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?

Ovarian Hyperstimulation Syndrome (OHSS)

This is a condition which can occur following excessive ovarian stimulation using specialised gonadotrophic drugs like Puregon, Gonad F and Menopur. In an IVF cycle, one of the ways of achieving a high pregnancy rate is to attempt to retrieve many eggs which could increase the chances of getting enough good-quality embryos that can be transferred. It is pertinent to note that the current IVF technology cannot create eggs but merely stimulates the immature eggs to reach maturity. In contrast to a natural cycle which is regulated to allow only one egg to reach maturity and be released, a controlled ovarian stimulation cycle would attempt to help more eggs reach maturity for subsequent egg harvest and IVF treatment.

How a woman would respond to any given stimulating dose can vary from one individual to another, and from one cycle to another. Whilst there are factors that can help us predict the optimal dose, a small minority can response outside the norm, i.e. having very few eggs developing to maturity, or having too many.

When too many eggs reach maturity, the ovaries can swell up by many times and can produce excessive amount of hormones. One of these hormones, i.e. VEGF, can cause small blood vessels to become leaky, thereby allowing blood fluids to leak out into the body tissues and cavity. As a result, the abdomen, hands and feet can swell up; the individual can feel breathless; the blood pressure can become unstable; and the urine output can drop. These changes form part of the condition we termed as Ovarian Hyperstimulation Syndrome (OHSS).

OHSS comes in varying severity. The mild form can be managed by mere observation as the condition often subsides after a couple of weeks. This observation includes daily weighing, and frequent monitoring of urine output and blood pressure. Restricting fluid intake to no more than two litres a day is also recommended. If OHSS is deemed to be more severe, hospitalisation would be recommended to allow adequate fluid / electrolyte support, management of abdominal distension, and prevention against deep vein thrombosis. Very rarely would OHSS be severe enough to end up in the intensive care unit.

We believe in good preventive measure as the best policy. If there are factors predicting a likelihood of OHSS, we shall commence the stimulating drugs at a lower dose. In addition, we will also routinely do the followings:

  • Follow the antagonist stimulating protocol which has been demonstrated to cause less OHSS than the conventional long down-regulating protocol. 

  • Monitor all ovarian stimulation cycles using a combination of blood tests and ultrasound scan

  • Adjust the drug dosage based on the response observed.


For those found to have too many eggs being stimulated, we would discuss and implement the following measures:

  • A choice between cancelling the cycle or proceeding with egg retrieval but deferring embryo transfer. If one opted to proceed with egg retrieval, to use a shorter-acting trigger injection like Luveris.

  • Commence oral Cabergoline medication at the time of egg retrieval to help suppress OHSS from developing and / or getting worse.

  • Reduce the drug dosage in future ovarian stimulation cycles.

Whilst OHSS is a recognised complication of ovarian stimulation cycles, it is getting less common and better managed nowadays because of our improved knowledge, technique and care. Nonetheless, we shall provide you a more indepth discussion should we deem you are at risk of developing OHSS.

Do you wish to have a baby in style?

Having a baby is a very personal journey. Some find it easy and straight-forward, others have a tougher and more risky journey. Whichever journey you go through, it is a personal one, which makes it sweeter if you have someone supporting you through, and have a specialist guiding you all the way to experience the best moment of your life – the birth of your precious baby. You may have read or hear stories about the things that could go wrong in pregnancy and childbirth, and may be constantly worrying about labour pain and how on earth the baby can come out. 

Yeap, those worries are legitimate because pregnancy and childbirth can be risky and potentially life-threatening to mother and/or baby, and these complications can happen even in young, healthy and supposedly low risk pregnant women. Looking back at history, it was not too long ago that our grandparents and the generations before them dreaded about the moment of not seeing their wife and baby survive through the childbirth process, and now these events are very uncommon, thanks to modern surveillance of pregnancy progress and childbirth in the labour ward with modern facilities like operating theatre, blood-bank, and nursery to provide emergency backup in case of any unexpected complications.

  

Our mission is to ensure you have a memorable pregnancy and childbirth experience; to support and guide you and your partner throughout this very personal journey; and above all, to make this process safe and comfortable.

  

In our clinic, you will see the same specialist throughout your pregnancy care, who is almost certain will be there delivering your baby. Your pregnancy care will include a comprehensive assessment and a personalised pregnancy care plan. With each subsequent antenatal visit, our specialist will monitor your health; the growth and well-being of your baby with an ultrasound scan to check your baby’s position, heartbeat, growth and fluid in the womb; and address any concerns along the way. You will be encouraged to attend antenatal classes organised by the private hospital you intend to have your confinement. The choice of delivery and pain management will be discussed to select the one you prefer, and although we would normally promote natural birth, how you wish to have a baby is entirely your choosing as long as it is deemed safe and reasonable. This would mean no homebirth or water-birth, and we would reason out with you why those choices pose a potential risk to you and the people looking after you.

  

We also put a strong focus on good pain management as we understand that labour can be painful and women can have varying degree of pain tolerance. Good pain management ensures you have control over your birthing experience, and help you avoid traumatic childbirth.

  

Our overriding goal is to provide you and your partner a comprehensive first-class professional care throughout your pregnancy journey til you have your baby in your arms, and to not only ensure a safe outcome but also bring you a memorable and wonderful experience. We call this, having your baby in extraordinary style.

  

The following is an example of a pregnancy care schedule.

Further reading on Pregnancy CareBirth plan and our Frequency Asked Question (FAQ) section.

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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