Bleeding on HRT with Consultant Gynaecologist Mr Osama Naji

Mr Osama Naji is a consultant gynaecologist at Guy’s and St Thomas’ hospital in London and he leads the busy department of women’s cancer diagnostics at Guy’s Cancer Centre. Mr Naji specialises in early detection of pre-cancerous conditions and is an international expert in advanced gynaecological scanning, contributing significantly to scientific research in women’s gynaecological health.

In this episode, the experts discuss the complexity and influence of the menstrual cycle, bleeding on HRT and when it should be investigated further, and the safety of HRT with regard to gynaecological cancers.

Mr Naji’s three take home messages are:

1. The workforce of women is needed now more than ever, therefore we must invest in women’s health and wellbeing and paramount to this is education about HRT.
2. Endometrial cancer is on the rise but can usually be detected at an early stage and treated very effectively through raising awareness, identifying the causes, managing risk factors and engaging and empowering the patient.
3. HRT is the very last item on the list of risk factors for endometrial cancer, therefore believe and trust the patient on whether the bleeding is abnormal for them and work through the management process using a shared decision-making approach.

For more information on Mr Osama Naji, visit www.rylonclinic.com

Episode Transcript:

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support at balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] So today on the podcast, I’m going to introduce to you someone that I’ve recently met, but I hope it’s the beginning of a fruitful relationship. It’s someone called Osama Naji, who is a consultant gynaecologist at Guy’s and St Thomas’. And there’s another connection there, actually, because the first job that I had as a student when I was still at school was a summer holiday job at St Thomas’ Hospital as a clinic clerk actually. And that was the first time that I’d had a bit of patient experience. I watched my first post-mortem there. I managed to get my way into the mortuary and really just created this thirst for medicine. And I used to sneak out at lunch and go and look at the South Bank and think how wonderful, what a great hospital it is. And it’s really built up and obviously now with Guy’s. So welcome to the podcast today.

Osama Naji [00:01:32] Thank you so much Louise for having me. I am delighted to be with you on this podcast.

Dr Louise Newson [00:01:36] Ah, so you reached out to me actually from my mutual patient and some of you might know we have somebody that does scans in our clinic. Actually, he’s very experienced and when women have bleeding, when they’re on HRT, we usually recommend them to have an examination and then have a scan. And it can either be done in the clinic or through their GP or through another gynaecologist. And you phoned me up and I, I’m always on the defensive, so I was worried that something went wrong. And it was delightful that you were very complimentary about Adrian my scanner, who’s phenomenal. He’s very good. And then we started to have the conversation more and a lot of you listening know, I am not a gynaecologist, I’m a physician, although I’m obviously interested in women’s health because as a GP you always are, but I don’t have it as a special interest. So tell me a bit about your background, if you don’t mind, and you lead the cancer diagnostic pathway, which I know is phenomenally successful and well-respected, but how did you get to doing what you’re doing?

Osama Naji [00:02:37] Thank you so much, if I may, before the introduction as well. Louise, I would like to add a little bit to the history of our recent – and I’m positive for – collaboration. You’re absolutely right. I came across one of your patients that has been looked after by your team and scanned with a very good quality report. And therefore, it just prompted me sometimes when I receive reports, I always look at the title, the operator, particularly when they report to pathology. And this pathology was indeed confirmed and treated. So when I looked up at your websites, I wanted to reach out and thank you so much for initiating also the facilitation for the connection and I am very pleased with this connection that looks like a fantastic clinic, very well led, very well organised and I am hopeful to be able to support it in every possible way within my capacity.

Dr Louise Newson [00:03:31] Oh, lovely.

