SHJ Women's Health Specialist

Hormonal Imbalance Series: Dysmenorrhoea

2013-08-28T13:14:00.001-07:00

3. Dysmenorrhoea (Period pain)

Why dysmenorrhoea is a problem

Dysmenorrhoea is medical term for painful menstrual cramp of uterine origin just before the menstrual begin and usually subsided one or two days after. Most of the time it is physiological but it is often associated with endometriosis and other uterine pathology. Studies have shown the prevalence of dysmenorrhoea in female population vary from 45%-95%. It is indeed the most common gynaecological condition in women regardless of age and race and nationality.

Dysmenorrhoea affects productivity due to common absenteeism from work and school. Studies have shown almost 13% to 51% of women have been absent from work and school at least once and 5% to 14% are often absent owing to the severity of symptoms. Yet despite this substantial effect on their quality of life and general wellbeing, few women with dysmenorrhoea seek treatment as many believe it would not help.

What types of dysmenorrhoea are there?

There are two type of dysmenorrhoea based on what the underlying cause is. Primary dysmenorrhoea is menstrual pain without a pelvic disease, and secondary dysmenorrhoea is menstrual pain due to identifiable disease. In primary dysmenorrhoea, menstrual cramp normally begins 6 to 12 months from the onset of the menarche (the first period) and occurs for 8 to 12 hours at the onset of menstrual flow. It is commonly accompanying by other symptoms like back and thigh pain, headache, diarrhoea, nausea, and vomiting. Primary dysmenorrhoea is common among the teenagers and young woman and one of the most common reasons for school absentism. Primary dysmenorrhoea often improves as a woman grow older and after childbirth.

Secondary dysmenorrhoea usually arises later when a woman is in her 30s or 40s, after the onset of an underlying pelvic disease. Other gynaecological symptoms, such as pain during intercourse, heavy menstruation, intermenstrual bleeding, and postcoital bleeding, may also be present depending on the underlying condition. Common causes of secondary dysmenorrhoea include endometriosis, fibroids (myomas), adenomyosis, endometrial polyps, pelvic inflammatory disease, and the use of an intrauterine contraceptive device. Secondary dysmenorrhoea often gets worse with time and the pain may become more severe in it intensity and duration and it may severely affect productivity and quality of life if not treated.

How would your gynae doctor investigate dysmenorrhoea?

Firstly, your gynae doctor would get a detail history of your menstruation and performed a physical examination. Information about the onset, location, duration, and characteristics of pain, plus any aggravating or relieving factors, would be sought. The doctor would perform an Ultrasound of the pelvis to look for evidence of undelying disease like endometriosis, uterine fibroid or polyp that may cause the menstrual pain.

Treatment and remedies for dysmenorrhoea

The aim of treatment of dysmenorrhoea is to releive pain and treating the underlying cause. The treatment modalities can be divided into two i.e non-hormonal drugs and hormonal drugs.

Simple analgesics (pain killer) - Simple analgesics like paracetamol and aspirin may be useful for mild to moderate menstrual pain

Non steroidal antiinflammtory drugs (NSAIDs) – is a good pain relief. Between 17% and 95% of women achieve pain relief with an NSAID for moderate pain over three to five days. However gastrointestinal effects (nausea, vomiting, and/or diarrhoea) are of particular concern with NSAIDs.

Oral contraceptives (OC) – there are some evidences that showed oral contraceptives pills relief dysmenorrhoea significantly especially those with secondary dysmenorrhoea. OC also reported to reduce mentrual blood loss. If a woman also wants to avoid pregnancy, then a combined oral contraceptive may well be a worthwhile treatment option. Adverse effects such as headache, nausea, abdominal pain, bloating, anxiety, loneliness, weight gain, and acne have all been reported in association with combined oral contraceptives.

Levanogestrel Releasing Intra-Uterine System (MIRENA) – MIRENA is an intrauterine device containing levonorgestrel hormone. It release the hormone into the uterine cavity for at least five years, thus preventing the thickening of the lining of the uterus. It has been shown to be effective in reducing dysmenorrhoea in women with endometriosis.

Alternative therapies

In all, 10-20% of women with primary dysmenorrhoea do not respond to treatment with NSAIDs or oral contraceptives. In addition, some women have contraindications to these treatments. Consequently, researchers have investigated many alternatives to drug treatments.

Herbal products or medicines, and dietary supplements - Herbal and dietary therapies are popular as they can be self administered and are available from health shops, chemists, and supermarkets. This availability, although helpful, can create problems with the control of dosage, quality, and drug interactions. Studies have shown that thiamine, pyridoxine, magnesium, and fish oil may be effective in relieving pain, although some of these may be associated with adverse effects. Vitamin E was also shown in some study to be effective in treating dysmenorrhoea, but it advises caution in use owing to potential adverse effects when used in high doses.

Exercise - Physical exercise may reduce dysmenorrhoea. It is postulated that exercise works by improving blood flow at the pelvic level as well as stimulating the release of β endorphins, which act as non-specific analgesics.

Summary points
Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated
Simple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of women
Oral contraceptives can be considered for women who wish to avoid pregnancy
For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective

Hormonal Imbalance Series: Dysfunctional Uterine Bleeding

2013-08-28T13:09:00.004-07:00

2. Dysfunctional Uterine Bleeding (DUB)

What is Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterus that is not due to pregnancy or other recognizable pathology in the women’s uterus, pelvic or systemic disease. It is a functional problem of the uterus largely due to hormonal imbalance and not related to structural or anatomical problem. It is commonly present as heavy menstrual bleeding (menorrhagia). However, the doctor can only derive to a diagnosis of DUB after all other causes for abnormal and heavy menstrual bleeding in a patient have been investigated and excluded.

Who gets DUB and why is it important to know

Almost every woman is at risk of experience DUB in their lifetime. Dysfunctional uterine bleeding occurs most often in adolescent and in women after 40 and close to menopausal age. Studies showed that nearly 80% of heavy menstruation (i.e. menstrual blood loss >80 mls permonth) is caused by DUB. Heavy menstrual bleeding may affect a woman’s health both medically and socially causing problem such as iron deficiency anaemia and social phobia or discomfort respectively. Dysfunctional uterine bleeding is the commonest cause of iron deficiency anaemia in women in the developed world and of chronic illness in developing world. It also affects productivity as almost 10 % of women absent from work due to heavy menstrual bleeding. For adolescent, heavy menstrual bleeding resulting in anaemia affects their school performance as they often feel lethargic and unable to participate in school activities too.

What are other causes of abnormal menstrual bleeding?

Other than DUB, the functional problem that often responsible for heavy or abnormal menstruation, there are many structural and systemic cause that need to be investigated and excluded first before DUB can be diagnosed. Other causes of abnormal uterine bleeding include the following:

Uterine Fibroid
Uterine Polyp
Uterine hyperplasia
Uterine Cancer
Adenomyosis
Intrauterine Device (IUCD)
Thyroid disease
Blood disorders
Kidney disease

Treatment of DUB: What to expect from your gynaecologist?

Although abnormal menstrual bleeding is often due to functional or hormonal imbalance but diagnosis of dysfunctional uterine bleeding cannot be made based on assumption without going through a full examination and investigation because it is not always the case. Your doctor will ask you about your personal and family health history and your menstrual cycle. It may be helpful to keep track on your menstrual cycle before your visit. Note the date, length, and type (light, medium, heavy, spotting) of your bleeding on a calendar. Based on your symptom your doctor might order some test which includes a pap test and ultrasound of the pelvis to rule out those structural causes of the abnormal bleeding. You also may have a test to see if you are pregnant. For women after 40, it is necessary to have a biopsy of the endometrium and a hysteroscopy to assess the endometrium and rule out serious pathology like endometrial hyperplasia or cancer.

The approach to the treatment of DUB is depending on the age and whether you want to have children. Most women with DUB can be treated medically and others may need surgery. The following are options of medical treatment that you may expect from your doctor.

Tranexamic acid – to be taken for 5 days during heavy period; effective in reducing menstrual blood loss by 50%. For young woman and adolescent, it is recommended that tranexamic acid is the first line therapy for DUB.
NSAID/Ponstan ─ to be taken for few days during heavy period; effective in reducing menstrual blood loss by 30-50% and relief period cramps.
OCPill ─ to be taken everyday for months; effectively reduced menstrual blood loss by 30-50% and relief period cramps. It also offers protection against pregnancy.

MIRENA IUS ─ a T shape intrauterine device containing progesterone hormones. For older women, it is highly recommended that MIRENA IUS to be the first line therapy, i.e first treatment option to be offered to the patient as it is the most effective in reducing menstrual blood loss by almost 70-90%.
Hysterectomy ─ removal of the uterus is reserved as the last option to be offered if everything else has failed.

