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Endometriosis is a chronic disease where the lining of the womb (endometrial tissues) is spilled into the surrounding organs– fallopian tubes, ovaries and the back of the womb. Many years ago, the medical teaching had been that young girds do not get endometriosis. As a result, many women with endometriosis were diagnosed late. According to one study, it could take up to 10 years from the onset of menstrual pain before a diagnosis of endometriosis was made. This was because many physicians did not believe the disease could affect teenagers. Current research has shown a completely opposite picture. Endometriosis is present in about two-thirds of adolescent girls with chronic pelvic pain and menstrual pain and is one of the leading causes of school absenteeism. In another study in which more than 4000 women with endometriosis were surveyed, two-thirds experienced symptoms when they were adolescents. All these studies indicate that menstrual and pelvic pain in young girls should not be taken lightly. Early diagnosis is important in the management. Adolescents who do not respond to simple pain killers and who have findings suggestive of endometriosis on physical examination should have a laparoscopy done. This is a procedure in which a long thin telescope with a high-intensity light and a high-resolution camera at the front is introduced into the pelvic cavity to visualise the pelvic organs. The affected area is burned, lasered or excised. Relief of pain after the operation can be dramatic. But the patient has to be reminded that recurrence is common and further medications may be necessary.

I am 40 years old and have 2 children. I have suffered from endometriosis for the past 7 years. 5 years ago, I had a “chocolate cyst”removed by open surgery and another one on the opposite ovary removed by key-hole surgery 3 years later. Recently, I started to have menstrual pain and backache again. Is there anyway of preventing endometriosis from recurring? What are my treatment options? Endometriosis is a chronic and progressive disease where the lining of the womb (endometrial tissues) is spilled into the surrounding organs-- fallopian tubes, ovaries and the back of the womb. These endometrial tissues respond cyclically every month to the female hormone, oestrogen, from the ovary and bleed during menstruation. The surrounding areas become irritated by the blood and form scars in the pelvis causing backaches, abdominal cramps during menstruation and pain during sexual intimacy. There is no definitive cure for the disease which will only regress after menopause when there is little or no circulating oestrogen The treatment for endometriotic cystslis surgical removal. But the recurrence rate is high,ranging from 20-50% within 5 years after surgery. How fast the disease recurs depends on the following factors: • Severity ofthedisease at the time of surgery • Completeness of the surgery • Use of suppressive hormonal treatment after operation There are a number of hormonal treatment options that may be used to delay the recurrence. Which option is right for you will depends on your condition. By reducing the levels of blood oestrogen, the chances of endometriosis recurrence are reduced. This can be done using oral contraceptive pills or a GnRH agonist. Recent studies have shown that insertion of Mirena, a hormone impregnated intrauterine contraceptive device (IUD) can be effective for delaying the recurrence. Some women may also choose to use an aromatase inhibitor to stop all production of oestrogen. If medical treatment fails, the surgical removal of the uterus (hysterectomy) with or without removal of the ovaries (bilateral oophorectomy) may be the last resort. See also the articles“ How does GnRH agonist work and what are the side effects?”under Q&A and “Endometriosis”under Gynae conditions

I am infertile. Recently, I was diagnosed with endometriosis. My gynaecologist suggested treatment with GnRH agonist. Can you explain how the medicine works? Any side effects? Endometriosis is a disorder of the female reproductive system in which there is a backflow of the menstrual blood (endometrial tissue) into the pelvic cavity. The endometrial tissue responds to the female sex hormone oestrogen and grows with each menstrual cycle (please refer to “Endometriosis” article on the website under Home > Articles > Gynae Conditions > Endometriosis). GnRH agonist is a drug modified from the naturally occurring hormone known as gonadotropin releasing hormone (GnRH), which controls the menstrual cycle. It stops the production of oestrogen by a series of mechanisms. This deprives the endometrial tissues of oestrogen, causing them to shrink and become inactive. This may help the reproductive organs to regain their function and allow the woman to get pregnant after the treatment is stopped. The usual length of treatment with a GnRH agonist is 3–6 months. You should notice an improvement in your symptoms within 4–8 weeks of treatment. The side effects are largely the result of the low oestrogen in the body. They are usually the symptoms associated with the menopause. Common side effects are: • Insomnia • Decreased libido • Headaches • Vaginal dryness • Mood swing The more serious side effect is thinning of the bones, particularly the bones of the spine. The decrease in bone density is usually about 5% if the treatment is prolonged for more than 6 months. Most of the bone lost during treatment regenerates within 6 months of completing treatment. GnRH agonist has been used to treat women with endometriosis for over 20 years. It is safe, effective and generally well tolerated when used in combination with add-back therapy which involves taking a low-dose oestrogen. This reduces the menopausal symptoms and prevents or minimises the thinning of the bones.

