Women's Health: PCOS, Endometriosis and Periods with Dr. Linda Bradley
Periods that last too long, abnormal pap smears, infertility and painful intercourse are just some of the women's health issues that Linda Bradley, MD, touches on in this episode. Learn about what’s normal, what’s not and when to see your doctor. But there’s one thing for certain – ob/gyn issues should not get in the way of you living your life.
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Women's Health: PCOS, Endometriosis and Periods with Dr. Linda Bradley
Podcast Transcript
Nada Youssef: Hi, thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. Linda Bradley. Dr. Bradley is the Vice Chair of Obstetrics, Gynecology, and Women's Health Institute. She's also the director of hysteroscopic services and the Fibroids and Menstrual Disorder Center. Thank you so much for being here today.
Dr. Bradley: Thank you for having me.
Nada Youssef: Sure thing. And today we're discussing women's GYN health issues. And please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. So, before we jump into the topic, I'm going to ask you some questions just to get to know you on a personal level.
Dr. Bradley: Okay.
Nada Youssef: So, what is the weirdest thing that you've ever eaten?
Dr. Bradley: The weirdest thing I've ever eaten were frog legs.
Nada Youssef: Frog legs? Okay.
Dr. Bradley: Frog legs, and-
Nada Youssef: I heard they taste like chicken.
Dr. Bradley: They taste like chicken.
Nada Youssef: Yes.
Dr. Bradley: And that's what I thought they were when they put the basket of food in front of me in Mexico, and I'm eating and eating, and the gentleman comes back, the waiter, says, "Would you like some more frog legs?" I'm like, "These are frog legs?" I did think that they were fried chicken legs.
Nada Youssef: Would you have eaten them if you knew?
Dr. Bradley: I probably ... It's better for me to not know what I'm eating.
Nada Youssef: Beforehand.
Dr. Bradley: Because I will try everything as long as I don't know.
Nada Youssef: Okay, god. Good to know. So, how about naming one thing on your bucket list?
Dr. Bradley: One thing? I actually, right now, would like to get a degree, a formal degree as a chef.
Nada Youssef: Really? Interesting.
Dr. Bradley: Mm-hmm (affirmative). I'd like to go to a culinary institute.
Nada Youssef: Okay.
Dr. Bradley: Or culinary school. There are many in Cleveland and local area.
Nada Youssef: Yeah.
Dr. Bradley: But I really, I love cooking. But I really, for some reason, just want to have the degree to make it official.
Nada Youssef: Yeah. Oh, interesting.
Dr. Bradley: Yeah.
Nada Youssef: Favorite dish to cook?
Dr. Bradley: I'm sorry?
Nada Youssef: What's your favorite dish to cook?
Dr. Bradley: Oh, I love anything Italian.
Nada Youssef: Anything Italian?
Dr. Bradley: And also, Indian.
Nada Youssef: Okay.
Dr. Bradley: Yeah.
Nada Youssef: Need to come over. So, what about ... What date in your life would you like to relive again?
Dr. Bradley: That's a great question. I really enjoyed all of my pregnancies.
Nada Youssef: Wow.
Dr. Bradley: So, I could relive all the days. I won't say labor. But moments leading up to the onset. But those, I just had great pregnancies for both of my kids.
Nada Youssef: Wow. That's great.
Dr. Bradley: And felt great. Took excellent care of myself.
Nada Youssef: Wow.
Dr. Bradley: And obviously, much younger and had a good experience.
Nada Youssef: Yeah. Good. Good for you. And we can talk about that and keep everybody healthy.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: All right. So, let's get into discussion. So, what is GYN Women's Health?
Dr. Bradley: So, GYN Women's Health really approaches everything that woman need to have taken care of, as it relates to menstrual cycles, pregnancy, contraception, menopause, female issues with the bladder, pelvic floor as we call it.
Nada Youssef: Okay.
Dr. Bradley: PMS, mood changes, irritability, sometimes depression. So, it really covers everything that an internist usually doesn't take care of.
Nada Youssef: Okay.
Dr. Bradley: The most common things that people would go to their gynecologist for, would be for a Pap smear and breast exam. But then, sometimes there are more problem-based visits that we'll talk about, which lead women to be seen. But if we looked at what I call the GYN organs, we don't take care of the breasts, so that would be by a general surgeon. But, uterus, tubes, ovaries, cervix, vagina, vulva, what we call the pelvic basin. Those kinds of things. Yeah.
Nada Youssef: Sure. Sure. Okay. Anything that makes a woman, a woman. So, can we talk about signs and symptoms of these problems that may require medical attention?
Dr. Bradley: Okay.
Nada Youssef: Besides your Pap smear, that's normal once a year.
Dr. Bradley: Right.
Nada Youssef: Why else would I go to the doctor?
Dr. Bradley: Well, most of the times we would go to the doctor for preventive care, you know, an ounce of prevention is worth a pound of cure.
Nada Youssef: Okay. Yes.
