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When I was an adolescent, I never imagined what it was like to be pregnant, go into labor and give birth. I was already 17 when my mother had her last child, and I vividly recall visiting my mom in hospital after she’d endured a difficult breech labor. My baby sister was adorable and pink, my mother looked exhausted and spent, while my father danced around, snapping away with his Polaroid as we welcomed the final edition into our family of 8. I never expected that in a flash – less than 6 years later – it would be my turn. This time I was the one being fussed over, while my newborn daughter was being measured and examined by the pediatrician. My entire extended family, my bemused hubby and his parents, all crowded around my bed jabbering excitedly. My daughter, all 3 lbs. 8 oz. of her, slumbered unfazed in her bassinet through the cacophony of billing and cooing well-wishers. I looked on, jubilant that the ordeal was finally over, and the attention had shifted off of me. Now that I had been properly initiated into the horror of labor and childbirth, I silently vowed never again to put my body through the grind. Fast forward 2 years and we were celebrating Anne’s second birthday; there I was leaning over her, 5 months pregnant, urging her to ‘wish’ before extinguishing the spluttering number 2 candle atop her Thomas-Tank-Engine cake! Her fan club were all present, singing Happy Birthday at the top of their voices, to my demurely composed Anne! Anne had been such a good and easy baby that we figured she deserved a sibling. we were expecting a boy and our family would soon be complete. However, it was not to be. A week later I lost baby Willie, as I had christened him from the outset, to pre-eclampsia. I held him stillborn in my arms and wept inconsolably, cursing the fates that had allowed this to happen. I was told I was lucky to have survived, but darkness eclipsed my whole world. And just like that, depression took hold. I was so down that I lost interest in my family and the world around me. My mother stepped in, and if it wasn’t for her strength and faith, I would have plunged headlong, utterly lost my footing and fallen into an abyss of no return. It was months before the ether cleared – if you’ve suffered a miscarriage, lost a baby to stillbirth, you’d understand the all-engulfing sadness and guilt that gnaws away at your insides, leaving you raw and numb. I clung to the image of my son as I had held him, tiny, cold and unresponsive, yet perfectly formed. The wake-up call that finally brought me to my senses was Anne. She’d been coming into room my for a cuddle and a kiss, before being whisked off to play-school. One morning she clambered onto my lap and propping herself up, she looked squarely into my face and said, “Mama sad”. After making this pronouncement, she wrapped her chubby arms around my neck and pressed her head against mine and sighed, almost inaudibly. It was as though someone had dunk me into icy cold water. I finally realized that my withdrawal was hurting others, not least the one who needed me most, Anne. Needless to say, I recovered, but in stages. I vowed to dedicate myself to my husband and daughter. Could I make up for lost time? Unequivocally no; grieving is a very personal journey and necessary for the human soul and psyche, at least that’s what I found out. After losing a child, even one that is still born, you need to grieve. If not for the loving patience and support of my husband, buoyed up by a close-knit family, I doubt if I would have survived the episode. I never thought of myself as a strong person, but such experiences prove your mettle, mold you. Ultimately it was my Anne who led me out of the darkness and back into the light and warmth of love. Carrying Willie left an indelible mark on me, changing me forever. It taught me how fleeting and precious life is, how we should never take anything for granted. I try now to live in the moment.