Osama Naji [00:03:32] To briefly introduce myself. I am a consultant gynaecologist, at Guy’s, St Thomas’ and I’m proud to have worked in this organisation throughout my research fellowships, training, as well as now becoming a permanent consultant for this organisation who has a very, very long standing history of reaching almost now a thousand years in healthcare. It’s an international centre renowned for its research, renowned for its excellence in clinical care. And I’m proud to say that now I have affiliated my work with the cancer team. I look after the cancer diagnostics and this includes the entire genital tract, suspected malignancy from cervical, from uterine malignancy, as well as ovarian. I am also fortunate to be working with a multidisciplinary team of very experienced, dedicated nursing staff, fantastic administration staff, as well as all the capacity of cancer work from radiologist, medical oncologist, clinical oncologist and cancer surgeons as well. So in a nutshell, they’re proud to be delivering firstly, the important message is from the patients coming to our Cancer Diagnostics Clinic to reassure the audience that the vast majority of them, they come back, they come as benign and they leave as benign. And our job is primarily to diagnose promptly and support throughout the journey or exclude accurately and safely and reassure. So it’s going well. I’m proud of it. We are quite busy and hopefully we will continue on this path.

Dr Louise Newson [00:05:08] Because you see a huge number of women don’t you, through your service.

Osama Naji [00:05:12] Absolutely, yes. Because there are multiple referral pathways. For example, our colposcopy service is probably one of the busiest in the UK will receive in excess of 200 films per week. We have extending up to Saturday to clinics every day for Colposcopy and Access Clinic as well. We run it throughout the week as well, receiving probably hundred a week as well. Yeah. So keeping us very busy in fact.

Dr Louise Newson [00:05:43] And it’s very interesting actually. I mean, bleeding can be very scary for women, but women, obviously, most women bleed every month when they were younger. And our bleeding pattern can change so much with all sorts of things can’t it, it can change even if you’re stressed sometimes, because stress can interfere with hormones, which can then interfere with our bleeding pattern. And it can be very frightening actually, because as people get older, there’s a more risk of other diseases as well. And we’ve known for many years that women, if they have estrogen on its own as HRT, it can stimulate the lining of the womb and it can cause changes. Actually, in the majority of women, it still doesn’t cause cancer, does it, when you have…

Osama Naji [00:06:25] Absolutely. Absolutely. Yes.

Dr Louise Newson [00:06:27] But there is a small proportion that will and we don’t know who that proportion are. And obviously, as clinicians, we do not want to do harm to our patients, of course, we want to try and help them as much as possible. So when they realised this many decades ago, they added in a progesterone or a progestogen a synthetic progesterone, to negate this effect of estrogen. And it does work really well. And in fact, the studies, I hope you agree, say that if a woman’s on a continuous progesterone or continuous HRT, she’s less likely to have endometrial cancer than if she wasn’t on any of the HRT.

Osama Naji [00:07:04] Indeed. Indeed. To be honest, since you mentioned the pattern of bleeding, if I may, add a little again and input on this particularly important point and I use in my clinic and also throughout my communication, I use a few analogies to resemble the picture to the patient so that they can get engaged more and feel empowered and be able to make a decision. In terms of the abnormal uterine bleeding, I explain it in a very simple fact. Imagine yourself flying a jumbo jet and the dashboard of the plane is full of gadgets. Okay, that’s how sophisticated this little protective system of the woman is, way more sophisticated than the male. And therefore, it requires a lot of gadgets to work together in order to ensure the flight is running smoothly. And the moment we encounter one of the gadgets probably not working, it needs to be identified and isolated, instantly and promptly so that does not affect the entire system. And my message is the soft marker number one to tell you that the dashboard is working well and operational, is when you have a regular, uneventful menstrual cycle. So therefore, my message from simple terms that whenever you have disturbance of the menstrual cycle, it tells you that the dashboard is giving you a sign. So it needs to be identified and quite rightly so. You said whether it’s changes in lifestyle, stress, I often see it. It’s a number one, to be honest contributor, particularly in young, healthy women when they’re related to job changes or moving homes as well. And frequent travel with work quite often triggers irregularity in the menstrual cycle. So the vast majority is we call ‘functional’ or hormonal changes. And there remain a small, tiny fraction of structural causes. And because of the unavoidable fact of the age-related changes, these structural causes, they may turn into a slightly higher index of suspicion with advancing age. So therefore, after 40, if you have a dashboard telling you that it’s an abnormal uterine bleeding, then it is definitely worth at least looking at structural causes to exclude them or identify them and manage them promptly because leaving them, they may increase the risk of gynaecological malignancy. And in all honesty, HRT, to be honest, it’s the bottom of the list of these risk factors, if any, to be honest. And we are going to work hard, hopefully to take it off this list at all.