Hormonal Imbalance series: Understanding Menstrual Cycle & Sex Hormones Function

2013-08-28T13:05:00.000-07:00

1. Understanding Menstrual Cycle and Sex Hormones Function

The Myths and The Facts About Menstruation

Menstruation is also known by the terms menses, menstrual period or period. Menstruation is the monthly shedding of the lining of a women’s uterus (more commonly known as the womb). The menstrual blood—which is partly blood and partly tissue from the inside of the uterus—flows from the uterus through the cervix and out of the body through the vagina.

Some people refer menses as a women’s good friend as it is expected to revisit monthly without fail. It is also regarded as a symbol of ‘womenness” and reproduction, without it women become less of a woman and incapable of childbearing which to some extent from a scientific point of view, it is a fact. Interestingly, many women regardless of their cultural and education background believe that menstrual period is a way that body eliminates dirty blood or bad element in their body monthly. Failing to have their monthly menstrual bleeding, it will make them unwell. For Muslim women and the Jews , having menstrual period means a holiday from all religious rituals and sexual intercourse as women during this period are regarded as in the state of ‘spiritually unclean’.

Many women do not know when it is considered normal menstrual blood loss and when it is not. Some women believe that heavier menstrual blood loss and longer days is better than less as dirtier element or blood is flushed out from the body. There are a number of women who are concern about the color and thickness of the menstrual blood as they fear it may be associated with some disease.

Phases of a normal menstrual cycle and it significance

Girls starting menstruation simply mean they are entering into the reproductive phase of life where their reproductive system is now begin to function preparing their body for a possibility of pregnancy each month. Most girls start menstruating at the age of 12, however, girls can begin menstruating as early as 8 years of age or as late as 16 years of age. The menstrual cycle is controlled by the rise and fall of hormones, namely oestrogen, progesterone from the ovaries, and hormones from the hypothalamus and the pituitary in the brain. A normal menstrual cycle has 4 phases.

The menses phase —the bleeding phase, which typically lasts from day 1 to day 5, is the time when the lining of the uterus is actually shed out through the vagina if pregnancy has not occurred. Most women bleed for 3 to 5 days, but a period lasting only 2 days to as many as 7 days is still considered normal. Menstrual blood loss more than 80 mls percycle is considered excessive and abnormal.

The follicular phase —this phase typically takes place from days 6 to 14. During this time, the level of the hormone estrogen rises, which causes the lining of the uterus (called the endometrium) to grow and thicken. In addition, another hormone—follicle-stimulating hormone—causes follicles in the ovaries to grow. During days 10 to 14, only one of the developing follicles will form a fully mature egg (ovum).

Ovulation —the fertile phase - this phase occurs roughly at about day 14 in a 28-day menstrual cycle. A sudden increase in another hormone—luteinizing hormone—causes the ovary to release its egg. This event is called ovulation. Some women may experience a sharp pain during mid-cycle due to ovulation.

The luteal phase —this phase lasts from about day 15 to day 28. After the egg is released from the ovary it begins to travel through the fallopian tubes to the uterus. The level of the hormone progesterone rises to help prepare the uterine lining for pregnancy. If the egg becomes fertilized by a sperm and attaches itself to the uterine wall, the woman becomes pregnant. If pregnancy does not occur, estrogen and progesterone levels drop and the thickened lining of the uterus is shed during the menstrual period.

A menstrual cycle calendar is considered to begin on the first day of a period. The average cycle is 28 days long; however, a cycle can range in length from 21 days to about 35 days. Women stop menstruating at menopause, which occurs at about the age of 50. At menopause, a woman stops producing eggs (stops ovulating) and can no longer become pregnant, the body stops preparing the uterus for a possibly pregnancy, and the monthly menses stops.

What is pre-menstrual syndrome?

Due to the changes in the level of sex hormones particularly progesterone level, it is common that women experience the following symptoms:

Moodiness
Trouble sleeping
Food cravings
Development of cramps
Bloating
Tenderness in the breasts
Light headaches

What is Abnormal Menstruation and Terms used?

Abnormal menstruation is simply means the menstruation that does not follow the order or normal menstrual cycle and may spell a symptom of disease affecting women’s reproductive system. There are many conditions of abnormal menstruation and it is often referred to using specific medical term as the following:

Menorrhagia ─ heavy menstrual bleeding every month of more than 80 mls per cycle. If it is not corrected it commonly cause chronic iron deficiency anaemia in women

Dysmenorrhoea ─ severe menstrual pain just before the menstrual begin and usually subsided one or two days after. Most of the time it is physiological but it is often associated with endometriosis and other uterine pathology

Polymenorrhoea─ frequent period of more than once a month.

Oligomenorrhoea─scanty period or infrequent period of less than 6 times per year. This is one of the common symptom of polycystic ovarian syndrome in women.

Menometorrhagia haemorhagica─erratic menstrual bleeding and usually very heavy with blood clots and flooding.

Menstrual Calender

It is indeed a good habit to keep record on detail of your period every month on a calendar. Pay attention on the date when the period starts, the pain ─ how severe and how long it last, and the menstrual flow─how heavy it is. Keeping menstrual calendar helps early detection of menstrual abnormality and helps you with pregnancy planning.

When do you need to contact your gynae doctor?

Contact your doctor if:

· You have not started menstruating by the age of 16

· You are bleeding between period

· You are bleeding for more days than usual

· You are bleeding more heavily than usual

· You have severe pain during your period

· You have bleeding after sex

· You are bleeding after menopause

· Your period interval is more than 35 days or shorter than 21 days

· You think you might be pregnant

Your Skin and Photo-Aging and why we need to use sunblock everyday

2013-01-13T07:44:00.000-08:00

Photo-Aging versus Natural Aging

Twin A is ageing naturally and Twin B has photo ageing

What is photo-aging and what is natural aging of the skin? Are they different? Definitely they are not the same. Natural aging is a natural process of skin aging due to old age whilst photo-aging is an accelerated skin aging due to exposure to ultraviolet light from the sun.

Natural Aging

Naturally aged skin usually smooth and homogenous. There is exaggerated expression lines with fine wrinkles and the skin appears thin and transparent. There is also loss of fat pad of the cheek that lead to hollow cheeks and deepening eyes. The skin tends to sagging due to bone resorption. The collagen fibres underneath the skin diminish but does not break or become thickened.

Photo Aging

On the contrary, photo-aging skin is noticeable at the exposed area especially the face and the hands. There are premature wrinkles with pigmented lesions like freckles, broken capillaries and veins, patchy hyperpigmentation and lentegenes. The skin also loss of tone and elasticity resulting in formation of jowl. The complexion of the skin appears blotchy, rough and leathery. There are marked epidermal thinning and the collagen and elastin fibres are broken and fragmented causing premature wrinkle formation.

Photo-aging is due to UV light radiation from prolonged sunlight exposure

UV radiation is divided into 3 categories i.e UVA, UVB and UVC rays.

UVA rays (320-400 nm) penetrate skin deeply, breaks the collagen and elastin fibres and causing premature aging skin, wrinkles formation, pigment disorder and potentially skin cancer.
UVB rays (290-320 nm) are sunburn-causing solar rays; they can also contribute to skin cancer.
UVC rays (200-290 nm) are absorbed by ozone gases in the earth's atmosphere, which is a good thing, since UVC rays are considered potentially deadly to humans. However due to global warming, the ozone layer may have become thin that UVC light might penetrate down to the earth.

Prevention and Treatment of Photo-Aging Skinerapy

	Main action
Medical • Sunscreens • Topical Retinoids	Prevent UV damage Repair Dermal Collagen
• Anti Oxidants • Vitamin C • Curcumin • Co-enzyme 10 • Green Tea	Repair dermal collagen Photo protection
Laser and light based • Ablative & Fractional	Stimulate wound healing and Resurfacing
• Non ablative	Resolve telangiectasia and pigmentation
Injectables • Botox and Fillers	Dynamic wrinkle Restore volume loss Water retention
Physical sunblock	Prevent UV damage

Aesthetic Medicine and Aesthetic Practioner

2012-10-28T09:41:00.000-07:00

What is Aesthetic Medicine?

Aesthetic medicine is a branch of medicine focused on satisfying the aesthetic desires and goals of patients. This specialty is primarily focused on the pathophysiology of aging skin, and adheres to scientific based procedures. In another words, I would say aesthetic medicine is about helping the patients to achieve their best outlook and body shape that may boost their self confidence and self-esteem in the effective way, evidence-based and most importantly it is safe to their health.

