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I saw S, a first-time mum in her second trimester who complained of chills, shivering, fever and excessive sweating for the past 3 days. She had frequent urination accompanied with pain and a burning sensation. The urine was cloudy with an unusually strong smell. She also felt her womb tighten quite frequently. She was having a high fever of 39-degree C. She looked dehydrated with cracked lips and a dry tongue. Her abdomen was soft with frequent uterine contractions. The foetal heart rates were rapid at 180/min. Both her loins and the lower abdomen were tender to touch.  She was quickly admitted to the hospital for observation. S was having a severe urinary tract infection (UTI) affecting both her bladder and kidneys. UTI is a common medical complication during pregnancy. It is estimated that bladder infections and kidney infections affect 1-4% and 0.5-2 % of pregnant women respectively. However, in up to 2 to10 % of pregnancies, the bacteria may remain dormant in the urine without manifestation of symptoms (asymptomatic bacteriuria). UTI is more prevalent in the pregnant than in the non-pregnant state, as the muscles of the tubes (ureters) that connect the kidneys to the bladder are relaxed due to the hormonal changes during pregnancy. This slows down the passage of the urine and allows bacteria time to multiply before they are flushed out. Similarly, urinary drainage is also impeded when the growing womb presses directly on the bladder and the ureters as pregnancy progresses. If the UTI goes untreated, the health of the mother and the baby may be affected. For the mother, an infection in the kidney may lead to scarring, with consequent high blood pressure and kidney failure later in life. For the baby, UTI can irritate the womb and cause premature birth. It is also associated with hypertension in pregnancy (pre-eclampsia), premature rupture of membranes (water bag) and low birth weight of the baby. UTI can be safely treated with appropriate antibiotics during pregnancy. Microscopic examination of S’s urine showed a large number of white blood cells. Urine sample sent for the culture and sensitivity tests revealed that she had E. coli bacterial infection which was sensitive to penicillin. S responded well to the antibiotic and her fever subsided within the next two days. To prevent relapse of UTI, S was advised to drink at least 6-8 glasses of water every day.  Unsweetened cranberry juice is a good beverage to consume as it reduces bacterial growth. She was advised not to hold her urine in. She should pass urine and empty her bladder completely as soon as there is an urge to pee. She should urinate before and after having sex After urination, she should wipe her vulva from the front towards the back to reduce the spread of bacteria from the anus. The genital area should be blotted dry and kept clean. A mild unscented cleanser should be used to wash the genital area while showering. She should wear cotton rather than synthetic underwear and avoid tight jeans and trousers. S was well during a subsequent review. Another urine culture showed that the bacteria were completely cleared. She had no further episodes of UTI and has since delivered a healthy baby girl at term.

Normal menstruation is the result of the shedding of the lining of the womb (endometrium) together with the blood. To facilitate the flow, anticoagulants are released by the body to keep the menstrual blood thin and fluid. If the menses are heavy and the blood is expelled too quickly, anticoagulants do not have enough time to work. As a result, blood clots will form. These clots are usually bright red or dark in colour. They are often released on the heavy days of menses and make the menstrual blood look thick. Occasional blood clots during menstruation is normal and is not a cause for concern. However, if this occurs repeatedly and is accompanied with heavy bleeding, severe anaemia, where there is a lack of oxygen carrying red blood cells may result. Some women are so accustomed to heavy menses that they may not notice the severity of the condition. Over time, excessive blood loss may lead to weakness , fatigue ,heart failure and even death. Thus, it is important to find out the underlying cause so that appropriate treatment can be given immediately. Common causes include: • Hormonal imbalance. In a normal menstrual cycle, there is a balance between two hormones-- oestrogen and progesterone --secreted by the ovary. These hormones regulate the growth of the endometrium. If hormonal imbalance occurs from irregular or defective ovulation, endometrium may grow in excess and shed by way of heavy bleeding. • Uterine fibroids. These are muscle growths of the womb. They can cause heavy or prolonged menstrual bleeding by increasing the surface area of the endometrium. • Adenomyosis. This occurs when the glands from the