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Home , Female Infertility, Irregular menstruation, Vaginal bleeding

26 & SEXUAL HEALTH Mei Yin, 40, is a bank manager. She got married when she was 32 years old. As she was pursuing her Master’s degree then, she decided to postpone starting a family. Three years later, she and her husband decided to try for a baby, but

at natural conception over the course of more than a year, she decided to seek help, and was placed on fertility treatment by her doctor.Mei Yin successfully conceived six months later, and is now the proud mother of a beautiful two-year-old daughter.

HEALTHY FEMALE BODY the , and passes out of the body through the Females start puberty between the ages of nine and 16. During this time, the female oestrogen is considered as Day 1 of your . If you and prepare the womb () for become pregnant, your will cease and a cycle of fertility, and the female body begins only return after childbirth. Just as the appearance menstruation or periodic (usually monthly) . Each month, the ovaries release an egg, which travels your reproductive years, your fertile years end with down the to the uterus. If the egg is . fertilised by a sperm cell and attaches to the uterus, Menstrual bleeding normally lasts between occurs. Otherwise, the unfertilised egg, together with the thick lining of the uterus (known menstrual cycle is 28–30 days, although anything as the ), is discharged from the body between 24–35 days is common. Some women, Preparing your during menstruation. however, have irregular menstrual cycles. The time body for pregnancy A period or menstruation is the monthly discharge between periods, the amount of lost and the includes paying proper attention of blood and tissue from the womb. Menstrual blood number of days bleeding lasts all vary widely. It is a to your fertility condition that a ects a woman’s fertility. and sexual health

78 BEAUTIFUL INSIDE OUT 79 The Female Reproductive System For the majority of women, these symptoms may be mild and tolerable. However, for a small group of Easing Painful Periods The female reproductive system includes the ovaries, fallopian tubes, uterus (womb), and cervix. women, these symptoms may be debilitating and Placing a hot water bottle or heating pad on your lower abdomen, In such cases, they are said to be su ering from a taking a warm bath, or gently condition known as premenstrual dysphoric disorder massaging the area lightly in a 1. Ovary (PMDD), a disabling condition marked by severe PMS 1 3 circular movement with your fingers 2 2. Fallopian Tube that can adversely a ect work and relationships with may provide some pain relief. 3. Uterus people. It is imperative to seek medical treatment to 4. Vagina manage the symptoms.

Causes pain with an underlying cause often related to 4 While the exact causes for PMS and PMDD are still problems in the female reproductive organs, such indeterminate, medical experts at the Massachusetts 2 6 General Hospital Center for Women’s and . It might also be caused by the A woman is generally fertile for over 30 years, (PMS) point out that researchers now agree that “these use of an intrauterine device (IUD), especially in the

th peaking between the ages of 22 and 26, and often Premenstrual syndrome (PMS), also known as disorders represent biological phenomena rather than early months after insertion. Pain from secondary declining after the age of 30. According to the premenstrual tension (PMT), refers to the physical, purely psychological events,” and that recent research dysmenorrhoea usually begins earlier in the Human and Embryology Authority psychological and behavioural symptoms that a ect has also drawn links to a particular sensitivity to menstrual cycle and lasts longer than common (UK), those at 35 are half as fertile as when they some 75% of women anytime between one day to normal hormonal changes during the menstrual menstrual cramps. were at 25, and at 40, half as fertile as at 35. two weeks before the onset of the monthly period. cycle. Stress, being and lack of exercise With more and more women now postponing These symptoms usually improve when the woman’s can also contribute to it. ty & Sexual Hea l

til i pregnancy, is increasingly a problem period begins, and disappear a few days after. as a result of changes to the reproductive system Fe r Painful Periods due to age and other external factors. Knowing all According to the Department of Obstetrics & Many women su er from painful cramps about your reproductive and sexual health is vital at KK Women’s and Children’s Hospital, immediately before or during menstrual periods. to safeguarding your fertility and ensuring your common PMS symptoms include: This condition is known as dysmenorrhoea. For some overall well-being. • Physical symptoms: Fluid retention, abdominal women, the pain can be so excruciating that they are discomfort and bloating, appetite disturbance unable to participate in their usual activities and are (typically increased), headache, backache, muscle MENSTRUAL DISORDERS ache, joint pain, breast tenderness, insomnia, There are two types of dysmenorrhoea: primary Painful periods need not be a given Most women menstruate over a span of more lethargy or fatigue, and nausea dysmenorrhoea and secondary dysmenorrhoea. – relaxation and than 30 years, from early adolescence until their • Psychological symptoms: Mood swings, Primary dysmenorrhoea or common menstrual exercise can help late 40s or early 50s. They usually get their periods feeling upset or emotional, feeling irritable cramps is due to excessive levels of the -like regularly without any problems. However, there are or angry, sensitivity to rejection, social prostaglandin causing contractions of the uterine women who su er from menstrual disorders such withdrawal, , anxiety, sense of wall, producing cramp-like, aching pain in the lower as menstrual cramps, (the absence of abdomen or back that can range from mild to severe. menstruation), heavy or irregular periods. confusion and forgetfulness These often start shortly before or at the onset of While each woman’s reproductive health is • Behavioural symptoms: Loss of interest in sex, the period, and last for 1–3 days. These cramps often unique, the more common menstrual disorders changes in appetite, and for some, occasional include the following: food cravings (e.g. carbohydrates) Secondary dysmenorrhoea is menstrual

80 BEAUTIFUL INSIDE OUT 81 2 6

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83 just beginning to menstruate. After a year or two, the relaxed and patient. Chances are, your menstrual • Abnormal growths in the uterus, such as menstrual cycle will usually start to become regular. cycle will be back to normal again soon. Warning: To rule out any abnormality, see a doctor if “”). A significant complication of Causes menstruation has not started by the age of 16, or if • , a condition in which the walls menorrhagia is deficiency, Irregular periods may be caused by di erent factors, your periods have been absent for more than six of the womb are abnormally thick as a result otherwise known as anaemia. including the following: months when you’re not pregnant or menopausal. of glands from the endometrium becoming • Genetic conditions such as gonadal dysgenesis, Treatment for irregular periods varies according to embedded in the uterine muscle. , congenital adrenal hyperplasia, the cause. • Conditions that produce high oestrogen levels, androgen insensitivity and polycystic ovarian such as certain ovarian cysts (see section on Pelvic drugs (NSAIDs) such as ibuprofen, which can reduce syndrome (see section on Pelvic Pain) Heavy Periods Pain), may stimulate the lining of the womb and • Puberty or nearing menopause Heavy menstruation, or menorrhagia, refers to the cause bleeding. or polyps are found, removing them will resolve the • Certain contraceptives and medications occurrence of abnormally heavy bleeding during • Medication bleeding problem. • Change in contraception method regular menstrual periods, over several consecutive and anticoagulants, or the improper use of In extreme cases where the bleeding is Lifestyle changes such as excessive exercise, menstrual cycles. hormone medication, can cause menorrhagia. debilitating and medication proves ine ective, your 26 • extreme weight loss or weight gain, eating The amount of blood discharged during a • Pregnancy complications. A single, heavy, late doctor may recommend inserting an intrauterine disorders and stress woman’s period can vary considerably from woman period not during the usual time of menstruation device (IUD) that releases the hormone progestin.

th • Hormonal changes involving the hypothalamus, may be due to a . An ectopic , or to remove the uterus, is pituitary, thyroid, ovary, or adrenal glands what heavy blood loss is. You will be able to tell if pregnancy – when a fertilised egg is implanted seldom prescribed, as the procedure will result in (e.g. hormone imbalance of oestrogen and within the fallopian tube instead of the uterus – sterility and the permanent cessation of periods. This progesterone, the hormones regulating the yourself using more sanitary pads or than also may cause menorrhagia. surgery should only be done after a full discussion menstrual cycle; ) usual, or that your clothes and bedding are stained. • Genetic blood-clotting disorders, such as von with your doctor and after careful consideration. and abnormalities in the reproductive If your periods are causing such disruptions to your Willebrand’s , a condition in which an ty & Sexual Hea l •