Dr Louise Newson [00:09:40] Which is very reassuring. And I think it’s also very interesting because when we look at trying to educate people, in a big way, it can be very difficult. And I’m going a bit off topic here, but if you think of something like trying to diagnose ovarian cancer, one of the symptoms could be bloating. Now we know most people have bloating at some stage, whether it’s just because they’ve eaten too quickly and they’ve swallowed some air or whether it’s because they’re stressed or something else. But we do know that a very small proportion of people who have bloating are going to have ovarian cancer. But how do we do that? In general practice, I must have seen thousands of women who had had bloating and I can’t refer them all for scans because that would clog the system and it would also deny me using my brain and asking about other symptoms that would either reassure me or worry me, depending on the situation and also the age of the patient, how long the symptoms have been going on for. All sorts of various other things, and also actually how worried the woman is as well. Because I’ve seen women with bloating who’ve had a mother and a grandmother who have died from ovarian cancer. And actually, I would investigate those women probably more than someone else who just had a bit of bloating for a couple of days or what have you. So with bleeding that’s abnormal in women who are on HRT, who are often in their fifties, for example, so you could define them as postmenopausal, but they’re having hormones, when they have bleeding, how do we know and that’s why it makes it very difficult. And as a GP, when I’ve seen people in general practice who’ve had bleeding on HRT and then I talk to them and they say, ‘Oh yeah, I was on holiday and I forgot to take my HRT for a couple of days and then I had some bleeding’. Then I’m thinking well it’s probably related to the hormones rather than something else.

Osama Naji [00:11:24] Absolutely.

Dr Louise Newson [00:11:25] But then as a gynaecologist or a specialist, the people that you tend to see are people that have more likely had more worrying types of bleeding as well. So we always look at different populations as well. And so for me, as a menopause specialist, I see lots of women who have bleeding and lots of the times women tell me, ‘well, I just have a bit of – I feel like I’m about to get my period and then I have two or three days of spotting or bleeding, and then it hasn’t happened again for three months’, but they still have bleeding. And so you should really then be thinking investigations, examinations, everything else as well. But then there’s more women on HRT generally now, and that’s going to increase. So what I don’t want to do as a menopause specialist is to clog up a system with inappropriate investigations. But I also don’t want to miss those ladies. And I think this is where us working together in the future is going to be very interesting because there are different questions that we can ask these women as well aren’t there. And I see a lot of women who have a lot of investigations and biopsies and all sorts, and I know it’s unlikely to show anything and they know, but we go through that mill, if you like. So it’s very interesting to hear about some of the ways that you’re sort of looking at that.

Osama Naji [00:12:41] Absolutely. To be honest, when we had our initial discussion, we took it to a broader picture, and I am absolutely in agreement with you. At the end of the day, Louise, medicine is an art it’s not a science. So when we discussed about how the nature of walking into a cancer diagnostic clinic can be quite frightening to – rightly so – to a lot of patients, and therefore, by sending me the very impressive structure on which I have taken it to Guy’s to trying to implement it, going through the research governance, you have sent me a very interesting risk stratification table to see which women will benefit from a little bit of an extra investigations, and rightly so, and the women who can safely be managed conservatively. And this is quite useful, in fact, simply because you apply the common sense into your approach. Essentially cancer, like any pathology, comes from risk factors. OK? And the absence of risk factors, this cancer becomes ‘background risk’. Thee is difference between ‘background risk’ or at ‘increased risk’. So every one of us will have a background risk and this is unavoidable, no matter what we do, we are all subject to this risk. However, some people, they have increased risk and to certain type of malignancy, like for example, smoking – lung cancer, and probably lack of engagement for cervical screening is a risk factor for cervical cancer. In terms of endometrial cancer, so there are very common known risk factors leading into it, particularly if increased BMI, hypertension, diabetes, family history as well. So when you have a patient probably in the process of considering initiating or continuing their HRT, if these risk factors come in the picture, then at the same time display it or discuss it with the woman, that these are risk factors so they can be engaged, they can be also feeling empowered, and they share that decision, which I’m very much fond of, shared decision making. And at the end of the day, we are in this consultation or discussion together, these are my thoughts, these are considered risk factors. Probably it’s a good idea to investigate. Unfortunately, yes, my clinic is quite busy, but at the same time, if you don’t know I have mentioned that to you quite often. I would say probably one in three, maybe now is becoming even more frequent, patients coming anxious, worried, terrified. And the end of the day, it’s a simply HRT related bleed without any risk factors. And this is, in my opinion, a loss for everyone involved. Firstly, a loss of the patient’s time, psychology, energy and loss to the health system, because we utilise resources for eliminating something that’s quite a background risk and also a loss to the entire system that probably might have been utilised to someone maybe at a higher risk. So therefore, if I need to give a message from this discussion is they apply common sense, apply risk factor stratification and then follow it accordingly.