endometrium become embedded in the uterine muscle, causing enlargement of the uterine cavity and thus the bleeding surface. • Endometriosis: This is due to the backflow of the menstrual blood into the pelvis. • Chronic pelvic infection: This usually results from sexually transmitted diseases • Polyps: These are small, non-cancerous growths on the endometrium. • Intrauterine device (IUD). Heavy menses is a side effect of the non-hormonal intrauterine contraceptive device. • Cancer. Uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding. • Other medical conditions including thyroid problems, bleeding disorders, liver and kidney diseases may be associated with heavy menses Treatment: Appropriate treatment is given depending on the cause of the bleeding and its severity. It may include the following 1.Medications • Iron supplements with multivitamins to correct the anaemia • Pain killers, tranexamic acid and oral contraceptive pills have been used to reduce blood clots 2.Insertion of Mirena, an intrauterine contraceptive device (IUCD) impregnated with progesterone. The hormone will reduce the thickness of endometrium. 3.Surgical Treatment • Dilatation and Curettage (D&C ): This will remove the endometrium for microscopic examination. • Hysteroscopy. A surgical procedure when a telescope is introduced into the womb to remove polyps and fibroids • Endometrial ablation or resection using hysteroscope to burn off or remove whole or part of the endometrium. • Hysterectomy. This involves removing the entire womb surgically. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/.

Recently, I attended a medical workshop and seminar on HIFU in China. It is an innovative way of removing a solid growth in the abdomen without open surgery. Hifu stands for high-intensity focused ultrasound, a therapeutic system in which ultrasound beams are focused to generate localized heat to destroy tumour cells without damaging the surrounding organs. It is done with no skin puncture or incision. The way heat is generated by the ultrasound beams is similar to that using a magnifying glass to focus light from the sun. In female diseases, Hifu can be used to treat · Uterine fibroids -- a noncancerous growth in the muscle walls of the womb · Adenomyosis/adenomyoma--a painful condition where the lining of the womb is embedded in its muscle walls · Placenta accreta, an uncommon condition in which the after-birth is very adherent to the womb · Caesarean scar pregnancy, a form of ectopic pregnancy · Non-cancerous breast lumps The advantages of Hifu surgery is that it is non-invasive with low complication rates comparable to or less than those of key-hole surgery. Patient can go back to normal activities quickly after the procedure. However, the procedure may not be suitable if the patient has: · Severe heart or respiratory diseases · Previous multiple abdominal surgery or radiotherapy · Acute infection · Suspected cancerous change in the fibroid · Difficulty lying prone for at least an hour Common reactions to Hifu surgery include · Bloated feeling in the lower abdomen, · Pain at the buttock and legs which is usually short-lived · Temporary weakness in the legs. · Redness of skin and feeling of heat in the treatment area Rare complications include injuries to the bowels and bladder which is less than 0.1 %. For the treatment of uterine fibroids, the patient is carefully positioned in a prone position on a movable table that slides her lower abdomen into the opening of the ultrasound scanner (fig 1&2). Sedation is given during the procedure to prevent unnecessary body movement of the patient. Focused ultrasound waves(sonication) are used to heat up the fibroid in small portions up to 100 deg C. Tissue changes in the fibroid are monitored. The process is repeated until most of fibroid is burned. Each sonication lasts a few second and there is a rest period to let the tissue cool down. Depending on the size and number of fibroids, it usually takes one to two hours to complete the procedure. Throughout the procedure, patient will be asked about the level of pain, the feeling of heat on her abdominal skin, legs and buttock and the ability to move the legs. After treatment, there may be slight vaginal bleeding and some watery vaginal discharge but they are usually transient and disappear after a few days. Depending on the size of the fibroid, it may take a few months for the fibroid to be absorbed by the body. But most women would notice significant improvement in their fibroid-related symptoms shortly after the treatment. Hifu offers an alternative option for women who would like to have children as integrity of the womb is maintained and normal vaginal delivery can be achieved with reduced risks of uterine rupture. A number of women with fertility issues have been successfully treated with Hifu. However, further studies are needed to explore the long‐term outcomes.

