INFORMATION

Empowering you with knowledge on Women's health, Infertility, Pregnancy & Menopause

Abnormal menstrual period

Are you troubled by heavy or erratic menstrual period? 

You are not alone. Period-associated problems are very common and most women put up with these for quite some time hoping they would go away on their own. Whilst this may be possible for some, many endure countless days of heavy menstrual flow, erratic bleeding and/or associated pain, and more often than not, end up feeling exhausted, becoming anaemic or finding it hard to cope with daily living, study and/or work.

There are many factors that can contribute to abnormal vaginal bleeding. Some are related to hormonal changes which are usually seen in adolescents, perimenopausal women, women with ovulatory problems, or women taking hormonal medications; while others may be due to underlying diseases such as fibroidsadenomyosispolyps, infections, pregnancy loss and cancers, to name a few.

At Yap Specialist, our gynaecologist will listen to your concerns and evaluate your history which may include treatments you have previously tried and what methods work best for you. A comprehensive assessment will then be performed to help determine the cause and the severity of your problem; this can include physical examination, blood tests, and/or ultrasound scan .  A range of treatment options will then be discussed and our specialist will assist you in selecting not only the most effective but the most suitable treatment to meet your needs. Treatment options can range from non-hormonal tablets, hormonal pills / injection / implant, or surgery. Thereafter, we shall continue monitor your progress until your problem is resolved or at least managed up to your satisfaction.

Further reading: how can I reduce or stop the heavy bleeding?

Are you wondering about having your own baby?

Having a baby is one of our greatest milestones in life – it is a wonderful experience to be able to give birth to our children and raise a family. There are many books and reading materials out there on pregnancy, but our specialist will help you focus on what is important and relevant to you. 

Here, we take a holistic approach to understand your needs, to demystify myths surrounding fertility, pregnancy and childbirth, and to manage problems which can affect your chances of having a healthy baby. Getting a pre-pregnancy counselling allows you to address all your concerns with our specialist who will listen to your queries, systematically assess your health and give you a comprehensive yet easy-to-follow roadmap. This process will start with a comprehensive history taking, an appropriate examination, and a set of blood tests and ultrasound scan. You will then receive counselling about your health status and ways you can do to enhance your health and your chances of having a spontaneous pregnancy. This would give you better preparation and greater confidence in going to the next stage of your journey to having a baby.

One pertinent point to note, don’t wait too long to start a family – get a fertility check-up which includes an assessment of your ovarian reserve to help you work out how much time left in your reproductive lifespan before it is too late. We can discuss the option of storing your valuable eggs or embryos if you wish to delay your childbearing plan.

Refer to our Fertility Care section and Frequency Asked Question (FAQ) section.


Further reading on Pregnancy Planning

Induction of labour

Once your pregnancy has reached term, you may decide on the timing of birth or await spontaneous onset of labour. If your pregnancy has gone beyond 40 weeks, it is advisable to organise an induction date as prolonging pregnancy over 42 weeks increases the risk of stillbirth.

Whilst inducing labour at 37 weeks and beyond may increase the chance of interventions like epidural anaesthesia, oxytocin infusion, and continuous foetal heart rate monitoring (CTG), current high-quality scientific review (totalling 22 trials with over 9000 women) concluded a better birth outcome in the induction group than the expectant group. Induction group were found to have fewer caesarean sections and fewer perinatal deaths & morbidities (like meconium aspiration syndrome, foetal acidosis, cerebral palsy and peripheral nerve injury) while rates of operative vaginal delivery (forceps or ventouse) were similar. Moreover, the rates of having a baby with a birthweight of 4.5kg or greater were reduced by a third in the induction group!

Induction of labour (IOL) is medically indicated if there are problems during pregnancy which suggest an increased risk of stillbirth or maternal illness. Some of the examples are worsening pre-eclampsia, poorly controlled diabetes, and abnormal foetal growth. In modern times, IOL is also considered as an elective option, once the pregnancy is over 37 completed weeks. Some of the purported benefits are lessening of pregnancy-related fatigue, musculoskeletal pain and false labour; better logistic organisation and time management; and reduced risk of complicated delivery and resultant emergency caesarean sections.

In short, it is considered safe to induce labour at term in modern obstetrics. There are several methods of inducing labour, and they aim to promote uterine contractions and cervical dilatation. 

The methods used for induction of labour are:

  • Membrane sweeping: gentle stretching of the cervix and sweeping of the amniotic membrane during vaginal examination. This method can induce labour in ~60% of cases.

  • Prostaglandin (PGs): PGs are substances usually released by the cervix during natural labour to soften/ripen the cervix and promote uterine contractions. This is given as gel form or a slow-release tape which sits inside the vagina. It usually takes many hours to work and hence the first dose is given the night before the day of planned childbirth. Some women can experience side effects of PGs, particularly gastrointestinal upset and mild fever. Very occasionally, some may experience strong contractions necessitating removal of PGs or even caesarean section if foetal distress ensues.