Dr Louise Newson [00:15:53] Yes, and that’s very important, obviously, in anything we do, isn’t it? As a clinician, you know, if everybody I saw with a headache, I referred for a scan it just wouldn’t work. And so the other thing is we see a lot of people – I spoke to a GP a few weeks ago who had told one of my patients who’d had a bit of bleeding, who was needing a scan, that she needed to stop taking her HRT before having a scan. And the patient was very worried because when I had seen her, she was very, very low and actually had some quite intrusive suicidal thoughts, which had got so much better with HRT. So she contacted me and said, “Dr Newson, I’m really worried that if I stop my HRT for six weeks before my scan, my mental health is going to deteriorate.” So I said, “Well, actually, you don’t need to stop your HRT before your scan”. And she said, “Oh no the local guidelines for my GP say that”. So I spoke to the GP who said, “no, our guidelines do say women should stop taking HRT for six weeks before a scan”. And I said, “but that doesn’t make sense to me because if it is HRT related, you want to see the womb in its full glory”, you know, like your dashboard on the plane, you don’t want to fix it before you want to know what’s going on. And then the GP said, “well to be honest, if her bleeding stops with her HRT stopping, well we’ll know it’s due to the HRT so she can stop taking it forever.” And I said, “But that’s not really… that’s too simplistic because there are benefits to her future health and to this lady to her mental health actually, from continuing HRT”. But it’s very – this confusion that’s happening and even in different regions, the guidelines seem to be different. It’s really affecting services. But also, like you say, the women and the anxiety because they often get referred for a two week referral, which, as you say, is a suspected cancer referral. And we’re not suspecting cancer. We’re just needing them to have a scan.

Osama Naji [00:17:45] I totally agree with you Louise, on this particular point, I don’t know. I am hoping on your power and your capacity together with this work to try and spread the word. Unfortunately, HRT related care has attracted quite controversial episodes throughout the times through the media. And I have just been following it through the headlines mainly that sometimes probably pro and most of the times are against. And the victim in this point in particular are the patients because whom would they be believing? By the time rather than reading a headline that is instantly on your tablet rather than booking an appointment try to seek a professional help or advice that’s taking time. So probably easier to disseminate an information through the media. I have to say the media hasn’t been always masterful on HRT work, if I’m honest.

Dr Louise Newson [00:18:39] No, I find it really sad actually, because the media is actually starting to be better at understanding the evidence, which is really good. But actually, there are some healthcare professionals that have really – and I’ve mentioned it before on this podcast – they seem to be out to get me and my work. But actually, it’s not… I’m just a messenger, actually. I just quote the evidence and look at the facts. But it’s even – I don’t know if you’ve seen it yet and some people listening might have seen it – there’s an article in the British Medical Journal today, and it’s quite inflammatory, actually, about me, but it’s also about women saying women are asking for hormones and it’s almost terrible because they are expecting to feel better. And I feel that’s really sad because then I can cope with being bullied and being rude about but I can’t cope with the thought of more women being denied something that is evidence based.