til i system (e.g. pregnancy, hypothalamic or pituitary everyday life, it may be an indication of excessive diseases, endometriosis and ) impaired, can cause abnormal menstrual bleeding. Fe r blood loss. WHAT’S CAUSING YOUR • Other medical conditions, such as pelvic PELVIC PAIN? What you can do: Causes Our reproductive system functions normally most of Missing a few periods is usually no cause for alarm. Most causes of heavy menstruation are not serious, Pelvic Pain), thyroid problems, endometriosis the time. With age, as well as the stress of pregnancy Make a few lifestyle changes, such as eating a healthy and are rarely due to cancer. According to the (see section below under Pelvic Pain), and and childbirth, problems can occur. diet and getting enough rest and exercise, and stay Department of Obstetrics & Gynaecology at KK or disease may cause menorrhagia. Pelvic pain that arises from the reproductive Women’s and Children’s Hospital, up to 50% of the • Cancer of the reproductive organs, including organs, typically perceived to be issuing from the area cases have no known cause, and are referred to as the uterus, cervix or uterus, in rare cases (see of the lower part of the abdomen located between Consult a doctor if you have prolonged dysfunctional uterine bleeding. pg 142 for more on ). the two hip bones, may be sharp or mild. Pain that menstrual pain is bad enough to interfere with your daily activities and heavy bleeding Some causes of heavy periods include: What you can do: may be an indication of a problem with one of the • Hormonal imbalance It is advisable to see your doctor if your periods last reproductive organs (uterus, ovaries, fallopian tubes, • Change in contraception method. Changes in longer than usual or if you experience excessive cervix or vagina) in the pelvic area. birth control pills or oestrogens, or use of the IUD. • of the womb See a doctor if you notice any of the following: • Dysfunction of the ovaries. Lack of which include pallor, weakness and fatigue. You will • Menstrual periods change from being relatively (anovulation) may cause hormonal imbalance be prescribed iron supplements if you’re found to be pain-free to painful and result in menorrhagia. anaemic, and may also be put on oral contraceptives • Pain interferes with your daily activities

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• Severe pelvic pain occurs with or without oestrogen produced by the ovaries from puberty and mefanamic acid may help to decrease the onwards appears to be a possible stimulant for their • Painful urination, blood in the urine, or an • Surgical treatment for broids includes during pregnancy and shrink during menopause, myomectomy to remove the broids, which • after which new ones tend not to develop. Hormonal preserves fertility but presents a 50% risk change in your bowel movements drugs that contain oestrogen, such as birth control of regrowth if more than three broids are • Pain during or after removed . Hysterectomy, the removal of the whole uterus, is the only permanent cure Aside from menstrual cramps, there are many causes Signs & Symptoms for broids, but this procedure results in associated with pelvic pain. Common gynaecological permanent infertility. sources of pelvic pain include the following: they feel symptoms such as: • MRI-guided ultrasound waves. This is a new • Pelvic pain Fibroids • Abdominal distension Fibroids (also known as leiomyomas, myomas, Heavy or lengthy menstrual bleeding Imaging of 26 • • Polyps common type of growth found in a woman’s . • Constipation Polyps are bulging growths in the lining of th These are benign growths (non-cancerous tumours • Pain or discomfort during sexual intercourse the uterus, called the endometrium. They are Treating Polyps – see Chapter 8) developed from muscle tissue and • Reproductive problems, such as infertility, formed from the overgrowth of cells in the Small polyps that don’t cause any problems may attached to the muscular walls of the uterus during multiple or early labour normal tissue lining the uterus, which then resolve on their own and don’t need to be treated, a woman’s reproductive years. According to the extend into the uterine cavity. They may also unless the risk of is present. Polyps Department of Obstetrics & Gynaecology at KK Treating Fibroids be found in the uterine cervix, and are usually causing heavy or irregular menstrual bleeding benign (non-cancerous). Polyps are more and/or containing cancerous cells will have to be ty & Sexual Hea l

til i develop into cancer (sarcoma). untreated and only need regular monitoring (2–3 common in women in their 40s and 50s, and removed surgically, via – the insertion The location, number, size and rate of growth of Fe r can develop in both pre-menopausal and post- of a scope that allows visualisation of the uterine non-minor symptoms, left untreated, can increase in menopausal women. cavity from the inside. Polyps may recur after they grow inside the muscle wall of the uterus – called have been removed. Curettage, a procedure in which in conceiving, even miscarriage. Causes & Risk Factors the lining of the uterus is removed, can be used to may grow as a single tumour, or in clusters of up to a address endometrial polyps in most cases. hundred, and can range from pea-sized to large, round Being obese puts you at greater risk of developing polyps, as does hypertension. Having polyps may Ovarian Cysts pelvis or abdomen completely. They are a common • Hormone therapy such as – occurrence among women, especially those between releasing hormone agonists (GnRH-a) halts the puts you at higher risk of having a miscarriage if the tissue where they are found. These can develop in the ages of 30 and 50, although women in their 20s intrinsic production of hormones that may cause you’re pregnant. any part of the body. Ovarian cysts are cysts that are sometimes have them. found within or on the surface of an ovary. It is not problems and are easier to remove surgically. Signs & Symptoms uncommon for women to develop ovarian cysts at Causes However, this is only a “stop gap” measure before Although uterine polyps. may not produce any some time. surgery, because it induces menopause and symptoms, some women may experience problems Ovarian cysts are divided into two broad thought to be a possible factor, predisposing muscle should not be used on a long-term basis. such as: categories: functional and non-functional. The most • Other medication to treat symptoms. • Irregular vaginal bleeding common ovarian cysts are functional (or physiologic) reproductive years. Tranexamic acid, birth control pills and anti- • Bleeding after sexual intercourse cysts – benign cysts that develop as part of the An increased level of the female hormone • normal menstrual cycle mainly during a woman’s

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childbearing years. During each menstrual cycle, a bleeding, and if the following symptoms have polycystic persisted for at least two weeks: and holds the egg. When the egg is mature, the sac • Getting full quickly when eating ovary syndrome usually breaks and releases the egg during ovulation. • Losing your appetite Polycystic ovarian syndrome (PCOS, or Stein- Follicular cysts, which are the most common type • Losing weight without trying , together of ovarian cysts, develop when the follicle fails to Leventhal Syndrome) is a common hormonal with abnormal menstruation, can A cyst is usually detected during a physical or pelvic disorder where there is an imbalance of a woman’s be a sign of PCOS form a cyst in the ovary. Also related to the menstrual exam or during an ultrasound test. female sex hormones, resulting in an abnormal cycle are corpus luteum cysts, which occur after an predominance of the male hormone androgen. It egg has been released from a follicle. The remaining Treating and Preventing Ovarian Cysts occurs in some 4–7% of women of reproductive • Acne, excess hair growth on the body area of tissue, known as a corpus luteum, usually There are three categories of treatment for ovarian age. The disorder is characterised by an irregularity (hirsutism), thinning of the hair on the head breaks down and disappears if pregnancy doesn’t cysts to consider: in the menstrual cycle: the eggs in the follicles do (male-pattern hair loss), decreased breast size • Conservative therapy: This involves having not mature and are not released from the ovaries, and deepening of the voice. These symptoms cyst with no symptoms, and usually only on one side simple observation and regular ultrasound scans but instead form very small cysts. The ovaries are are related to elevated androgen levels, which 2 6 of the ovary. to monitor the size of the cysts. often enlarged, with numerous small cysts present leads to virilisation (i.e. the development of male Non-functional cysts are caused by disease • Medical treatment: The prescription of pain on the outside. sex characteristics). th and include dermoid and endometriotic cysts (see relief and hormonal medication, which regulate • Oily skin “Endometriosis” below). your periods and shrink the cyst at the same time, Causes & Complications • Obesity and weight gain and prevent the formation of new ones. The exact cause of PCOS is not known, although • Elevated levels and insulin resistance, Signs & Symptoms • Surgical methods: Depending on your symptoms, it is likely to be the result of both genetic characterised by changes in skin pigmentation Most times, ovarian cysts don’t cause any the doctor may recommend the surgical removal and environmental factors associated with around the armpits, groin, neck, and breasts symptoms and are usually harmless. However, of the cyst (cystectomy), or the cyst together with abnormalities in insulin production and unusually Infertility ty & Sexual Hea l •

til i rapidly growing cysts that rupture or bleed may the ovary (oophorectomy) via a pelvic elevated male hormone (androgen) levels. • High cholesterol levels (keyhole surgery) or laparotomy. This may be However, women with this disorder may have Elevated blood pressure Fe r cause symptoms such as: • • Lower abdominal or pelvic pain shortly before or followed by if the cyst is found to be difficulty becoming pregnant due to infrequent after menstrual period, during intercourse, or cancerous. In cases where a large goes or non-ovulation. Treatment with strenuous movement. This may be in the untreated, it may become twisted, causing ovarian It is important for PCOS to be diagnosed early. Risks associated with PCOS may be minimised form of constant, dull aching pressure or sudden torsion and rupture suddenly, resulting in severe Failure to do so can lead to complications such with proper treatment targeted at each of the and severe pain often accompanied by nausea . Emergency surgery will be needed. as , high blood pressure, heart disease, manifest symptoms. These include: and vomiting depression and snoring in the long term. In • Birth control pills may be prescribed • Abdominal distension Endometriosis addition, there is also a small increased risk of (especially to young women) to stimulate