Doctors practicing Aesthetic Medicine are trained in both invasive and non-invasive treatment modalities, and typically utilize a combination to meet the needs of the patient. So, it is obvious that Aesthetic Medicine practitioners are only for doctors and it is not for beauticians!

What are the different between an Aesthetic Practitioner and a Beautician?

Many people think a doctors who is practicing aesthetics has become a beautician and a beautician practice is the same with aesthetic practice. In fact they are different like the sky and the earth!

Unlike beauticians, aesthetic physicians being a doctor, they obviously have far better knowledge of the skin from anatomy to pathophysiology and it functions and how it responds to various treatment modalities and scientific equipments and they are aware of the complications that might arise from the procedures that they may take anticipatory measures to prevent the complications or at least they can inform the patient first before they decide to undertake the procedure. Aesthetic physician takes full responsibility to explain to the patients what procedure is suitable and what is not suitable for the patient's skin knowing the patient's medical background and they also in a position to treat the complication if it arises. The aesthetic doctor also has basic knowledge to understand the science behind scientific equipments like lights and laser and the products which are beyond the comprehension of the beauticians that they may apply safety precautions and recommend to the patient who has the right indications for that particular equipment or products. So, in another word, the patient is in a safe hand of the adequately trained person to make sure the patients achieve what they desire without compromising their health.

The law that regulate beauty practitioners are very vague and poorly implemented that there are many errant beauticians out there are crossing the line from their scope of practice. Beautician practices are supposedly to confine within beauty products and doing some minor skin procedure up to epidermis level of the skin, not more than 1 mm depth. Yet, many are daring enough to give injections and using highly scientific equipments like laser that can be dangerous and are meant only for doctors. That is why almost all the complications and complaints of aesthetic malpractice that were reported and filed to Consumer Tribunal are from the errant beauticians!

When I gave a medical aesthetic talk recently, one of the participant asked me whether they can sue the doctor when there is complication or if the expected result is not achieved? My response to her question was that the doctors are doing what are within their scope of practice and knowledge; she should sue the errant beauticians instead for doing what they are not qualified to do, for placing the patient at risk of danger, for misleading information and over promise of the result in order to sell the beauty products. However, there are also many doctors nowadays who fail to adhere to profesionalism and code of ethics that they are willing to be hired by the beauticians to do some aesthetic procedure without taking responsibility. We also know there are many beauty centres that engage foreign doctors from Korea, China and Taiwan illegally to do aesthetic procedures and surgery to their clients in their poorly equipped centre or in the hotel.

The patients or the clients who are seeking for beauty, most of them however are high risk takers. People are willing to take whatever risk and spend lots of money just for beauty and satisfaction. That is the reason why they undertake the procedure secretly so that when something goes wrong, nobody is pointing finger back at their risk taking behaviour or if everything is turned out to be perfect, they're enjoying the comments and wanders from their friends who are not aware that they have done something to their face. Many people are shy to let others know that they have gone for a beauty procedure.

Time has come that people should no longer feel shy to seek for beauty or aesthetic procedure. There is nothing wrong wanting to look perfect and beautiful, slim and sexy, or looking younger and attractive as long as we don't put our health at risk that we make an informed choice instead of doing it blindly. It is among the options that are available to the modern society to combat sign of aging from the environmental insults and ageing process.

Abnormal Menstruation

2012-08-04T02:23:00.000-07:00

Abnormal Uterine Bleeding

What is abnormal uterine bleeding?

Abnormal uterine bleeding is any bleeding from the uterus (through your vagina) other than your normal monthly period. Having extremely heavy bleeding during your period can also be considered abnormal uterine bleeding. Very heavy bleeding during a period and/or bleeding that lasts more than 7 days is called menorrhagia (say: “men-oh-raj-ee-ah”). Women who have menorrhagia may, for example, bleed enough to soak through 1 or more tampons or sanitary pads every hour.

What causes abnormal uterine bleeding?

Many different things can cause abnormal uterine bleeding. Pregnancy is a common cause. Polyps or fibroids (small and large growths) in the uterus can also cause bleeding. Rarely, a thyroid problem, infection of the cervix or cancer of the uterus can cause abnormal uterine bleeding.
In most women, abnormal uterine bleeding is caused by a hormone imbalance. When hormones are the problem, doctors call the problem dysfunctional uterine bleeding, or DUB. Abnormal bleeding caused by hormone imbalance is more common in teenagers or in women who are approaching menopause.
These are just a few of the problems that can cause abnormal uterine bleeding. These problems can occur at any age, but the likely cause of abnormal uterine bleeding usually depends on your age.

Women in their teens, 20s and 30s

A common cause of abnormal bleeding in young women and teenagers is pregnancy. Many women have abnormal bleeding in the first few months of a normal pregnancy. Some birth control pills or the intrauterine device can also cause abnormal bleeding.
Some young women who have abnormal uterine bleeding do not release an egg from their ovaries (called ovulation) during their menstrual cycle. This is common for teenagers who have just started getting their periods. This causes a hormone imbalance where the estrogen in your body makes the lining of your uterus (called the endometrium) grow until it gets too thick. When your body gets rid of this lining during your period, the bleeding will be very heavy. A hormone imbalance may also cause your body not to know when to shed the lining. This can cause irregular bleeding (“spotting”) between your periods.

Women in their 40s and early 50s

In the years before menopause and when menopause begins, women have months when they don't ovulate. This can cause abnormal uterine bleeding, including heavy periods and lighter, irregular bleeding.
Thickening of the lining of the uterus is another cause of bleeding in women in their 40s and 50s. This thickening can be a warning of uterine cancer. If you have abnormal uterine bleeding and you’re in this age group, you need to tell your doctor about it. It may be a normal part of getting older, but it's important to make sure uterine cancer isn't the cause.

Women after menopause

Hormone replacement therapy is a common cause of uterine bleeding after menopause. Other causes include endometrial and uterine cancer. These cancers are more common in older women than in younger women. But cancer is not always the cause of abnormal uterine bleeding. Many other problems can cause bleeding after menopause. For this reason, it’s important to talk to your doctor if you have any bleeding after menopause.

2012-08-04T01:58:00.001-07:00

Pelvic Organ Prolapse Treatments

Pelvic organ prolapse (POP) is a relatively common occurrence for women older than 50. In fact, it is estimated that as many as 50 percent of women in this age group have some degree of POP. Treatment for pelvic organ prolapse can be as simple as dietary changes or daily exercises, or it can include surgical procedures.

One of the most recent developments of surgical treatment of POP has included the use of transvaginal mesh. Even though transvaginal mesh has been declared "high risk" by the FDA, it continues to be used in routine gynecological practices around the nation. It is important that women educate themselves on their treatment options to avoid unnecessary health risks.

What is Pelvic Organ Prolapse?

The organs in a woman's pelvic region — the uterus, bladder and rectum — are connected by muscles and ligaments that hold them in place. These tissues become compromised, usually by pregnancy and childbirth. By the time a woman reaches menopausal age and beyond, the connective tissues can become so weakened that certain organs can shift, or drop.

In some cases, this shifting is so mild that the woman is unaware of it and it is diagnosed by her gynecologist in a routine pelvic exam. For other women, these organs can shift and drop so much that they begin to collapse into the vaginal canal. This can be uncomfortable and/or painful. In worst-case scenarios, a woman's ability to urinate or defecate can become severely compromised.

Treatment for Pelvic Organ Prolapse

There are a variety of treatments available for POP. It is important that women realize that treatment is often unnecessary. If a doctor diagnoses POP in an asymptomatic woman, the condition can continue to be monitored without any treatment as long as there are no negative side effects.

Non-Surgical Treatments

Dietary and Lifestyle Changes - Decreasing caffeinated beverages can reduce the need to urinate. Increasing fiber intake can prevent constipation. As obesity is linked to POP, maintaining a healthy diet and regular exercise routine can also help. A healthy lifestyle can reduce mild symptoms of POP.

Physical Therapy - Kegel exercises should be done regularly to strengthen the pelvic floor. Sometimes doctors will use electrical stimulation to contract the muscles in the vagina and pelvic floor to strengthen the connective tissue and reverse the condition.

Vaginal Pessary - A pessary is used like a diaphragm. It is carefully fitted into the vagina and provides the support necessary to keep organs from dropping further.

Surgical Treatments

Hysterectomy - If the prolapse is concentrated in the uterus, and a woman is through her childbearing years, a hysterectomy can often remedy the symptoms.