  • Mechanical cervical dilatation: The cervix can be dilated using an inflatable balloon (e.g. foley catheter, ATAD catheter) which is sited on the lowest part of the womb, just above the cervical canal. It can promote the cervix to release its own PGs.

  • Artificial rupture of amniotic membrane (ARM): Also termed as amniotomy, this is performed after the cervix is ripened, using a tiny blunt hook to break the water. Thereafter, it allows further descent of the foetal head to put pressure on the cervix, thereby promoting more cervical PG release and cervical dilatation. It also allows the monitoring of the colour of the liquor (which is the fluid from the womb) for any signs of infection, bleeding or foetal distress.

  • Oxytocin infusion: oxytocin is naturally released by the pituitary gland (which is situated at the base of the brain) at the time of labour to promote rhythmic uterine contractions. You may have heard of it as the love hormone or lactation hormone. Research has shown that oxytocin infusion helps induce labour, overcome slow labour progress, and prevent postpartum haemorrhage but not increase the risk of operative delivery like caesarean section.

More discussion about the choice of induction will be undertaken during your antenatal visits.

Further reading: 

Pregnancy Care and our Frequency Asked Question (FAQ) section

Induction of Labour techniques. South Australian Perinatal Practice Guidelines

Cochrane review: induction of labour for improving birth outcomes for women at or beyond term

Perinatal Outcomes following an Earlier Post-term Labour Induction Policy: a historical cohort study (2015). BJOG, 122 (10), 1377-85

Randomised Trial of Labor Induction in Women 35 Years of Age or Older (2016). New England Journal of Medicine, 374 (9), 813-22

Fewer elective early term deliveries, more stillbirths? (2016), Comtemporary Ob/Gyn

Family Planning

Family planning is basically a strategy to influence the number of children one wishes to have and when. Although it is often not a precise method, it allows people to choose and to manage their family size and structure, and this is often a very personal choice influenced by one’s background, faith and society. There are many different methods to choose from and basically can be categorised into 5 groups: natural methods, barrier methods, contraceptive pills, non-pill alternatives, and sterilisation.

There is no right decision, just one which suits your needs and is compatible with your belief and values. It is also something that can change over time, and as such, it is important to choose methods which give you the flexibility to change your plan as your circumstances evolve.

Menopause

Reaching menopause can be a life changing event for women as it indicates the end of reproductive age. The experience of going through menopause is highly individualised, from minimal symptoms to significant disruption to one’s daily living. It can be influenced by various bio-psycho-social factors like health condition, lifestyle, family history and cultural factors etc. Click Read More to find out more about menopause and its management.

What is menopause?

Menopause is a natural aging process that usually begins at 45-55 years of age, with an average age of onset in Australia at 51 years. Sometimes, it can be brought on by medical or surgical treatments. As we know, the ovary produces female hormones (oestrogen and progesterone) in a cyclical fashion to stimulate breast development and to regulate menstrual cycles through the growth and subsequent shedding of the womb lining (also called the endometrium). These hormones are actually produced by the maturing eggs, and hence, as the egg reserve becomes depleted with aging, so also the ovarian hormone production which starts to become erratic and eventually the levels become negligible. This explains why women approaching menopause often experience irregular periods which can also be heavy. This duration, which is also known as perimenopause or the transitional phase, can last for several years which can be a rather disturbing time of one’s life. Medically, a woman is diagnosed to be in menopause after she has gone for one full year without periods. From then onwards, the woman is considered to be in the postmenopause.

What are the symptoms?

Typical symptoms are irregular period, hot flushes and night sweats. Other common symptoms are headaches, mood swings, sleeping difficulty, general aches and pains, and tiredness.

  • Period change: Irregularity or any change of period probably is the first thing you will notice. You may skip periods or they may occur closer together. Your flow may be lighter or heavier than usual.
  • Hot flushes: A typical hot flush lasts a few minutes and causes flushing of your face, neck and chest. Some women become giddy, weak, or feel sick during a hot flush. Some women also develop a thumping heart sensation (palpitations) and feelings of anxiety during the episode. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years.
  • Sweats: It commonly occurs when in bed at night. In some cases, they are so severe that sleep is disturbed and bedding and clothing need to be changed.

In the long run, there are some recognised associated changes affecting other parts of the woman’s body like dry skin and hair, dry vagina, breast changes, increased urinary frequency, weak bladder and accelerated bone calcium loss resulting in osteoporosis.

How is menopause diagnosed?

Menopause can be diagnosed when your period has stopped for a continuous 12 months and you are over the age of 45. If you are taking specialised medications to suppress your FSH production, your menopause can be medically induced until such time you come off the effect of the medications. And if you have both ovaries are removed surgically, your menopause will occur soon after.

For women reaching menopause before the age of 45, your doctor can organise a simple blood test (for FSH and oestradiol levels) to help confirm the diagnosis, and consider further tests to screen out other medical conditions like hypothyroidism, anaemia or depression which can mimic, or sometimes co-exist with, menopause.

How is menopause managed?

