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Q. I have just delivered my baby four months ago. I have noticed that my hair has started to shed more than usual. Is this normal? What is the cause? Is there anything I should worry about? A. It is a normal phenomenon that many mothers will shed a considerable amount of hair on their scalp a few months after delivery. This “excessive shedding” is usually temporary and the hair will regain its fullness usually between 6 months to one year.Normally, 85 to 95 percent of the scalp hair is in the growing phase and the rest in the resting phase. Hair in the resting period will shed off soon during brushing or shampooing and will be replaced by new growth. It is estimated that a woman sheds an average of about 100strands of hair a day. During pregnancy, the increasing levels of oestrogen will stimulate more hair in the growing phase. As a result, many women will have thicker and luxuriant hair.After delivery, levels of oestrogen plummet and more hair enter the resting stage resulting in an apparent excessive shedding when women shower or brush their hair. This process will slowly taper off and the hair will regrow to its pre-pregnancy state.While waiting for the hair to regrow, you may like to try the following: Get a good haircut: shorter hair may be easier to manage. Experiment with a new hairstyle. Some haircuts may make the hair look fuller. Try different styling products: these may “bulk up” the appearance of your hair. Use a good quality shampoo and conditioner. Avoid using a brush or comb that pulls or stresses the hair. If the amount of hair loss is more than normal or if the regrowth is slow, you may like to consult a dermatologist as there may be other underlying medical conditions such as hypothyroidism (low thyroid hormone) or anaemia that may cause hair loss. 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/.Other related articles areHair treatment during pregnancy

Natural Birth or vaginal birth refers to delivery via the normal birth passage. It is a natural physiological process and in most situations, is a safe and preferred way of giving birth. Compared with caesarean section which is a delivery by abdominal surgery, vaginal birth carries much less complications to the mother. These complications can be divided into immediate and late complications. Immediate complications include: · Injuries to the soft tissues: Tears from the stretching of the vagina by the emerging fetal head and/or cut from the episiotomy to enlarge the birth passage can occur in the vagina, perineum (area between vagina and anus), urethra (urinary passage) and anus. The tears may be small or extensive with varying amounts of bleeding. The damage is usually aggravated by assisted deliveries using forceps or a vacuum cup. · Injuries to the perineal blood vessels: If the bleeding is not stopped in time by careful stitching, accumulation of the blood clots can occur around the vulva resulting in extensive bruising or the formation of a haematoma. · Injuries to the surrounding organs: Bladder injury can result in difficulty or inability to urinate or incontinence (leaking urine). Injuries to the anus and rectum can cause inability to control defecation (faecal incontinence). Late Complications include: · Prolapse of the uterus: Sagging of the womb can result from weakening of pelvic floor muscles and is more common in women who have delivered many children. · Incontinence of stool or urine: This can occur after deep tears in the vaginal walls which go unnoticed at that time. These tears cause infection and subsequent scarring around the bladder and rectum. resulting in incontinence. Direct damage to the muscles controlling the openings of the anus or bladder can also be the cause of incontinence. · Sexual dysfunction: Vaginal scars can cause pain during sexual intercourse. A loose vagina from weakened pelvic muscles may reduce sexual pleasure in some women. · Psychological trauma: The unpleasant experience of vaginal birth and fear of getting pregnant again may result in difficulty in vaginal penetration (vaginismus) and/ or reduced sexual desire. 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/. Other related articles are Vaginal Delivery Caesarean-section vs Vaginal-delivery