“When I got married at 25, starting a family was furthest from my mind as I was busy building my career.  I was nearly 30 when I decided it was time to start a family.  After trying unsuccessfully for 6 months, I turned to my gynaecologist for help.  It was then we found out both of us had issues. The following months led to years of visits to numerous Western and Eastern doctors.  Each visit was filled with hope followed by loss.  Some months it was just unbearable. The accumulation of disappointments started to overflow into bouts of depression. I know some couples do not make it because they just cannot work out how to support each other. That is why I am grateful I have a very supportive and understanding husband who provided me with the emotional support I needed whenever the lows were deep and painful. I met another woman who was struggling to conceive as well and we leaned on each other for comfort. We reminded each other to take ‘mental holidays’ from TTC (trying to conceive) and egged each other on during treatments.   What happened ‘in the end’ you ask? Well, after 5 years we decided we would adopt and continue trying for a baby. Our daughter brought us so much joy that we often forget we are an adoptive family! Statistics say that the chances of conceiving increases when a couple adopts, well, it’s only 5% and we were not in that 5%. After 4.5 years, we adopted our second daughter. 15 years on, we are so grateful we changed our mindsets – our girls are indeed blessings and we remain forever grateful toward their birthparents for the gifts of life! Infertility is a silent grief which many amongst us experience that is difficult for others to understand. Oftentimes, the couple suffers quietly; gingerly avoiding full month parties, sometimes they fall into pieces on hearing someone else announce their pregnancy, festive seasons become torturous because they get asked over and over when they will bring a baby along to the next gathering… If you are going through a similar journey, know that it helps to speak to another on the same journey. It is alright, too, to take a break from treatments. Perhaps, set a realistic time line for plans to run on and when to change or explore other treatment plans. Remember too that there are people around you who love you, and whether or not you become a mom, they want to still hang around. Those who stop hanging around just because you can’t become a mom, perhaps they may have issues of their own that you are not aware of.  Men and women process emotions linked to infertility very differently; men are often more able to compartmentalise their emotions and can go about their daily tasks more steadily whereas women can often feel overwhelmed and struggle to manage their day to day tasks.  Knowing this does not mean that infertility impact males less than the females – they just handle it differently. If you know someone who has been unsuccessfully trying to conceive, offering a shoulder to cry on and a listening ear is always welcome. You can offer to help run some errands or accompany her when your friend is undergoing treatment. Refrain from saying, “You can always adopt”, “Just relax”, “It could be worse”, and a host of well-meaning, yet sometimes hurtful, comments. If you don’t know what to say, just be present for them. Do reach out to her husband too, who may also be feeling down and all the attention seems to be extended mainly to his wife. Invite the couple out. Ask them to go for a walk, watch a movie, grab some coffee, or any other enjoyable activity to provide a change of scenery and to recharge their spirits. At aLife, we journey with couples who are finding it difficult to conceive. Make an appointment to see our Counsellor if you would like us to journey alongside you. Call us at 62588816, email contact@alife.org.sg or book an appointment online at https://www.alife.org.sg/book-online/counseling-service .