"I’m sorry but your baby’s condition is not compatible with life,” I told E. She was dumbfounded. She could not believe what I was saying. As I continued to show her the images of her baby on the ultrasound, she began to realize that this was really happening. Tears started to roll down her cheeks as she touched her growing tummy gently. E, 32, has delivered two healthy children aged 4 and 2. This was her third pregnancy. Ultrasound examination at 12 weeks of gestation revealed that the bones around the front and sides of the head of her baby were missing and the brain was underdeveloped. Her baby had a serious birth defect called anencephaly in which the brain and the skull of the baby are not fully developed leaving part of the brain exposed in the amniotic fluid. During foetal development, the brain is formed from a tube-like structure known as neural tube which arises from the rolling and fusion of a flat plate of cells. The neural tube normally closes at around 3 to 4 weeks of gestation. If it fails to close properly, the developing brain will be exposed in the amniotic cavity. The amniotic fluid will slowly cause the brain tissue to degenerate resulting in a loss of a large parts of the brain. The bones of the skull are also missing or incompletely formed. The birth defect is called anencephaly. About 75 percent of babies with anencephaly are lost in miscarriages or stillborn. Newborns who survive are mostly unconscious and are usually blind and deaf. Some babies that have a remnant primitive brain tissues may seem to respond to sound or touch, but their reactions are involuntary. The newborns usually die within several hours, days, or weeks. It is estimated that anencephaly occurs in 1 in 5000-10,000 pregnancies. The exact number is difficult to estimate as many anencephalic babies end in miscarriages. There are more female newborns than males, possibly because of a higher rate of miscarriages or stillbirths among male fetuses. Causes of anencephaly are unclear and complex. It is likely caused by the interaction of genetic and environmental factors. Some of these factors have been identified, but many remain unknown Among the environmental factors, folic acid deficiency in the mother before and during pregnancy is probably the most significant. Other possible maternal risk factors include diabetes mellitus, obesity, exposure to high heat (such as a fever or use of a hot tub or sauna) in early pregnancy, and the use of certain anti-seizure medications during pregnancy. Anencephaly is usually diagnosed during pregnancy by ultrasound or MRI. There is no known cure or treatment for anencephaly. Support and grief counselling to help the mother and her family cope with the loss of her child are most important. E decided to continue with her pregnancy because of her religious belief. However, at 30 weeks of gestation, she could not feel the baby’s movement for a day. Ultrasound examination confirmed an intrauterine death. She opted for induction of labour which was carried out with insertion of vaginal medication. The foetus was delivered normally after 5 hours of labour. E remained calm throughout her stay in hospital and was discharged well on the next day. On her review 6 weeks later, E passed me a note in which she wrote. “Doc, thank you for respecting and supporting me on my decision to continue with this pregnancy. This has given me time to prepare psychologically after birth when I am most vulnerable. All of the pain and all of the grieving we went through has absolutely been worth it. I could have chosen an easy way out by terminating the pregnancy. But I feel that would have been showing a terrible example to my children - it would have been akin to saying them that if there had been something wrong with them, I would have terminated them as well. God Bless”.

Nita used to think that having a big brood of lively and healthy kids, with a doting husband to boot, was the definition of marital bliss and domestic fulfillment. As a young girl back in her hometown of Pekanbaru in the Riau Province of Indonesia, she had always dreamt of this whilst helping her father in their vegetable allotment. When she met her husband Ram and eventually moved to Singapore more than twenty years ago, it seemed as though she was on the cusp of realizing that dream. The first few years of Nita’s simple life were idyllic; she and Ram worked feverishly to save for a flat of their own. Nita being a nimble with needle and thread managed to find work making alterations at a small boutique, while Ram worked as a crane operator at a large construction firm. When they found out they were expecting their firstborn, their happiness knew no bounds. Baby Gerard was ushered into the world on the same day Ram was promoted to assistant foreman at his job site, a sign that the stars were aligned in their favor. Time passed and the couple welcomed two more children in quick succession; they imagined their family was complete. Then disaster struck when Ram suffered a slipped disc; it proved far more serious as it had affected critical vertebrae in his spine and he was confined to bed. Upon recovery a month later, the specialist advised him to lay off strenuous work altogether, as it could lead to paralysis. Not wanting to incur workplace injury that would threaten his