Reconstructing Vaginal and Pelvic Organ Support - There are several surgeries that can be used to rebuild the support of the vagina and connective tissues. Sometimes this surgical support is constructed using grafting tissues. A synthetic transvaginal mesh is an alternative to natural grafting tissues in these types of surgeries. Women need be exceedingly cautious before allowing transvaginal mesh to be used to correct POP. There have been serious complications linked to the use of transvaginal mesh. There are even patients who have started to file a transvaginal mesh lawsuit against the mesh manufacturers because of such complications.

Women should educate themselves on the various treatments for POP and make sure to talk openly with their doctor regarding whether treatment is even necessary, as well as ensuring the treatment that is used will be the safest choice for their situation.

Staying Healthy at 50 and Beyond

2012-07-24T16:47:00.001-07:00

How to stay health at 50+

At the age of 50, many women may have menopause while the rest are at the brink of menopause. Women after 50 are at risk of cardiovascular disease like high blood pressure, diabetes mellitus and heart disease especially of those who have positive family history, obese, high cholesterol, smoking and have not been exercise regularly. The most common cancer affecting women at this age is breast cancer, colon cancer, cervical cancer, uterine cancer and ovarian cancer. In Malaysia, statistic shows that breast cancer is number one cancer killer in women followed by cancer colon. All over the world number one killer of women after 50 yrs of age is heart disease.

Get the Screenings You Need

Screenings are tests that look for diseases before you have symptoms. Blood pressure checks and mammograms are examples of screenings. You can get some screenings, such as blood pressure readings, in your doctor’s office. Others, such as as mammograms, need special equipment, so you may need to go to a different office. After a screening test, it's important to ask when you will see the results and who you should talk to about them.

Breast Cancer. The recomendation b the College of Surgeon, that women after 45 need to do a mammogram

Cervical Cancer. Have a Pap smear every 1 to 3 years until you are age 65 if you have been sexually active. If you are older than 65 and recent Pap smears were normal, you do not need a Pap smear. If you have had a total hysterectomy for a reason other than cancer, you do not need a Pap smear.

Cancer Uterus and Ovary: Have your doctor do pelvic examination and transvaginal ultrasoundwhen you come for pap smear ever 1- 3 years. Checking blood tumour marker like Ca 125 is a good complimentary for detection of cancer ovary. Almost all cancer ovary present with symptom at a very late stage.

Colorectal Cancer. Have a screening test for colorectal cancer. Several different tests—for example, a stool blood test and colonoscopy—can detect this cancer. Your doctor can help you decide which is best for you. If you history of colon cancer in your immediate family member, having a colonoscopy done once in every 1-3 years is a recommended.

Depression. Your emotional health is as important as your physical health. Talk to your doctor about being screened for depression especially if during the last 2 weeks: You have felt down, sad, or hopeless. You have felt little interest or pleasure in doing things.

Diabetes. Get screened for diabetes if your blood pressure is higher than 135/80 or if you take medication for high blood pressure. Diabetes (high blood sugar) can cause problems with your heart, brain, eyes, feet, kidneys, nerves, and other body parts.

High Blood Pressure. Have your blood pressure checked at least every 2 years. High blood pressure is 140/90 or higher. High blood pressure can cause strokes, heart attacks, kidney and eye problems, and heart failure.

High Cholesterol. High cholesterol increases your chance of heart disease, stroke, and poor circulation. Have your cholesterol checked regularly if: You use tobacco. You are obese. You have a personal history of heart disease or blocked arteries. A male relative in your family had a heart attack before age 50 or a female relative, before age 60.

Life-style Modicafication

Although it is easy said than done, living a healthy life style is a hallmark of staying healthy after 50 and beyond. As our body undergo accelerated aging after menopause, healthy life style e.g. exercising regularly helps to slow down aging, improves blood circulation, keeping muscle at work and healthy heart.

2012-07-24T15:52:00.000-07:00

About Body Image

When you look in the mirror, do you like what you see?

Is your body image positive or negative? If your answer is negative, you are not alone. Many women feel pressured to measure up to a certain social and cultural ideal of beauty, which can lead to poor body image. Women are constantly bombarded with "Perfect body " images. By presenting an ideal that is so difficult to achieve and maintain, the cosmetic and diet product industries are assured of growth and profits. It's no accident that youth is increasingly promoted, along with thinness, as an essential criterion of beauty. The message we're hearing is either "all women need to lose weight" or that the natural aging process is a "disastrous" fate.

Other pressures can come from the people in our lives.

Family and friends can influence your body image with positive and negative comments.
A doctor's health advice can be misinterpreted and affect how a woman sees herself and feels about her body.

Learning to love what you see in the mirror

And don't forget your kids!

Parents’ attitudes about appearance and diet can affect their kids' attitudes.

We all want to look our best, but a healthy body is not always linked to appearance. In fact, healthy bodies come in all shapes and sizes! Changing your body image means changing the way you think about your body. At the same time, healthy lifestyle choices are also key to improving body image.

Healthy eating can promote healthy skin and hair, along with strong bones.
Regular exercise has been shown to boost self-esteem, self-image, and energy levels.
Plenty of rest is key to stress management.

Your body image plays a role in your children

"On a diet, you can't eat." That is what one 5- year-old girl had to say in a study on girls' ideas about dieting. This and other research has shown that daughters are more likely to have ideas about dieting when their mothers diet. Children pick up on comments about dieting concepts that may seem harmless, such as limiting high-fat foods or eating less. Yet, as girls enter their teen years, having ideas about dieting can lead to problems. Many things can spark weight concerns for girls and impact their eating habits in potentially unhealthy ways:

Having mothers concerned about their own weight
Having mothers who are overly concerned about their daughters' weight and looks
Natural weight gain and other body changes during puberty
Peer pressure to look a certain way
Struggles with self-esteem
Media images showing the ideal female body as thin

Many teenage girls of average weight think they are overweight and are not satisfied with their bodies. Having extreme weight concerns — and acting on those concerns — can harm girls' social, physical, and emotional growth. Actions such as skipping meals or taking diet pills can lead to poor nutrition and difficulty learning. For some, extreme efforts to lose weight can lead to eating disorder such as anorexia or bulimia. For others, the pressure to be thin can actually lead to binge eating disorder: overeating that is followed by extreme guilt. What's more, girls are more likely to further risk their health by trying to lose weight in unhealthy ways, such as smoking.

FDA Issues Second Warning about Birth Control and Increased Risk of Blood Clots

2011-09-28T20:40:00.000-07:00

The FDA recently issued another report about drospirenone-containing birth control pills, stating that they remain concerned about the increased risk of blood clots with the use of these birth control pills.
The first FDA warning about drospirenone-containing birth control pills was issued in April 2010, when the administration explained that the pills had been linked to an increased risk for thromboembolic disorders and other vascular problems. The latest warning discusses the preliminary findings of the FDA’s examination of the two 2011 studies that looked at the risk of blood clots for women who use drospirenone-containing birth control pills; preliminary results suggest that women who use drospirenone-containing birth controls are at an approximately 1.5-fold increased risk of blood clots compared to women who use other hormonal contraceptives.
The FDA recommends that healthcare professionals who prescribe drospirenone-containing birth control pills be particularly aware of the risk factors for each patient when deciding whether to prescribe the medication. Factors that are known to increase the risk of blood clots include smoking, obesity and family history; the FDA recommends careful consideration of these factors before deciding to prescribe if a drospirenone-containing birth control pill. Yaz and Beyaz are two FDA-approved, drospirenone-containing birth control pills that have also been approved for the treatment of acne.

The most effective Vitamin for Dry Skin

2011-09-26T12:05:00.000-07:00

Dry skin is an irritating problem that most commonly affects the arms, the lower legs, the thighs and the sides of the abdomen. Those suffering from dry skin problems generally experience itching, scaling, and cracks in the skin. Luckily, by using a vitamin for dry skin, this problem can be prevented and even reversed.

Causes of Dry Skin

Dry skin is a common problem, particularly during the winter months when it is cold outside and artificial heat is used indoors. The harsh outside weather combined with the lack of humidity indoors makes it hard for your skin to stay moist. Certain activities, such as gardening, can also dry out the skin. In addition, using harsh soaps or bathing too often can wash away your skin’s natural moisture.

Lifestyle Changes to Prevent Dry Skin

To help prevent dry skin from occurring, you should keep your baths and showers short and never use hot water. You should also use as little soap as necessary, using it primarily on the armpits, face, and genital region. Also, be sure to use mild soaps if dry skin is a problem for you. Adding bath oils to your water can also help moisturize your skin, just be sure to avoid ones with alcohol in them because alcohol dries the skin out. Using a humidifier to keep the air moist and drinking water throughout the day also helps prevent your skin from drying out.

