Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Dear Dr. Pat,

I am 58 years old and live in a rural area, about 100 miles from a regional hospital in the Southeast. I don’t want to identify the area any more than this. because our poor state gets enough bad attention as it is. We have only one gyn left here in the county and some nurse-midwives, who have to care for many women who are having babies and the usual female problems. I am an elected county official, so I have some ideas about why we have such poor care for women in the rural parts of our state.
The costs of the malpractice and of running a practice, along with the increasing numbers of out of work folks who just can’t pay their bills, and late payments by insurance companies and the federal payment systems, just made it impossible for the other two gynecologists who were practicing here to stay. We had to raise money locally to be able to provide an incentive for this one formerly retired OB-GYN who has moved to our area, and we are grateful that it worked. In addition, we have a small hospital with only one anesthesiologist, and a radiologist who visits once a week. I think my question to you has something to do with the information that I have just given you.

I am, as I wrote earlier, 58 years old. I don’t smoke or drink. I am a bit overweight, 5’5″ and 160 pounds. I don’t exercise much. I am married and have two grown, healthy children. I never took hormone therapy. There has never been any cancer in my family, but we do have diabetes. I have a sugar problem myself and am taking some pills for it, and my numbers are not always that good. I had some vaginal bleeding about five months ago. Sure surprised me! I got in to to see one of the nurse midwives, and she sent me over to the hospital for an ultrasound of my uterus and ovaries. The radiologist only comes once a week, but I got to talk to him when the tech took the pictures, and he told me that nothing was wrong. The nurse-midwife said that since the ultrasound was normal, the bleeding would probably not happen again.
Two months ago I had the feeling that I used to get when I had my period, and then I had another episode of vaginal bleeding. This time it wasn’t just a day, it was three days! So I insisted on seeing the gyn doctor. He reviewed the pelvic sonogram and said that the pictures did not show a clear measurement of the endometrial stripe and that this sometimes occurs with age. He suggested that I have an endometrial biopsy in the office. It certainly wasn’t a pleasant procedure, but it did go just as he said it would. I heard from his nurse that the biopsy results were normal and that I should not worry.

Well, I have had another episode of this bleeding now and am worried. I did some research and am concerned that this biopsy could miss something. I learned that being overweight and having a tendency to diabetes can increase a woman’s chance of cancer of the endometrium. I talked to the doctor and he said that I could just have a hysterectomy and then I could stop worrying. He did tell me that it was not normal for me to have three episodes of vaginal bleeding in four months.

I did some research on women’s health and I came up with your site on menopause through Google. Can you tell me if having a hysterectomy is the right thing to do? I certainly don’t want to get cancer diagnosed at a late stage. On the other hand, I know women who have had terrible experiences with this surgery—infections and blood clots—or were just never right afterwards.

Thank you,
Dorothy

Dear Dorothy,

I grew up in a rural county in southern Kentucky, where many of my family live still. It is true that the costs, financially and emotionally, of being a solo ob-gyn in a large rural area are daunting. An ob-gyn who practices alone often goes months on end with no time off, because there is no one to cover that practice unless a doctor from another county will agree to do this. And the costs of running a practice are often fixed, while the revenue is terribly unpredictable.

You and millions of other rural Americans are lucky that you have access to the Internet and can do research on health problems. “Just Google that” has become a catchphrase for inquiring minds across our country. We at www.womensvoicesforchange.org are grateful that Google sent you to us!

Post-menopausal bleeding always requires investigation, and a simple ultrasound, when it cannot visualize the entire endometrium and give a measurement of it, is not useful. In areas with more opportunities for evaluation, the next step would likely be a sonohysterogram, where sterile saline is inserted through the cervical opening into the endometrial cavity while a sonogram is being performed. This provides a clear picture of the measurement of the actual lining and allows the doctor to look for any local areas of thickening or a formed polyp. In some practices the next step would be a directed biopsy of the areas that appear abnormal under ultrasound guidance. That would mean, however, that the gynecologist would need to have both ultrasound equipment in the office and a technician to help with the performance of this more complicated procedure. This, of course, is expensive.