Cervical cancer is cancer that starts at the neck of the womb(cervix), a cylindrical shaped organ that occupies the lowermost part of the womb (uterus) (fig 1) It is the 10th most common female cancer in Singapore (Singapore Cancer Registry 2010-2014). About 190 new cases are diagnosed every year. It is a preventable and potentially curable cancer as it can be detected easily. Due to the widespread use of the Pap smear test to detect early cervical abnormalities, the incidence of and deaths from cervical cancer have declined steadily over the last decades. Cervical cancer usually occurs during midlife. Women under 20 are seldom affected. Half of the women diagnosed with the disease are between 35 and 55 years of age and about 20 percent of cases occur in women older than 65. Thus, it is important for women to continue having cervical cancer screening until at least the age of 70. Pre-invasive cancer often occurs in women in their late 20’s to 30’s. These are termed Cervical Intraepithelial Neoplasia (CIN). Over time, these pre-cancerous lesions can progress and become invasive cancer if left untreated. Causes and Risk Factors Almost all cervical cancers are caused by human papillomavirus (HPV), a common virus that is transmitted sexually. Most people with HPV infection do not develop cancer. The infection typically resolves on its own. But if the infection persists, cervical cancer may develop. Other risk factors include: · Having early sexual activity before the age of 20 · Having other sexually transmitted infections (STIs) such as chlamydia, syphilis and HIV/AIDS · Having multiple sexual partners · Cigarette smoking · Using birth control pills for a long time (five or more years) · Having given birth to three or more children · A weak immune system. Symptoms and Signs of Cervical Cancer · Asymptomatic: Pre-cancer and early cancer of the cervix generally do not have symptoms · Abnormal vaginal bleeding: this can happen o after sexual intercourse (post-coital bleeding), o between menstrual periods (inter-menstrual bleeding) and/or o after menopause (postmenopausal bleeding) · Watery, thick foul smelling vaginal dischargeIn advanced stages, symptoms may include · lower back pain · pelvic pain · weight loss · leg swelling 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/. Other related articles are What is HPV? Endocervical or Cervical-polypColposcopy and Cervical Biopsyi have bleeding between periods for a few months does vigorous exercise cause such bleedingAbnormal pap smear and colposcopyBlog on hysterectomy

CIN is a short form for “Cervical Intraepithelial Neoplasia”. It is a condition in which the healthy cells in the cervix (neck of the womb) undergo abnormal changes. The cervix is a cylindrical organ situated at the lowest part of the uterus. It has an outer surface which is covered by squamous cells and an inner surface lined by another type of cells called columnar cells. The area where these two types of cells meet is called the squamo-columnar junction. It is usually around this area that abnormal changes in the squamous cells take place. These cells do not invade into the deeper layers of the cervix or spread to other organs through blood or lymphatic vessels. But if left untreated, they have the potential to turn into cancer. CIN is caused by human papillomavirus (HPV). Of the over 100 types of HPV viruses, only about 20 are responsible for the abnormal changes in the cells. About 4 out of 5 adult women would have had cervical HPV infection at some time in their lives, and only a small number develop precancerous changes and a few finally progress to cervical cancer. Most patients with CIN have no symptoms. Occasionally, abnormal vaginal bleeding may occur. The cell changes are not visible to the naked eye and can only be suspected by an abnormal Pap smear or HPV DNA test. Diagnosis is made by biopsy of the cervix using a magnifying telescope (colposcope). CIN represents a spectrum of disease, ranging from CIN I (about one third of the cervical cells are abnormal ) to CIN2 (almost two third of the cells are abnormal) and CIN3 (almost all the cervical cells are abnormal). It is estimated that one out of six women will develop CIN 1, which usually resolves itself as the virus is cleared by the women’s own immune system. Further treatment is not required. But women with CIN 2 and CIN 3 may not spontaneously clear the lesion. They need further follow-up examinations and treatment to destroy the abnormal cells .The energy sources used include heat (electro cautery), laser and freezing techniques (cryotherapy). Although treatment of CIN 2 and CIN 3 using above modalities is generally effective, follow-up exams are essential. Consensus guidelines published in 2006 by the American Journal of Obstetrics & Gynecology (AJOG) report that the failure rate for the treatment processes is generally 5-15 percent. As a result, the incidence of invasive cervical cancer among women previously treated for CIN 2 and CIN 3 is substantially greater than in the general U.S. female population. For women who have completed the family or who do not wish to have any more children , removal of the womb (hysterectomy)may be another option. If treated early, CIN is 100% curable. 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/. Other related articles are cervical cancer causes and symptoms abnormal pap smear and colposcopy

