes not. And they tend to affect women who are older and their treatment is usually more extensive. So overall, you know, two types, one is most of hormone-related and in younger patients. And the other one is usually hormone independent in older patients and tends to have a worse prognosis.
Host: Okay. Understood. And so regardless of type one and type two, can you talk a little bit about how treatable these endometrial cancers are and how you go about doing it?
Dr. Semaan: So the first thing is to make the right diagnosis. You know, usually these cancers do present at an early stage because they cause bleeding. So that's the sign that, you know, anybody can, can figure out that there's something's wrong. And then they seek care. Once patients seek care, you know, we do use ultrasounds and biopsies to obtain tissue and to analyze the tissue under the microscope and make that diagnosis. Once you make the diagnosis, whether it's type one, or a type two cancer, you go through a workup to make sure that that cancer didn't spread or metastasize elsewhere. Sometimes that might include some blood testing and CT scan. Once that's done, then usually we move to the second phase of treatment, which has surgical staging.
So, all of these cancers are treated initially with few exceptions, surgically. And the information that we get from the surgery is what, what the next step would be.
Host: Okay. Understood. So, after that surgical staging and you're determining what the next steps are, what are the different pathways that you could take from there?
Dr. Semaan: So, you know, the, to talk a little bit about staging. Usually, you know, most of the, most of the surgeries we do for endometrial cancer are minimally invasive. So people are surprised these days to know that a lot of our patients leave the hospital the same day after the surgery. So surgeries are mostly done robotically. Robotic technology has been key in the last, I would say 10, 15 years., You know, in terms of getting these patients quick recovery, getting out of the hospital the same day and be ready for any additional treatment that might be needed very quickly, as opposed to the old ways of doing things, which was through an open incision.
So robotics staging or minimally invasive staging is usually the next step done through five small incisions where we do a full hysterectomy, remove the uterus, the cervix, the ovaries, and the fallopian tubes. And then we sample the lymph nodes from around the uterus to make sure that the cancer did not microscopically spread to the lymph nodes, patient leaves home, leaves the hospital the same day.
Usually they recover up to 80% of their physical abilities within the first two weeks. By week three or four, most of them are back to normal, with also a normal activity schedule. By then, we would have the report come back from the lab, looking at all these specimens that we removed and we categorize patients into risk factor for a reoccurence based on you know, certain pathologic findings. One, you want to see what stage that cancer is. The more advanced the stage, the more treatment is needed. You know, type two cancers that we mentioned tend to require more treatment after surgery than type one. A lot of type one patients can get by just with a hysterectomy or with, you know, minimal adjuvant or additional treatment. And if you want us to talk about what these additional treatments can be, I can give you an idea about that.
Host: Okay. Yeah, why don't, why don't we go ahead and get into that. What are the additional treatments?
Dr. Semaan: So usually the two modalities that are used in endometrial cancer, in case we need them, are chemotherapy and radiation. Radiation is split into what we call internal radiation or radiation in the vagina, which is usually a short course of treatment with very few side effects. Or external radiation, which has radiation that is a little bit more extensive and, you know, chemotherapy is sometimes needed in conjunction with radiation or even without the radiation.
It all depends on the stage and the agonisivity of that cancer and the chances that it might come back. So, you know, in a nutshell, radiation and chemotherapy are usually the mainstay of additional treatment or adjuvant treatment after surgery.
Host: Okay, understood. And you know, especially if you're younger and you do want to conceive and you don't, you don't want that full hysterectomy, do you see a lot of people taking the modalities of chemotherapy and you know, what does the success rate look like once it's discovered?
Dr. Semaan: That's an excellent question. You know, the more we're seeing that you know, increase in body mass index and weight with our population, we're seeing these cancers at an early age. So, women in their even late twenties, you know, mid thirties, forties are showing up with these low-grade cancers.