mobility, Ram tried to negotiate with his boss for lighter duties. However, he was unsuccessful and ended up being retrenched; his firm was downscaling since the construction industry was entering a slump. Despondent and nursing a bad back, Ram became increasingly moody and withdrawn, leaving Nita to manage their 3 boys, then 10, 6 and 4, single-handedly. An added worry that beset Nita, causing many a sleepless night, was the fact that she was pregnant once more. Though only a few weeks along, Nita recognized all the classic symptoms, particularly a strong craving for hot and spicy food. Gerard a sensitive boy and the eldest, realized something was amiss when his mother would suddenly rush from table to retch in the back room. Ram however was oblivious to the situation, gripped by his own malaise. When I met Nita at the polyclinic, she was already 12 weeks pregnant. Attired in a loose smock and being rather petite, she concealed her condition well. She wanly told me that against her better judgement, she had decided on termination. I could see hopelessness etched in her careworn, prematurely lined face. “As a mother I should be protecting my child, but I don’t know what else to do,” she whispered, her breath catching on the last word, she began to sob piteously. I weighed my response carefully, urging she discuss her decision with Ram. But Nita’s mind was made up, she felt that Ram had enough to bear, was barely coping as it was. She shared that her salary barely put food on the table, and Ram’s compensation package, meagre to say the least, went toward his medical expenses. Still I entreated her to reconsider. She acquiesced, all the while cradling her belly with both hands, as though warding off an invisible blow to the fetus within. To me, this spoke volumes, presaging how she felt about the abortion. Nita and I became very close as a result of her coming to see me; I managed to put her in touch with various government agencies that offered her some measure of provisional relief and family support. Through aLife’s best efforts, we were able to get the family re-housed into a smaller, more affordable rental flat, which was a temporary reprieve on their finances. This was a huge relief for Nita and Ram. When Nita opted to continue with the pregnancy, a decision occasioned by the first fluttering of movement in her womb, I signed her up for the ‘Milk & Diaper Program’. Through this platform clients are supplied with disposable diapers and infant milk formula within the first two years of their baby’s birth. aLife was there for Nita at every turn; we found someone to mediate when unemployed Ram, at his lowest ebb, resorted to anti-depressants. The case worker was able to steer him back on the right path, and find him a job as a part-time school-bus driver. Moreover, aLife was instrumental in helping to find a tutor pro-bono for all 3 boys. They were also enrolled for enrichment activities and literacy classes at the Centre, giving them a much-needed head start at school. Best of all, aLife rejoiced with the family when their bundle of joy, a healthy baby girl, was delivered safely on Christmas Day that year, over a decade ago! She was not only a much-cherished gift of life but the long-awaited daughter Nita had secretly prayed for. Nita has never forgotten what aLife has done for her and her family. She and the boys volunteer regularly at the Centre, and though they may not have much materially, their contribution of time and talent is immeasurable. Nita designs and sews costumes for drama plays, Gerard, an eagle boy-scout, organizes holiday camps for the Caterpillar Club kids. Ram too does his part, ferrying beneficiaries to and from the Centre for family services like counselling. Moreover, aLife greatly values that he and his boys help collect, pack and deliver rations to needy families. “Paying it forward is the least we can do, it also sets a good example for my kids to always be mindful of others less fortunate than ourselves,” Ram shared. ‘We know first-hand what it’s like to struggle and live rough.” What is even more astounding, despite the odds, Nita and Ram welcomed their fifth child early last year! Though little Nathan was born with Down’s Syndrome, his wide-eyed wonder and responsiveness to his siblings is such a blessing to everyone, even perfect strangers comment on his friendly cheerfulness. “God has been very good to us…”, Nita told me the last time we met up. “True, He has sent us testing times, but look at our dividends!” Resisting her initial decision to abort her daughter Noella, now 11, has molded Nita into a deeply spiritual person. “I used to be fearless and stubborn, believing I was tough enough to deal with any situation. But if not for divine intervention, a guiding light, I wouldn’t be where I am today!” she beamed. Whenever she speaks of her family, Nita is inexplicably transformed, lit-up from within, her energy is infectious. I even catch myself envying her, why, I’m not quite sure. Maybe it’s the fact that nothing gets her down nowadays, she’s buoyant and upbeat despite her on-going struggles and financial hardships. But then her philosophy is simple as it is heart-warming, “Fairy-tales do come true…For Ram and me, home is wherever the children are, where they’re safe and contented, that’s all that matters!”

