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Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole, and today we are really highlighting and discussing bleeding after menopause. It's so important for women to be aware of their own bodies, to be aware of the symptoms of things that might change, certainly after we go through menopause. Joining me is Dr. Kathryn Kennedy. She's a Gynecologic Oncologist with Cancer Partners of Nebraska.

Dr. Kennedy, it's such a pleasure to have you join us. So, when we think of reproductive health at different stages and different ages, I'd like you to kind of give us just a brief overview as we start in our twenties, when we start seeing a gynecologist and getting those pap smears and talking about HPV and all the things we start to talk about.Until then, we get up to our postmenopausal women, such as myself. And the things that we're looking for. Then just a little quick, brief overview. I know it's a big ask, but I know you can do it.

Kathryn Kennedy, MD, FACOG: Absolutely no, and thank you so much for having me here to talk about this because it is the kind of topic that, you know, amongst our friends and family and amongst women just chatting, you learn a lot and you realize, oh, maybe I should ask this, or maybe I should follow up with my doctor. And, to be able to talk about it openly is so great.

So, as you referenced, the range of what's normal changes dramatically throughout our lives. So in the premenopausal patient population, that means you're having cycles generally approximately every 28 days. So when you first start getting your period, we call it menarche, most women have very irregular cycles, and that is okay and normal.

But basically as you're, we call it maturing, which is kind of a funny term, but as the axis between your brain and your ovaries matures or develops, those cycles should become more regular. So the vast majority of the premenopausal years, you should be having pretty predictable monthly cycles. Now around the age of 50 or 51 in the United States is, the average age of menopause is 51.

You should have about one year of no periods. So when the periods go away for a complete year, not eight months, not nine months, not like three months, and then they start and stop. But a year without any vaginal bleeding means, you are now going through menopause, and once you've gone through that one year cycle, you should never have bleeding again.

So anytime after the age of menopause, after you've not bled for one year, if you have even a spot or two of blood, you should talk to your doctor because at that point you should be done. And that's, kind of the general pattern.

Host: Well, thank you for that overview, and I can tell that you are so great with your patients. The way that you speak is so understandable. Now, you said there comes a point when we should not have any bleeding at all, So, what are we looking for? Because I mean, sometimes, you know, hemorrhoids bleed, so you look in the toilet, you see that it's like a little terrifying, but that's GI related.

So what are we looking for that would signal something a little bit different?

Kathryn Kennedy, MD, FACOG: It is kind of tough to tell sometimes, so people will be on the lookout for something like a period, but you're absolutely right with that hemorrhoid reference. Sometimes it is just a spot of blood on your underwear or on a pad or just that you notice in the toilet. So I always tell patients a spot or two of blood is something just to take note of and watch for again. If it happens a second time, that's when you should go into your doctor and you can be really honest with your doctor and just say, look, I'm not totally sure where it came from, and they'll help you figure that out. So it's really not on you to say, I'm sure it's from my bladder. I'm sure it's from the rectum, or, this is definitely vaginal.

You don't have to know. It's enough to just go in and say, look, I saw something. I've been told no bleeding down there is normal because the same does hold true for the bladder or the rectum. You shouldn't have bleeding there either, so no matter what it warrants a workup.

Host: So that's really great advice. Now as far as seeing our Doctors, our gynecologists for our annuals, in this age of HPV vaccination, Gardasil, knowing more about what we know about cervical cancer, do we still need pap smears and pelvic exams at certain ages? As we grow older, does that change how often we get those exams?

Kathryn Kennedy, MD, FACOG: It does, and honestly, sometimes the guidelines change too. So it's always good to just check in on this. But one of the important causes of bleeding that's unexpected, is bleeding that is a result of an abnormal pap or what we call cervical dysplasia. So dysplasia is pre-cancerous changes in the cervix, not necessarily invasive cancer, but something that would be detected on a pap smear.

So when you have those inflammatory, irregular precancerous cells on the cervix, they can bleed. So even post-menopausal women should be going to get pap smears because even if you don't get the HPV virus as an older adult, it's something that over 90% of people are exposed to in their lifetime and can kind of act up as time goes on.

So the rule is if you reach the age of 65 and in the previous 10 years, this is the key part, because a lot of people say, oh, I hit 65, I'm done. The key part is you have to have been on schedule getting the paps you were supposed to be getting for the preceding 10 years in order to be eligible to actually stop at age 65.

So they've done some studies in Europe, that show if we just arbitrarily stop everybody at age 65 and then screen people later, people who weren't up to date leading up to that age, do have higher rates of cervical dysplasia and even cancer. So it's really important that before you stop, you've been on track and you talk to your doctor about whether you've had a history of any abnormal paps, whether you need to have like one or two more just to make sure you're caught up and then make that decision together.

Host: This may sound like not the smartest question, but why would we want to stop? I mean, my doctor will only give me one every three years, but I'll keep going till I'm 85. Why would we stop getting a pap smear?

Kathryn Kennedy, MD, FACOG: Totally, and this is the problem with screening tests, right, is you get results that sometimes you may or may not want or you may or may not know what to do with. And so that's what starts to happen with age. One of the things that can happen is as we age as women, we have less estrogen in the vagina. So one thing that that causes is just discomfort.

You may have dryness, you may have irritation. And particularly with a pelvic exam and the actual swab, that is the pap smear, it can be uncomfortable. So that's really the number one reason that people want to stop. But the second reason is sometimes that means you might have an insufficient result or you might not get enough cells, or you even may find something that's very slightly abnormal and not cancerous.