Using A Vitamin For Dry Skin Prevention

There are several vitamins that can help prevent or heal dry skin when taken orally or used topically. One vitamin for dry skin is Vitamin A, or retinol. A diet with insufficient amounts of vitamin A can actually lead to dry skin because vitamin A is responsible for the maintenance of healthy skin, as well as hair. Therefore, be sure to include plenty of vitamin A in your diet. The US RDA recommends 700 RAE per day of vitamin A for women. Good sources of vitamin A include carrots, sweet potatoes, boiled kale, turnip greens, mango, papaya, raw spinach, red and green bell peppers, cantaloupe, apricot, milk, eggs, romaine lettuce, tomatoes, broccoli, and oranges. Research has shown that using vitamin A as a topical skin treatment also helps decrease signs of dryness and aging.

Another vitamin for dry skin is Vitamin B Complex. Like vitamin A, a diet deficient in vitamin B can lead to dry skin. Vitamin B is actually comprised of multiple vitamins: Thiamine (B-1), Riboflavin (B-2), Niacin (B-3), Pantothenic Acid (B-5), Pyridoxine (B-6), Biotin (B-7), Folic Acid (B-9), and Cyanocobalamin (B-12). For this reason, vitamin B is often referred to as B-Complex. One of the jobs of vitamin B is to help maintain healthy skin. Other health benefits of vitamin B is that it enhances the immune system, improves muscle tone, and promotes cell growth and division. B-Complex is also know to help reduce stress and depression when included in the diet, which can indirectly help your skin stay moist and healthy. B vitamins are often found together in foods, but the best way to ensure you are getting enough vitamin B in your diet is to take a B-Complex vitamin once or twice per day, depending on the dosage level and the recommendation of the manufacturer.

Vitamin C is another vitamin for dry skin. Vitamin C is necessary to produce collagen in the skin. Collagen helps new tissue develop and strengthens the blood vessels, both of which help your skin maintain proper circulation and moisture. The US RDA recommends 60-90 mg of vitamin C to be included in the diet per day. Good sources of vitamin c include citrus fruits, potatoes, tomatoes, black currants, papaya, brussel sprouts, broccoli, cauliflower, strawberries, cantaloupe, spinach, cranberries, kiwi, and red peppers. When used in topical moisturizers, vitamin C can also be beneficial in treating dry skin.

Vitamin E is another great vitamin for dry skin. Although vitamin E can be added to the diet through foods such as wheat germ, vegetables, and nuts, the best way to use vitamin E is topically. It has been shown to eliminate both dryness and itching skin. In addition, vitamin E creams can help fight against free radicals and minimize the appearance of wrinkles.

The best way to get enough of these vitamins for dry skin into your diet is to take a Multivitamin once or twice per day. If you make sure to purchase a multi-vitamin that contains B-Complex, you can take care of all of your dry skin needs with just one wonderful little pill!

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What color is your vaginal discharge?

2011-09-26T11:50:00.000-07:00

Most vaginal discharge is normal especially if you are of childbearing age.

Glands in the cervix produce a clear vaginal discharge that keeps the vagina walls moist. The purpose of normal vaginal discharge is to clean and moisten the vagina and help to prevent and fight infections - much the same way that saliva cleans and regulates the environment of the mouth.

Normal vaginal discharge is sometimes white in color but can turn yellow when exposed to the air and leaves a yellow stain on the underwear.

A normal vaginal discharge has no odor (or very mild odor), causes no irritation and, again, is usually whitish or clear. Although it's normal for the color, texture, and amount of vaginal fluids to vary, some changes in discharge may indicate a problem.

Normal vaginal discharges can vary somewhat in texture and color. They can be somewhat thin, sticky, and elastic or thick and gooey.

If you think you may have a problem, you should see a doctor as soon as possible. First, though, it helps to learn some of the differences between normal and abnormal vaginal discharge. This will help you to recognize changes that may occur.

Green vaginal discharge can be a sign of cervical disorder and requires the attention of your physician. A green vaginal discharge may be due to a sexually transmitted disease such as Trichonomis, particularly in women with multiple sexual partners. The vaginal discharge resulting from Trichonomis is often frothy and can range in color from gray to green to yellow, with a watery to milky consistency.

A yellow-green vaginal discharge could also be due to Gonorrhea, a sexually transmitted disease (STD) caused by a bacteria. The bacteria can be passed from one person to another through vaginal, oral, or anal sex, even when the person who is infected has no symptoms. They can also be passed from a mother to her baby during birth. A woman who has Gonorrhea may have no symptoms at all or her symptoms may be so mild that she doesn't notice them until they become more severe.

A thick white vaginal discharge that resembles cottage-cheese may signify Candida Yeast Infection. Candida Yeast is a treatable fungal infection of the vagina. Yeast infections result from an overgrowth of bacteria in the vagina — the most common being a fungus called Candida Albicans. The main symptom is itching, but you may have a white, thick vaginal discharge that resembles cottage cheese.

Dark brown vaginal discharge can be a sign of an infection, such as Vaginitis. Vaginitis is a broad term for a vaginal condition often characterized by swelling, itching, burning or infection in the vagina that can be caused by several different germs such as the germ that causes Trichonomis. A dark brown vaginal discharge can also be caused by an object such as a tampon that’s been lodged or forgotten in the vagina (yes, this has been known to happen!) It is therefore important that you check with your doctor so that you can determine the exact cause and receive treatment if necessary

Thick yellow vaginal discharge could be due to Cervicitis which is an inflammation or infection of the cervix. There are two types and either may be contagious. Cervicitis is very common, affecting many women at some point during their adult lives especially those with multiple sexual partners, a history of sexually transmitted disease or intercourse that began at an early age.

Many women with Cervicitis may not experience any symptoms at all, however those who do may experience the following:

*Yellow vaginal discharge, that may also be gray or white in color.
*Abnormal vaginal bleeding after intercourse, between periods or after menopause
*Sense of pelvic pressure or heaviness
*Painful sexual intercourse

A grayish vaginal discharge could also be due to Bacterial Vaginosis (BV) and may cause your discharge to be heavier than usual. Your vaginal discharge may become foamy or frothy and have an embarrassingly fishy odor. If your condition is due to BV, then you may want to try an effective natural alternative to antibiotics like Metronidazole that doctors give to patients when BV is the cause of feminine odor.

As you can see, the symptoms of these infections and the vaginal discharge which they produce can overlap quite a bit and can be very similar, so it is important to see a doctor if you have any of the symptoms of abnormal vaginal discharge so you can find out exactly what the cause is and treatment can begin.

Recognizing The Symptoms of Hormonal Imbalance in Women

2011-09-26T11:45:00.000-07:00

Hormonal imbalance is caused by shifts in the body’s levels of progesterone and estrogen, two important hormones produced in the ovaries. The main function of these hormones is to regulate the menstrual cycle during a female’s reproductive years. The amount of hormones your body produces can vary from one day to the next and is affected by such factors as stress, nutrition, amount of sleep, exercise, and whether or not your body ovulates. Another major factor of hormonal imbalance includes chemicals found in the environment--encountered through air, food, and water--that mimic estrogen and upset the natural balance of estrogen and progesterone. If these hormones become imbalanced and are not produced in appropriate amounts, unpleasant symptoms are experienced. The symptoms of hormonal imbalance are varied and can become apparent as early as the late 20s and continue through the early 40s. If left untreated, symptoms of hormonal imbalance can increase in severity with age. Some symptoms of hormonal imbalance include:

Low Sex Drive
Joint pain
Stiffness
Fibrocystic Breasts
Endometriosis
Memory loss
Dry skin
Dry hair
Sugar cravings
Breast pain and tenderness
Irregular periods
Feelings of depression and anxiety
Fatigue
Hair loss
Hot Flashes
Growth of facial hair
Urinary tract infections
Incontinence
Weight gain
Bloating and water retention
Fuzzy thinking
Headaches and dizziness
PMS
Mood swings and irritability
Restless sleep
Insomnia
Night sweats
Vaginal dryness
Acne
Difficulty conceiving Osteoporosis (decrease in bone density)

If you're suffering from the above symptoms, then you may want to have your hormones tested to be certain of the cause. Your doctor can do it for you, or you can have it done in the privacy of your home through websites which offer home testing kits, such as this one.

Various symptoms of hormonal imbalance can occur in women, including a deficiency in progesterone, which is the most common type of hormonal imbalance due to excess hormone in our food chain in such foods as meat and dairy products. Hormonal imbalance due to this reason has been linked to cases of girls 3 years old growing pubic hair and having menstrual cycles.