G’s husband entered my consultation room looking worried and distressed. “Doc, I need you help urgently,” he said. "You just delivered my son a week ago. My wife was well in the hospital except for a few episodes of what I thought were “baby blues”. When she was back at home, she could not sleep at night and would roam about in the room feeling high and singing loudly to the baby, even though the baby is asleep. She has also become increasingly irritable and lashes out at everyone close to her. Her behaviour has gone erratic and weird. Last night, she told me that somebody in the hospital had swapped her baby. She could hear voices telling her that our neighbour was plotting to kill her. I am at my wits' end and feel really helpless and desperate. What shall I do now?” G is suffering from a rare but serious mental health illness called postpartum psychosis. It is much less common than baby blues or postnatal depression and occurs in about 1 in every 1000 women (0.1%) who has delivered. Patients with this condition usually have symptoms which start suddenly within the first two weeks after giving birth. Occasionally, the illness may start several weeks after the baby is born. Symptoms vary and can change rapidly. They include: Hallucinations: These are sensations that appear to be real but are created within the mind. E.g. hearing voices which are not there. Delusions: These are thoughts or beliefs that are unlikely to be true.High mood (mania), feeling “high” and  low mood, with signs of depression Restlessness and confusion Causes of postpartum psychosis are not well understood. But there are several risk factors, including family history and genetic factors. Hormone levels and disturbed sleep patterns may also be involved. Mothers with a history of a traumatic birth or pregnancy, bipolar disorder or schizophrenia are also more vulnerable. As postpartum psychosis is a serious illness, I referred G to the psychiatrist, who admitted her immediately to the hospital and started medical treatment with antipsychotic drugs and mood stabiliser. G’s condition improved slowly with medications and behavioural therapy and was discharged from the hospital after 2 weeks. She looked well when I saw her 6 weeks later. She still occasionally felt depressed and anxious with little social confidence. With a strong family support, G has fully recovered from the illness 8 months after her delivery.

Have you been effectively communicating with your loved ones? Our words have the power to build our loved ones up and guide our communications in the right direction, or they can have the opposite effect. But our words only account for 7% of the overall message that is communicated, which means that 38% of what we communicate is done through our tone, and 55% is done through our body language. Keeping that in mind, here are ten positive family communication rules you can follow in your home to generate loving relationships: Think before you speak. Take the time to think about what you want to say before you say it. Make sure your words, tone and body language reflect what you mean. Tell the truth. It might feel like the right thing to bend or hide the truth to avoid hurting your loved ones, but being dishonest breaks trust. However, the truth should always be spoken gently and with love. Being brutally honest hurts feelings, but gentle truth builds intimacy. Respect each other’s viewpoints. Is it more important to be “right” or protect your relationship? Remember there are a lot of “rights,” depending on who you are talking to, so avoid getting caught up in right vs. wrong, and instead learn to respect each other’s differences. Ask directly for what you want, desire or need. How many times have you said “He should just know what I need?” People are not mind-readers, and many of us have short term memories. So keep saying “Will you please…?” Listen to yourself. The only way for us to know how our words and tone truly sound to others is to pay attention to ourselves. Listen to how slow or fast you speak, how soft or loud you are, how loving or angry you may sound. This is what your family members hear. Let others speak. You know how frustrating it can be when you are trying to speak and someone cuts you off in the middle of your sentence. Allowing others to speak until they are finished without interrupting is a great rule for everyone to follow. No psychics allowed. Avoid making assumptions about another’s thoughts, feelings, or anticipated behavior because none of us are mind readers. If you want to check in with someone and ask if your assumptions are true, that is okay, but you must never act on them (as if they are true) by making accusations or criticisms. Be open about your feelings. Give absolute permission for all family members to verbalize (not act out) what they feel, see, want, think and sense. Be careful that you do not squelch feelings and perceptions you disagree with. Acknowledge and validate all feelings so there is freedom to express again in the future. Be a good listener. When someone is speaking to you, give them your attention. Avoid thinking about what you are going to say next. Focus on what is being said, what your family member might be feeling, and how you can empathize. Enhance your communications. You can improve your communications by learning to ask for clarification or checking in with your family member to verify your understanding. Simply say, “So what I’m hearing you say is…”, and repeat back what you heard. Communication is something we do every day, yet it’s still one of the most difficult areas in a relationship to navigate. If we practice and pass on healthy communication rules to our children, it will be easier for them to have successful relationships. (Taken from: http://www.themomiverse.com/motherhood-and-family/10-positive-family-communication-rules-for-your-home/ ) Should you feel communication at home could improve but don’t know where to begin, why not speak to our Counsellor who can help you process and work through some of it? Contact us at 62588816, email contact@alife.org.sg or book an appointment online at https://www.alife.org.sg/book-online/counseling-service