Dr. Bradley: So, there's still some guidelines, even if you're well with no problems, that you should be seen for. For just some screening, things that happen. But other things that might come up, would be quality of life issues that are affected by GYN problems. Those could be things ... the most common things are periods.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: How many periods do women have? Between four and 500 in their lifetime. And so, at some point, when we think of starting our periods at age 11 or 12, having them monthly until age 51 to 58. Something will go awry.
Nada Youssef: Sure.
Dr. Bradley: The period's too long, too heavy, we don't get a period, problems with pain or discomfort, spotting after sex, spotting between periods. So, that would drive a patient to be seen.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: The other might be at the other extreme of life when our period's stop. And some women are bothered by vaginal dryness, hot flashes, night sweats, pain with intercourse. So, related to a lack of estrogen.
Nada Youssef: So, that's menopause and going on? Okay.
Dr. Bradley: Menopause. Even pre or perimenopause, there's some hormonal fluctuations that can lead to some discomfort and problems.
Nada Youssef: Okay.
Dr. Bradley: And really, we look at quality of life. Vaginal problems, what are those? Odor from the vagina, itching, discharge, pain in the vagina, a lot of vulvar itching, lesions like herpes.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: Sexually transmitted diseases, such as gonorrhea, syphilis, chlamydia. So, we would see those kinds of things. And then, lastly, our patients, increasingly, I think with the Me Too generation, are coming to gynecologists and being much more proactive, speaking with us about interpersonal relationships with their partner. Both, whether it's heterosexual or homosexual, the issue of domestic violence, abuse, physical abuse, mental abuse, financial abuse. Things like that.
And another great part of being a female is our sexuality. And patients may come to use with problems with arousal disorders, decreased libido, lack of interest in intercourse, pain with intercourse. Those kinds of things.
Nada Youssef: Okay.
Dr. Bradley: So, GYN doctors really see the gambit of these kinds of conditions. And there are many other things, I'm sure we'll get to talk about.
Nada Youssef: Sure.
Dr. Bradley: But these come to mind right off the bat, the kinds of patients that I would see in the last week or in my career.
Nada Youssef: Sure. And then, when you talk about any kind of abuse that's involved. What do you have to do at that point, when you hear something like that? I mean, do you have to get anybody else involved? Is there going to be a psychologist that you will refer too? What's the next step for that?
Dr. Bradley: So, we know that domestic violence is a big problem. And many women in our society, and actually worldwide, face this problem.
Nada Youssef: Yes.
Dr. Bradley: So, first is to find out if there are problems that are there. So, for instance, in our bathrooms, women go to the bathroom and we have a hotline, a pull-off sheet on the back of the door.
Nada Youssef: Oh.
Dr. Bradley: Sometimes patients will come with their partners, husbands, boyfriends. And really, before this became a real big issue, I used to think, "Oh my god, what a doting partner, a doting husband, there for every visit." But then, we start looking at some of the signs of possessiveness and other things that can become a little bit unusual.
Nada Youssef: Sure.
Dr. Bradley: And so, women, if they're in the office with their partner, they may not answer yes to certain questions.
Nada Youssef: Sure.
Dr. Bradley: So, most men are not going to go into a women's bathroom.
Nada Youssef: Right.
Dr. Bradley: So, we have some signs. So, in terms of what we'd do if we recognize it. We have to talk with the patient about it. We also have social workers, we have the ability, sometimes to get in contact with the police if there is actual physical harm that you can see and witness.
Nada Youssef: Right.
Dr. Bradley: Psychological help. All those kinds of things.
Nada Youssef: Sure.
Dr. Bradley: So, first is to bring awareness and attention. And it's important for physicians to be aware. It's really a sad statement, but I have to be honest and very transparent. It wasn't something that I was taught during residency.
Nada Youssef: Right.
Dr. Bradley: It was probably 25 years after I became a physician that we start hearing about this.
Nada Youssef: Wow.
Dr. Bradley: You know, we're taught how to do a hysterectomy, how to do a tubal ligation, how to take care of patients in terms of prescriptions, but the issue of trauma was really not discussed.
Nada Youssef: Right.
Dr. Bradley: So, we are bringing it up. And more importantly, I think through social media and just awareness, patients are coming to us to discuss that.
Nada Youssef: Sure, sure. It's very good to know.
Dr. Bradley: Mm-hmm (affirmative), mm-hmm (affirmative).
Nada Youssef: So, let's talk about why it's important to recognize some of the abnormal symptoms that we talked about earlier, early. And to see a physician right away. Why is that very important?
Dr. Bradley: Well, I think, again, prevention is the best thing. And early recognition of disease. So, I think as women, we know our bodies. If we just look at some things like menstrual cycles, we know that there should be every 28 to 30 days, last for three to seven days. So, a woman that's coming in bleeding for 10 days, 14 days, 50 days, 100 days, that's not normal.
Nada Youssef: Right.
Dr. Bradley: So, we would say that we want women to come in to be diagnosed early. Some patients are afraid to come in because they think we're going to tell them that they have the "C" word, cancer.
Nada Youssef: Yeah. Yeah.