I am 29 and a first-time mum. I had a bad and traumatic experience during my delivery. My labour lasted more than 16 hours. The obstetrician had to use a “vacuum’ cup to extract my baby after I was exhausted trying to push my baby out for more than 2 hours. My baby weighed 3.7 kg. He had a large swelling over his head. The paediatrician told me that he had a cephalohematoma which would take a while to subside. What is Cephalohematoma? Will it have any effect on my baby’s health? A cephalohaematoma is an accumulation of blood clot in the space between your baby’s scalp and his skull bone. It is the result of bleeding from scalp’s blood vessels due to compression between the foetal head and the pelvic bones in prolonged labour. The injury is further aggravated by assisted deliveries using forceps or vacuum extractor. If the amount of bleeding is little, the swelling is small and soft. Otherwise, it is firm and hard. It happens more often in the first -time mum and the risk is increased with bigger baby. Cephalohematoma is associated with some medical problems. They include: · Skull fracture: Cephalohematoma may be a sign of an underlying skull fracture, particularly if forceps or vacuum are used during delivery. The baby must be closely monitored as developmental delays may occur later. · Jaundice: The clots in cephalohematoma may disintegrate and release the yellow pigment (bilirubin) into the blood stream causing jaundice in the baby. The jaundice may be severe if the cephalohematoma is big. The bilirubin released may result in brain damage and cerebral palsy (a form of childhood movement disorder). · Infection: If the clots get infected, the skull bone and the brain will be affected with serious consequences. · Anaemia: If the bleeding is severe, the baby may become anaemic, fatigued, weak, and uninterested in feeding. Your baby will be monitored by your paediatrician closely and appropriate treatment will be given if complications arise. 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/.

Q. I delivered prematurely at 32 weeks last year. I am now 5 months pregnant. My obstetrician did a vaginal scan and told me that the cervix was 2.3 cm in length. He said that I had a short cervix. As the risk of premature birth is high, he suggested that I should have a stitch around the cervix. What is a short cervix? Is the cervical stitch safe? What can be done to prevent me from having another premature birth? During pregnancy, the cervix is firm, long, and closed until late in the last trimester when it gets softer and shorter (efface), and opens up (dilate) as you prepare to give birth. The cervix can be accurately measured by vaginal ultrasound. The average cervical length varies from 3.5cm to 5cm. Your cervix is 2.3 cm long and is thus considered short. Studies have shown that premature delivery is related to short cervices. The shorter the cervix, the higher the risk. Measurement of cervical length at 20 to 24 weeks gestation has been considered a good marker for premature birth. One study has found that premature birth would occur in one out of five women whose cervical length is less than 2.2 cm at mid-trimester. Since you have a history of premature birth and a cervical length of 2.3cm, it is generally recommended that a cervical stitch (cervical cerclage) be done to avert a premature labour. Cerclage is a procedure in which a band of strong thread is stitched around the cervix to reinforce and help hold it closed. It's usually performed under a short general or epidural anaesthesia. You have to rest for a few days at home as you may have slight staining or bleeding and/or mild cramping. Sexual intimacy should be avoided until after delivery to prevent infection. Vaginal discharge is usually increased and may continue for the rest of the pregnancy. The procedure is usually safe with very minimal complications. Possible risks include: · Accidental puncturing of the amniotic membranes(water bag) · Infection of the cervix leading to intrauterine infection and premature birth · The cervix may form scar tissue after cerclage and fail to dilate during labour · Cervical tears may occur if labour happens before the thread is removed Recent studies have found that cerclage is effective in the prevention of premature birth in women with short cervices. To detect cervical infection, tests for urinary and vaginal infection and blood tests will be done. You may be given antibiotics to prevent infection and drugs to stop uterine contractions. Your level of activity should be reduced and you should refrain from exercise and intercourse and take frequent breaks. Progesterone tablets (oral or vaginal) may be prescribed and steroid injections given to help your baby's lungs develop more quickly. Your cervix will be checked regularly until the stitch is removed at around 37-38 weeks of pregnancy for normal labour to set in. 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/. Other related articles are what is cin how is it diagnosed what is the treatment? Blog on hysterectomy Cerclage – Operation to Raise Chance of Keeping Pregnancy