Not really going to cause you problems long term, but you're obligated to follow it up and you may end up having more exams or biopsies. That said, we have to find the age at which the risks of doing that are less than the benefits in order to make that decision. So we think at about age 65, the discomfort and likelihood of finding something that you don't really care about, starts to become greater than the risk that you would actually find a cancer.

So as time goes on, your risk of cervical cancer really does get much, much lower if you are part of that group that's eligible to stop.

Host: Well, I love that answer and thank you for that because that makes a lot of sense. Now, God forbid somebody hears those words ovarian, that's really scary. Cervical, uterine cancer. What are some promising treatments? What's exciting in your field right now, Dr. Kennedy?

Kathryn Kennedy, MD, FACOG: There's honestly a lot. So on the note of cervical, just because we were talking about PAP smears, cervix in particular is a field where, we had really standard chemo and radiation that has not changed for essentially since 1999 or the year 2000 is kind of when the landmark studies came out that established how we treat most cervix cancers.

And it really wasn't until this past year, that we had some real groundbreaking developments in how we manage those cancers. So a big thing that's true in cervical as well as uterine and starting to emerge for ovarian is immunotherapy where basically we use the body's own immune system. We essentially unlock the body's ability to use our own cells to fight cancer.

Those have their own set of side effects. They're not totally innocent. It's not, the same set of side effects of chemo, but it is really exciting. Also, in these types of cancer, we have a few new drugs that I describe them, almost like a Trojan horse. They're called antibody drug conjugates or ADCs, where basically a molecule is linked to the chemotherapy so that that molecule targets very specific markers on cancer cells. So the treatment actually just gets delivered to where the cancer is and released and unloaded there, rather than distributing chemo throughout the entire body, which causes more side effects. So there's some really cool stuff out there.

The most important thing to me as a physician is what you see from these studies is they're not just cool, but patients actually are surviving longer. You're seeing improvements in overall survival, which is really remarkable as far as making a dent in how we treat these cancers.

Host: Well, I think that is cool. It's absolutely fascinating, really what's going on and, it's moving quickly and it's really an exciting time in your field, Dr. Kennedy. Now I'd like you to tell us about your team because it's very important for a multidisciplinary approach when women are talking about reproductive cancers, but also, I know from firsthand experience, you get those words and the world starts to spin a little bit, and there's usually one person or a group of people that help guide you through the system, help you, make your appointments. So those nurse navigators are essential. Tell us about your team, Dr. Kennedy.

Kathryn Kennedy, MD, FACOG: Absolutely. So we have a whole team that basically when a patient comes into the office or when they come in for surgery, I introduce them to a whole new crowd of people and just let them know every one of us is here for you and we're going to be a big part of your life moving forwards. Because you're absolutely right.

You need to know who to turn to. So we have our nurse navigators who basically guide you through, especially those logistics. There's so many appointments and scans and all that kind of stuff, and it's honestly hard to keep track of. So you need basically to keep organized, some point people.

So they are really invaluable in terms of guiding our patients through the process and coordinating, especially when you need additional, support from say, a radiation doctor or a medical oncologist, just to keep all of that straight. We have our wonderful PA, a nurse in the office too who also help me with the day-to-day of things.

And so really when you come in, you have a whole crew who's here for you, and you're stuck with us. We're going to be keeping our eye on you no matter what for a long time. Once you have one of these diagnoses.

Host: Well, I imagine your patients really fully realize how lucky they are to have a doctor like you that's so invested and so compassionate. Dr. Kennedy, I can just hear it in your voice. As we wrap up, and this has been such an informational episode, really so important to get this information. What would you like women to know about female reproductive cancers overall?

Wrap it up. Give us your best advice, summary for being our own best health advocate, because as you know, Dr. Kennedy, if we don't put our own masks on, we can't do it for those we love. We have to take care of ourselves, or we can't be the caregivers of the world that we are. So wrap it up with your best advice for us.

Kathryn Kennedy, MD, FACOG: That's a hundred percent true. And you know, I always see women who are taking care of multiple family members and really are kind of the backbone and focal point of their household, and you have to remember to take care of yourself first. You can't pour from an empty cup. You have to be y our best self in order to take care of anyone around you.

So especially as women, I think just being in tune with your body, not being afraid to bring things up to your doctor. And we've all heard the horror stories of women feeling that their symptoms were dismissed. Be an advocate for yourself. Find a doctor who will listen. Repeat it to them as many times as you need because you are that focal point of your household, and it is essential that you advocate for yourself and get yourself taken care of, and know that these cancers have a really bad reputation historically, but people are living longer, doing well. They are not sick and suffering in the way that we think of historically, you know, cancer patients. I have patients that are out and about taking care of their families, working full-time, living full lives, traveling, all while they're on treatment.

So things are different than they used to be and you basically have the power to get through it, if you just advocate for yourself.

Host: Great advice, Dr. Kennedy, what an excellent guest you are. Thank you so much for joining us today and sharing your incredible expertise for women out there and those that love them because we all need to hear this information. I'd also like to thank our Bryan Foundation partner Forvis Mazars. And to listen to more podcasts from our experts,you can always visit our website at bryanhealth.org/podcast. That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate and review Bryan Health Podcast on Apple Podcast, Spotify, iHeart, and Pandora, and be sure to share these shows with your friends and family on your social channels as we're all learning from the experts at Bryan Health together.

I'm Melanie Cole. Thanks so much for joining us today.