Dr. Bradley: Most of the times, it's not cancer. It's something that's so simply treatable, even without surgery. And so, basically, it's better to be evaluated. And then, as a doctor, we look at all the different causes so that we can come up with a cure, so to speak.
Nada Youssef: Sure.
Dr. Bradley: So, I think when patients hide symptoms, delay diagnosis, if there is something that's not good, like a cancer, it's always better to catch something early, than late.
Nada Youssef: Sure.
Dr. Bradley: So, I would say, for that, it's important. Quality of life, even period problems. Young girls could not miss school for pain and discomfort.
Nada Youssef: Yeah.
Dr. Bradley: Should not miss hobbies, should not miss sports. So, once a GYN condition becomes ... doesn't have to be life-threatening, but quality of life changes.
Nada Youssef: Sure.
Dr. Bradley: A bigger problem after children and with aging, is incontinence, loss of urine when you cough or sneeze, not being able to hold your urine. So, what would that prevent? That would prevent someone from exercising, because some women have problems when they're jogging or running.
Nada Youssef: Sure.
Dr. Bradley: They can't golf, they're always looking for a bathroom. They want to jump out of a car every 45 minutes to go urinate. They won't go skiing, they might not go camping. So, it's not that they're going to die from any of this, but it affects our quality of life. And I think it's so important as women that our GYN issues should just not get in the way of anything.
Nada Youssef: Right.
Dr. Bradley: And so, if there's a change in how we feel, I'll point down there, see a doctor.
Nada Youssef: Sure.
Dr. Bradley: Don't be afraid.
Nada Youssef: Sure.
Dr. Bradley: Come in and talk. And I think physicians, both with the history, physical examination, blood testing, sometimes imaging. Sometimes with ultrasound, cat scans or MRI, I mean, I won't say everybody gets everything.
Nada Youssef: Right.
Dr. Bradley: But we can focus the workup and the evaluation so that we really target what that woman needs.
Nada Youssef: Sure.
Dr. Bradley: But, suffering, you know, that's something back in the 1800s.
Nada Youssef: Yeah.
Dr. Bradley: We don't need to suffer.
Nada Youssef: Right.
Dr. Bradley: We have lots of great cures to help women.
Nada Youssef: And it's important to educate our audience. And I'm so glad you're here to talk about it, because thinking about it, since we're 11 or 12 or 13. Let's say, you've always had a heavy period, let's say, you've always had pain. Not knowing what is normal, because you've always had it.
Dr. Bradley: Right.
Nada Youssef: That's very important to educate yourself.
Dr. Bradley: And there are also some things that you just talked about, that run in families. But in the older days, our mothers, grandmothers, great grandmothers, suffered in silence.
Nada Youssef: Yes.
Dr. Bradley: And so, sometimes women will hear, we talked earlier about endometriosis, pain, discomfort, lots of symptoms.
Nada Youssef: Yes.
Dr. Bradley: And sometimes, it's genetic or fibroids, again, genetic. And there are some other unusual conditions like Von Willebrand disease that make women hemorrhage. But it runs in families. But just because your mother and grandmother, sister, aunt, have it, does not mean that you have that condition.
Nada Youssef: Right.
Dr. Bradley: But that you couldn't be treated. So, I think for me the take-home message is, our GYN health, pelvic health, should never interfere with the quality of life and keeping us from doing things. I did an interview once or was asked to quote something that's going on in Europe. I don't remember what country. But shouldn't women be given five days off a month, as a part of their job benefits because of GYN problems? And I just said, "I'm sorry, I do not agree with it. They need to see us."
Nada Youssef: Yes.
Dr. Bradley: Our great department at the Cleveland Clinic.
Nada Youssef: Yes.
Dr. Bradley: Or a doctor. No, you don't need five days off or three ... You don't need any days off a month for period related issues.
Nada Youssef: Yes, right. Right.
Dr. Bradley: And the other end of, sort of that, end of our life or reproductive life, you shouldn't lose sleep and have insomnia from hot flashes and changing your clothing and your hair's a mess because you're sweating all the time.
Nada Youssef: Yeah. Right.
Dr. Bradley: And you know, avoiding sex because of pain. I mean, women are living older.
Nada Youssef: Yes.
Dr. Bradley: And so, with that, we now have lots of things. I just gave a lecture not long ago, and the average ... You know what the average age of death is in 1850s was for women?
Nada Youssef: Probably 40.
Dr. Bradley: 43.
Nada Youssef: Wow.
Dr. Bradley: Okay. So, women never got to menopause.
Nada Youssef: Wow.
Dr. Bradley: You know, the average women had 15 children, 15 pregnancies, because there wasn't contraception. And so, now women, we find that if you're healthy, even with a chronic condition at age 65, but you have hypertension and diabetes, but you take care of yourself, you're going to live another 15 to 20 years. And if you make it to 80, you're likely to make it to 100.
Nada Youssef: Wow.
Dr. Bradley: So, we have, sort of, the menopause years, used to be never.
Nada Youssef: Right.
Dr. Bradley: Then it became a third of our lives, meaning when our period's stop. But it can be almost up to half of our lives.
Nada Youssef: Wow.