F,40, a mother of two walked into my consultation room with a wobbly gait. Her face looked as white as a sheet. She had to pause frequently to catch some breaths while talking. “Doc, I have been having heavy periods with clots for a year. But it is manageable as the bleeding would stop after 5 days. But for this month, it is terrible. I have to change the menstrual pad every hour and the bleeding does not seem to stop. I have bled for the past 10 days and I feel very week and giddy now.” F’s pulses were rapid, weak and thready at 112 /min. Her blood pressure was low at 80/50mmHg. Fresh blood was oozing out from the vagina. Her uterus and ovaries were normal. Ultrasound examination of the pelvis did not reveal any fibroid or ovarian cyst. She was anaemic with a low haemoglobin of 6.7g/dL (normal range 11.5-13.5g/dL). She was admitted to hospital straight away and was transfused with blood. When her condition was stable, a hysteroscopy was performed. This is a procedure in which a thin telescope is inserted through the cervix into the uterus to examine its cavity. The tissue lining the uterus (endometrium) was sampled for microscopic examination. F’s heavy bleeding was due to the shedding of a thickened endometrium from hormonal imbalance. Many women of reproductive age have heavy menstrual bleeding but a large number do not seek treatment until severe anemia sets in, causing symptoms like breathlessness and giddiness. Hormonal imbalance is one of the common causes of heavy periods. In a normal menstrual cycle, there is a balance between the hormones secreted by the ovary. These hormones regulate the endometrium, which is shed during menstruation. If hormonal imbalance occurs (which may be due to the ovary not producing and/or releasing the egg), the endometrium grows thicker and finally sheds by way of heavy bleeding. Other common causes of heavy menses include uterine polyps , fibroid, ovarian cyst, endometriosis and pelvic infection. Medications are usually given first to treat heavy menstrual bleeding. They include hormones, oral contraceptive pills, clot promoters (tranexamic acid) and hormone manipulators (Gonadotropin releasing hormone, GnRH agonists) Other modes of treatment include: Insertion of hormonal intrauterine device (IUD) commonly known as Mirena. This is a hormone impregnated IUD which releases a hormone to thin the endometrium and reduces menstrual flow, Endometrial ablation in which the endometrium is destroyed with heat using hysteroscope or other devices, Surgery: This includes removal of uterine fibroid(myomectomy), polyp (polypectomy) ovarian cyst (ovarian cystectomy) or the uterus (hysterectomy). F had been sterilized by tubal ligation previously. She was not in favor of taking hormones. She opted for endometrial ablation using Thermablate. (fig. 1) This is a non-hysteroscopic technique in which a heat shielded catheter is inserted into the uterine cavity. At the tip of the catheter, there is a soft tipped silicone balloon. A heated sterile liquid flow through the catheter and into the balloon which is inflated and conformed to the contour of the uterine cavity (fig. 2). It is less invasive and is done under a short general anesthesia. Patient has a short recovery time and can assume normal activity within a day or two. Mild side effects include cramping, nausea and vomiting, spotting and/or discharge after theprocedure. F had the procedure done 8 months ago. Her menstrual flow had reduced significantly. Her hemoglobin returned to normal and she was happy with the outcome. Figure 1 Figure 2

I met Madam R and her husband Encik S some years ago at a social service agency. At the time, Encik S worked as a school-bus driver, while Madam R was a home-maker and skilled seamstress who took in tailoring commissions from neighbors to supplement the family income. A hard-working couple, they upheld family above all else. When Madam R gave birth to her first child, a boy, it was apparent even to her that he was not a normal baby. Although full-term, his limbs appeared stunted and frail. It came as a jolt to learn that he was congenitally blind as well. However, Madam R and her husband were proud of their little baby, and from the moment Encik S laid eyes on him in the maternity ward, he was smitten by his son’s jet-black curly hair and sweet smile. Their hearts were captivated and little Johari completed them. Initially it was hard as he required all Madam R’s time and attention, plaintively crying when it was chilly as his stricken limbs would go numb. In the years to follow, the couple went on to have 5 more kids. When Madam R went in for a routine examination while carrying her second child, she was asked to consider abortion, as the fetus’s development seemed anomalous. Madam R, being a devout woman, mentioned to me that it was never an option for her to end a life simply because the baby’s development was not consistent with what was considered ‘normal’. I remember at the time having mixed feelings about this; on the one hand there was the ethical aspect and I respected her for her staunchly held views. Conversely, I questioned bringing a child into the world who at inception already had a string of defects to contend with. Johari who was already a toddler when his sister was born (also blind and mentally challenged), was according to his parents a chubby and cheerful little boy. I was overwhelmed when Encik S pulled out his wallet and proudly displayed snapshots of all 6 kids. It was one of those multi-leaved wallets, and I couldn’t help feeling that he was indeed a wealthy man as it bulged not with dollar notes, but