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 fibroids, adenomyosis, polyps, 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?
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.
Further reading on Pregnancy Planning
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.
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.
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.
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:
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.
For further reading:
Recurrent pregnancy loss (RPL) is not common but poses a considerable distress to women who keep experiencing RPL.
There are various definitions used to diagnose RPL, and so it is often better to list out the pregnancy history, stating the time period, the gestational age when losses occurred, and the contributing factors. Whilst the diagnostic criteria stated 3 or more consecutive pregnancy losses, it does not mean that we should ignore the need to investigate and review the case if it does not meet the criteria when there are other significant history, like unexpected foetal death over 10 weeks gestation, premature birth due to pre-eclampsia or growth restriction, strong family history of RPL or DVT, and maternal age over 40.
Assessment for RPL should be comprehensive before we diagnose it as unexplained which accounts for 50% of RPL. Assessment include history taking, examination, blood tests, pelvic ultrasound scan and probably diagnostic laparo-scopy and hysteroscopy.
The known causes of RPL are very diverse and can be categorised into 5 groups: hereditary chromosomal defects, autoimmune diseases, endocrine disorders, thrombophilia and uterine factor.
Hereditary types of chromosomal defect are uncommon and there is no curative therapy for the affected individual. Genetic counselling would be helpful for individuals to decide whether to have embryo testing for selecting normal euploid embryos prior to transfer, or to use donor gametes.
Autoimmune disorders are very diverse but the one that is often implicated in RPL is anti-phospholipid syndrome (APLS). Its diagnosis is based on the Sapporo criteria involving clinical history of vascular thrombosis, RPL, fetal death after 10 weeks gestation or preterm birth before 34 weeks gestation, PLUS two positive tests of anti-cardiolipin antibodies or lupus anti-coagulant on two occasions at least 12 weeks apart. Treatment with aspirin and heparin appeared to improve pregnancy outcome in women with APLS but not in women with unexplained RPL.
Embryo implantation & placentation is a complex process involving maternal hormonal changes, immune responses and embryonal development. Natural killer (NK) cells were suggested to be associated with implantation failure and RPL. However, a meta-analysis Hum Reprod Update.2014;20:429 involving 22 studies reported higher peripheral NK numbers in women with RPL compared to control, but no significant difference was seen with uterine NK cell count. The diagnostic and prognostic role of NK cell count remains uncertain at this stage, let alone determining the effective management for women with RPL and high NK cell count.
Endometriosis is now being recognised as a contributing factor for subfertility, but its effect is less than straightforward. Women with endometriosis can still have a normal pregnancy but are found to have lower pregnancy rate and higher miscarriage rate. It is difficult to determine what type and how severe the endometriosis has to be before it is recognised as a cause of RPL.
Although autoimmune disorders and inflammatory processes are implicated in the pathogenesis of RPL, the use of immunotherapy and steroids have not been shown in many trials to be beneficial in improving outcome.
Recent studies have suggested that uterine arc, which is often misdiagnose as normal or minimal partial uterine septum, can cause RPL and that surgically trimming off this arc can improve pregnancy rates and reduce miscarriage rates. Having said this, no RCT has yet been done to prove this theory, and hence, surgical treatment should be reserved for those with RPL not improving with other proven treatment modalities.
Progesterone supplementation has been purported by some studies to be beneficial in early pregnancy. However, a recent large trial N Engl J Med. 2015;373(22):2141 involving 1568 women with a history of unexplained RPL showed no improvement in live-birth rates with use of vaginal micronized progesterone400mgBD compared to placebo.
It is unclear whether women with RPL would benefit from having vitamin supplementation. A recent Cochrane review of 40 trials did not show any reduction in miscarriage rate with supplementation of vitamins, iron, folate or anti-oxidant.
Our View & Approach:
RPL remains one of the toughest challenges we faced in repro-ductive medicine. One reason is because of the emotional impact women with RPL have to go through, especially when it is unexplained or when there is no reliable treatment available.
Our first approach is to determine whether the patient has RPL. Strictly following the current diagnostic criterion of three or more consecutive miscarriages before treatment is initiated may not be very practical especially for women who are of the older age group having had one pregnancy loss and already finding it difficult to conceive.
Moreover, women who had at least one preterm birth, IUGR or pregnancy loss after 10 weeks gestation may have APLS or uterine / cervical factor.
Hence, we take the pragmatic clinical approach, by providing counselling for all women who had a pregnancy loss, and determine carefully on an individual basis who would benefit from having further evaluation.
Our management encourages the patients’ active participation and decision making, so that they can appreciate the limitations of current studies and what approach they can try.
Preliminary investigations include blood tests for FBC, metabolic changes, thyroid function and OGTT, and pelvic ultrasound scan.
For those who have met the diagnostic criteria for RPL, a more comprehensive screening tests for APLS, thrombophilia, karyotyping and diagnostic laparoscopy and hysteroscopy can be considered. These investigations are very costly and should be chosen wisely.
Having said that, these tests should be done for women with RPL before the diagnosis of unexplained RPL is made.
The management is largely dependent on the clinical diagnosis after performing a proper history taking, examination & investigation.
Basic management should include counselling for stress management, healthy lifestyle modification and weight control.
We discourage patients from falling into the temptation of taking unproven supplementations. This is achieved by explaining how RPL occurs and why these supplements may not help, contrary to what is claimed in their packaging labels.
Once the patient conceives, early obstetric referral would be recommended for counselling and monitoring. Dating ultrasound scan would be very helpful.
We provide an individualised plan for each patient who will have their own set of risk factors. The plan would include monitoring of pregnancy progress, and treatment relevant to the cause of their RPL.
Pregnancy of women with RPL are considered high risk of developing complications like antepartum haemorrhage, IUGR, preeclampsia, and preterm birth. This could be related to placental insufficiency or cervical incompetence which may not be apparent until later as the pregnancy progresses.
We would routinely monitor for cervical changes, foetal growth and well-being, and maternal health.
Moreover, women who had surgery for uterine factor like septum or submucosal fibroids are at increased risk of having placental accreta. This condition may not be apparent until the day of delivery where the placenta may not be separating after childbirth. Imaging tests are helpful but not totally reliable in excluding accreta. Un-recognised accreta could result in massive postpartum haemorrhage. Hence, we would only deliver high risk pregnancy in hospital with good operating theatre and ICU facility. Risk of hysterectomy should be explained to these women.
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Phone: 08 8297 4338
Mobile: 0422 014 044