Dr. Bradley: So, we have a whole continuum of things that we now are learning about, as doctors, that we didn't have to know about, because women didn't live to be that old.
Nada Youssef: Yeah, yeah.
Dr. Bradley: And so, you know, we didn't mention bone health. That's another thing that we'll see as we get older with osteoporosis and fractures.
Nada Youssef: Sure.
Dr. Bradley: Things like that. So, I mean, it's all those kinds of things that we think about.
Nada Youssef: Sure. With aging.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: So, let's talk about the most common gyno problems that you see in your practice.
Dr. Bradley: Okay. I would ... I think that the things that we see the most would be related to what I call structural problems with the uterus.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: The most common being fibroids.
Nada Youssef: Fibroids.
Dr. Bradley: And there's 60 to 80% of women have them. But not everybody has symptoms, probably less than half.
Nada Youssef: Okay.
Dr. Bradley: Increasingly, we're seeing more women because of being overweight and obese, with problems with their periods due to PCOS or polycystic ovarian syndrome. We are also seeing, as with aging, the issues with incontinence and bladder issues.
Nada Youssef: Sure.
Dr. Bradley: And even sometimes, rectal problems. So, those would be, when I think of things. And I would also say that women are taking better care of their self. And most, I just read, that the average American woman has 1.8 children in her lifetime, that means our birth weights are going down. But also, contraception.
Nada Youssef: Yes.
Dr. Bradley: Especially in women that are under 50.
Nada Youssef: Sure.
Dr. Bradley: And since we're living longer, contraception also has to continue into our 40s and really all the way into menopause. Last year I diagnosed a 51-year-old with a pregnancy.
Nada Youssef: Wow.
Dr. Bradley: I mean, she wasn't an IVF patient, wasn't infertility and all of that. So, we can get pregnant all the way till we don't have a period for a year. So, I just look at that as a big continuum that we need to look at also.
Nada Youssef: Okay. That's very good to know. I want to touch on PCOS.
Dr. Bradley: Mm-hmm (affirmative). Mm-hmm (affirmative).
Nada Youssef: Because you mentioned it could be due to obesity.
Dr. Bradley: Right.
Nada Youssef: A way that we're eating. Can we talk about what is PCOS? And why is it related to obesity?
Dr. Bradley: So, I'll ... So, PCOS stands for polycystic ovarian syndrome. And basically, symptom wise, women often don't have regular periods. Sometimes, they don't get periods at all, months and months, and even sometimes years and years. Other times, the periods are coming very frequently. It can also have some physical symptoms with really bad acne. Sometimes with excess hair growth, facial hair, chest hair, hairy arms. And we would ask, "Does it run in your family?" So, everything that I'm saying doesn't mean, you know, if you're Italian and everybody has lots of hair, I wouldn't say you have PCOS.
Nada Youssef: Right.
Dr. Bradley: I mean, there are certain cultures that just women are a little big harrier.
Nada Youssef: Sure.
Dr. Bradley: So, basically, it's acne, it's hair growth, sometimes hair loss, being overweight. We don't always know all of the reasons. There can be problems with the adrenal gland, okay, which makes hormones. It could be a problem with the ovaries itself. But we also know that our weight and what's in our waist, W-A-I-S-T, our central fat.
Nada Youssef: Okay. Yes.
Dr. Bradley: This stuff is not sleeping.
Nada Youssef: Yeah.
Dr. Bradley: It's not dormant, it's not hibernating. And so, when we're overweight, we make a lot of chemicals, these fat cells. And those chemicals are hormones. And those hormones are estrogen, or they're converted into estrogen and some byproducts, that can lead to just changes in the menstruation. Which then, puts women at increased risk of not being able to get pregnant because they don't ovulate regularly.
Nada Youssef: Right.
Dr. Bradley: So, infertility. We can also see pre-cancer, what we call endometrial hyperplasia inter earlier onset of uterine cancer. So, we do a lot of testing looking for tumors and things like that.
Nada Youssef: Right.
Dr. Bradley: Most of the times we don't find it.
Nada Youssef: Okay.
Dr. Bradley: We check for the thyroid, we check the adrenal glands, I mean, that's important to be thorough, but really, the majority of the time, we can look at a patient and say, "You know, you're over your ideal body weight." And that the fat itself, I don't use that word, but the stuff that we carry in our waistline, our buttocks and our hips really is, I just look at as, inflammatory cells that make things go awr ...
Nada Youssef: Sure. Right?
Dr. Bradley: Make things go awry.
Nada Youssef: Okay, awry.
Dr. Bradley: Yeah, awry is what I wanted to say, yes.
Nada Youssef: Okay. So, do these disorders, any of them relate to infertility?
Dr. Bradley: Yes, if women are not making an egg every month and getting periods that are, what we call, ovulation, where you make an egg. That will lead to difficulty getting pregnant.
Nada Youssef: Okay. So, what are some of the tests that you do for a woman to evaluate the issues that they may have?
Dr. Bradley: For infertility, in general?
Nada Youssef: For infertility or for some of these disorders that we talked about. I'm sure there's a lot of different things.