rather a makeshift album of memories. Each time Madam R went into labor, she ensured that she never revisited the same medical facility twice for fear she was a ‘marked’ woman. She had good reason to be wary, as each time she added to her brood, the baby would be born with something amiss. Each time she would be advised to speak to an expert on family planning. Each time she chose to move on. She and Encik S had both come to expect their babies to be born with some kind of defect. If they wondered why, they did not question their fate. It was the ‘norm’ for them, up until baby number 5 came along. Healthy in every respect, his arrival was accompanied by a lusty cry and a voracious appetite to match. Iskandar, now a grown man and recently married, adores his siblings and idolizes his parents for their unstinting love and support despite the odds. I met him recently quite by chance when I happened to bump into the entire family at a night-market in my housing estate. Later, over drinks at the neighborhood kopitiam, his proud parents regaled me with stories of his callow youth, while this handsome and solemn young man listened indulgently. At the first lull in the conversation, he remarked how growing up, he’d look on as his mother and father struggled to put food on the table and school them. His four elder siblings all attended a special school, but rather than keep them there to board for the entire week, his father would fetch them home after day-lessons, sending them back in the morning. His mother would ensure their uniforms were spruce and ironed for the next day. Madam R cut in at this point to add that only her kids wore a green uniform rather than the standard orange one. This was to differentiate them from the boarders. Iskandar, eyes shining with respect, hugged her and I felt a lump in my throat. I had honestly never known such devotion. The baby of the family, Jun, 17, also mentally challenged and both hearing and visually impaired, shows a great fondness for music and finger-painting. She is also very attached to Iskandar. Even his new-bride, Lisa, joked, ‘inseparable’, rolling her eyes in mock despair. I was curious how she felt marrying into this unique family. Lisa who struck me as a practical and no-nonsense person had this to say, ‘Marry a man marry his family, right? But seriously life is a gift, everyone, even the less fortunate, have a right to be here. At the end of the day, looking after them and caring for their needs can be tough, but I truly believe we are better human beings for it.’ In the face of what may seem like adversity, many may label Madam R and Encik S ignorant and foolhardy. Their mutual choice to defy the odds and raise a family of children with multiple defects, albeit one, may seem irresponsible and even a recipe for disaster. Personally, I salute Madam R and Encik S. Their cheerful outlook belies a stoicism and deeply engrained spiritualism that has carried them through the years. Their story is one of hope and inspiration and causes one to reflect on the premium we put on human life. (All names have been changed to ensure anonymity)

She looked anxiously on the monitor screen while I scanned her with the ultrasound machine. “Doc, is the cyst still there?” She asked. “No, it’s gone” I replied. “Thank God!” she exclaimed joyfully. M, 30, experienced some niggling pain on the right side of her lower abdomen 2 weeks ago. She saw me a week later when the pain started to get worse. A vaginal ultrasound scan then revealed a 3 cm cyst in her right ovary. It was filled with clear fluid with no solid components. The blood tumour marker test CA125 was normal. I told her that it was probably a functional cyst. As it was around the second half of her menstrual cycle, I told her to have a re-scan soon after her menses. The cyst has since vanished on her second scan. What is a functional cyst? A functional ovarian cyst is a sac that forms on the surface of the ovary during or after ovulation. It holds a maturing egg. Usually the sac empties itself after the egg is released. However, if there is disruption in the way the ovary produces or releases an egg, a functional cyst may develop. There are two types of functional cyst, the follicular and luteal cyst. · Follicular cyst: The cyst is formed in a follicle where the egg is not released properly during ovulation and fluid rapidly accumulates and causes a  swelling. · Corpus luteum cyst: The cyst develops in the corpus luteum, which is the tissue that fills an empty follicle once it has released the egg during ovulation. The cyst may bleed and cause pain. Functional ovarian cysts can occur at any age but are much more common in women of reproductive age. They are rare after menopause. They are also different from other abnormal ovarian cysts or growth such as cancer as they usually subside without any treatment. But occasionally, the cyst can expand rapidly, become large and cause complications such as bleeding or get infected, twisted or rupture. What are the symptoms? Most functional ovarian cysts do not cause symptoms. The larger the cyst is, the more likely it may cause symptoms, which include: · Lower abdominal pain which is usually mild. · Delayed menstrual period. · Irregular vaginal bleeding. · Pain during or after sex. · Frequent urination if the cyst is big and is pressing on the bladder · Severe abdominal pain if the cyst develops complications How is it diagnosed? Functional cysts are diagnosed by pelvic ultrasound. The cyst will reduce in size or disappear around menstruation as in M’s case. If the cyst is big, it may take one or two cycles to resolve. M was treated conservatively with medications for pain relief and heat pads to sooth her tense muscles and anxiety. The pain subsided with the dissolution of her cyst. She was monitored for another two menstrual cycles with no sign of recurrence. She has remained well since.