I am married for 7 months; I feel pain every time I have sex. What could be the cause? What is the treatment? Answer: Pain during sexual intercourse or “dyspareunia” can occur at the entrance of the vagina, or deep inside the vagina. Common causes include • Endometriosis: a condition due to the backflow of menstrual blood. The pain occurs during deep penetration • Vaginismus: a condition when there is involuntary contraction of the pelvic muscles at the opening of the vagina. The pain is superficial. • Vaginal dryness or inadequate lubrication from insufficient foreplay, menopause or during breast feeding. • Intercourse soon after pelvic surgery or child birth • Vaginal infection from sexually transmitted diseases such as Chlamydia and gonorrhoea. • Ovarian tumour or cyst: Pain is experienced if the tumour or cyst is hit during deep penetration. • Urinary tract infections • Allergic reaction to condoms, clothing, spermicides or douches • Genital irritation from soaps, detergents, douches, or feminine hygiene products Treatment of dyspareunia depends on the cause, which can be elicited by detailed medical and sexual history and physical examination. • For endometriosis: Endometriotic deposits or cyst should be removed surgically followed by medications to prevent recurrence. • For vaginismus: Successful treatment can be achieved with appropriate sexual counselling using plastic dilator. Surgery to “enlarge” the vagina is not necessary. • For painful intercourse in women after surgery or delivery: - Wait for at least 6 weeks after childbirth before resuming sexual intimacy - Be gentle and patient when resuming sexual intercourse. • For vaginal dryness from inadequate lubrication: - Adequate foreplay and stimulation of clitoris. - Water-soluble lubricant like K-Y Jelly should be used. Vaseline should not be used as it may encourage vaginal infections. • For genital tract or urinary tract infection, use appropriate antibiotic or antifungal drug.