If the ultrasound-guided office biopsy reveals a pre-malignant or malignant growth, then the next step is pre-operative staging and planning for surgery for endometrial cancer. If the biopsy is “normal,” as it often is, then the patient needs surgery anyway. That surgical procedure should be a hysteroscopic evaluation of the endometrial cavity and removal of any visible growth, followed by a thorough curettage or scraping of the endometrial cavity. Hysteroscopy involves the insertion of a small fiber-optic telescope into the cervical opening. The endometrial cavity can be thoroughly evaluated, and surgical removal of any visualized abnormality can be performed without any abdominal incision. Often a polyp can be vascular and cause bleeding but not be malignant. This is the next step you need before you resort to the major surgery of hysterectomy.

I suggest that you make an appointment with a gynecological cancer doctor or surgeon who does lots of hysteroscopy procedures at the hospital affiliated with the medical school in your state. Take the ultrasound pictures and the pathology slides and the report from the endometrial biopsy when you go for this consultation. You are an educated health care consumer now, not just an obedient patient. You are right that obesity and diabetes are risk factors for endometrial cancer. Ask the specialist for a hysteroscopical surgical procedure with curettage of the cavity. If there is no evidence of pre-malignant or malignant tissue, then you can see this specialist one more time in a few months. If you have no more vaginal bleeding, then this problem will have been solved without the old-fashioned “Might as well take that uterus out just in case it turns cancerous on you.” Those were the bad old days for women that we certainly knew about in the South. Women are smarter now. They only want what is necessary not what is just frightening.
If you are lucky, and this turns out as it often does to be a non malignant problem, then you have been given a gift. You have a responsibility that comes with this gift. You know now that being really overweight and having poorly controlled diabetes is something that you can fix. So, get to it.

Eat like a diabetic should: three small meals a day and three snacks. Learn to check your blood sugar and rely on that number to guide you to improved glucose control. Exercise daily. If you are not fit, begin slowly but don’t waste a minute. Your blood sugar and your risk for all the diseases that obesity and diabetes can bring should decrease dramatically if you lose 30 pounds and get really aerobically fit.

Then, as a county official, take this health program to another level. Organize the women in your town and in your county—neighborhood by neighborhood, church by church, community group by community group—to develop healthier ways to eat and to find time to support each other with shared meal plans and grocery shopping trips. Find an exercise buddy for every woman who chooses to put some small part of herself before the care of others. Recognize that the economic depression in our country, so terrible in rural areas, causes despair and emotional depression. Community support for everyone from everyone is the true character of the American citizen we can once again aspire to have.

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  • Dr Pat Allen August 23, 2011 at 10:29 am

    Dear Ms. Nash,

    We are pleased that information about women’s health that you have found here has made you more prepared to discuss specific issues with your doctor. Thank you for reading and commenting. Do come back and bring your friends.

    Best,

    Dr Allen

    Reply
  • Georgina Nash August 22, 2011 at 3:45 pm

    I am over ten years post menopausal and now have unexpected bleeding for four days. I have an gyn appt. day after tomorrow. Your article on this iszue is so very helpful, and will enable me to be informed on my visit – thank you so much! Best Regards, Georgina Nash, Napa Valley, CA

    Reply
  • Debbie Miller May 22, 2010 at 6:10 pm

    Dr. Pat,
    I read the article “Life in the slower Lane by Donimique Browning in Good Housekeeping. She mentions you gave her a diet that included 4 permissible foods. I would love to know more about your eating advice.

    Reply
  • Teresa Domingo August 14, 2009 at 9:17 pm

    I just would like to ask a question regarding early menopausal, i’ve been ligated for 7 years and sexually active for more than a year. And its bee almost 2 months that i had no menstruation. and this is not normal. i have tried to take a pregnancy test and the result was negative. I have always have a normal mentrual cycle and it is always heavy. i have not consulted yet any OB or gynecologist.

    Reply