Dr. Bradley: Yeah, there are a lot of things. I think, when we look at infertility, I always used to say, "It takes two to tango." To make a baby.
Nada Youssef: Right.
Dr. Bradley: So, 60% of the problem may arise within the women. I should say 50%, about 40% with men. And then 10%, both have a problem.
Nada Youssef: Okay.
Dr. Bradley: So, the issues with women could be age. As we age, our ovarian reserve, the eggs them self, the quality, the number of eggs change. Especially over the age of 35 and over 40. Other causes can be infection that could've caused problems with pelvic inflammatory disease.
Nada Youssef: Sure.
Dr. Bradley: Infection of the tubes. Problems with the uterus, such as, polyps or fibroids, or there could be some unusual anatomic problems where women have what's called a septum, sort of a malformation within the uterus that may need correction.
Nada Youssef: Yeah.
Dr. Bradley: Those would be the more common things that we look at. So, we kind of start from head to toe, to think about the pituitary gland, which is our master gland. Is it functioning right? There are tests that we do for that. I won't go through all the details, but we kind of go from head to toe looking at the different organs, the thyroid, the ovaries, the adrenal glands, to sort of put the story together.
Nada Youssef: Sure.
Dr. Bradley: And then, for men, we have to look at a semen analysis. Are there enough sperm? Do they swim fast enough? Are they modal enough? Do they have the right anatomy? So, we look at that.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: And so, we kind of look at all of these factors.
Nada Youssef: Sure.
Dr. Bradley: Also, things can impact infertility. You could be perfectly fine. Smokers, women who smoke. The nicotine's not good for anything. And it often ages our skin, our face with wrinkling. Our bones get thinner. But also, women who smoke have ... it impacts by sort of killing off the ovaries. I should say ovarian function. So, sometimes it's simple as getting people to stop smoking.
Nada Youssef: Sure.
Dr. Bradley: We know the impact for drug use. That impacts the whole head, ovary problem. Smoking, drug use, alcohol abuse, those kinds of things. Sometimes if you're too underweight, it impacts where you don't get a period.
Nada Youssef: Yeah.
Dr. Bradley: Anorexia, bulimia, eating disorders. So, you can be too thin, which can make you not get periods. You can overweight and not get periods regularly. So, we had to have to ...
Nada Youssef: Find a good balance? Yeah.
Dr. Bradley: It's hard to bundle everything, but we have to sort of ... You know, if I see a person that weighs 80 pounds, I'm going to think differently about why she's not getting periods, versus somebody that's 400 pounds.
Nada Youssef: Right. Right.
Dr. Bradley: And so, as a doctor, it's really not a cookbook. We really try to individualize the care of the patient and look each part of the women, to look at her in a whole way.
Nada Youssef: As a whole. Sure. So, when you talked about alcohol. I just want to ask you this question that came to mind.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: Some women drink wine during pregnancy, some women are like "I can't touch alcohol during pregnancies or even during breastfeeding." What's your take?
Dr. Bradley: I think we should not drink any alcohol. It's just deleterious. I mean, it's hard to say one drink.
Nada Youssef: Yeah.
Dr. Bradley: You know, most women don't know that they're pregnant by a couple of weeks until they've had a missed period.
Nada Youssef: Sure.
Dr. Bradley: But I'm talking about ongoing drinking. I think the human body is so fragile and when we look at how we develop, that who's to say. And so, I think avoidance during this time in your life is important.
Nada Youssef: Critical?
Dr. Bradley: Yeah.
Nada Youssef: Okay. Great. And then, so I want to talk about four of the most common gynecological problems that women face. First one being endometriosis. So, can we talk about what it is? And if there are any causes.
Dr. Bradley: Okay. So, endometriosis, first of all, in medicine, for the most part, we don't know anything.
Nada Youssef: Okay.
Dr. Bradley: Okay, I mean, why do we get gray hair? Why do we wrinkle?
Nada Youssef: Yeah.
Dr. Bradley: Why do we sleep? I mean, so I'll just kind of ... So, there's a lot of theories and when I'm speaking in the public, I don't want to say this is "Dogma", so there are theories about why women may get endometriosis. One may be genetic, it just runs in families. Some people look ... So, what is endometriosis? Endometriosis is a condition where the menstrual blood, instead of it just being seen through the vagina and on our sanitary pads or tampons, the blood ... one theory is that it refluxes, it retrogrades. Blood goes backwards from the uterus, through the tubes, to the ovaries, and then to the peritoneal cavity, the organs, the bowel, the bladder that are there. There may be something that pushes the blood back, there may be structural problems. We don't know why, but it can be a condition that's common with no symptoms. But what would draw a patient to a doctor would be pain, usually.
Nada Youssef: Okay.
Dr. Bradley: Bad menstrual cramps, missing work, missing school, having a significant pain within intercourse, sometimes there's not a lot of symptoms. But the blood backs up and a doctor does an exam and can feel a large cyst on the ovary. And that's called an endometrioma, where blood accumulates by the ovary. And when we do surgery and there's a cyst that's like a little balloon and we open it, it looks just like Hershey's chocolate syrup, just old blood.