“You should have your womb checked as you have been taking tamoxifen for a while now,"  the oncologist advised M, a 52-year-old housewife who had a stage I cancer in her right breast 2 years ago. The cancer was detected during a mammographic examination at her annual health screen. It was small, about 5 mm  in size. The lymph nodes in the axilla were not involved. M decided to have a lumpectomy, in which the tumour, together with part of the right breast, was excised. After the surgery, she had radiotherapy, followed by hormone therapy since the cancer cells were positive for oestrogen receptor. Breast cancer is the most common cancer among Singaporean women accounting for more than 25% of all female cancers. According to statistics, between 2011 and 2015, there were 1,927 women diagnosed with breast cancer and over 400 deaths from the disease each year. These figures will escalate with our ageing population as the risk of getting breast cancer increase with age. Chinese women are at a higher risk, when compared with Malays and Indians. Depending on whether the cancer has spread within the breast or to other parts of the body, breast cancer is classified into 5 stages. The stages are the numbered zero (in situ carcinoma, which means it is not invasive and does not have metastatic potential) and the Roman numerals I, II, III, or IV. The higher the number, the more advanced the cancer. In M’s case, her cancer was stage I, indicating that the growth is less than 2 cm without spreading to the axillary lymph nodes. Treatment for breast cancer consists of surgery, radiotherapy as well as drug treatments like chemotherapy, hormonal (also known as endocrine) therapy and targeted therapy that are used after surgery to lower the risk of relapses and improve the cure rate. About 80% of all breast cancers are “oestrogen receptor-positive.” (ER+) which means the cancer cells will grow in response to the female hormone oestrogen. In M’s case, tamoxifen was used to suppress the influence of oestrogen on the cancer cells. Tamoxifen is a non-steroidal anti-oestrogen. It is the most commonly prescribed drug and can be given for 5 years or more. However, it has a drawback. Although effective in suppressing breast cancer cells, it can stimulate the cells lining the cavity of the womb (endometrium). As a result, the endometrial cells may become hyperactive (endometrial hyperplasia), uterine polyps may occur and uterine cancer may develop. Nevertheless, studies have shown that the small risk of developing uterine cancer is outweighed by the significant survival benefit. The committee of gynaecologic practice of the American college of Obstetricians and Gynaecologists in 2014 stated that tamoxifen use may be extended to 10 years based on data demonstrating additional benefit. But patients should be warned about the risks of abnormal changes in the lining of the womb and womb cancer. M did not have any abnormal vaginal bleeding, bloody vaginal discharge, staining, or spotting. The thickness of her endometrium was less than 5 mm on ultrasound examination, which indicated that there was no obvious abnormal cellular activity. She understood the possible side effects of tamoxifen on her womb and agreed to come for monitoring on a yearly basis.

Fact number 1: A union between two persons usually involves their larger families a lot more than one realizes. It is often when you are already married that you see how your respective family of origin (refers to the significant caretakers and siblings that a person grows up with, or the first social group a person belongs to, which is often a person's biological family or an adoptive family ) comes into play. Fact number 2: We all need and crave for our spouses to show us love and care. Sometimes, we don't feel it at all even if we know they do. Fact number 3: Sometimes the role may be reversed. We do sincerely love our spouse but don't really know how to make it known to them. So how do we find out if they love us? Usually, it is demonstrated more than vocalized. Gary Chapman shares that we usually express our love in 5 different ways and he has categorized them into 5 Love Languages. Identify your preferred love language; how you like to be shown and receive love and your spouse may share his/hers with you. Now that you completed the test, you may start noticing how your spouse has been expressing his/her love for you. It may differ from your preferred way of being shown love and perhaps that is why you may be wondering if you are loved. You may also start to express your love for your spouse by 'speaking' his/her preferred Love Language for your spouse to 'receive' your love. It'll be a fun exercise; why not give it a try soon?