Osama Naji [00:19:31] Whatsoever at all to be honest. Even sometimes, the way I see it also, for example, a woman who has probably ticked every single risk factor for endometrial cancer comes to the clinic asking for HRT, I have no power or capacity to deny her this treatment at all. I would tell her, “You have my support. These are the facts. This is the evidence. I can support you in whatever decision you would like to take. However, if you allow me to give my advice, then that’s absolutely fine.” And we are not in a place to deny any form of treatment, provided the patients are able to take their informed decision on this matter, really.

Dr Louise Newson [00:20:08] Yeah. And it’s so important. I used to do quite a lot of lecturing actually about consent, when I was just qualified as a GP, I’d go to other practices and talk about consent and what it means. And if you’re a consenting adult and often in general practice, it was lot about contraception in teenagers, but it’s exactly the same in these sorts of conversations that people are allowed to accept or even refuse treatment, even if it’s going to do harm, if they understand the potential risks and benefits.

Osama Naji [00:20:36] Absolutely, it’s a very simple common sense. Again, back to the sticking to this very simple concept of consenting. Absolutely.

Dr Louise Newson [00:20:43] Yes. And I find, some of this, maybe I’m allowed to say it because I’m a woman is because it’s women. And I’ve had people very high up when I’ve said let women decide whether they want to take HRT and allow them the choice. I’ve had people say to me, “No, we can’t do that because these women won’t understand. And these women are falsely asking for antibiotics when they’ve got viruses. So we’re worried that they’re going to be asking for HRT inappropriately.” Well I do have an issue of inappropriate antibiotic prescribing. But I don’t have an issue of inappropriate HRT prescribing because women won’t carry on taking it if it doesn’t improve their symptoms. So sometimes in medicine, we give a therapeutic trial, don’t we? We say, well, you can try something and see.

Osama Naji [00:21:26] Absolutely. The trial-and-error approach, it’s a common medical approach for any type of probably let’s try the treatment. I totally agree with that. To refer to your earlier point by stopping HRT before an ultrasound scan, in fact, I am finding it difficult to justify this approach. I’ll give you an example, woman with heavy menstrual bleeding who are on blood thinning medications, warfarin or…so again, would you stop the warfarin and run the woman at high risk of developing a clot because of probably other contributing factors to the bleeding? Just have a helicopter view, a little bit of a stepwise approach, and HRT could be a contributing factor to probably a very small fraction, in fact, of endometrial pathology. I stress the fact is not at the top of the list for the risk factors whatsoever and therefore to stop it before even initiating an investigation, it’s totally irrational. However, I have just seen a patient, in fact quite a few, last week, who was on HRT leading a very fulfilling, satisfying life, and she developed abnormal bleeding. So the ultrasound scan does suggest probably some pathology not necessarily related to malignancy, like a polyp, which is most of the times is a benign lesion. So I told her, look, there are two options here: either we probably instigate further investigations straight away to ensure this polyp that’s been addressed, looked at and biopsies instantly, so would minimise the time of disrupting the HRT process, or probably we can pause it and take a little time to repeat the scan to see if this pathology would probably be addressed by the next cycle. And so she had the choice. She said, “No, please, HRT is quite important to me. Let’s do a little faster lane on this management.” And in fact, without disrupting the HRT, we managed to look into this polyp and the polyp came back benign and happy days and without any discontinuing of her ongoing treatment.

Dr Louise Newson [00:23:30] Absolutely. I think one of the things we’re looking at is actually the risks of not taking HRT, because for years we’ve been told the risks of taking it. Of course, we know they’re very low, if at all any, with some types of HRT. But actually we know also some studies that show that the first year of stopping HRT, there’s an increased risk of cardiovascular disease and strokes. So we have to be really careful what we’re doing. But I think what you’re saying also is really important about the patients being in control. You know, I’m not here to force people to take HRT. Like I’m not here to force people to do yoga. You know, I choose to do yoga as my form of exercise, but others will think it’s the most ridiculous thing ever and they prefer to go for a run. That’s fine, you know, I think the important thing is having choice. You know, I love your aeroplane analogy and you know, if you don’t want to ever be in a plane crash, don’t go in an aeroplane. But if you want to take that risk, then, you know, and it’s personal choices. And I think this is where… when things get very debated and like you say, in the media and social media about this HRT, and it’s this noise going on in people’s heads about is it safe? Is it not? I think this is a really important time for us to take a step back and reflect and think about where the good sources of information are and reliable sources. And then we can make a decision that’s relevant for us at the time. And I think with we’re talking a lot about bleeding, but there’s different types of bleeding – sorry to be graphic on a podcast – but women often know their bodies. And I think for this, whether they’re on HRT or not, is very important. And I’m sure you’ll agree, that if anyone has any, whether they’re symptoms, but especially any bleeding that doesn’t feel right, then I often think that’s probably the most important marker that they need investigation rather than anything else, because people often know their bodies and they’re often scared about talking about bleeding. There’s something about vaginal bleeding that they don’t want to trouble the doctor. And I think it’s – if they are worried or concerned, then they absolutely need to get it checked out, don’t they?