• Weight gain Endometriosis is a condition where cells from the cancer of the uterus. a normal menstrual cycle and combat the

• Irregular menstrual periods lining of the uterus are found outside the uterus excessive male hormones, thereby reducing

• instead, in areas such as on the ovaries, fallopian Signs & Symptoms the risk of uterine cancer. large cysts tubes, outer surfaces of the uterus or intestines, Symptoms of PCOS may surface early on, at the Weight loss can also help to normalise

• • Constipation or pain during bowel movements, on the surface lining of the pelvic cavity, or on the start of menstruation, or may appear later on in the menstrual cycles and increase the possibility in the case of large cysts bowels or bladder. These abnormal growths, called reproductive years. These include: of pregnancy, while reducing the risk of • Nausea and vomiting endometriosis implants, are benign (not cancerous), • Abnormal menstrual periods. This is the most complications such as Type 2 diabetes and although they can cause problems. common sign, whereby there is irregular or no heart disease. Call for an appointment with a doctor if you have Endometriosis is one of the most common menstruation, or prolonged periods of very light • Fertility treatment may be necessary if there is these symptoms, have severe pain or abnormal gynaecological diseases. Some 30–40% of women or very heavy menstruation. difficulty conceiving.

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– without the removal of the uterus – may be episodes of PID (chronic PID) run a much higher needed to remove the abnormal endometrial risk of such complication. PID is the primary usually laparoscopy. implants. Endometriosis-related infertility is preventable cause of infertility in women. often treated successfully using hormones and The overall incidence of PID is estimated at Symptoms of endometriosis include: surgery. As the chance of recurrence after surgery 10–13 in every 1000 women, with the highest • Extremely painful or heavy periods may be as high as 40%, oral medication are incidence at 20 in 1000 women between the • Irregular vaginal bleeding between periods usually prescribed after surgery to help maintain ages of 15–24. • Pain during or after sexual intercourse symptomatic relief. • Pain when moving bowels Pregnancy itself is a natural treatment for Causes & Risk Factors • Chronic pelvic pain, including the lower back endometriosis, which also regresses and “burns At least 60% of PID cases are due to the bacteria and pelvic areas out” on its own upon the onset of menopause. that cause two common sexually transmittable • Chronic fatigue Women with endometriosis are often advised (see section on STIs in this chapter) – not to delay having children. The condition could and gonorrhoea. The exposure of the Treating Endometriosis likely worsen over time, which would further cervix to these bacteria weakens its ability to 2 6 Treatment for endometriosis can include: a ect fertility. prevent the spread of disease-causing organisms to • Pain medication. Medication from over-the- the internal organs in the upper genital tract. Early counter remedies to strong prescription drugs can treatment of STIs can help prevent PID. Pregnancy is a be prescribed for mild pain and other symptoms. In rarer instances, secondary PID can occur by natural treatment Hormone therapy. Ideal for endometriotic infection that spread directly from other internal for endometriosis • implants that are small or when there is or reproductive organs, including womb lining minimal pain. (endometrium), uterus, fallopian tubes, cervix appendix in acute appendicitis. Other microbial with endometriosis are infertile, making it one of • Surgery. If endometriosis is extensive, or if there or ovaries. In extreme cases, abscesses can occur infections as well as fungal infections in those with the top causes of . is severe pain, surgery is usually recommended. in the pelvis (tubo-ovarian abscess), and this may low immunity may also cause PID, while viral or become a generalised infection, with potentially parasitic infections are less common. Causes & Risk Factors For women with developed symptoms but who life-threatening consequences. While the cause of endometriosis has not been do not wish to become pregnant, endometriosis Factors associated with developing PID include: established, doctors believe that the condition may be treatment usually involves medication, including • Previous diagnosis of an STI hormone therapy and pain medication, to regulate Note: • Being sexually active and under the age of 25 of blood into the pelvis during menstruation. This leads menstruation and relieve pain. At least 60% of PID cases are • Having multiple sex partners to the cells of the lining in the uterus to be implanted Oral contraceptives (birth control pills) and due to the bacteria that cause • Lack of use of barrier method contraception, i.e. outside of it. two common STIs - chlamydia condoms There also appears to be a link to genetic factors. help relieve pelvic pain and menstrual cramping, and gonorrhoea. • Douching. This can push bacteria into the pelvic Oestrogen, a hormone involved in the female while gonadotropin-releasing hormone analogs organs and cause infection. It can also hide reproductive cycle, also appears to promote the (GnRH-a) have also been e ectively used to relieve signs of an infection. growth of endometriosis. Women who have not pain and reduce the size of endometriosis implants. • Use of an intrauterine device (IUD) given birth are at higher risk for it, as are those with The latter induces menopause and its associated side • Abuse of and recreational drug usage a history of pelvic infection. PID or seeking treatment can lead to the scarring • headaches, depression, bone loss, and vaginal dryness of the reproductive organs, which can cause • Having surgery and instrumentation of the Signs & Symptoms (see next chapter on Menopause). infertility, increased risk of womb, such as a hysteroscopy, , Most women with endometriosis don’t experience If symptoms are severe and not eased by (pregnancy occurring outside the womb), chronic dilatation & curettage (D&C), endometrial any symptoms at all, and having trouble getting medical therapy while fertility is desired, surgery pelvic pain and painful menstrual cycles. Repeated sampling, or evacuations for miscarriages

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Signs & Symptoms not show any symptoms. Otherwise, infection will acidophilus tablets if you’re on antibiotics. If the discharge doesn’t clear up after a few days, Mild cases of the condition often don’t have any likely recur when you resume sexual activity. • Maintain good personal hygiene. Keep your see a doctor who will prescribe a treatment symptoms. In severe cases, there may be lower genital area clean and dry and avoid douching, depending on the cause of the problem. abdominal pain and fever. PID can come on fast with which may actually worsen extreme pain and fever, especially if it’s caused by GENITAL PROBLEMS by getting rid of healthy bacteria present in Yeast Infection gonorrhoea. It is often detected when women see Many women experience minor vaginal problems the vagina. Yeast infection or is a common infection occasionally. Some may clear with or without • Wipe from front to back after urination or pregnant, or when su ering from chronic pelvic pain. treatment. However if they persist, you should see bowel movement, so as to avoid spreading to as candida . Most women are likely to have an your doctor. bacteria to the vagina. occasional bout of yeast infection. Typical symptoms of PID include: • • Lower abdominal pain. This is the most Vaginal Discharge clothes such as skin-tight jeans or shorts, Signs & Symptoms common symptom. Having a certain amount of vaginal discharge (the which may cause irritation. Avoid synthetic Symptoms of yeast infection or vaginitis include: • High spiking fevers or chills and trembling • Itchiness, redness or pain around the vaginal Foul-smelling, purulent, bloody vaginal discharge produced by glands in the vaginal wall and cervix) is and increase sweating in the genital area. and vulva () 26 • • Irregular menstrual periods normal. The appearance and amount of the discharge • Use condoms during sexual intercourse so • Whitish, cottage cheese-like, thick vaginal • Abnormal vaginal bleeding, such as secreted by the vagina usually changes during the as to avoid contracting or spreading sexually discharge th bleeding during or after sexual intercourse menstrual cycle, due to hormonal changes in the transmitted diseases. • Burning sensation or soreness (post-coital bleeding) • Pain during sexual intercourse and/or urination • Nausea and vomiting and without any unpleasant odour. During times The Urinary Tract Lower abdomen, cervical motion, and uterine of emotional stress, ovulation, breastfeeding and Treatment • The urinary tract consists of the kidneys, ureters, and/or adnexal tenderness sexual arousal, it can turn thick and opaque. It may bladder and urethra. A yeast infection may clear up on its own, but see Pain in the upper right abdomen (rare) sometimes be accompanied by intense itching. your doctor if the symptoms persist. In most cases, ty & Sexual Hea l • til i • Vaginal discharge you will be prescribed oral or topical antifungal Signs & Symptoms medications, or antifungal vaginal tablets or Fe r Without treatment, PID can lead to severe problems Abnormal discharge should be taken note of, as it suppositories to soothe the discomfort, although such as infertility, ectopic pregnancy, and chronic may be an indication of infection or other disorders. oral antifungal medications are not recommended pelvic pain. If you suspect a case of PID, consult a Signs to look out for include: 1. Kidneys for use during pregnancy. It may take up to two doctor right away. • An increase in the amount of vaginal discharge 2. Ureters weeks for the treatment to work, and your doctor • 3. Bladder may also prescribe the same treatment for your Treating PID • Pain that accompanies vaginal discharge 1 4. Urethra partner to prevent reinfection. The main treatment for PID is oral antibiotics to 2 combat the bacteria and pain medication to ease the Causes Urinary Tract Infection (UTI) symptoms. Depending on the results of laboratory The causes of abnormal vaginal discharge include: The urinary tract consists of the kidneys, ureters, tests, the doctor will prescribe the appropriate type recent antibiotic use, yeast infections, bacterial 3 bladder and urethra. A urinary tract infection (UTI) of antibiotics accordingly. If the symptoms fail to vaginosis, PID, sexually transmitted infections (STIs) occurs when excessive bacteria grows in the urinary clear up within 2–3 days, or if you have an abscess in or the use of douches and scented soaps that may tract, most commonly in the lower urinary tract cause allergic reactions. (bladder and urethra), a condition known as cystitis. the fallopian tube or ovary, are pregnant or have low 4 immunity, hospitalisation for intravenous antibiotics E. coli, a common pathogen that crosses over from the and/or surgery will be needed. Prevention anal region, accounts for a whopping 85% of all UTI. If you are diagnosed with PID, your sexual Some methods to prevent infection include: UTIs are the second most common type of partner(s) also have to be treated, even if they may • Eat yogurt with live cultures or take lactobacillus infection in the body. Women are more prone to UTIs