There are many treatments available to treat the causes and relieve the symptoms of hormonal imbalance. Many doctors have been prescribing recommending Hormonal Replacement Therapy (HRT) to women suffering from hormonal imbalance symptoms, however, studies have shown that HRT has had dangerous results on many women.

Abnormal Pap Smear Results: What they might mean

2011-09-26T11:40:00.000-07:00

If you have received a report from your doctor’s office that includes an abnormal Pap smear result, the first course of action is often to panic. What does it mean? Do you have cancer? The first step in analyzing your abnormal Pap smear result is to relax, because in most cases, the findings do not indicate a malignancy. It is important to have a good idea of exactly what a Pap smear tests for before you can understand exactly what the results of your test mean.

What Exactly Is A Pap Smear?

A pap smear is a test that takes a collection of cells from the cervix for observation and evaluation under a microscope. When some of the cells appear to be unusual or atypical, you will have an abnormal Pap smear result. Abnormal cells can come from a variety of sources that include infections, inflammations or a virus like human papillomavirus or HPV. Sometimes the cause is as simple as the use of a douche or vaginal cream, or because of recent sexual activity prior to the exam itself. It can also be an indication of cancer or a precancerous condition, so it is important for you to talk to your doctor after getting an abnormal Pap smear result to determine what the next course of action should be, or if anything should be done at all.

The Cause Of Your Abnormal Pap Smear Results

Your next step may be determined by exactly what type of atypical cells was discovered to give you an abnormal pap smear result. The outcomes of these exams are graded by the laboratories that perform them, and generally fall into five categories. If your abnormal Pap smear result was on the lower end of the scale, your doctor may determine that the result was the cause of an infection or inflammation, and may simply recommend that you repeat the test in six months to a year. If the cells looked more ominous under the microscope, he may suggest a procedure called a colposcopy, which will allow him to look at the cells around the cervix a bit more closely and remove a sample for a biopsy if he determines that is necessary.

The Good News About Your Pap Smear Results

The good news about a pap smear is that the results are generally fairly accurate for this type of screening test. This means that if you have a good result, you can rest assured that you probably don’t need to worry about any problems until your next exam. If you receive abnormal Pap smear results, there are plenty of diagnostic tests that can be done to find and treat your problem. Most doctors will recommend that you get a Pap smear every year as a part of your annual exam, although some medical professionals will stretch that time frame out to every two years if you have had a number of normal pap smear results in succession.

Using A Herbal Remedy To Fight Yeast Candida

Keep in mind that a Pap smear, while an important test for women to have, is merely a screening device for your doctor. It does not diagnose any types of problems that you may encounter, so you may require additional testing if you receive an abnormal Pap smear result. The good news is that only about one in ten Pap smears that are conducted come up with abnormal results, and of that number, very few indicate something as serious as cancer.

Article by Wendy Travis

Cervical cancer: A preventable and treatable disease

2011-09-12T09:11:00.000-07:00

Though cervical cancer is completely preventable, with screening exams and treatment, it continues to claim a considerable chunk of women population throughout the world. Considered the fifth most deadly cancer in women worldwide, cervical cancer affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year, that is 800 women a day.

It remains unfortunate that about 83 per cent of the cases occur in developing countries, representing 15 per cent of female cancers. In Tanzania, cervical cancer ranks as the first most frequent cancer among women between 15 and 44 years of age. Tanzania is said to have a population of 10.97 million women aged 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 7,515 women are diagnosed with cervical cancer and 6,009 die from the disease though data is not yet available on the HPV burden in the general population of the country. However, in Eastern Africa, the region Tanzania belongs to, about 33.6 per cent of women in the general
population are estimated to harbour cervical HPV infection at a given time.

Pap smear screening can identify potentially precancerous changes. Treatment of high grade changes can prevent the development of cancer. In developed countries, the widespread use of cervical screening programmes has reduced the incidence of invasive cervical cancer by 50 per cent or more.

Human papillomavirus (HPV) infection is a necessary factor in the development of nearly all cases of cervical cancer. HPV vaccine effective against the two strains of HPV that cause the most cervical cancer has been licensed in the US and the EU. These two HPV strains together are currently responsible for approximately 70 per cent of all cervical cancers. Since the vaccine only covers some high-risk types, women should seek regular Pap smear screening, even after vaccination.

Signs and symptoms
The early stages of cervical cancer may be completely asymptomatic. Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere.

Symptoms of advanced cervical cancer may include: Loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or faeces from the vagina, and bone fractures.

Causes
Human papillomavirus infection. The most important risk factor in the development of cervical cancer is infection with a high-risk strain of human papillomavirus. The virus cancer link works by triggering alterations in the cells of the cervix, which can lead to the development of cervical intraepithelial neoplasia, which can lead to cancer. Women who have many sexual partners (or who have sex with men who had many other partners) have a greater risk.

The medically accepted paradigm, officially endorsed by the American Cancer Society and other organizations, is that a patient must have been infected with HPV to develop cervical cancer, and is hence viewed as a sexually transmitted disease, but most women infected with high risk HPV will not develop cervical cancer. Use of condoms reduces, but does not always prevent transmission. Likewise, HPV can be transmitted by skin-to-skin-contact with infected areas. In males, HPV is thought to grow preferentially in the epithelium of the glans penis, and cleaning of this area may be preventative.

The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus (HPV) infection, smoking, HIV infection, chlamydia infection, dietary factors, hormonal contraception, multiple pregnancies, exposure to the hormonal drug diethylstilbestrol (DES) and a family history of cervical cancer. There is a possible genetic risk associated with HLA-B7.

Diagnosis

While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix. Further diagnostic procedures are loop electrical excision procedure (LEEP) and conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.

Treatment
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.

If a cone biopsy does not produce clear margins, one more possible treatment option for patients who want to preserve their fertility is a trachelectomy. This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care, as few doctors are skilled in this procedure.

Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown. If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent.

Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.

Larger early stage tumours (IB2 and IIA more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy.

Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy.

Prevention
The widespread introduction of the Papanicolaou test, or Pap smear for cervical cancer screening has been credited with dramatically reducing the incidence and mortality of cervical cancer in developed countries. Abnormal Pap smear results may suggest the presence of cervical intraepithelial neoplasia (potentially premalignant changes in the cervix) before a cancer has developed, allowing examination and possible preventive treatment. Recommendations for how often a Pap smear should be done vary from once a year to once every five years. The ACS recommends that cervical cancer screening should begin approximately three years after the onset of vaginal intercourse and/or not later than twenty-one years of age.

The HPV test is a newer technique for cervical cancer triage which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving.

HPV vaccines have come in handy in fighting the disease as they are targeted at girls and women aged between 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The use of the vaccine in men to prevent genital warts and interrupt transmission to women or other men is initially considered only a secondary market.

HPV testing and Vaccination Could Cut Cervical Cancer Screening to Twice in a Lifetime

2011-09-12T08:57:00.000-07:00

Women who have had the human papillomavirus (HPV) vaccine could need only two HPV screening tests for the rest of their lives according to new calculations being presented at the NCRI Cancer Conference in Liverpool. HPV testing is a more accurate cervical screening method than the current smear test, which looks for abnormal cells.

Professor Peter Sasieni, a Cancer Research UK scientist at Queen Mary, University of London, will urge the UK governments to consider making HPV testing the main method of cervical screening* across the health service as a priority. He believes women who have been vaccinated will no longer have to go for screening every three to five years, as is the current practice.

Research suggests that the HPV vaccine will prevent at least seven out of 10 cervical cancers and new vaccines currently being evaluated should prevent even more. It typically takes over 10 years for a cancer to develop after HPV infection. Research shows that cancer caused by HPV types not prevented by the current vaccines take even longer. This could allow the first cervical screen to be safely offered much later than at age 20 or 25.

Professor Sasieni said: “The UK cervical screening programme has done a fantastic job in reducing cervical cancer, but it is based on an old screening test. HPV testing could prevent an even greater proportion of cervical cancer with just half the number of screens over a lifetime. If HPV testing were to be rolled out from next year, it could be used nationally by 2015.

“With continued high coverage of HPV vaccination and targeting of screening resources towards unvaccinated women, cervical cancer should become a truly rare disease. And if the government plan for this change now, they could save hundreds of millions of pounds in the long run.”

Cervical cancer is the second most common cancer among women under the age of 35, and the majority of cases are caused by two strains of HPV, types 16 and 18.

In the UK, girls aged 12 to 13 are offered the HPV vaccine. Girls have three injections over six months given by a nurse. A two year catch up programme also started in autumn 2008 to vaccinate girls aged between 13 and 18.