It is important to accept that menopause is a natural course of life and nothing to be embarrassed or worried about. Although nothing can be done to prevent menopause, unpleasant symptoms can often be reduced by maintaining a healthy lifestyle with a well-balanced diet and regular exercise; and having supportive friends and positive thinking. Some general tips you may wish to try are:

  1. Choose a wide variety of fresh & healthy foods, ensure adequate fluids, and go for low-fat dairy foods with high calcium content, but try to limit alcohol intake (e.g. to no more than one standard drink per day).
  2. Have regular exercise like walking at least 30–45 minutes on most days of the week.
  3. Have some sunlight for natural vitamin D. Daily sun exposure is about 7 min during summer and 15min during winter but avoid the mid-day sun due to skin-damaging intense ultra-violet ray. Alternatively, you can take daily vitamin D tablet. 
  4. Quit smoking. 
  5. Treat vaginal dryness with lubricants such as K-Y Lubricant before vaginal penetration. Vaginal hormonal cream / pessary can be considered if over-the-counter treatments do not work.
  6. Consider effective contraception for 12 months after the last period. Although the ovulation becomes irregular, there is a risk, albeit a very slim one, that you may fall pregnant during the transition period.
  7. Be social and maintain a positive outlook.

Talk to your doctor about the option of going on hormone replacement (HRT) so that you can consider the benefits and purported risks associated with HRT. Studies have demonstrated that HRT is by far the most effective therapy for controlling menopause-related problems. Most importantly, management should be individualised as each woman's experience is different and unique. A proper counselling in this regard is very worthwhile.

What to prepare before going to your appointment?

Because there are a lot of things to discuss during consultation, it is a good idea to do some preparation before you go and see your doctor.

  1. Keep track of your symptoms. For instance, make a list of what symptoms you have, how often you get hot flushes and how severe they are.
  2. Make a list of any medications, herbs and vitamin supplements you are taking, including the doses and the frequency you take them.
  3. Tell doctor your recent Pap smear, mammography result, past medical & family histories like osteoporosis, heart disease, breast cancer, DVT and mood disorder. 
  4. Prepare a list of questions you may wish to ask your doctor. List your most important questions first.


For further reading:

Menopause | Better Health Channel. 2015

Diagnosing Menopause | Australasian Menopause Society 2015 

Management of The Menopause | the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2014

Mar 2017: Vaginal Prolapse

Vaginal prolapse is very common in women, believed to be over 30% of the female population. Conservative treatment includes pelvic floor exercises, pessary support and vaginal oestrogen supplement (for postmenopausal women).

Surgical options can be divided into 2 main groups: 1) reconstructive, and 2) obliterative types. The former option is suitable for women who wish to retain vaginal sexual function.

For reconstructive surgery to be durable in preventing recurrent vaginal prolapse, the supportive fascia would have to be strengthened and reinforced, and this can be achieved by a combination of physiotherapy, oestrogen supplement, and native tissue repair using dissolvable sutures. Unfortunately, this approach still accounts for a recurrent rate of 10% to 70%.

To improve on our long term clinical outcome, several approaches have been introduced. Mesh was popularised in the 2000s and not long after, had been introduced worldwide as the panacea for vaginal prolapse.

In recent years, there have been quite a lot of bad publicity against the use of artificial meshes as more and more women reported unacceptable complications like dyspareunia and mesh erosion. Mesh erosion rate was reported as high as 25%.

Cochrane review recently reported a significantly higher rate of needing repeat surgery in women who had transvaginal mesh surgery compared to those who had native tissue repairs.

These complications resulted in some high profile lawsuit in the United States and review by the FDA.

Facing the threat of expensive lawsuits, many manufacturers of mesh began to withdraw their products from the market, e.g. Ethicon, AMS and Bard. AMS which became Astora in 2015 decided to settle more than 20,000 of its own cases for reportedly more than $2.4 billion.

Now, the only manufacturers left to provide transvaginal mesh in Australia is Boston Scientific and Restorelle. Studies on their mesh products are too limited to draw a conclusion on benefits & safety.

Our View & Approach:

We have always been sceptical of the use of transvaginal mesh because of the unique anatomy & function of vagina as opposed to abdominal hernias. So far, all our patients who needed vaginal prolapse repair did not end up having mesh put in.

Our approach to women needing prolapse repair is to have:

1) Good patient selection

2) Proper preoperative preparation

3) Careful anatomical repair

4) Long-term postoperative care

With patient selection, we offer vaginal reconstructive surgery in those whom we think have reasonable healthy native tissue. Those who have very weak tissue / fascia and are not sexually active are given the option for obliterative surgery, also called colpocleisis, which have a very low rate for recurrence and complications.

For those who wanted vaginal reconstructive surgery, every effort is made to strengthen their native tissue and maintain this long term. Our recurrence rate is comparatively low, with only two known cases in the last 5 years! As expected, there have been no reported failure rate for vaginal obliterative surgery in our cohort of patients.

Practice Hour

Monday-Friday 9am till 5pm
After hour by request only

Phone: 08 8297 4338
Mobile: 0422 014 044

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