“I am baffled by the medical terms, “abortion” and “miscarriage”. I always believed that they are two different medical conditions. Recently I had a miscarriage and had a D&C (Dilatation and Curettage) done. I was taken aback when my doctor labelled the miscarriage as a “missed abortion” in my discharge summary. I was confused. I told him that I had planned for this pregnancy for a while and I did not ask for an abortion. In order to allay my feelings of guilt, can you please explain to me the difference between these two terms?” This was the question posed to me by a member of the audience at the seminar I had recently spoken in. To most people, an abortion is different from a miscarriage. “Abortion” refers to the termination of pregnancy using artificial means, whereas “miscarriage” means demise of the foetus from natural causes. However, to medical professionals, the term “abortion” is a generalised one. It refers to the expulsion of the contents of the uterus in early pregnancy, without making any distinction whether it is a spontaneous and induced event. Thus, the confusion. According to the National Centre for Biotechnology Information (NCBI) in the United States of America, a miscarriage is called a 'spontaneous abortion', in which the unborn baby has an unintended death due to naturally occurring events like genetic or developmental abnormalities. If the baby is expelled completely it is called a “complete abortion”, otherwise it is labelled as an “incomplete abortion”. Sometimes the baby may not be formed properly or has died inside the womb. The mother may have minimal or no symptoms of bleeding and abdominal cramps. This is called a “missed abortion” as the patient may not realise that the pregnancy loss has occurred. Termination of pregnancy or “abortion” in layman’s term, on the other hand, is known by the medical terminology “induced abortion”, in which the baby is still alive and is expelled unnaturally by either medical or surgical means. Over the years, some eminent gynaecologists have tried to advocate differentiating the usage of these 2 terms in the medical community, but their efforts have not been very successful. The term “abortion” continues to be used to describe “miscarriage”. Personally, I prefer to use the term “miscarriage”, rather than “abortion”, when dealing with early pregnancy loss with my patients. The term conveys empathy, and will help in easing grieving process of the patient.

“Doc, let me tell you a funny incident,” B said jokingly. "I was trying to get the microwave oven to work the other day. I kept pushing the start button but it would not turn on. I felt so frustrated that I yelled at my husband for help. He calmly walked over, closed the oven door, pressed the start key and bingo, it was on. I then realised that I forgot to shut the door!” B, a 32-year-old first time mum in her second trimester told me this story during her routine antenatal check-up. She was worried whether the memory lapse would deteriorate later in the last trimester and get worse during her postnatal period. Forgetfulness during pregnancy or “pregnancy brain” is quite common and is present in about 50 and 80 percent of expectant mothers. The memory loss is usually subtle and can affect women differently at various times of their pregnancy. In general, the memory decline appears to start during the first trimester and then remains stable till the end of the pregnancy. In some cases, it may last up to a year after birth. For reasons unknown, some studies have shown that women pregnant with girls are, on average, more forgetful than those carrying boys. A study in England has also found that the spatial memory—the memory that tells us how to plan a route to a desired location and to remember where an object is located or where an event occurred is slightly impaired during pregnancy. Researchers have suggested that the memory loss could result from the hormonal and lifestyle changes. High levels of sex hormones circulating in the body during pregnancy could have a negative impact on the nerve cells in the brain responsible for memory. Expectant mothers are probably more preoccupied with the upcoming birth and may be anxious about the changing lifestyles after the baby is born. Stress and anxiety would interfere with the ability to concentrate and remember things. The fatigue and the difficulty in getting quality sleep may further aggravate the situation. All these factors would definitely make cognitive performance worse. Although “pregnancy brain” does not appear to be permanent, a small study using MRI has shown that some grey matter, the outer layer of the brain containing the nerve cells, was reduced during pregnancy. I told B that in order to improve her memory, she should: · Keep a daily calendar, · Schedule alerts for important meetings, · Use a note-taking app or carry a note book, · Ask the husband or friends for help when needed, · Reduce stress, exercise regularly and have adequate rest and sleep, · Eat a balanced diet especially DHA -rich food. B seemed to take it seriously after the consult and asked her husband to take note of the steps I had suggested to boost her memory.