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than men, which is likely due to their having Signs & Symptoms shorter urethra (the tube that carries urine out Early recognition and adequate treatment of UTI is from the bladder during urination), which makes necessary to prevent complications. it easier for bacteria to move up to the bladder. The urethral opening in women is also nearer Signs to look out for include: sources of bacteria from the anus and vagina. • Painful, burning sensation during urination According to the Department of (dysuria) Urogynaecology at KK Women’s and Children’s • Frequent urination and the feeling of urgency to Hospital, as many as one in two women will urinate even when there’s little urine experience at least one UTI during their lifetime. • Cloudy, dark, foul-smelling or bloody urine • Discomfort in the lower abdomen 20–65 will su er at least one attack every year, • Fever, tiredness or shakiness and 3% of the cases turn into chronic recurrent • Nausea or back pain (signs of renal infection) UTI (RUTI). 2 6 The bacteria E. coli A renal ultrasound Seek treatment if the infection doesn’t clear up in a accounts for more can be a helpful test than 80% of all UTIs for a recurrent UTI Risk Factors Some factors that increase women’s risk of bladder, but may spread to the kidneys, which is th developing UTI include: serious and may cause permanent damage. • Age. The rate of UTIs in women gradually recurrent UTIs increases with age Treating & Preventing UTI A recurrent urinary tract infection (RUTI) is and to measure residual urine volume • Incomplete bladder emptying , which allows The main treatment for urinary tract infection described as symptomatic infection occurring Abdomina X-rayl: To detect urinary tract stones the residual urine to be infected by bacteria is antibiotics, together with an adequate intake ty & Sexual Hea l • present. Causes include: til i after the apparent cure of a previous UTI, • Urine culture: To test for tuberculosis • Pregnancy: About 15% of pregnant women Drinking cranberry juice is also believed to help Fe r typically more than twice over a six-month • Urine cytology: To assess for any cancerous period. Two-thirds of all RUTI have been found cells in the urinary tract (which most commonly will experience UTI prevent infection, as it contains certain enzymes to be due to the same strains of E. coli despite presents with blood in the urine) • Bladder, uterine or any other pelvic organ that help reduce the chance of bacteria sticking to adequate treatment. • Cystoscopy: A specialised camera is inserted prolapse the bladder skin lining, which leads to infection. The mainstay investigations for diagnosing through the urethra to look for abnormalities • Sexual intercourse is a common trigger for Probiotics (live culture yoghurt) have also been shown UTI include urinalysis or urine culture; where such as stones and tumour in the bladder. UTI infection in many women via the physical to reduce the chance of getting UTI, as “good” live microscopy looks for white blood cells, red blood action that exposes the urethra to bacteria bacteria is introduced into the bowels of patients and cells, the presence of nitrites and leukocytes, and Treatment for RUTI typically includes antibiotics • Use of diaphragm and condoms with reduces the chance of the “bad” bacteria in our bacteria that point to a UTI. The culture identifies for the longer term, or stronger antibiotics, spermicidal foam as contraceptives bowels spreading and causing UTI. the specific bacteria causing the UTI, and although follow-up urine culture is necessary to • Immunosuppression with certain UTIs can be prevented by ensuring proper indicates a specific antibiotic that can be used “test-for-cure”. If left untreated, the infection can medication or drugs personal hygiene and regular emptying of the to treat the UTI. An alkalinising agent may also spread upwards to the kidneys, leading to renal • Diabetes bladder. As the source of the bacteria comes from the be administered concurrently to make the urine infection and increasing the risk of renal failure or • Menopause, with the attendant loss of bowels, it is also vitally important to clean from front more hostile to bacteria. permanent damage. oestrogen to back after defecation to avoid faecal contamination In extreme situations, bacteria may spread via • Abnormalities of the urinary tract, such as of the vaginal region. In RUTI, further tests are required, which include the bloodstream, leading to a generalised body- the presence of kidney or renal stones Regular, daily cleansing of the genital area with the following: wide infection or septicaemia (blood-poisoning), • Instrumentation of the urinary tract, such water is encouraged, especially before and after • Renal ultrasound: To look at the kidneys which may be fatal in certain cases. as catheterisation or cystoscopy sexual intercourse, but avoid the overzealous use of

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vaginal cleansers to reduce the chances of getting UTI. ageing. Although it happens more often in older • Waking up more than once in the night to women, urinary incontinence is a medical problem urinate (nocturia) stimulation and special medical continence devices. away urine possibly contaminated with bacteria. All that can be treated, and should not be seen as • Urine leakage if unable to reach the toilet in In cases of SUI, a tension-free vaginal tape active vaginal infections should also be treated, or something that is part and parcel of ageing. time (urgency urinary incontinence, or UUI) obturator (TVT-O) operation o ers excellent results. bacteria may spread on to the urinary tract. The severity of the problem can range from an • A weakened or damaged In cases of severe and unremitting OAB, there is occasional leakage of urine when one coughs or the option of surgery, but this is the last resort and Urinary Incontinence sneezes, to sudden and unpredictable episodes of urine stream, possible dribbling and a sensation should be carefully discussed with experienced urine leakage – from being a slightly cumbersome of not completely emptying the bladder. It can and skilled specialists. refers to a problem with muscles or the surrounding problem to being an utterly debilitating source of also be caused by diabetes and spinal cord injury. tissues that keep all of the pelvic organs (bladder, public embarrassment and deterrence from social • Functional incontinence: Physical and medical uterus, and rectum) in place. Incontinence is activities and engagement. Most bladder control conditions that interfere with thinking, moving, characterised by the inability to prevent the loss of problems are due to weak or overactive muscles. or communicating and hence getting to a toilet which results from the deterioration or relaxation urine (water and waste products removed by the Di erent types of urinary incontinence include: in time in those that otherwise have normal kidneys) from the bladder. • Stress urinary incontinence (SUI): When the bladder control. This is common among the aged. pelvic organs (bladder, uterus, and rectum), which While women are twice as likely as men to su er bladder neck or urethral muscles are weak, Causes include arthritis, Alzheimer’s disease, or then descend or drop (prolapse) from their normal from incontinence because of pregnancy, childbirth, often as a result of physical changes owing to being wheelchair-bound. positions, causing problems. menopause, and the structure of the female urinary pregnancy, childbirth or menopause, it may • Transient incontinence: A temporary episode of tract, it can also come about as a result of obesity, cause leakage as a result of physical exertions urinary incontinence that can be triggered by: Types of pelvic organ prolapse include: neurological injury, birth defects, stroke, multiple that increase intra-abdominal pressure, such • Certain medications • Cystocoele (bladder prolapse). The bladder sclerosis, and physical problems associated with as laughing, chronic coughing, sneezing, or • Urinary tract infection (UTI; see section above) is no longer supported and descends into the heavy lifting. According to the Department of • Mental impairment Urogynaecology at KK Women’s and Children’s • Restricted mobility urinary incontinence (SUI – see previous Hospital, this is the most common type of urinary • Severe constipation section). This is the most common type of incontinence, a ecting half of all women with • Ignoring bladder needs and postponing going prolapse in women. urinary leakage. to the toilet for too long • . This occurs when the womb • Overactive bladder syndrome (OAB): According • Mixed incontinence: A combination of stress (uterus) drops down the vagina. It is the second to the Department of Urogynaecology at KK incontinence and urge incontinence symptoms, most common type of prolapse. Women’s and Children’s Hospital, this occurs with typically one particular type predominating. • Rectocoele (rectal wall prolapse) in 40% of women with urinary leakage, with • “True” incontinence: Classically caused by a • Enterocoele (prolapse of the small bowel) approximately 10% of the general population • Vaginal vault prolapse having this type of urinary incontinence. OAB urinary tract and the vagina. Can be caused by tends to increase with age, and is more common Risk Factors in menopausal women, those with spinal certain diseases. The risk of pelvic organ prolapse increases with: cord injuries, previous pelvic surgery, diabetes • mellitus, multiple sclerosis, or pelvic radiation Treating Incontinence or deterioration, such as pregnancy, vaginal treatment, although it is often idiopathic (with no Treatment for urinary incontinence can vastly delivery and menopause improve the quality of your life, so seek help early. • Conditions that increase and cause chronic • Sudden and overwhelming need to urinate Treatment options include physiotherapy with pressure in the abdominal cavity, such as