Dr Lesley Walker, Cancer Research UK’s director of cancer information, said: “HPV vaccination has been a huge step towards reducing the number of women that will be diagnosed with cervical cancer in future years. And the very high uptake of the vaccine in the UK has been a real success story.

“This is exciting and poses interesting questions for the screening programme in terms of the best way to screen women in the future who have been vaccinated.

“But for now it remains vitally important that all women continue to take up the invitation to go for screening when they receive it.”

Frequency of Cervical Cancer Screening Depends on Case. (3-Year Interval for Sexually Active).(Brief Article): An article from: Family Practice News

Notes

* If cervical cells test positive for HPV, the sample will then be tested using the current liquid based cytology method.

Professor Sasieni’s recommendations: Screening post vaccination

1. For women vaccinated aged 11 to 14, HPV testing at age 30 and 45

2. For women vaccinated aged 15-23, HPV testing at aged 25 to establish those not protected by vaccine, and further tests at age 35 and 50

3. For women who are not vaccinated or who have only received one dose, HPV testing at age 25, 30, 35, 45, and 55

Current cervical screening

In England:

- women aged 25-49 are invited for screening every 3 years

- women aged 50-64 are invited for screening every 5 years

- women aged 65 or over are only screened if they have not been screened since age 50, or have had recent abnormal results.

In Scotland, women aged 20-60 are invited for screening every 3 years.

In Wales and Northern Ireland, women aged 20-64 are invited for screening every 3-5 years.

Source:
NCRI Cancer Conference

Cancer in Malaysia

2011-09-12T07:11:00.000-07:00

The incidence of cancer is on the rise in Malaysia. It can strike anyone regardless of colour, creed or status. Nearly 70,000 new cases were reported over a two-year period recently, with breast cancer the biggest threat.

The new cases were diagnosed among Malaysians in Peninsular Malaysia between 2003 and 2005, according to a report released in early 2008 on the incidence of the disease in West Malaysia.
The Cancer Incidence in Peninsular Malaysia 2003-2005 report, published by the National Cancer Registry (NCR), states that the total 67,792 new cases were diagnosed among 29,596 males (43.7 per cent) and 38,196 females (56.3 per cent). The annual crude rate for males was 100.2 per cent per 100,000 population, and 132.1 per cent per 100,000 for females.

The most frequent cancer during this period in Malaysians was breast cancer (18 per cent) followed by large bowel cancer (11.9 per cent) and lung cancer (7.4 per cent).
Despite a grim outlook, all hope is not lost. Between 30 and 50 per cent of cancer cases can be prevented if you practice a healthy lifestyle, undergo regular checks for early detection, and seek the right treatment when necessary.

Lung Cancer
Lung cancer is one of the main causes of cancer deaths in Malaysia. In fact, 95 per cent of lung cancer patients die within five years of diagnosis. A whopping 90 per cent of lung cancer is caused by cigarette smoking. The occurrence of lung cancer is also high among non-smokers who are exposed to second-hand smoke (passive smoking).

Breast Cancer
The most common cancer and the number one cause of cancer deaths among women in Malaysia is breast cancer. This cancer is caused by an uncontrolled growth of cells within the breast tissue.
If not detected and treated promptly, breast cancer can metastasise, spreading to the lymph glands and other parts of the body, including lungs, bones and liver.

Cervical Cancer
This is the most common gynaecological malignancy, and the second most prevalent cause of deaths among female cancer patients in Malaysia. With the number of cases diagnosed increasing over the years, the importance of early detection and treatment is becoming more apparent.

Leukaemia is a rare disease in children. However, it is the most common form of childhood cancer. According to the most recent Cancer Incidence in Peninsular Malaysia, 2003 – 2005 report, leukaemia remained the most frequent cancer incidence among male and female Malaysian children from birth up to 14 years. However, over the last decade, there have been major advances in the treatment of leukaemia in children. As a result, a considerable number of children can now be effectively cured. However, some forms of leukaemia can be treated more successfully than others.

source:
MAKNA – Majlis Kanser Nasional
BG 03A & O5, Ground Floor,
Megan Ambassy,
No 225, Jalan Ampang,
50450 Kuala Lumpur,
Malaysia

HPV vaccination: NIH study shown two doses is adequate as three doses

2011-09-11T23:17:00.000-07:00

NIH STUDY FINDS TWO DOSES OF HPV VACCINE MAY BE AS PROTECTIVE AS FULL COURSE

Two doses of the human papillomavirus (HPV) vaccine Cervarix were as effective as the current standard three-dose regimen after four years of follow-up, according to researchers from the National Cancer Institute (NCI), part of the National Institutes of Health, and their colleagues. The results of the study, based on data from a community-based clinical trial of Cervarix in Costa Rica, appeared online Sept.9, 2011, in the Journal of the National Cancer Institute.

Worldwide, approximately 500,000 new cases of cervical cancer are diagnosed every year, and about 250,000 women die from the disease. An overwhelming majority of these new cases and deaths occur in low-resource countries. Virtually all cases of cervical cancer are caused by persistent infection with HPV. Cervarix is one of two vaccines approved by the U.S. Food and Drug Administration to protect against persistent infection with two carcinogenic HPV types, 16 and 18, which together account for 70 percent of all cervical cancer cases. The vaccine is intended to be administered in three doses given over the course of six months. To date, investigators have observed up to eight years of protection from persistent HPV infection with the vaccine. Studies are ongoing to determine the maximum length of protection.

The cost of the vaccine as well as the logistical difficulties of administering three doses to an adolescent population in resource-poor countries is greater than administering two doses. Even in wealthier countries such as the United States, few adolescent females complete the entire course of three vaccinations. According the Centers for Disease Control and Prevention, although approximately 49 percent of American girls ages 13 to 17 received one dose of the vaccine in 2010, only 32 percent received all three doses. In the United States, the predominately used HPV vaccine is Gardasil, which has a different formulation than Cervarix. Gardasil also protects against up to 90 percent of genital warts because it targets HPV strains 6 and 11 as well as 16 and 18.

The NCI-sponsored Costa Rica Vaccine Trial was designed to assess the efficacy of Cervarix in a community-based setting. Women ages 18 to 25 years were randomly assigned to receive the HPV vaccine or a Hepatitis A vaccine as the control treatment. Although the investigators intended to administer all three doses of the assigned vaccine to all 7,466 women in the study, about 20 percent of the participants received only one or two doses of the HPV or control vaccine. A third of women did not complete the vaccine series because they became pregnant or were found to have possible cervical abnormalities, reasons that would not likely bias the findings.

The investigators found that, after four years of follow up, two doses of the vaccine conferred the same strong protection against persistent infection with HPV 16 and 18 as did the full three-dose regimen. From just a single dose, they also observed a high level of protection, but they are cautious about the long-term efficacy of a single dose because other vaccines of this type usually require a booster dose. Additional studies are needed to evaluate the efficacy of a single dose, as well as the duration of protection for both one and two doses.
Our study provides evidence that an HPV vaccine program using two doses will work. It may be that vaccinating more women, with fewer doses for each, will reduce cervical cancer incidence more than a standard three-dose program that vaccinates fewer women," said Aimée R. Kreimer, Ph.D., lead author and investigator in NCI's Division of Cancer Epidemiology and Genetics. "The main question will be whether the duration of protection from fewer doses is adequate."

Kreimer emphasized that findings from this study of the Cervarix vaccine in women in Costa Rica may not be relevant for all populations, such as those in which HIV infection, malnutrition, or endemic diseases may influence the immune response. In addition, it is not known whether the same results would be obtained with the other FDA-approved HPV vaccine, Gardasil, because the vaccine formulations are different.

"Further studies are needed to confirm our findings in other populations as well as to quantify the duration of protection for fewer than three doses," said Kreimer. "If other studies confirm that fewer than three doses provide adequate protection against persistent cervical HPV 16 and 18 infection, we may be one step closer to prevention of cervical cancer, especially for women in resource-poor settings, where the need is greatest."

It is important to note that regulatory agencies have approved the HPV vaccine based on prevention of cervical precancers, not persistent infections. From studying the natural history of HPV and cervical cancer, experts know that persistent infections are first steps toward precancer. Furthermore, vaccine recommendations take into consideration many factors and studies. In the United States, the CDC's Advisory Committee on Immunization Practices determines federal recommendations regarding vaccination.

REFERENCE: AR Kreimer, et al. Proof-of-Principle Evaluation of the Efficacy of Fewer Than Three Doses of a Bivalent HPV 16/18 Vaccine. J Natl Cancer Inst. Epub ahead of print Sept. 9, 2011. In print Oct. 15, 2011.