Osama Naji [00:25:37] To be honest, again, I couldn’t agree more. And we saw patients come to my clinics, I asked them again, very simple question to start with. There are two types of approaching whatever we have discussed. You tell me, “Mr. Naji, what is the problem? Mr Naji, is there a problem?” So because there could be a problem, but I am able to manage my life with this problem. Why would I need to bother myself about it? But if there is a problem, I need to know so that I can make my decisions, plan my life, my family, my work, in order how to address this problem. So therefore, in terms when it comes to bleeding, like we said, this is a soft marker that tells you the dashboard needs to be looked at a little bit more closely. And most of the times, addressing it is a very simple, straightforward way and very far from any cancer pathway that the NHS is proud to say I have that is still intact and operational, despite of all the wear and tear that’s happening in the system at this moment in time. But the cancer care is still intact and functional. Therefore, my duty at this point is to ensure that it’s kept in its operational capacity rather than being probably used and overused with less clinically concerned matters. I have seen probably patients are rightly so worried and some of our colleagues in the GP practice, they address this worry in the right way. However, by a little bit of attention to the history, risk stratification, they could be managed either successfully in the primary care or to be referred to a dedicated menopause clinic, rather than having a very low threshold to trigger a cancer pathway that will probably maybe add more anxiety and stress to the patient for addressing a simple matter that this is simply a HRT related bleed, can be easily sorted by probably a trial of adjusting the doses, adjusting the agents, and to see, particularly within the first year of trying in the absence of risk factors, then see and after that the probably more qualified. But unfortunately, it is a fact that a large proportion of our patients are referred still within this pathway that are not indicated.

Dr Louise Newson [00:28:01] Yeah. So there’s a lot of work we need to do and I’m hoping I can invite you to come back in future when we could talk about the work that we’ve done together. So I’m very grateful for your time because I know how busy you are today, so thank you. But before you say goodbye, I know you’ve been very organised and written your three take home tips, so if you could share them with us, that would be great.

Osama Naji [00:28:23] Thank you so much again Louise, for having me. I hope I have been helpful to you and your audience. Thanks a lot. Please, I would like to summarise from my side my three important messages. In the current challenging times, a women’s workforce is needed more than ever, so paving the way for maximum productivity must be achieved in investing in the wellbeing and health of this workforce. So therefore, HRT education is of paramount importance. Number two is endometrial cancer globally is on the rise. However, it is a type of pathology that can be detected at an early stage and therefore treated very effectively. With increasing awareness, identifying the causes, then managing the risk factors, this approach can be quite efficient and successful together with the patient involvement and engagement. Lastly, HRT is the bottom line – I stress this important fact – HRT is the bottom line, is the bottom item on the list of risk factors when we look at cancer. And therefore, rather than being overlooked or underlooked, it should be approached with a little bit of individualised prospect based on trusting the patient, what they say, believing if they think this is probably not normal to her, and then work through this abnormality based on the very common known risk factors to see if the HRT is playing a part in underlying endometrial pathology or not.

Dr Louise Newson [00:30:00] Very good, very clear. So lots of information. There is… an area that we’ve not really talked about on the podcast before, so some of you might want to listen to it more than once. But thank you so much for your time today and look forward to speaking again.

Osama Naji [00:30:14] Thank you so much Louise for having me and I wish you a nice day ahead and a nice weekend.

Dr Louise Newson [00:30:21] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.

END.