Her face grimaced in pain and her hands clutched her belly. She staggered into my consultation room. “Doc, help me. I am suffering from my usual menstrual cramps again.” She cried. G, 23, has been suffering from menstrual pain for the past 5 years.  “I had my first period at 11 and experienced the menstrual cramps every month. The pain wasn’t too bad at first. It usually lasted a few hours and was relieved after a hot shower. Mum said it was quite common among teenagers. She gave me some Chinese herbal tonics after my menses and the pain was gone for a few years. But by late teens, the pain returned. It lasted longer than the usual one day and became more severe.  I had to take Panadol regularly,” she recalled. “Soon panadol and other pain killers such as ponstan and synflex were not effective. Mum brought me to see the family physician who suggested that I took oral contraceptive pills. I   did not take them as I was afraid of the side effects. The cramps became worse . I was completely incapacitated. On one occasion, I almost passed out.” When I examined G, her womb was tender to the touch and relatively immobile. An ultrasound scan showed a left ovarian cyst about 7 cm in diameter. I discussed the various options of treatment with her. She finally agreed to have the cyst removed by the key-hole surgery. This was done using a telescope with a lighted camera (laparoscope) and delicate surgical tools which were inserted through several small cuts - 0.5 to 1 cm in diameter in the abdominal wall. The operation was performed by viewing the organs through through a video screen. It went smoothly and G was discharged well the next day. Microscopic examination revealed that the cyst was an endometriotic cyst or “blood cyst”. What is ovarian cyst? An ovarian cyst is a collection of fluid surrounded by a thin wall within or on the surface of an ovary. The ovary -about the size and shape of an almond –is located on either side of the womb (uterus). It is the organ where eggs develop and mature and are released every month during the childbearing years. Many women have ovarian cysts at some time during their lives. Majority of ovarian cysts present little or no discomfort and are harmless. Most are functional cysts which are formed during ovulation and they usually disappear without treatment. There are two types of functional cysts, the follicular cyst and corpus luteal cyst. Follicular cyst: The ovaries normally grow cyst-like structures called follicles each month. The follicle produces the hormones oestrogen and progesterone and release an egg around the middle of the menstrual cycle.  Sometimes the follicle does not rupture or release its egg and keeps on growing into a functional cyst called follicular cyst. Corpus luteal cyst: After a follicle releases its egg, it is called the corpus luteum. Sometimes, the exit opening of the egg seals off and fluid accumulates inside, causing the corpus luteum to expand into a cyst called corpus luteal cyst. Other types of ovarian cysts are not related to the normal function of the menstrual cycle. They include: Endometriotic cysts (blood cysts): These cysts are also called chocolate cysts because it contains thick and old clotted blood. They are due to the backflow of the menstrual blood in the pelvic cavity and the ovary   . They will grow with time and cause severe menstrual cramps and pain during sexual intercourse. Occasionally, it may rupture causing sudden, severe abdominal pain mimicking that of appendicitis and requiring emergency operation. Very rarely, it may become cancerous. Dermoid cysts (hairy cysts): These cysts are usually non- cancerous .They are often filled with fatty cheesy contents with hairs , teeth and bones. They are often small and may not cause symptoms. When they become large they can have complications. Cystadenomas. These cysts develop from ovarian tissue and may be filled with a watery liquid (Serous cyst) or a mucous material (Mucinous cyst). Both types of cyst can become cancerous. What are the symptoms and complications of ovarian cyst? Most ovarian cysts do not have any symptoms.  They are usually discovered during routine pelvic examination .They may cause problems if complications develop such as torsion (twisting), bleeding ,infection, rupture and cancerous changes. Ovarian cancer is often “silent” and spreads widely before it is detected. Symptoms of ovarian cysts include: •         Severe abdominal Pain •        Feeling of fullness (bloatedness) in the abdomen •         Difficulty and frequent urination •         Dull ache in the lower back •         Pain during sexual intercourse •         Painful menstruation and abnormal vaginal bleeding •         Sudden loss of weight •         Nausea or vomiting •         Loss of appetite •      Low grade fever Ovarian cancer usually does not have any symptoms in the early stage. There may be non-specific symptoms such as loss of appetite, loss of weight and having abdominal  bloatedness. In the late stage, there may be swelling of the abdomen with fluid and swelling of legs and feet. Diagnosis Some of the ovarian cysts are found during the annual gynaecological check-up by vaginal examination. Some of them are discovered by ultrasound examination in which sound waves are used to create an image of the ovaries. This helps determine the size and location of the cyst as well as its contents. If the cyst contains a mixture of fluid and solid components, it may be  an indication that the cyst may be cancerous Dermoid cysts are occasionally detected by X-ray of the abdomen because of the teeth or bones they contain. Other imaging tests include Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). These are highly detailed imaging scans and help in assessing the extent of spread of the ovarian cancer. Blood tumour marker test such as CA-125 has been used for women with higher risk for ovarian cancer. It is a protein and its level tends to be high in some women with ovarian cancer. But this test is non-specific as patients with non-cancerous conditions such as endometriosis and pelvic infection may also have raised levels. Treatment Once the cyst is found, a repeat scan during or soon after the period should be done. A functional cyst will shrink or disappear. If the cyst persists and appears benign on account of ultrasound and CA125 findings, a laparoscopic removal (key-hole surgery) may be done. If the cyst is too large or suspicious of being cancerous, the conventional laparotomy is performed under general anaesthesia. A large vertical or horizontal incision is made in the abdomen. The cyst is then removed and sent for a frozen section (a microscopic test in the operation room). This may indicate whether the cyst is cancerous or benign. If it is benign, the cyst is then removed and the normal structure of the ovary restored by suturing. If it is cancerous, a more extensive operation called debulking is done where as much of the tumour tissues as possible is removed. Depending on how far the cancer has spread, the ovaries, uterus, fallopian tubes, omentum -- fatty tissue covering the intestines -- and nearby lymph nodes will also be removed. Other treatments for ovarian cancer include: •             Chemotherapy : The drugs are given through a vein (Intravenous), by mouth, or directly into the abdomen to kill the cancer cells. They can have side effects such as nausea , vomiting, hair loss, kidney damage, and increased risk of infection. These side effects usually go away after the treatment is over. •             Radiation : High-energy X-rays can  kill or shrink cancer cells. This treatment can cause side effects, including redness on the skin, nausea, vomiting, diarrhoea, and fatigue. Radiation is not often used as most ovarian cancers are not radio-sensitive. Surgery in combination with chemotherapy is the usual mode of treatment. If recurrence occurs, further surgery may be necessary. Although there is no definitive way of preventing the growth of ovarian cysts, annual gynaecological check up with pelvic examinations , ultrasound scan and blood tumour marker test are methods  of early detection of  changes in the ovaries. In addition, one should pay attention to changes in the menstrual cycle like irregular bleeding and other nonspecific symptoms such as bloatedness, gastric discomforts and loss of weight. Talk with your doctor about any changes that concern you.