Progression of Cervical Disease after HPV infection

2010-04-19T06:17:00.000-07:00

Cervical cancer does not happen over night or out of sudden. Many studies have shown that it may take 10 - 15 years from the exposure of persistent HPV infection before it progress to become an invasive cervical carcinoma. That is why it is said that cervical cancer is 100% preventable and curable. This is because the stages of cervical disease caused by the HPV infection can be easily detected and treated if a woman comes for her routine cervical smear screening.

Following the HPV infection, the virus get embedded into the DNA of the cervical epithelium and cause changes into the genetic material of the normal epithelium. After a certain period, the normal cervical epithelium will be replaced by the abnormal cells and this cervical disease is called Cervical Intraepithelial Neoplasia (CIN) or Squamous Intraepithelial Neoplasia (SIL). There are 3 grades of CIN, depending on the thickness of the abnormal cell replacing the normal cervical epithelium.
CIN 1- 1/3 of the normal epithelium is replaced; CIN 2 - 2/3 of the normal epithelium is replaced;
CIN 3- whole thickness of the cervical epithelium is replaced. Once the abnormal cells invade the deeper layer below the basement membrane of the cervical epithelium it become an invasive cervical carcinoma. It is not clear whether there is a progression from a lower grade CIN to a higher grade before it becomes an invasive cancer but many studies have shown that higher grade SIL (CIN 2 &CIN 3) has a higher tendency to progress into invasive cancer at a shorter period of time compared to the lower grade SIL (CIN 1).

Most of women infected by HPV would clear the infection naturally but women infected by HPV type 16, 18 and other oncogenic HPV types are likely to have persistent infection. The good news is almost all of these condition are curable. Hence, the role of pap smear is to detect HPV infected cervical epithelium and cervical pre-cancerous lesion before it progress into an invasive cancer.

HPV Infection and HPV Types

2010-04-17T09:52:00.000-07:00

There are plenty of evidences that showed Human Papilloma Virus (HPV) is the sole agent that cause cervical cancer. HPV infection is the most common sexually transmitted disease in the world. It is estimated that up to 50 - 80% of women will acquire HPV infection in their lifetime. The woman can also get infected by a multiple HPV types at one time. As the infection carry no symptom, most women often not aware that they have acquired the infection.

To date, there are about 72 types of Human Papilloma Virus (HPV) identified. Not all HPV types but HPV 16, 18, 31, 33, 45, 52, 58 are oncogenic and associated with cervical cancer. Globally, almost 70 % of cervical cancers cases are caused by HPV 16 and 18 while another 30% are due to HPV 31, 33, 45, 52, and 58. Hence, by vaccinating against HPV 16 and 18, over 70% of cervical cancer cases can be prevented.

Most women who acquired HPV infection cleared or recovered from it spontaneously without any treatment. Those who have persistent HPV infection may eventually develop cervical cancer over period of time. Infection with HPV 16 and 18 and other oncogenic type HPV are more likely to persist than infection with other low-risk HPV types. In younger women aged 15-25 years, almost 80% of HPV infection are transient but in older women, cervical HPV infection are more likely to persist.

Almost all HPV infection are acquired through sexual intercourse either through genital to genital, finger to genital or oral to genital contact. Condom used may help to reduced risk but not fully protective against contact with HPV infected male organ.

Hence, we can conclude that all women who are or have been sexually active are at risk of exposure to HPV infection at any time of their lifetime unless they and their sexual partner/spouse have a lifetime mutual monogamous relationship.

Referrences:
1. Munoz N, et al. Int J Cancer 2004; 111: 278-285
2. Trottier H & Franco El. Am J Manage Care 2006;12;462-472
3. Parkin DM & Bray F. Vaccine 2006;24:11-25
4. Anhang R, et al. CA Cancer J Clin 2004;54:248-259
5. Lee SK et al. Am J Epidemiol. 2003;157:218-226

What Causes Cervical Cancer?

2010-04-15T07:12:00.000-07:00

In the past, we are not so clear of what is a cause of cervical cancer. There was a link between Human Papilloma Virus (HPV) and cervical cancer but it was not very clear whether there was some other factors involved. After an extensive research and studies by the scientist for many years, we are now certain that the sole culprit that cause cervical cancer is HPV, and no other.

If cigarette smoking is a hazard as it brings 10 times increase risk of lung cancer, the study has shown that woman infected with HPV has 300 -500 times chances to develop cervical cancer (Wallboomers JH, et al. J Pathol 1999). Scientists has identified many types and strains of HPV, however not all HPV types cause cervical cancer. The type of HPV that causes cervical cancer is HPV 16, 18, 45, 33, and 31. This type of HPV not only cause cancer of the cervix but also anus, vagina, vulva, mouth and oro-pharynx.

But the question is how does a woman get HPV infection? HPV infection is acquired through skin to skin contact, largely through sexual intercourse. It is sexually transmitted like any other sexually transmitted diseases. Any sexually active woman is at risk of HPV exposure in their life time but the following group of women are at high risk of acquiring the HPV infection.

1. Sexually active young women (20 - 24 years old)
2. Women with multiple sex partners
3. Women with partner who has multiple sex partners (including polygamous man with many wives)
4. Women who had sexual intercourse at very young age
5. Women who smoke
6. Women who use contraceptive pill for longer term

How does HPV causing cervical cancer? Cervical cancer does not happen overnight but it takes 10 - 15 years after a woman is infected with HPV to develop cancer. It causes pre-cancer lesion of the cervix that can be detected by pap smear and can be treated.

The Burden Of Cervical Cancer

2010-04-13T19:11:00.000-07:00

Let us talk about cervical cancer for this month. Since the availability of HPV immunization to young women in effort to prevent cervical cancer, there are so much confusion, misunderstanding and scare about the vaccination programme. People especially parents are sceptical about the benefits of vaccinating young girls. Some people say it might encourage promiscuity and some say it is harzardous.

In order to get the correct information one must refer to the best available evidences that support or refute the practice or recommendation for vaccination. Before we come to that, let us understand the burden of cervical cancer on our population and the rationale of it prevention.

Worldwide, every two minutes a woman dies of cervical cancer. In another word in one hour 30 women die of cervical cancer. Up to 80%, it occurs in less developed regions where there is lack of effective cervical screening programme (Ferlay J et al Globocan 2002). For comparison, in developed country like USA, there are about 14500 new cases of cervical cancer diagnosed annually and 6000 deaths due to cervical cancer. Where as in Asia including Malaysia about 266 000 new cases detected and 143 000 deaths annually. Why is such a big different? This is because a developed country like USA, has an effective cervical cancer screening programme that pap smear is compulsory for every sexually active women annually. Therefore, most of the cervical infection and pre cancerous conditions are treated before it progress to become a cancer.
On the other hand, in Malaysia and most of Asian countries has no proper screening programme and cervical smear is done as an opportunistic test. It means that whenever the woman come to see gynae doctor for some reason, it is an opportunity to offer/do pap smear. If not, it is up to the woman's level of awareness to request for a pap smear. WHO health survey in 2001/2002 reported only 20 % of Malaysian women have had a regular pap smear and the majority of them are from a low risk group of getting cervical cancer.

What Causes Cervical Cancer?

Cervical cancer is the only cancer that is sexually transmitted. How? Follow my next posting.

Welcome to SHJ Women's Health Specialist Blog!

2010-04-13T10:17:00.000-07:00

Welcome to my blog. This blog is specially set up to provide a platform to educate my patient and improve their understanding on various women health condition and at the same time sharing my experiences as a practising gynaecologist to other audiences as well. I usually spend some time talking to my patient in the clinic trying to give them as much knowledge as I can of their gynaecological condition and answering all their questions but time is always a limiting factor. Thank you to the modern Information Technology that we are now have many other means and alternative to communicate more effectively. Despite living in the Information Era where knowledge and information is available before our eyes by just a click of our finger, however not all these information are readily digestable and reliable as there are plenty from various sources. I think people still need a confirmation of what they read from the website from their own doctor. Evidence based practice has become a core and integral part of any medical practice nowadays where the opinion of doctor and the treatment they offer are not only supported by their experience but largely by the facts derived through the best quality research/evidence available at that time of practice. What is written theoretically is not necessarily proven in reality thus it requires a series of experimens/trials to confirm what is claimed. Furthermore, medical practice are changing from time to time. What is practice before may become obsolete and no longer acceptable when new reliable evidence surface. Doctors have to keep updating their knowledge in order to provide their patient the best advice.