She jogged. She ran. She worked out in the gym every day, 7 days a week. H, a 28-year-old lawyer was an exercise buff since she was a teenager. She was also an avid runner, taking part in marathons the last 2 years. “Doc, I am so fit physically, why has my menstruation eluded me the past 5 months?” she asked. On further questioning, H had regular menses every month until a year ago while preparing for a marathon. She suddenly noticed that her menstrual flow was getting scanty and the cycle length was getting longer, occurring every 35 to 50 days. But she did not pay any attention as she thought it was normal. She was slightly concerned when she missed her menses for 5 months.  She was baffled as to why the menses had ceased and would like to know whether this could have any impact on her reproductive health. H was having a medical condition called exercise associated amenorrhea (EAA) which occurs in 3 to 4 percent of women who exercise too intensely. This condition arises when the energy expended from exercise far exceeds the caloric intake from food, a result of intense training. To conserve the available energy for other more important physiological processes, the body shuts down the function of less essential ones like those in the ovary. The brain centre (hypothalamus) which controls the ovary alters the way it releases the hormones. As a result, the ovary stops ovulation. This leads to reduced production of the female hormone(oestrogen) resulting in the cessation of menstruation. Besides amenorrhea, EAA can lead to a reduction of bone mineral density as oestrogen is important in the metabolism of calcium. Bone fractures may occur more easily. Research studies have shown that this loss of bone mineral density may be permanent and may not be reversed once it occurs. Though the damage may be mitigated with hormone replacement treatment, the lost minerals cannot be replaced, resulting in irreversible long-term damage to bone health. I told H that in order for her menses to resume, the following steps had to be taken: 1. She had to cut down the frequency and duration of her exercise. 2. She had to increase her caloric intake and maintain a certain amount of body fat and protein. Studies have shown that at least 16 percent body fat or more is necessary for normal menstruation. 3. She had to consume 1500 mg of calcium a day to maintain her current calcium needs. This was to reduce her likelihood of stress fractures and osteoporosis later in life. H understood the seriousness of EAA. She started to make lifestyle changes. She began to put on weight and her menses had resumed, albeit still slightly irregular, 6 months after the consult.

C, a 29-year-old first time mum, woke up one morning and was taken aback when she saw a small amount of yellowish fluid oozing out from her breasts. She was 30 weeks pregnant at that time. She hurriedly rushed down to my clinic as she wanted to know whether the breast discharge might lead to premature labour. Soon after the leak, she had experienced some uterine contractions. She was also concerned whether the leak would affect her milk supply after birth. After the physical examination, I confirmed that the yellow discharge was the colostrum or pre-milk secreted from her breasts  and reassured her that  the discharge had no relation with premature labour  and would not have any impact on her milk production. During pregnancy, the breasts are enlarged from the growth of the ductal and glandular tissues due to the stimulation of pregnancy hormones. This is in preparation for providing  milk to the baby after delivery. Colostrum or pre-milk is the first stage of milk production. It occurs between 16 and 22 weeks of pregnancy and lasts for several days after the baby is born. It is full of protein, minerals and vitamins to sustain the growth of the baby in the first few days of life. Though it is much thicker than the mature milk, it is easy to digest due to its low-fat content. Vitamin A and carotenoids which give the distinctive yellow colour to the colostrum are important for the baby’s vision. Other minerals such as magnesium, copper and zinc are important in supporting the growth of baby’s brain, heart, bones and immune system. Up to two-thirds of the cells in colostrum are white blood cells. These cells plays a crucial role in building the immune system of the baby and help him or her in fending off infections. Colostrum also maintains the baby’s gut function by providing the “good bacteria” with appropriate nutrients. Jaundice in the newborn, a common phenomenon, can also be reduced by colostrum. It  acts as a laxative by making the baby poo frequently. The frequent bowel movements help the body remove bilirubin, the yellow pigment that causes jaundice. It is normal for colostrum to leak during pregnancy especially in the last trimester, during sexual intercourse or breast and nipple stimulation. But it may not happen in all mothers. The amount that leaks also varies. Some may leak quite a lot, soaking the bras wet while others may just have a little ooze. Leaking colostrum can be an uncomfortable and embarrassing experience. The simplest way to deal with it is to use breast pads to absorb the moisture. Wearing breast pads inside the bra will absorb the fluid and prevent wet patches showing through the clothes.