First-time mum-to-be K asked me the other day: “Doc, my mum tells me to drink plenty of fresh coconut water in the last trimester so that I will have an easy birth. “My friends also tell me that it will help cleanse my baby’s skin. Is this true?” This is just one among many of common nutritional myths and advice dished out to expectant mothers by well-meaning friends and relatives who know that a healthy diet is important for foetal growth. Pregnant women are, after all, motivated to improve their nutrition and they want to do things right for their developing babies. They want to know which foods they should eat or avoid. A common misconception is: “I can eat what I want when I’m expecting; I don’t have to worry about my diet. I should eat for two.” In fact, most pregnant women require only an extra 300 calories per day, equivalent to two glasses of milk or four slices of bread, or four pieces of fruit and seven wholemeal biscuits. A nutritious, well-balanced eating plan should be adopted. Recommended daily serving include five to seven servings of carbohydrates (about three bowls of rice or noodles). This provides energy for vital body functions. Two servings of fruit (two small apples, oranges or pears) and two servings (two cups) of vegetables. They provide vitamins (especially folic acid and vitamin C) and minerals (iron) for the baby. Folic acid plays a key role in reducing foetal abnormalities especially of the nervous system. Iron helps increase the mother’s blood volume and hemoglobin (pigment that carries oxygen in the red blood cell) and prevent anaemia. There are two sources of iron: green leafy vegetables (such as spinach, broccoli and lettuce) and red meat (like beef, poultry and seafood). Iron from vegetable sources is less well absorbed but can be enhanced by eating foods rich in vitamin C. Calcium decreases its absorption. Four servings of dairy products (about four glasses of milk or yogurt) are also recommended. They are main source of calcium which helps build the baby’s bones and teeth. Three servings of protein (three palm-sized pieces of chicken, fish or mutton or two cups of cooked peas, beans and lentils) are essential for foetal growth. Fats and sweets (desserts and drinks) should be eaten sparingly. Some foods can cause harm to the baby. Meats should be thoroughly cooked to avoid toxoplasmosis (parasite) salmonella and other bacteria. Alcohol should not be taken during pregnancy. It increases the risk of foetal alcohol spectrum disorders (FASD) – developmental problems that can affect a child’s ability to learn throughout his lifetime. Mercury contamination could turn seafood into a serious risk with potential harm to the nervous system of the developing baby. Shark, swordfish, King mackerel and tilefish should be avoided. Moderate amounts of coffee and other caffeinated beverages like tea, soda and chocolate drinks are unlikely to harm the baby. So they can be taken in small amounts. Unpasteurised cheese, which is seldom consumed by pregnant mothers here, can cause food poisoning and increase the risk of miscarriage, premature birth or stillbirth. Gaining the right amount of weight during pregnancy by eating a healthy diet is a good sign that the baby is getting all the nutrients he needs. However, dieting and trying to lose weight during pregnancy is potentially hazardous. If junk foods are eliminated from the diet, there would be appropriate weight gain. Expectant mums who put on excessive weight by eating calorie-rich foods could be condemning their unborn children to a lifetime of obesity with associated health risks. To err on the side of caution, pregnant women should consume food in moderation. A well-balanced and nutritious diet will ensure a safe and healthy pregnancy.