Urinary incontinence (urgency) chronic cough, asthma, constipation, carrying occurs more frequently • Urinating more than seven times during the exercises – see box on next page) to strengthen the heavy objects or loads, and obesity in older women, especially those with day (frequency) • Previous pelvic surgery other physical problems

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what are How to perform Kegel exercises on the type and severity of the condition. These In most STIs, the signs and symptoms usually 1. Sitting or standing upright with thighs slightly include: a vaginal hysterectomy for utero-vaginal show up on or around the sex organs. Some of Kegel exercises? apart, simultaneously tighten the urethra, vagina these include: Kegel exercises, the more commonly known and anus. • Vaginal discharge and/or vulval itching term for pelvic floor exercise (PFE), are exercises 2. Lift and draw up the pelvic floor muscles inside for vaginal wall prolapse (e.g. cystourethrocoele or • Abdominal pain designed to increase muscle strength and you. Hold this squeeze and lift for 5–10 seconds. rectocoele), which reduces unsightly bulges and • Pain during sex or when urinating elasticity in the female pelvis. For a start, you may only be able to hold the discomfort. For severe cases, where there is a high • Small, painful ulcers or blisters that turn into contraction for 1–2 seconds. Over a period of chance of recurrence in the future, a synthetic mesh scabs on the genital area To identify your pelvic floor muscles, do either one weeks, aim to gradually increase contraction time may be used to support the prolapsing organ(s). • Flu-like symptoms, including swollen glands, of these two tests: to 10 seconds. Whilst abdominal or laparoscopic surgery is fever and body aches 1. As you urinate, try stopping the flow of urine 3. Let go slowly and rest for 10 seconds before possible, vaginal prolapse surgery has the advantage • midway. You are contracting your pelvic starting on the next contraction. of the absence of a scar on the abdomen and a lower around the genital area floor muscles to stop the urine flow. Then 4. Repeat four times. level of pain experienced by patients during the post- relax your pelvic floor muscles to completely 5. Now do five short, fast but strong contractions. operative period. In women, there are often no symptoms at all, 2 6 empty your bladder. 6. Do this exercise routine at least three times every The type of surgery should be decided in consultation and the health problems can be quite severe. This Do this test once a week to check if your day. Slowly increase the repetitions to 10 holding with a urogynaecologist, who will be able to assess the can be dangerous – if left untreated, STIs can spread

th pelvic floor muscles are getting stronger. The contractions and 10 fast contractions. risks and complications involved, anaesthesia required, as from the to other parts of the body, stronger they are, the quicker you will be able well as post-operative management. causing serious and potentially life-threatening to stop the urine flow. You are never too young or too old to exercise your complications. It might be spread to others through 2. Insert one finger in your vagina. Contract your pelvic floor. Do it on a daily basis, and whenever you sexual contact, while pregnant women may also pelvic floor muscles and feel the grip around are sitting or standing, e.g. while waiting for the bus, SEXUALLY TRANSMITTED spread the disease to the baby during pregnancy or your finger. waiting at the traffic lights or standing in a queue. INFECTIONS (STIs) at childbirth. Women in the high-risk group, such as ty & Sexual Hea l

til i Sexually transmitted infections (STIs) are infections those with multiple sexual partners or risky sexual that are contracted through sexual contact, which

Fe r practices, should consult a doctor. Signs & Symptoms age, prolapse severity, underlying medical diseases, includes kissing, oral-genital contact, and the use of The signs and symptoms of pelvic organ prolapse and whether childbearing has ceased. shared sexual “toys” such as vibrators. They can also The most prevalent STIs among Singaporean young depend on the degree of prolapse. They include: The most popular conservative or non-surgical be spread by the direct contact of broken skin with women are gonorrhoea and chlamydia. Common • Feeling a sense of heaviness in the vagina open sores, blood or discharge, via , STIs include: • Pelvic discomfort Kegel exercises (see box above) that can help to or the use of contaminated needles in drug users. • Seeing or feeling of protrusion of the uterus and The causes of STIs are bacteria, parasites and Gonorrhoea cervix through the vaginal opening the progression of the prolapse. PFE may improve viruses. STIs caused by bacteria or parasites (e.g. Gonorrhoea is a very common disease spread • the condition in the short run, but does not cure it, as chlamydia, gonorrhoea, syphilis) can be treated with through contact with the penis, vagina, mouth • Lower back pain prolapse will worsen once PFE is stopped. It is only antibiotics or other medicines, but many STIs caused or anus. It is caused by neisseria gonorrhoeae, a • Chronic vaginal discharge or bleeding, resulting suitable for milder degrees of prolapse. by viruses such as Hepatitis B, Hepatitis C and HIV bacterium that thrives in the warm, moist areas from repeated injury to the prolapsed organ in Those with severe pelvic organ prolapse but are have yet to have a cure. Antiviral medications can of the genital tract, mouth, throat, eyes and anus. severe cases not suitable for or do not want surgery may have sometimes help to speed up recovery and keep the • Enlarged ureters and kidneys, in cases of severe symptoms of STIs under control, while the correct Signs & Symptoms utero-vaginal prolapse or cystocoele organ and for symptomatic relief. Regular pelvic usage of latex condoms can greatly reduce (although The signs and symptoms of gonorrhoea usually appear examinations every 3–4 months will be required. not eliminate) the risk of contracting or spreading between 2–10 days after sexual contact with an Treatment STIs. As a preventive measure, you may immunised The treatment for pelvic organ prolapse depends on There are many surgical options available, depending against Hepatitis B. It is often mistaken for a bladder or vaginal infection.

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Syphilis Treatment Syphilis is a bacterial infection usually spread Syphilis is treated with antibiotics, and treatment is times more at risk of acquiring HIV infection than through direct contact with syphilis sores (ulcer) especially successful in its early stages. non-su erers. Chlamydial infection can spread on the body of an infected person carrying the bacterium treponema pallidum . The painless sores Chlamydia discharge and pain. usually develop on the external genitals, vagina, anus, Chlamydia is an infection spread through vaginal, Neisseria gonorrhoeae lips and tongue, and can show up anytime from 10 to anal, and oral sex with an infected person carrying Treatment 90 days later. the bacterium chlamydia trachomatis . It can also Chlamydial infection can be e ectively treated with spread from an infected mother to her baby during antibiotics, with the infection usually resolving Initial symptoms include a painful or burning Signs & Symptoms vaginal delivery. within 1–2 weeks. sensation when urinating, increased and/or bloody Depending on the stage of infection, the signs and vaginal discharge, or vaginal bleeding between symptoms of syphilis vary: Risk Factors Genital Herpes periods. Symptoms of rectal infection may include • Primary stage: The risk of infection increases with risky sex practices. Genital herpes is a highly contagious, common viral discharge, anal itching, soreness, bleeding, or painful According to the Health Promotion Board, Singapore, infection caused by a strain of herpes simplex virus 2 6 bowel movements. stage. These usually appear at the location sexually active teenage girls and young women are (HSV). It is primarily spread through sexual contact. where the bacterium entered the body and more prone to develop chlamydial infection, as the

th Complications typically heal without treatment. opening of the uterus (cervix) has not fully matured. Signs & Symptoms The symptoms of gonorrhoea may go away without • Secondary stage: The appearance of a rough, This also increases their risk of developing other STIs, The signs and symptoms of genital herpes appear treatment, but the bacteria remains in the body. This reddish brown rash on one or more areas of the such as gonorrhoea and syphilis. about 2–10 days after sexual contact with an infected is why it is important to seek treatment. body, including the palms and the soles. Other person and may be mild or indiscernible. These Gonorrhoea is also a common cause of pelvic symptoms may include fever, swollen lymph Signs & Symptoms include itching or burning sensation in the genital glands, sore throat, patchy hair loss, headaches, The signs and symptoms of chlamydia are mild, area, vaginal discharge, and small sores or blisters ty & Sexual Hea l and often show up within 1–3 weeks later, although in or near the vagina.