M would never forget the day when she collapsed in the bathroom at home with heavy menses. She was rushed to the hospital by the ambulance. When I saw her in the emergency room, she was barely conscious and her face was as pale as a sheet with a pulse that was weak and rapid at 120 per minute. Her blood pressure was low at 80 mmHg systolic and 60mmHg diastolic. Her blood haemoglobin, the oxygen carrying protein in red blood cells, was dangerously low at 6.6g/dl (normal range:12-15.5g/dl). M was in a state of shock. She was immediately given an intravenous drip and transfused with four pints of blood. Medications were also given to stop her menses. She gradually regained her consciousness. Her first words she uttered to me were “I should have listened to your advice”. M, 40, was a marketing manager with 2 children. She was found to have a small 1 cm fibroid in her uterus during the postnatal check after her second delivery four years ago. I told her that the fibroid was usually non-cancerous and advised her to leave it alone since it was small and asymptomatic. But I told her to come back for review yearly to monitor its growth. Due to work commitments and frequent travels, M forgot to return for regular review. Four months ago, she noticed that her menstrual flow was getting heavy. “I bleed a lot on the first 3 days of my menses. I have to use 8 to 10 pads a day, double the number I normally change and they are thoroughly soaked.  I have to use an extra-large pad at night. Otherwise, my bed sheet will be stained,” she said. She also began to feel breathless and giddy while doing housework but she ignored these symptoms. She did not seek medical advice until the day when she passed out. M’s condition was stable the next day. Ultrasound examination revealed that the fibroid detected four years ago had grown to 3cm in size and had protruded into the cavity of the uterus. This was probably the cause of her heavy menses. M was advised to have it removed through a hysteroscope- a thin, lighted tube that is inserted into the uterus which will enable one to visualise the womb lining. With her husband’s encouragement, M finally consented for the surgery which was successfully done. She was discharged well the next day. M had a submucosal fibroid. Fibroids begin as growths in the muscle wall of the uterus. They are called intramural fibroids. With time, some may grow inwards towards the uterine cavity and form  submucosal fibroids while others may expand outwards into the pelvic cavity and develop into the subserosal fibroids (Figure 1). Because submucosal fibroids grow just beneath the inner lining of the uterus, they often cause more bleeding than other types of fibroids. This is because they increase the surface area of the uterine cavity lining. As in M’s case, the menstruation is usually heavy and prolonged. They can also lead to pregnancy and fertility problems such as repeated miscarriages, foetal growth restriction and premature delivery. Submucosal fibroids are usually removed through hysteroscopy. The procedure is done under general anaesthesia. Under the direct vision of the hysteroscope, fluid is introduced into the uterine cavity to lift the walls of the uterus. The fibroid is then shaved off in pieces by a resectoscope (Figure 2). The outcome is usually good but patients may experience cramping and light staining a few days after the procedure. M recovered well. She was given iron tablets and her haemoglobin gradually returned to normal after a month.