Nada Youssef: Blood? Yes.
Dr. Bradley: Sometimes, the blood continues on other organs. So, what sits in front of the uterus? The bladder. Some women with ... and behind it is the bowel. So, some women may have very painful urination, we call the dysuria.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: Sometimes this blood, because it's inflammatory, it kind of erodes through the bladder tissue. And some women, when they go to urinate can see blood through the urine.
Nada Youssef: Oh, I see.
Dr. Bradley: Sometimes women have very bad pain, we call that tenesmus, bad pain with bowel movements. Difficulty, aching, almost not wanting your stool to come out because the endometriosis leads to inflammation and scar tissue. Some women, because it can erode through the bowel mucosa, the surface, it can lead to blood in the stool. And so, I would say, the most common symptoms that bring a woman in, it could also lead to some change in menstrual cycles, but usually, it's pain, and it may be potentially secondary infertility. Meaning, not being able to get pregnant.
Nada Youssef: Okay.
Dr. Bradley: And, there's different degrees of endometriosis. We call it stage one to stage four. Minimum, mild, moderate, or severe.
Nada Youssef: Okay.
Dr. Bradley: And certain things, very severe cases if we ... We here at the Cleveland Clinic, use ultrasound and MRI very liberally. We may be able to see some of the evidence of scaring or cyst formation. The ovaries should kind of be like away from each other. Sometimes the scar tissue, we call them kissing lesions, the ovaries get stuck to each other because of the scar tissue. So, there are different things that we might see on imaging, pockets of scar tissue, sometimes old accumulated blood in the peroneal cavity. So, it all depends on ...
And the patient talks to the physician, sometimes on examination, it even erodes into the vagina where we can see these purple, bluish nodules that are there, erode onto the cervix. So again, talking with our audience today, I would just say see your physician if pain is a big issue. If there's some major discomfort with intercourse, and then, let the doctor kind of go from there to work you through what test, what medications, if you need surgery, what type. Because it's very individualized.
Nada Youssef: Right. So, is there a cure for endometriosis?
Dr. Bradley: Getting pregnant.
Nada Youssef: Getting pregnant?
Dr. Bradley: Yes, yes. It's a cure. So often what-
Nada Youssef: Or birth control, right?
Dr. Bradley: Or birth ... I was going to say, or the other is to stop menses. So, one of the theories is just sort of incessant ovulation, having periods month, after month, after month. So, women who've had kids, who breastfeed a long time, you're not getting a period. And they tend to not have these symptoms.
Nada Youssef: Okay.
Dr. Bradley: Or just by not having a period, the body heals itself. I often think if you were to look internally with a laparoscopy, it looks like an old bruise in there, sometimes. And just like if you bruise your finger, that blood that's in your ... If you smash your finger in, it doesn't drip out of your fingernail.
Nada Youssef: Yeah. Right, it's just on the surface.
Dr. Bradley: It gets absorbed, you know.
Nada Youssef: Yeah.
Dr. Bradley: Goes from black, to blue, to green, to yellow and it fades. So, getting pregnant allows the endometriosis to sort of become dormant and sleeping.
Nada Youssef: Sure.
Dr. Bradley: And so, birth control pills and/or other medications. We have a IUD that's progestin based, there's many different names. So, I won't mention names. But a medicated IUD that could help also suppress symptoms until someone's ready to get pregnant.
Nada Youssef: So, what I wanted to talk about was the insurance. So, because infertility occurs in about 30 to 40% of women with endometriosis, does that mean insurance doesn't cover the condition if you're trying to get pregnant?
Dr. Bradley: So, you know, we have at the Cleveland Clinic, over 500 insurers. I would say we have to look individually.
Nada Youssef: Yeah. Sure.
Dr. Bradley: And sometimes, we doctors will code differently, mainly how they identify. So, if you come in, sure, you're trying to get pregnant, but you have painful sex, you have very bad menstrual cycles. We might say ... list the word dysmenorrhea, heavy periods, pelvic pain as a diagnosis, without putting diagnosis of infertility front and center.
Nada Youssef: Infertility. I see.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: Okay. And the next thing I wanted to talk about was an abnormal Pap smear. So, it should be done yearly, but what does-
Dr. Bradley: Not yearly anymore.
Nada Youssef: Not yearly?
Dr. Bradley: No.
Nada Youssef: Oh, what is it, every ...
Dr. Bradley: Well, so it's now every ... So, we usually would say you should get your first Pap smear within three years of having intercourse.
Nada Youssef: Okay.
Dr. Bradley: And then, what we do now are usually by age 21. Or whenever we start the Paps, it's yearly to make sure that it's normal. But if you have all normal Paps, it's gone to five years.
Nada Youssef: Oh, so once every five years?
Dr. Bradley: Mm-hmm (affirmative). If they've been all normal.
Nada Youssef: Wow.
Dr. Bradley: And if you get to about age 65, and have never had a problem with your Pap, then we don't do it again.
Nada Youssef: Okay.
Dr. Bradley: But again, these are guidelines.
