Insights About Blood Disorders in Adults

A longtime leader in women’s health issues, Bethany T. Samuelson Bannow, MD, joined Cleveland Clinic to lead the Classical Hematology department. Previously a clinician with Oregon Health & Science University, Dr. Bannow treats patients with hematologic disorders, including thrombosis and abnormal uterine bleeding. In January, she will also become editor-in-chief of ASH Clinical News.

ConsultQD had the chance to talk with Dr. Bannow about her plans for advancing clinical care and research for patients with hematological conditions.

Q: Can you share a bit about your vision for the Classical Hematology team?

Dr. Bannow: We have one of the bigger programs in terms of the sheer number of adult classical hematologists, which is great. There are many growth opportunity to educate people about our programs and to attract even more talent.

I'd also like to see us increase our lifespan care in subspecialties, specifically in terms of hemostasis, thrombosis disorders and sickle cell disease. We have a large population of individuals with sickle cell disease and other hemoglobinopathies in Cleveland, and I look forward to building on our lifespan center here and expanding research options for our patients.

Q: Can you explain a bit about what comprehensive lifespan care involves for sickle cell disease?

Dr. Bannow: Sickle cell disease impacts the whole patient's life, so what we like to see is multidisciplinary care, starting with pediatric hematologists and leading into adult hematologists as the patient ages as well as having nurses with expertise in sickle cell care available. Also having social workers and other non-physician team members who stay the same throughout the patient’s life is an important aspect of comprehensive care.

Q: What are some of the biggest challenges for this population of patients?

Dr. Bannow: Sickle cell disease can be very painful. We hear a lot that patients are not always believed when they seek care for pain. That leads to a breakdown in trust with providers. We see a lot of interrupted care because of that.

It's also a disease that really impacts quality of life and the ability to participate in family and society. If someone is hospitalized for complications even two or three times a year, that can impact their ability to hold a job and maintain medical insurance. It’s also an inherited disease, and it’s always hard when multiple family members have a chronic illness.

We as a medical community haven’t made as much progress in sickle cell disease as many other conditions. We’re catching up and that’s good, but we have a long way to go.

Q. What are your goals in terms of hemophilia care at Cleveland Clinic?

Dr. Bannow: I come from an institution that was a designated hemostasis and thrombosis center. I was there for seven years and learned a lot there and would like to bring a lot of those skills here.

Hemophilia care is much like the sickle cell care in the need for a comprehensive care model where patients are seen by pediatric hematologists, adult hematologists, specialized nurses, physical therapists with specialization in hemophilia as well as specialty pharmacists. My hope is to be able to provide that type of multidisciplinary care for patients who have bleeding disorders like hemophilia and Von Willebrand disease.

Q. Can you share a bit about your work caring for women and girls with bleeding disorders?

Dr. Bannow: There are a lot of patients who suffer with heavy menstrual bleeding who either don’t know that what they’re experiencing is abnormal or who don’t talk to their doctor about it because of stigma. It’s very hush-hush and people don't feel comfortable talking about it.

I hear that all the time, especially in families with bleeding disorders where every single woman has horrendous periods and they all just think it's normal because it's not something that we talk about or educate people about.

In theory, we talk about periods in school, but nobody ever says what's normal or not normal. I think the school system would be a great place to have that starting conversation, educating girls about recognizing what they should be worried about and when to talk to your doctor. We’re not there yet.

Q: What advice can you share with physicians about becoming more confident in having those discussions?

Dr. Bannow: The more conversations you have, the more comfortable you will be with it. And the more comfortable the clinician is with it, the more comfortable they'll make their patient with it.

“Do it scared” is a good motto. It might not feel comfortable, but we're doctors. We talk about all kinds of personal things but for some reason we don't necessarily bring that same comfort level to talking about periods.

It's amazing how eager people are to talk about it when you give them that permission. I think giving ourselves that permission, giving our patients that permission and just doing it until we get comfortable. Much like the practice of medicine, it's actually not fundamentally that different. We were all uncomfortable taking a patient history the first time we did it, but we got better with time.

Q: How pervasive is the problem of abnormal periods?

Dr. Bannow: One in three women will have heavy periods. It's particularly common in adolescence because the body is figuring out what to do and periods can be irregular, and that leads to heavy bleeding. It's also common in the later years as we approach menopause. Also, the risk of fibroids increases over time. By the age of 50, up to 80% of Black women will have fibroids, which are a common cause of heavy periods.

Q: What are some warning signs that patients should look for?

Dr. Bannow: We use the 7-2-1- rule. If someone is experiencing periods that last longer than seven days, saturating a pad or tampon more than every two hours and/or passing clots larger than one inch in diameter, those are things to talk with a healthcare provider about. Also, any bleeding after menopause or bleeding with sex need to be checked out.

Muscle cramps, hair loss, fatigue or decreased exercise tolerance can be signs of iron deficiency, which often accompanies abnormal bleeding. Patients may also have pica, which is craving non-food items like ice.

Q: I understand you serve on the VENUS Women’s Health Committee. Can you talk a bit about this work?

Dr. Bannow: VENUS is a consortium of hematologists throughout the country who are interested in various aspects of thrombosis care. I co-chair the Women’s Health subcommittee along with my colleague, Dr. Alice Cohen. We’re looking at investigator-initiated trials.

Recently, we used a large database of deidentified medical records to look for iron deficiency in menstruating women on anticoagulation, and found this condition is vastly underinvestigated and certainly underreported as a result. Another area of research focuses on women on anticoagulation during pregnancy. Our goal is to better understand the management of anticoagulation in pregnancy, specifically around delivery, and how different approaches affect patient outcomes. I’m excited to see the data that comes out of that.