Sex is pleasurable to most people but not for H’s husband. H was 39 and her husband 41 years of age. They had been married for 4 months and were trying to conceive. During her honeymoon period, sexual intimacy was frequent and enjoyable. One day, she was taken aback when she released “wind”  from her vagina after sex. She suddenly remembered what her mother had said about “bad air" or “wind” entering her body through sex. The “wind” would migrate to the head and would cause a severe headache and ill health. She told her husband about her fear and insisted that all the windows be closed and the air-conditioner and fan be switched off during sex. “Doc, every time I have sex, I feel like having a workout in a furnace. My whole body sweats and it becomes very uncomfortable,” H’s husband complained. “Sex becomes a chore. It is no longer pleasurable. I fail to convince her that her concept of “wind” going into her vagina is false. We always have heated arguments on this matter. I finally gave up and hardly have sex with her now.” Gas passing out from the vagina is quite a common and normal occurrence during sex. Air can get into the vagina and get trapped during sexual activity due to the movement of the penis in and out of the vagina. When the muscles surrounding the vagina get tense from an orgasm or when the penis is removed, the gas will then be released. This can cause a sound similar to common flatulence from the anus. Insertion of feminine hygiene products such as tampon can also allow air to get trapped inside the body. This air can escape when the product is removed, or during physical activity or stretching. Severe coughing can also cause the pelvic muscles to tense, pushing air downwards and out of the vagina. Certain exercises involving stretching of the pelvic region, such as yoga, often allow the vagina to open or relax, allowing air to enter. During a change in pose or position, air trapped in the vagina can suddenly be released. Occasionally, release of vaginal gas can also be a symptom of malfunction of the pelvic floor muscles. Very rarely, gas escapes from the vagina due to the presence of a fistula, an abnormal hollow tract between the vagina and the large intestine. The gas is mixed with scanty faecal material and they pass from the rectum to the vagina regardless of whether there is sexual activity or not. There is usually a past history of trauma or injuries to the vagina e.g. following childbirth. I examined H and found that her vagina was normal with no sign of injury or fistula. I then explained to her the various ways air can get trapped in her vagina and told her that her mother’s “bad air” theory was an old wives’ tale. H appeared to be convinced when she left my clinic. A few weeks later, I received a call from her husband who told me that the situation had returned to normal and that H was well on her way to motherhood.

H, a 28 year-old lady walked into my consultation room with an anxious and depressed look. She worked as an account assistant in an accounting firm and studied a part-time degree course at night. “Doc, my work-life has been quite stressful recently. I have been suffering from tummy cramps with constipation and bloating for the past six months. The symptoms have become worse during menses. I have googled and thought that abdominal pain during menses could be the symptoms of endometriosis. I am worried.” she said. On further questioning, H had more symptoms of the digestive tract than those related to her reproductive system. Though she had constipation most of the time , she would have occasional diarrhea if she ate certain “sensitive“ foods. Her tummy was always bloated. “Sometimes, I have no choice but to rush to the public toilet to ease myself. I feel embarrassed because of the noise of the gas and the smell from the bowel movements,” she sheepishly confessed. Her menstrual cycle was regular and the pain was described as “mild” and occurred occasionally on the first day for the last two months. Vaginal examination did not reveal any tenderness around the womb and pelvic ultrasound examination was normal. I reassured her that she did not have clinical evidence of endometriosis and referred her to a Gastroenterologist who diagnosed her to suffer from irritable bowel syndrome (IBS) after investigations. IBS can mimic endometriosis in that the abdominal cramps can be pronounced during menses. The menstrual cramps can occur during bowel movements. There may be nausea and/or vomiting during menses if the pain is severe. However, there are some differences. IBS patients are more likely to have bowel habit changes, i.e. constipation, and/or diarrhea. The colicky pain does not always coincide with the menses. Gaseous distension and pain in the upper abdomen are more common. The cramps are triggered by food and/or stress. Patients with endometriosis, on the other hand, tend to have more menstrual symptoms such as bleeding between menses and heavier menses. The menstrual pain may start in the premenstrual phase and may last throughout the menses. Pain during sexual intercourse and infertility are more common. Research studies have found that IBS symptoms which are aggravated during menstruation are due to the effects of sex hormones produced by the ovaries. Sex hormones affect IBS in the following ways. First, they affect the smooth muscles of the intestines which control how fast the food passes through the digestive tract. In an animal study, the intestines took a longer time to empty when they had a low dose of the hormones than when they received a higher one. This may explain why constipation is worse during menses. Second, low levels of sex hormones during menstruation reduce the pain threshold of the patient resulting in more severe cramps. Lastly, sex hormones can raise the levels of inflammation throughout the body including the gut, thus making IBS symptoms worse. Few months had passed. H came to update me on her condition. “Doc, thanks for your prompt referral. My condition has improved a lot. Besides medications, I have been counselled on stress reduction, lifestyle and dietary changes. I am more careful with what I can or cannot eat. I practice yoga 3 times a week and I don’t have to rush to toilet so often now” I am happy that H is on her way to recovery.