Nada Youssef: Right. Everybody's different.
Dr. Bradley: So, everybody's different.
Nada Youssef: Sure, sure.
Dr. Bradley: So, I would say. So, we do Pap and now we know that one of the causes of precancer or cancer is what's called the HPV virus or human papillomavirus. So, when we're doing Paps, begin it at age 30. For women, once they're 30, we start doing co-testing, the traditional Papa tests, coupled with the HPV virus.
Nada Youssef: Okay.
Dr. Bradley: Because when we look backwards, even with slides and reference material from the 1900s that's here at the Cleveland Clinic, they didn't have testing for HPV.
Nada Youssef: Right.
Dr. Bradley: But when you pull those samples and now uses this testing, the women with cancer had HPV.
Nada Youssef: I see.
Dr. Bradley: So, we feel that cervical cancer is an STD, a sexually transmitted disease, because it's most commonly associated with the HPV virus.
Nada Youssef: Wow.
Dr. Bradley: And we're now, hoping, that this next generation of physicians will not ever have to see cases, because we're recommending vaccinations.
Nada Youssef: Okay.
Dr. Bradley: For boys and girls in adolescents.
Nada Youssef: Yes. Okay.
Dr. Bradley: A series ... I won't go through everything. But you would go to the pediatrician, and they would do a series of three vaccinations over time.
Nada Youssef: Okay.
Dr. Bradley: And that, nothing with vaccination's 100%, but it decreases the risk of precancerous cells and the subsequent development of cancer. That's something really hot off the presses in the last year.
Nada Youssef: Good. I'm glad you touched on this.
Dr. Bradley: That our teens and preteens, it doesn't mean that this is going to make your 11-year-old or 13-year-old sexually active.
Nada Youssef: Right.
Dr. Bradley: It is a method of prevention.
Nada Youssef: Sure, sure. That's excellent. So, going back to the abnormal Pap smear. What does an abnormal Pap smear look like? And what are the next steps?
Dr. Bradley: Most women with an abnormal Pap smear don't know it. Because it's ... even sometimes as a doctor looking grossly with our eyes, we don't see anything. It's the cells, we take a scraping of the cells, and then it's looked at under the microscope by our pathologist.
Nada Youssef: Okay.
Dr. Bradley: And it just has an abnormal appearance. And then we do the co-testing with the HPV and it often will be seen. And then, from there, if the Pap test is abnormal, depending on the type of abnormality, we may have the patient come back for a test called a colposcopy.
Nada Youssef: Mm-hmm (affirmative).
Dr. Bradley: And it's just using a set of binoculars. And in the office, we can look and magnify the cervix. There's something we put on the cervix that might highlight some abnormal cells. And then take biopsies of that. I don't know how much detail to go in. And then there's different treatments that are often office based.
Nada Youssef: Sure.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: All right. And then we talked about uterine fibroids. And they are the most frequently diagnosed tumor of the female pelvis.
Dr. Bradley: Benign tumor.
Nada Youssef: Benign.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: That was going to be my next question.
Dr. Bradley: Mm-hmm (affirmative). Right. Non-canc ...
Nada Youssef: So, they're mostly benign, correct?
Dr. Bradley: Yes, yeah. And I actually ... I mean, what you said is correct. I really like to take out the word tumor.
Nada Youssef: Okay.
Dr. Bradley: Because when we ... I don't tell a patient ...
Nada Youssef: It's scary. It's a scary word.
Dr. Bradley: It sounds like cancer.
Nada Youssef: Yes.
Dr. Bradley: So, I just say you have a very common growth of the uterus, the muscle of the uterus.
Nada Youssef: Okay.
Dr. Bradley: The 60 to 80% of women have. And let's see what symptoms you have. And then, what are your reproductive choices? What symptoms can we treat in different ways?
Nada Youssef: So, they're benign, but do they increase a woman's chance of having uterine cancer?
Dr. Bradley: No. Because uterine cancer comes from the actual cells of menstruation.
Nada Youssef: Okay.
Dr. Bradley: The fibroids are different. There's about one out of 350 women that have cancer within the fibroid.
Nada Youssef: I see.
Dr. Bradley: It's very, very rare. I've been here over 25 years. I've seen three patients in my practice, despite the thousands of women that have fibroids.
Nada Youssef: Wow. Sure, sure.
Dr. Bradley: So, it's ne ... I'm not going to say it's never on my mind, but I don't want women hearing the word tumor and thinking cancer.
Nada Youssef: Right. Thinking that it's cancer.
Dr. Bradley: Right.
Nada Youssef: Okay. Great.
Dr. Bradley: Mm-hmm (affirmative).
Nada Youssef: And then, lastly, abnormal uterine bleeding. So, I know we talked, there are so many different things. But is there something that's most likely associated with abnormal vaginal bleeding?
Dr. Bradley: We look at it at different life cycles. Let's first say, because I always want patients to learn from what I see or all of us see. Once our period's stop, which is between ages 45 to 58, once we go one full year without a period, we should never see blood in the vagina.
Nada Youssef: Okay.