Now fortunately, most of these cancers in that younger population are type one cancers, you know, the vast majority and fortunately these type one cancer can sometimes respond to hormonal treatment. So what we do is we try to reestablish that balance between estrogen and progesterone, by giving these patients excess progesterone, and that can be given by mouth, or it can be done through inserts or intrauterine devices that we place that can secrete progesterone and reverse these changes. So the two things we do most of the time is we initiate hormonal treatment and we follow these patients up with multiple samplings to make sure that the changes in the uterus are getting reversd and going back to normal. The other thing is we hook them up with an infertility physician early on to have a plan in case, you know, we end up having to do something more substantial.
You know, there are a lot of things that can be done. One of them would be egg freezing so that they maintain the ability to have their genetic children and the future, and that collaboration with an infertility physician early on is very important.
Host: Okay. Yeah, that makes a lot of sense. You know, one of the things that you touched on before is how most of these surgeries were done, minimally invasively or with robotics, maybe talk a little bit more about recent advancements in the treatment of endometrial cancer.
Dr. Semaan: So, you know, robotic staging is, is is a huge addition to our armamentarium, you know, in terms of treatment of these cancers another you know, main advancement is doing what we call sentinel lymph nodes. You know, women who've had breast cancer or people who are aware of how breast cancer is treated know that this has been done for years for breast cancer. We've started over the last few years, applying it for endometrial cancer. You know, one of the things we want to know, in endometrial cancer is whether any of the lymph nodes that are around the uterus are involved. The old way of doing that was to harvest a lot of these lymph nodes with potential side effects, including swelling of the lower extremities, you know, chronic lymphedema and things like that.
More recently, we've been injecting a dye in the cervix and the uterus and following the dye to the sentinel or first lymph nodes that drain the uterus and sampling that lymph node and making sure that that lymph node is clean. If it is, the likelihood of any other lymph nodes being involved, is very, very small and that is making the surgery shorter, you know, less complications and then preventing that lymphedema or chronic swelling of the lower extremities. The other, I would say advancement is we understand more, the molecular makeup of these tumors. And we understand more and more about some of the genetic predispositions that patients might have to develop these tumors.
And a secondary improvement in knowing how these tumors work molecularly is we've developed certain drugs that can target these molecular changes and you know, targeted treatment and immunotherapy are becoming more and more available in difficult cases or cases where these cancers come back. So the more we know at the molecular level, the more we can design treatments that specifically target that cancer, rather the way usual chemotherapy works and you know, the side effects that we see with chemo. So there's a lot that is exciting. And that is spanning out of all of these molecular studies and targeted treatments that we're seeing come on the market from years of studying these cancers and knowing more about them.
Host: Yeah, it's absolutely fascinating to hear about all the advancements. You know, just before we close here today, one thing I always like to ask is, you know, Dr. Semaan, you have so much experience dealing with women that might unfortunately have been affected by endometrial cancer. You know, out of all that experience, if there's one thing that you know to be true or you just wish more women knew before they came to see you, what might that be?
Dr. Semaan: I think the most important thing is to be aware of your body and listen to signals that your body is giving. If you develop anything that is out of the usual for you, you, know, the period is not what it used to be. The changes are getting worse. If you are unsure about any of these signs or symptoms that you develop, reach out to your OB GYN, it might be these days, a Telehealth visit or a phone visit where you ask about these symptoms and you know, the investigation has become, you know, more available you know, the, the amount of discomfort, or you're going to go through to investigate that it's so minimal and so worthwhile. So when in doubt, always reach out to your primary care, always reach out to your OB GYN. Doing things early on means, you know, you're going to go through a much shorter treatment. We're going to address the issue and you're going to most likely have to you know, get much less treatment than if we wait for things to progress. So be aware of any unusual sign or symptom that your body is giving you.
Host: Dr. Semaan, I think that's wonderful advice and the perfect place to end. Thank you so much for your time.
Dr. Semaan: Thank you for having me.
Host: That was Dr. Assaad Semaan, a Gynecologic Oncologist for AMITA Health. Thanks for listening to the AMITA Health Cast, the podcast from AMITA Health. For more information, you can visit Amitahealth.org/care.
My name is Prakash Chandran. Thank you so much for listening and we'll talk again soon.