A friend wrote in to us - Dear Doctor, can you advise how to improve female hormone imbalance? I have been told by my IVF doctor that I may have hormone imbalance. He also said I do not have PCOS but they are behaving like one. Desperately seeking for an answer as I have tried all means but not pregnant for few years. Hope to hear from you soon. Thank you. The answer - Female hormones are secreted by the ovaries. If you have an imbalance of female hormones, I presume it means the ovulation is defective or dysfunctional. This would also indicate that the pituitary hormones that direct the ovary to ovulate may be also defective. As this is a complex problem, you need your doctor to find out what causes defective ovulation so that it could be treated accordingly. Thanks for writing in to us and and best wishes to our friend in her journey!

We were asked a question about taking Folic Acid before Conception - My current weight is 80kg & I'm 165 cm, we plan to conceive only when I reach a healthy weight range which is about 65-68kgs. Is it okay if i start taking folic acid from now itself? Or when should I start to take folic acid? What other supplements should I take? The answer- You can start folic acid now since you are preparing for conception. Other supplements include Iron, Zinc, Vitamin Bcomplex and DHA.

One of our Fans asked us - Can I colour my hair as I am currently breastfeeding? Will the chemicals affect the breast milk? The answer - The concentration of the hair dye that is absorbed into the scalp is usually not significant. It should not affect the quality of the breast milk.

I have existing Endometriosis condition. Recently, I heard of a new drug - Visanne - which is supposed to control this disease. I am 34 year and had this condition 5 years ago. I went for a laparoscopy 5 years ago and received treatment with 4 jabs to control the condition thereafter. Yes, the latest drug for treating endometriosis is Visanne. It has the components of oral contraceptive pills. However, it can treat the symptoms but cannot arrest the condition.

1.Is exercise during pregnancy recommended? Ans: Yes. Exercise is recommended during pregnancy as it is beneficial for both the mother and the child. 2.How long should I exercise a day? Ans: According to the American College of Obstetricians and Gynecologists (ACOG), you can exercise in moderation for 30 minutes or more every day, as long as you don't have a medical condition or complication (see below). 3. What type of exercises are suitable? Any precautions to take? Ans: Most exercises are safe during pregnancy provided one exercises with caution and in moderation. Swimming, brisk walking, stationary cycling and low-impact aerobics carry little risk of injury and can be done in moderation. One should avoid exercises that require too much balance or coordination. Exercise may not be advisable if there are medical problems, such as asthma, heart disease or diabetes and if there is any of the following: • Bleeding or spotting in pregnancy • Low placenta confirmed by ultrasound examination • Threatened or history of previous recurrent miscarriage • Previous premature births or history of early labor • Incompetent or short cervix confirmed by obstetrician

How much weight gain is normal during pregnancy? Ans: There's no one-size-fits-all approach to pregnancy weight gain. How much weight gain depends on various factors, including pre-pregnancy weight and body mass index (BMI). Maternal and foetal health also play a part. The following are the general guidelines for pregnancy weight gain: Pre-pregnancy weight -> Recommended weight gain Underweight (BMI less than 18.5) -> about 13 to 18 kilograms Normal weight (BMI 18.5 to 24.9) -> about 11 to 16 kilograms Overweight (BMI 25 to 29.9) -> about 7 to 11 kilograms Obese (BMI 30 or more) -> about 5 to 9 kilograms