Dr. Bradley: Or on our panties.
Nada Youssef: Okay.
Dr. Bradley: It doesn't mean cancer. But, I've had women who are 70 and start having what they call, quote, a period, every other month or they're bleeding. And some women said, "Oh, I'm getting younger." No, it doesn't mean you're going back to being 25.
Nada Youssef: That'd be nice.
Dr. Bradley: It is abnormal. A lot of women say, "Oh, it was just a little bit." "Oh, I had no pain." Any bleeding should be evaluated. Turns out, the number one cause of bleeding is that the tissue gets so dry and fragile and like parchment Paper, it's so thin that it bleeds. That's the number one cause.
Nada Youssef: Okay.
Dr. Bradley: The fifth most common would be cancer. But between that dryness, it could be polyps, fibroids, pre-cancer, infection, cervical problems.
Nada Youssef: Mm-hmm (affirmative). Okay.
Dr. Bradley: So, if they see blood, the first thing is not cancer. But I don't want people to wait if it is cancer. The symptom would then let ... if you keep going on and on and on, it grows, invades into the muscle of the uterus, spreads outside the uterus, and then they have pain.
Nada Youssef: I see.
Dr. Bradley: So, it turns out, for uterine cancer, if you ask me, "Of all the cancers GYN, if I had to choose one to have?" It would be uterine cancer.
Nada Youssef: Okay.
Dr. Bradley: Why? 85 to 90% have a symptom of bleeding. It gets worked up quickly. You have cancer, you get a simple hysterectomy, no chemo, no radiation.
Nada Youssef: Just get it taken out?
Dr. Bradley: It's done. But you know, I'm just saying.
Nada Youssef: Yeah, right.
Dr. Bradley: But when people are waiting ... And the other thing is a really abnormal discharge, feeling wet, moist, can also ... So, it does ... it can be brown blood, red blood, pink blood. It's just never normal.
Nada Youssef: After menopause?
Dr. Bradley: After menopause. And I know the doctor puts a speculum, we look at the cervix. Bleeding can come from the cervix. There's vaginal cancers. It's very rare, but we look in the vagina when we have the speculum in.
Nada Youssef: Sure.
Dr. Bradley: It could be endocervical cancer. And just inside the cervix. It can be uterine, it can be ovarian. 3% of bleeding in women presents ovarian cancer. Presents. I mean, usually, it's bloating, weight gain or weight loss, urinary frequency, feeling nauseous, feeling full as soon as you eat. But 3% of ovarian cancers present with abnormal bleeding. So, there's a whole host of things the doctors do to rule in and rule out what a patient has.
Nada Youssef: Sure.
Dr. Bradley: And so, I would say that stuff, definitely. And then, as we mentioned earlier, changes in the cycle.
Nada Youssef: Right.
Dr. Bradley: Too heavy, too long, many more clots, anemia, bleeding so much that you're tired, your short of breath, you lose hair, you're craving ice, that's called pica, craving starch, craving dirt. Unusual food cravings is a sign of profound anemia that most commonly, if you're in the reproductive age, if you have anemia, where is the blood coming from usually? It's from the uterus. It's not colon cancer. You're not vomiting up blood.
Nada Youssef: Right, right.
Dr. Bradley: So, you know, we have to take a good menstrual history. So, I mean, that's the things that I would look at.
Nada Youssef: Sure. Sure, now, can stress be the culprit of, any of these issues that we talked about today?
Dr. Bradley: I would say stress can lead to things like irregular periods of you're very, very stressed. Everything from the pituitary gland kind of gets shut down. Sleep, your poor sleep hygiene.
Nada Youssef: You mentioned diet earlier.
Dr. Bradley: Diet, and also, stress as we ... In the menopause, can lead to more hot flashes and sweating.
Nada Youssef: Sure. And that's also imbalance in hormones can cause a lot of these issues?
Dr. Bradley: Yes.
Nada Youssef: And that also could be related to thyroid, is that right?
Dr. Bradley: Thyroid is always checked.
Nada Youssef: Okay.
Dr. Bradley: Thyroid, we always check.
Nada Youssef: Okay.
Dr. Bradley: About one out of 100 women have a problem. But we ... That's an easy test, it's a cheap test. You'd hate to miss that.
Nada Youssef: Yes.
Dr. Bradley: So, we just look for it.
Nada Youssef: Sure. Sure. Thank you. Well, that's all I have for today.
Dr. Bradley: Excellent. Thank you.
Nada Youssef: Thank you so much for coming in today.
Dr. Bradley: Thank you.
Nada Youssef: Very, very informative.
Dr. Bradley: Thank you.
Nada Youssef: And, to make an appointment with a physician in the OBGYN and Women's Health Institute, you can call 216-444-6601. Thanks again, to our listeners and viewers for joining us today. To listen to more of our Health Essentials Podcasts from Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEPodcast. Or you can subscribe on iTunes. And for more health tips, news, and information from Cleveland Clinic, make sure you're following us on Facebook, Twitter, Snapchat, and Instagram @ClevelandClinic, just one word. And we'll see you again next time.
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