til i in women, which can lead to complications such as weight loss, muscle ache and fatigue. Latent stage: If secondary syphilis is left some su erers may not develop any symptoms at all. Fe r chronic pelvic pain, a ect the reproductive organs • and may even lead to infertility. It is also a cause of untreated, the infection remains dormant in the These include a yellowish-white vaginal discharge, Complications blindness, as well as joint and blood infections in body, sometimes for years. mild burning sensation during urination, painful Genital herpes is a self-limiting infection and babies who contract it from their mothers at birth. • Late stage: In the late stages of syphilis, the sexual intercourse, lower abdominal or back pain, infection that recurs is incurable. The sores may Left unchecked, gonorrhoea can spread through disease may have damaged vital organs such and/or bleeding after sexual intercourse or between heal after a few days, but may recur for years after the bloodstream to other parts of the body including as the heart, blood vessels, brain, nerves, menstrual periods. that, although the episodes of breakout tend to joints, brain and the heart, which can become life- eyes,liver, bones and joints. Complications lessen with time. A woman with genital herpes threatening, as well as put su erers at greater risk of such as meningitis, stroke, dementia and heart Complications may infect her baby at childbirth, causing blindness disease may occur with serious consequences Chlamydia can cause PID (see section on PID on pg and mental retardation. (HIV) and other STIs. – even death. 91) without any symptoms in up to 40% of women, which may in turn cause chronic pelvic pain, Treatment Treatment Complications infertility and ectopic pregnancy (pregnancy outside Treatment with antivirals helps to speed up the The typical treatment prescribed for gonorrhoea is a Syphilis su erers have a greater risk of HIV infection the womb). Infection during pregnancy can result healing of sores and relieves pain and discomfort, course of antibiotics, although in many parts of the because of the existence of open sores. An infected in premature delivery and stillbirth. An infected but cannot prevent recurrence. world, treatment of gonorrhoea is becoming more mother may pass the infection to her unborn baby mother can also pass the infection on to her baby during pregnancy, causing birth defects such as during vaginal delivery, resulting in infections such as Genital Warts use of latex condoms and practising can mental retardation or seizures, and is also at higher pneumonia or conjunctivitis. Genital warts, also known as venereal warts, is reduce the risk of catching or spreading the STI. risk of miscarriage, stillbirth and premature birth. According to the Health Promotion Board, one of the most common STIs in Singapore and

100 BEAUTIFUL INSIDE OUT 101 2 6

102 Fertility & Sexual Health co sy Gen As most peop to go for regular P cance H & Signs pa infected v t is c sy Co BEA and bl an H virus (H H al There is no tre Tre w in u c b the by w Ma baby d obstructed del Signs & & Signs breast milk. a a agi u a l all orl IV/A m m e use uses 70% of all cervical cervical all of 70% uses n ving gen m m r n vi a UTIFUL INSIDE OUT r tact w ansm ptoms ptoms for i y peop n tme ( i tal d ps on the IV plic a n bi al r ting and tre wide i a ood. -infected person, . tching ur Those infected w I r h t w , IV). D th ca S S o i a n u on as a resu ing pregn y y a i t S i t m r tted by skin-to-skin co skin-to-skin by tted th an infected person m m i r , Itisspreadthroughsexualcon Aw the infect al and a and al on . l ts i 90% of all gen all of 90%

e after co tal r an p an ptom ptom n tne , pain and a a a l s al) y e v i tme ppear w w v om ears agi m ery as a resu r . a a a . r a pil a s s ting the diseases c an wi n ts n ancy y not p smears n , and can ta t for the virus a or around the a l al sexual i sexual al l m i t of the expanded n o on often t m a i r thin three mo , con acting y in th H a i h a virus ( virus a b th gen t childbir a urning sens v i c tal tal tamin . e a l IV/AI In add rease the t of m H k n n w i . e The tal IV y signs an tercourse w tercourse a w i a H DS caninfecther tself y go unnoticed u n a r a m PV) p to 10 th orthroughher ts are c are ts w ted needl i tact tact . r The infect The t a ts on the i a w a used by n n on , y on a r r , us t ths of sexua a

ts are a isk of cervica t w w h r , i d

on ts i a l a hich als hich t y those fo u v h d r y tact wi m a a r e n ts . a ears t in use ppear a t a , i es H an th a th v m y als g d o P agi i vise d a o V d . y o . n

o th n n o l r d a s l l progress to three person w infect There is no cure for Tre some cancers diseases and cond It also in O all kinds of infect system Co sy d t not best su a are l h preg • • • • • • • Bi B tre If Tre medical he ead h v a e

v y r I m a ailab v v th co er time a m ou suspect t R t a . e e m a L Persiste Skin Nig Pr W Tirednes

tme ptoms t T tme y , n y plic l TH o and the time span bet t op A o pr our pa a i eig ou to think t o anc in on or cance w n l , i l h c e t n onged f n ered resistance to infect y safe and e ect c y g a r n t . i h y tr a It on of the disease ts i as reases the s e ears after d y t th A , C t s our needs and preferences I

using A t the virus i v o , D S w ’ l . plan the on s Self-medic h l p ear n e h l or co ONT os r TI S s e u tner see n t diarrhoe a , . a s the end stage of I p to t the recurrence of infect s t s DS usual t h e m s a l v i y ons t a I e r n . h DS su erers to be susceptib i Di ere y . y be expe y t R H r t a H ou to choose a method t i ou a r ons as n t e acept k O e , ttac o IV/A

umber of children v y w s tre v w a a e ou m e l L hich can be life-thre y dies bet t l e i r i oping A v k a on is not a i v I ’ ty of some commo n e bi s the bo v y DS a . e i

w on al t e been cured tme r w h , r S ell as the tre . a ienced inc It is a f een each of them TIs require di ere r v th co H e co n l i a o on I t as IV infect tme D w w d S een one and a s y n d n s , a ’ usual visab w t s im tr . y tal disease n r ou to pr r acted o ell t can del isk of gettin i l on l method ude y . m w i ou on l , l e

hen un y fro m a , : as . h S w Som n tening a e TI a e a l k e t t wil . y a n i v m n , e sur Ther t see . ou’r

y th e t A t t s m o n e h g o t l a al . k

e e y e e f

choose and frequency of sexual act co use Bi and for one menstrual b – • Exa f k Th Bar • • • • • • e eepin

w r r n is is th co tilise t tilise hen a m tr i

is re ou also beeasil and otherS to be e ect i from re t condoms also pr cannot get throug i w Condoms Pr i A Thic Stopping Killing or da the K No Co r y t n n m r bar ier Metho eeping the sperm from reaching the egg i egg the reaching from sperm the eeping , o our desire to l ansm p and the possib orn ter tercourse te e l should depend on factors such as pla tl n l , g v m

es of co n The ad i r v t ets. u k e r t is i t v ing the lining of the r tr ersibl ie h ening the a teru n acept w n o e h tter e e e o ting sperm and egg from meetin v n t i r l o e spe e Italsoo ersprotecti tted diseases a easing eggs each mo

l er erect an penis m l y t m m eeding for t t w i ear if o i gg o s : po on of the fe w

et v an e andhighl or n

vul n i . i TDs (seepre on can be used u Apa an v m h y procuredfromcommerc These are thin t . ho r d rm k

e r a ta h aging the sper acept h s in di ere a . tages tothismethodareth t method of bi

o as not

t a n d p d m

v i r from v l on and pr o t to kn e side e ects er 50 t from pr ucus in the cervix so t e children in the f vide protect i h v r e i i on using this method are w t . v They y e h r e . o , y sim

tilised eg o n ad a pe n n y w h vi umber of sexual pa n te ts ts ears if aged under 50 u d t ous secti e e terus to pr u , r rubber she m co w v pl in v o r e r m ing sexua e a w n ust be used correct th co n on ag . n e touse, g n

n ys i til menop Y r th via hormo on a ting concept t c i i ting the our choice of bi t g od or a . ept h These inc w e e n u or ainst H on S g tr ture v i o ainst sexual y k ag o e our hea n n s v andcan l l a , n h h y e ial retail i . b th o g n

y a o a n o v y us a u t sper t s w t a IV/AI a l t TDs). r ude r n t i e tners i o ie on a o l t