Here is an abstract from what may be called a symptom diary: “March 1: Menstruation begins. As usual, a slight tummy ache on first day. “March 16: Getting tired. Insomnia last night. No appetite today. Tummy feels bloated. “March 20: Feeling miserable. Forgetful. Breasts are painful. Tearful for no reason. “March 22: Unable to concentrate. Feeling anxious and panicky. “March 23: having loose stools. Breast tenderness getting worse. Upset with colleague. Feeling depressed. “March 29: Menstruation starts again. No more negative feelings. No more breast pain.” This account is by F, 23 and single, who had been instructed to chart her symptoms daily for three months. The physical and emotional symptoms fluctuated in intensity and timing but they were cyclical, occurring one to two weeks before menstruation and disappearing soon after. Some of the symptom were debilitating and caused disruptions in F’s lifestyle. After excluding other psychiatric conditions, she was diagnosed as having premenstrual syndrome (PMS). PMS is a mixture of physical and emotional symptoms linked to the menstrual cycle. It is common, affecting about 75 per cent of females of reproductive age. It occurs mostly in teenagers and women in their early 20s. Common physical symptoms are abdominal distention, headaches and breast tenderness. Psychological symptoms include fatigue, forgetfulness, poor concentration, irritability and depression. To confirm the diagnosis, the patient has to chart her symptoms daily. These emerge about two weeks preceding menses and resolve completely when menstruation starts. In pregnancy and menopause, when menstrual cycles are absent, patients are completely symptom-free. While symptoms may be particularly intense in some months, they may only be slightly noticeable in others. For most women, symptoms are not severe enough to affect their daily routines and activities but in a small proportion of women (about 5 per cent), they can be severe and disabling. The exact cause of PMS is still unknown. Recent research indicates that women vulnerable to premenstrual mood changes do not have abnormal levels of hormones or disturbances in hormonal regulation. It is probably a result of the brain’s sensitivity to normal cyclical hormonal changes. There is an abnormal transmission of serotonin, a brain chemical that plays a crucial role in mood regulation. This may explain why symptoms such as irritability, moodiness or depression, sleep problems and food cravings are associated with PMS. During our counselling sessions, I gave F relevant information about her condition. This is important in PMS management as studies find that women educated about its biological basis have an increased sense of control over and relief of the symptoms. F kept a symptom diary. This helped her to identify the triggers and timings of symptoms so that behavioural intervention could be implemented. Psychotherapy, using behavioural cognitive therapy and stress management, may also ameliorate or eliminate symptoms. In addition, F kept to a structured sleep schedule with consisted sleeping and waking times during the second half of menstrual cycles. This was to ensure that she had adequate rest as sleep disturbances would affect her mood. She was advised to exercise regularly in gym. Women with PMS who did aerobic exercises reported fewer symptoms. F was encouraged to eat healthy, balanced diet rich in fruit, vegetables and wholegrain carbohydrates. This promotes good health and a sense of well-being. Dietary changes were suggested, including salt restriction to minimize bloating, fluid retention and breast swelling and tenderness She was also told to avoid caffeine to reduce irritability and insomnia. Evening primrose oil supplements were added although there is no general consensus on their benefits. After two months of these lifestyle adjustments, F’s physical symptoms improved although emotionally, she still had occasional panic attacks and depression. I prescribed a small dosage of Zoloft during second half of her cycle. This is a psychiatric drug from the group Selective Serotonin Reuptake Inhibitors. Numerous double-blind, randomized studies support its effectiveness. F responded very well to the drug and is now on her way to recovery.