S and her husband were devastated. She had just miscarried. She was hoping that things would go well in her pregnancy. At five months of gestation, she suddenly felt the water bag burst with a gush of “water” running down her legs. Without any warning of abdominal cramps or pain, the baby just slipped out of her within minutes. All these happened so fast that she did not even have time to call her husband who was working. This was S’s second pregnancy. Her first pregnancy was terminated at 10 weeks gestation when she was a teenager many years ago. There was lack of support from her boyfriend and her family then. When S was married a year ago, she did not waste any time trying to conceive. She was overjoyed when she realised she was pregnant a month after her marriage. However, her excitement was short-lived. S has cervical incompetence or cervical insufficiency, a condition in which the muscle fibres of the cervix (neck of the womb) are weak. In a normal pregnancy, the cervix is close and firm. It would hold the baby in the womb till it is full term. In cervical incompetence, the cervix is unable to hold the baby when it reaches a certain weight, usually in the second trimester. The cervix would open early, with the water bag bulging through. Without any uterine contractions, the water bag would rupture and the baby delivered prematurely within a short time. Some mothers may feel slight pressure in the lower part of her abdomen or may have some mucous-like discharge prior to the delivery but in most cases, there are no warning signs. The cause of cervical incompetence is not well-understood but seems to involve combination of inherent structural abnormalities and some external factors like inflammation. If the weakness of the cervix is due to a genetic reason, the miscarriage would happen in the first pregnancy. Otherwise, it may happen following a previous surgery on the cervix or trauma during a difficult birth or a D&C (dilation and curettage) from termination of pregnancy An incompetent cervix can be difficult to diagnose and treat. If there is a history of fast miscarriage or premature birth in the second trimester, a procedure that closes the cervix with strong sutures (cervical cerclage) may be recommended in the subsequent pregnancy. After S had overcome her grief, she conceived again within a short while. At 14 weeks gestation, her cervix was found to be soft  and short. A cervical stitch using a synthetic tape was performed and S was advised to rest in bed most of the time. She was asked to abstain from sex and not to put on weight excessively by eating a well-balanced diet. Progesterone medication was given. Her antenatal course was closely monitored for infection. Fortunately for S, her pregnancy this time progressed smoothly. The cervical tape was removed at 38 weeks of gestation and she delivered a healthy baby boy normally.

I think parenting has been the hardest job I have ever been given in my entire life yet at the same time, it is the most rewarding. Do you agree? I was a perfect parent….. before I became one. Whenever I saw children throwing tantrums in public with parents at a loss as to what to do, or whenever parents get upset in such an uncool way – I would roll my eyes and declare that they are just failures, muttering under my breath that “if it was my child, I would smack the child and tell him to behave or face the consequences….” Well, I have had to swallow many humble pies since becoming a mom 14 years ago. Just when I thought I’ve mustered motherhood with my elder daughter, number 2 posed a whole different set of creative challenges! Parenthood has forced me to continuously reflect, examine and transform myself to be a better parent and person...and I’m certainly still a work-in-progress! The influence we have on our children is way deeper and further than we know; what was your own childhood like? Take a minute to just reflect on how your parents have impacted and molded you into who you are today. How did the way they love or not love each other affect you? What about the way they tackle their disagreements? What sort of memory do you have of your growing up years? Which traits did you inherit from them that you would gladly pass onto your children? What about the ones you are least fond of? How are you going to do them differently? What are your most memorable lesson as a parent? Care to share? Which parenting style have you been adopting? What are your thoughts? To ascertain which is your primary parenting style, click on this link. https://www.brighthorizons.com/family-resources/parenting-style-four-types-of-parenting At aLife, you may wish to seek counselling concerning parenting matters. Call us at 62588816, or email contact@alife.org.sg or book an appointment online at https://www.alife.org.sg/book-online/counseling-service