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    by Ngozi Osuagwu, MD | November 10th, 2019


    I recently read one of my journal articles that I found disturbing. The title of the article was Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer1 by Kemi M. Doll, MD, MS and other authors. We know that 92 % of women diagnosed with endometrial cancer present with bleeding. As I have mentioned in previous blogs, unlike breast cancer that has the mammogram as a screening test or cervical cancer that has the pap smear, there is no test at this time to screen for endometrial cancer.  As health care providers we rely on the patient reporting abnormal uterine bleeding that will then lead to an investigation to find out the cause of the bleeding.

    Unfortunately when it comes to endometrial cancer, only 53 % of Black women are diagnosed at an early stage compared to 70% of White women.  What was mentioned in the article is that when Black women come to a doctor with complaints of abnormal bleeding, particularly postmenopausal bleeding, they often are not worked up properly. The guidelines on how to manage the abnormal bleeding is not followed consistently with Black women as it is for White women. This may be one of the reasons why endometrial cancer is found at a later stage in Black women than White women.

    Why, you might ask. This came directly from the article:

    Regarding appropriate clinical response from providers, there is evidence that Black women in particular do not elicit the same clinical concern as other patients. This has been most notably reported in cardiology simulation study where Black women with identical symptoms as White men and women and Black men were referred for cardiac catheterization at a significantly lower rate than all other groups. Black patients are less likely to have pain treated adequately, and myths about difference in Black bodies that originated in the 18th century are still present among medical trainees. In gynecologic setting, which is more closely related to this work, in addition to a record of racism in reproductive health care and access, there is also early evidence of normalization of abnormal bleeding among Black women themselves. In this context, it is reasonable to consider that providers may more often overlook or misattribute postmenopausal bleeding based on a host of biases that have deep roots in the field of medicine.

    What does this mean for women especially Black women?  YOU NEED TO SPEAK UP.

    1. You should not ignore abnormal uterine bleeding especially when it occurs after menopause. Bleeding when you have gone a full year without bleeding is abnormal and should not be ignored. After menopause, even spotting or ‘smearing’ needs to be investigated.  At minimum, you should get an ultrasound and possible have a biopsy.
    2. If you are bleeding more than 8 days and/or your cycles are coming less than 24 days, you need to see your health care provider.
    3. If you are bleeding after intercourse, you need to see your health care provider.
    4. If you are bleeding in between periods, you need to see your health care provider.
    5. If you are not sure what is normal, then talk with your health care provider.

    There are many reasons that your bleeding is abnormal. It is not always cancer. You will need to have a work-up to find out the cause of the abnormal bleeding. Write down when the bleeding is occurring. Be prepared to talk with your health care provider. Do not be afraid to ask, “Doctor, I am worried, how do I make sure this abnormal bleeding is not due to cancer?” Your health care provider should explain what they are doing to make sure that it is not. Ask questions. Speak up. If you are not satisfied with the answer, you can always get a second opinion.

    We all have biases, but it is definitely a problem when it affects the health of a group of people. I will tell you it is being addressed in the medical field. As this is happening, we still have to be advocates for ourselves and our loved ones. SPEAK UP, do not have your symptoms ignored.

    1Doll KM, Khor S, Odem-Davis K, et al. Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer. Am J Obstet Gynecol 2018;219:593.e1-14

    2 Responses to “SPEAK UP”

    1. Thank you for this very timely message

    2. Bea says:

      I am a living witness to this. Thanks to Dr. Ngozi.

    Leave a Reply

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