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103 2 6

104 Fertility & Sexual Health BEA t r Eme b ma on wit firs d c c the D “ the bi r • • • • h I morning after c c c r of unp a de as r p f edu egula edu egula o p mo o ondo o o o

a e e e o f y e n n n n ving vi l r r UTIFUL INSIDE OUT o t r a h t n egular bi m n out of p A W W S A met A r t t t t 24 c em he i r r u ying c t r in 5 d y r r r r c c e o o o n f n l i gen a a a a e ( a ’ t he he t lise es t e r x v v t d n ing a al houg r r m er c c c c ne r th e u o e h ho

i h o t y if ept ep ept ept h n t c s de n n o al as r v

t o ou t t ee p o f o se i sl d c a n o h c e h e a a e n

ed u a w n t ad d y c o r egg f v ip t r e r c a t o io i ion ion r y m f r rs n l ep t e v

w c e ul n h s a t c a t t t

i ng r r s r p c e e s n a a o s

er p ion ub n r o i a t r

is t c onal un

th om t a a it c h a o e d r ed f s ti h t ti n us c

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r ou n ious e un e e h e r p o e me r il e no l t a om o or o s a r w

r c

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e y b c i n i pi e o k c d p e whi e ge t o a st ng o f t o k e aks s tion e a e x e e r as c o p d

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v o o wh t y y na in x s r a t e lu f ass e i f en i r a

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b y no n c n r n . b muc or t f a pp g i r

r l din r a n on c

n io r n y o , e io t

a b

e a y 99.9% c t eq I ta o k t dia e wit i p s as c i n UD i t b ep i n i m e n n lis ly e b m d l ci r

v y e t us e is k n g r g c

. ui i

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• •

correct ca re as a condom or di chemicals inthesecon before ord disad con together w the di used w hours after i a the ir is si is or di three methods of bi Sponge sperm v c Spermi pr the cervix or e a from

this c t and the l The disa w r agi ream or s t t t l r act infect hen used w l v i e use UTIandall e t ersibl v h a rg mp tr v E ect The ad E ect Th E ect n e a t e s e agi p h acepti v i a before i n ph a y issues y on from the use of spermi . an e e a M ph ting the sperm from e h l i l c y am th a pter) and al e t e n , a ar d r di ide , e, a 85% tages: agm a a by the user and d v r i i i tex or chemicals v v v y be used on wi u agm and cervical c m o v a i v e ti e a i ur ons (see pr eness eness eness n v th spermi ppos : an use use n n a ph

a es areth y of the other methods ab n tages? It i th noph tercourse i ing in c . th spermi . n Chemicals in the form of foam Some m tages tousingthese w t n ies r theym ag t agm and cervical c cervical and agm hen used w tercourse to kill or disab r e a i ance to the ergic reacti : : : tory to be inse ,

. nd nd a

es t es

a Th ph l tercourse,

nd nd ergic react 70% on r Good protect 75% th co w a c e dis e a o r ysical sidee ects. e ide ls agm t theyaresafetouseand n omen expe a . usin ca tr For better protect v c i y becomedisl terr o ts i id acepti w ous sect

n n . n ac

a o e hen used correct m . tr l b d u eft in place eig i wn or on a condo i g th spermi ts ts ons. ts o v a w e e e n pts i a andthela spe y c a l te p should be use i omb an a o ons v w n r c a s s wn es m r t ted in th a ork by c ide ing n si i ag a i rm use u on on UTI i on r tercourse .

l ience gen a l . y p y Should b u es es . p . i These ar a b c w

: c odged y also

d ides roc r ar hen use o ide r i i The ca tex or v l n o e e e e i ar u v . on h n , Thes : suc e

r l i t y t , e y t r

n i , , , in e d ta

m 90 e d h d g l e %

Hormo and c • • through the cervix m oestrogen in the bo the Hormo Hormo

ucus to thic

l

recommended forw hear r b per headache, are th e ects, v o co not protectag skin andac sym the menstrualcy and/or oestrogen Bi ta are t are similar to o mo progesterone hormone w Co m usual e isk ofstro ery l v u h v ork by s r k a ar n t ser th co th els of fe n anging the lining of the en n n n n i tain the sy Whil The ad E ect A ods, t ptoms (seesecti ian andendometr y h al methods come in s al methods t diseaseandbreastcancer n th r l d o acept a y resume a w e al Method v w dosesofhormonestominimiseside l t t i i commonsidee ectsincl v y or three-mo ous sidee ectsincl a omen n w i ery d e con t n t ise ecti tr u ’ k i s safe tages to using the i v eigh m breasttenderness, k v ppressing en o eness ne, i e, an v l pills l a e i e , bl a l

n tr e hormones progesterone and/o m m tages tothishormon andalsored y ainst S . r t g

, thetic hormones progestoge . al pills w n acepti high ood cl

d aking a w ject cl y : hen the i y not ain andmoods . : ork by pr For the pill to

. They also c s e, v

e, 99% if ta m on P i l omen w n o TDs. ons y e ect Most bi safeandeasytouse. . v After abo ots, i th vul ial cancer t an h e pillstoda . These can be g h a l y i : v

age P a a highbl e n e pe t r e v u n ject uce ther d for the sperm to ge i ude inc on w e v terus via in MS), ter k i r Hormone i v e ho smo n r en as instructed th co spottingbetw al forms a e n ject r i MS andP use the cervica v , i on is stopped ting

u ods . als l w . Or im

ong-lasting i ude n t a wings. ood pressure, th a sy y con ork i on metho n . reasing the Side e ect al pillsarenot al method . pro tr Pe y o isk k ear of use , vul o

e, : i

t l pill s of a r c v i tain anddo n n Rare v i h usea, reasin od e oil MDD a ject en theti as to b t i

o s s a n n , i d y een

on . t

.

c l g s r ,

s e t

• •

protect to pr plastic rod co inse I Co c w pr bein i t i w a pe pr and he I d mo co hormo co should stop after common inc i easy to use and does not i w m for n n n U n h opper i e a all of the eig to the to the tercourse t a a o e D inc n m vice is required y r n l y expe t co 6 v gestin (sy n ude headaches a , t The co The non-medic There are t The IUCD is a r E ect E ect t r t r g p e r th – u e h ted under the skin in the inner r i h acept od of bet fe n acept l v 12 mo te t ete e c n n l a ts the fe e l y chec i g ude menstrual pain n r t on a u vy b r al I n u tilised a ain ine d ine to the o l te l t y r terus by a docto i i in coppe y v v pper I ience irregular menstrual c n , o w i U irregular r v . eness eness i w Disa us to p , t v vul l g and n n e method D omb (i.e r eeding e i e n acept hi ainst preg t k ths after stopping the i . w e h Some users stop menstru w taining sy a s on the proper funct r a u vice (I vice l m etic progeste o types of I tilised egg from nd t e using the hormo U t een terus d m i : : D re 6 pla on .

e v Common side e ects of coppe r r , v , – a e i a a a

v h a , Almost 100% e ect Almost 100% e ect ersib n v

9 mo y ted d . v e i w 3 Once inse nd hormo . c n e emb e i U , tages are t l agi

h e ne – w t m . n hich is re Possib m D or IUCD) or D : a a 5

n t c hi ses v pla n , l n pla

ancy for three e co y n e prob w e c thetic progesterone i o r n U al b ears . ths h p vice is e ect A s r

ncept eig te , n D a

y n r v t s o one) n : r agi t is almost 100 a non- l l . r m fere w f m

e side e ect eeding h . t n e t The hormo r r r d i t v al h acept all o ted on) l a all n ems conce uced w e i g o m a ttaching to th ,

al disc o n : w , ain and t some

n n m

a nes t m ts the egg fro i . , u al I

It is inse . mou hic i

m i i oning of th n edic I t pr th sexua pper ar n the sam a y , i

v ject pl w tchstick-size c U h e metho i The I l y v i i h v v i es an a h hic is re D o n a th th ears e fo a a e e n arg i vide tin . t o , ted one w ons

t mos . . s t n h a c i ome a % vin U f l t m r g o r . e e l i

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105 2 6

106 Fertility & Sexual Health

ob t t of di and menstrual c a method of co BEA • • signs of The sy as reliab signs of methods of co N N These methods of co w the fe h h n

a ho cannot use other co a a

t e d e e o x tu se ph tu h UTIFUL INSIDE OUT iet vul

taking y pe o regular pe ta (see B Basal bo Basal y R pe to conce possibil w t Th ab h r e e our menstrual c r vul , h a

al methods or fe i r r k r v a w th sexual i m r y r e e ythm method ythm agm ti te te il m al Method a en to be s t is safe and e ect a fo i , E ect aking te od i l st t o a t l n ptother e pe ty t ty i enst e i r of on i te the f vul o a B a , r and should be combined w . tu

te the ns T c , ess ess i

T for more e ect ty of infect o o our tem i a a d v r n r v esti r , n i i t k e after t h

y te y a od u v r v a i ul n e t t on and abstaining from sex i or l l a eness o a ods nd nd r n t m m y fam r o acept a r e l l l . w tercourse t) v illness c They are nor h acept m m t l v c pe al method of esti es l l i . a all of the o e history en d h y Users of this method should o . s a pe t as the d wing mo c per i en n n r y te te : l k n h : a l

y pl y

c e r i eeping t i t ture r a v ons in the on til l i c r , a e and p a a t

on a i 98% e ect acept For this method of determinin w e e a . . i ture (B ture ys before and after In i s s v ture wi n ty a , d such as a condom o e h r acc t . nnin Disa w elies elies i , ( r i and does not i v a r : u a basal bo acept ch are cases ork by recognising th e resu i w terus a n l i u y y on are y m th

r areness-base a m r ack of cervical B g d r y th ano a tterns o al e v u . T) method T)

ou

a te m Y i n t n a co . terus or fal v l y y i y used by l our fe n v m e methods ts l et y y b o tages inc e r d h . , din a vul . the I

e e ho y te a e e , ting the d

i s p s y vula th anothe a r ou need t d d a e g r m ti ted and wil g n o s s e U r r l al d te e ul ssi c pe e pe ti a : D ca d

o l u ted ted q l n opia w on l r y no a vul ude th r fer b ui r m . d r r

in ome a i l r ture) t r e ucu n a a e g h i b e y od i n r t t t o a y s e e i o v n s e e n , s l

g

pregn Ster St • for men. form oftuballig Cervical Cervical e r is red u tem consecu cy by 0.2 of aperson getting ou 4 3 2 and semen and other disc 1 cervical se menstrual p cervical method c Li ilisa i y . . . .

pon theini

l g

c cl i ancy feels sl After th A f as sticky ag the o is cal not thick or stick is last da does not stretch s a l vul e e un ti a per t h l

ub i o . e This method uced w on isaperm on is an ope t a m w d vul – h i a r . o l Surgicalster a d 0.4°C aftero r a ed the peak d t , m ucus is the most stretc til afterrecor ic requires the abil ti m i n ture ch v y ofthese l i on a y a ppery and can be stretched bet v e sex a a ucus c a c t ucus/billings method ucus/billings t ofbed. e da ys l ain. t i t, ret on is most unli , i a the most fe n tial restingtem on them a hen h t com ttern and ide y ti a i ons A . y ons forw m ys. . te

anges arenotob , c h v ucus r r anges Theaccur l oid sextillthreeda anen , a , the ou , . a distinguishing also kn ucus dec pl When this B “fer t ving afe vula i ilisa on ete rest. d ding ar a h . These d y or T isthebod y and coin m til arges c t methodofpre w r d ti ti omen andv ucus becomes c e” ti i u on. here the fal ty to understand one on isa n l k o y e pe sec r e tify the c el ing her menstrua wn as the per reases andbecomes acy ofthismethod v l Refr Aw y ise inB l er a o . h h a

reti r used by infect wish a a , ys are safe for sex ab i and/orw v od ture ofthebod : ppens c

vi ailabl ain fromsexual om ides w ons. m y tem l ous. e . On this d ucus fro . h m asectomies an’ l ys afterthe angin T forthree opia o A ucus t e inthe It’ , vul v she shoul s B w per en i l t w s relian eare o h hen n a ee ting m g t a T r i m h ture o l an a n i r a o n y ises ,

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ts a y pre y n isk isk olli c T r vula ine c t ts to e t e a a e a l he he r y t o tio y pi y ain and spine and ain r h ou l ollicles intheo c eption. m er r r o s y baby f l .g o timein al tube defects tube al y e of the eg the of e es ollicle ismonit e n a tion monit f high-o f h n m c a o p oc d c t . a r i l o C i t igher num igher omb

m erc l ther tion nal in nal y for preg for y ti e t e tal s tal o C 0 o thefallopiantub r s r d d r e essed andinjec isk of pre lomid) oriso , oble l – G G f as as is is oun i a d isappr

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n e t t

109 have shown that if you start taking folic acid the art of at least four weeks prior to conception, the risk of birth defects of the spinal cord and skull making babies can be reduced by more than 70%. This should be taken one month before conception and Assisted reproductive technology (ART) is a continued through the 12th week of pregnancy. group of different methods used to help a couple conceive by artificial or partially artificial means. Signs & Symptoms It works by removing eggs from a woman’s body, which are then mixed with sperm to be fertilised of pregnancy is missing one or more consecutive Injecting a Frozen human into . These embryos are then put back in healthy sperm embryos in IVF menstrual periods. Women who experience into an egg in ICSI the womb for pregnancy. treatment menstrual irregularities should see their healthcare The IVF Centre at KK Women’s and Children’s Hospital (KK IVF Centre) offers a comprehensive Some advances in IVF treatments at KK IVF According to the American Society for whether there is another health problem. 2 6 range of diagnostic and treatment procedures for Centre include: Reproductive Medicine, these include: infertility. The is about 40%, which • Laser assisted hatching for repeated IVF failure • Ovarian hyperstimulation, where the Although these vary across woman to woman,

th is comparable with the best in the world. These and thick zona (the shell of the egg). ovaries become swollen and painful. other signs and symptoms of pregnancy include: procedures include: • Blastocyst culture, which extends the • Multiple pregnancy. Many fertility • Nausea or vomiting, “morning sickness” cultivation of embryos by three more days in the treatments increase the chance of • Swollen, tender breasts or sore nipples (IVF) lab, and choosing the more advanced embryos pregnancy by increasing the number • Darkened areola This involves combining the eggs and sperms to increase the chances of implantation. of eggs produced by a woman or by • Bloating together outside the body, leading to fertilisation Ultrasound-guided transfer, which replacing more than one embryo into Fatigue ty & Sexual Hea l • • til i in the laboratory. After fertilisation, the embryos or uses ultrasound technology to place the the womb, hence resulting in multiple • Headaches Fe r fertilised eggs are allowed to grow for a short period embryos into the womb more precisely. pregnancy and multiple births (twins or • Food cravings or aversions of time before being implanted into the uterine • Pre-implantation genetic diagnosis, triplets). Multiple births carry risks to the • Mood swings lining. A successful pregnancy can be confirmed which involves the screening of embryos health of both the mother and the unborn • Frequent urination, especially in the night about two weeks later. for pre-existing genetic conditions, prior babies. The risk of premature delivery • Urine leakage when coughing, sneezing Initially used more in cases where the to implantation. in multiple is high, and or laughing fallopian tubes are blocked or damaged, IVF is babies may be born too early to survive. • Increased body temperature now used to treat many causes of infertility, such as INTRACYTOPLASMIC SPERM Premature babies require prolong and • Enlargement of the abdomen endometriosis and male factor, or when a couple’s INJECTION (ICSI) intensive care and may run the risk of infertility cannot be unexplained. This method involves directly injecting a healthy lifelong handicaps due to preterm delivery. A is the best way to determine looking sperm into the cytoplasm of an egg • Higher risk of ectopic pregnancy, if you’re pregnant. Home pregnancy test kits are The basic steps in an IVF treatment cycle are: through its shell. This is used when the sperm especially if the woman has existing available over-the-counter and are considered highly • Ovarian stimulation: Medication or “fertility may be unable to fertilise the egg even in close problems that affect her fallopian tubes. accurate. Your doctor will also be able to conduct a drugs” are used to stimulate multiple eggs to proximity using the conventional IVF method, • Miscarriage pregnancy test. grow in the ovaries rather than the single egg which is usually due to severe sperm factor. • Possible higher risk of birth defects that normally develops each month. Physical, financial and emotional stress Credits: The following health institutions were consulted in this chapter: • Department of Urogynaecology; Department of Reproductive Medicine; Egg retrieval Complications associated with costly treatments with a • Women Wellness Centre; Nursing – KK Women’s and Children’s Hospital; ; Fertilisation and embryo culture Like all medical treatments, fertility programmes high incidence of failure at any point of Department of Obstetrics and Gynaecology , Singapore General Hospital; • Obstetrics & Gynaecology Department, Bao Zhong Tang TCM Centre, • such as IVF and ICSI carry some risks. the treatment. Singapore.

110 BEAUTIFUL INSIDE OUT 111111