Sleep plays an important role in our physical and mental health. When we sleep, our body is busy restoring and regulating fertility hormones such as those produced by the pituitary gland (a pea-sized gland at the base of our brain), the thyroid gland and the adrenal glands. Any disturbance or lack of sleep will invariably cause imbalance in these hormones. With the advent of artificial light, curtailing the hours of sleep is becoming a norm in our society, Sleep has been reduced to the minimum tolerable so that more time is available for work or leisure. This reduction in the quantity and quality of sleep are increasingly recognised as important factors affecting female fertility. Recent studies have shown a link between lack of sleep and a decrease in the production of reproductive hormones. When these hormones decline, conception becomes difficult. Sleep disorders can also affect the male. Sleep apnoea, a condition when breathing repeatedly stops and starts during sleep, can negatively impact the hormonal system. Men who suffer from sleep apnoea produce very low levels of male hormone, testosterone. Sleep-deprived men also produce fewer sperm, the quality of which is also compromised. Fatigue due to lack of sleep may lead to chronic stress and performance anxiety. This may cause erectile dysfunction and diminished sexual drive resulting in further reduction in the chances of conception. Below are some of the suggestions to help sleep-deprived couples improve fertility: · Establish a healthy sleep pattern: Be strict in the sleep routine. Go to bed and wake up at the same time each day. Don’t oversleep in the weekends · Do not sleep for prolonged periods in the day so as not to upset your sleep cycle · Exercise regularly but not before bedtime · Avoid drinking coffee, tea and alcohol at night · Stop smoking · Avoid medications that may interfere with sleep · Start a relaxing bedtime routine: Take a warm bath. Dim the lights and keep the temperature of your bedroom cool. 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/. Other related articles are Fertility Awareness

Recently, my friend delivered her baby early, at 32 weeks gestation by caesarean section. Fortunately, the delivery was uneventful and both mum and child are well. I would like to know the causes of premature birth and the immediate health issues of the baby. A. A normal pregnancy usually lasts 40 weeks. Premature birth is one that occurs before 37 weeks of gestation and happens in about 10 %of all pregnancies. Depending on how early the birth occurs, it is further subdivided into: • extremely premature (earlier than28 weeks) • very premature (28 to 32 weeks) • moderate to late premature (32 to 37 weeks). Very often, no specific cause of premature birth can be found. However, there are factors that may be associated with premature birth. These include: · Intrauterine infection of the membranes and/or amniotic fluid that surround the baby. It is estimated that the infection is associated with about 40% of premature births · Excessive amniotic fluid as found in gestational diabetes and multiple pregnancies e.g. twins and triplets. · Hypertension during pregnancy, in which Caesarean section or induction of birth has to be done early for medical reasons · Chronic medical conditions in the mother e.g. kidney failure, heart disease and diabetes mellitus. · Teenage pregnancies · Laxity of the neck of the womb (cervix) resulting from repeated abortions or surgery to the cervix · Structural abnormalities of the womb (uterus) e.g. uterine septum, double womb · History of a previous premature birth · Smoking · Poor nutrition Understandably, premature birth gives the baby less time to develop in the womb. Premature babies, especially those born very early, will have organs that tend to be less developed, which make them more prone to complicated medical problems. They can also become ill fast, when a mild condition can suddenly deteriorate and prove fatal. Not all premature babies experience complications. Generally, the earlier a baby is born, the higher the risk of complications. Life-threatening complications include: · Respiratory distress syndrome: Immaturity of the lungs will present this breathing problem from lack of surfactant. Naturally occurring, surfactants are substances that keep the lungs inflated and help prevent the air sacs in the lungs from collapsing. Some preemies may experience prolonged pauses in their breathing, known as apnoea. · Heart problems: The most common problems are patent ductus arteriosus (PDA) and low blood pressure (hypotension). PDA is a persistent opening between two major blood vessels leading from the heart. This heart defect often closes on its own. Left untreated, it can cause heart failure and other complications. · Temperature control: Preemies can lose body heat rapidly; they don't have enough stored body fat of a full-term infant to keep warm. Smaller preemies require additional heat from a warmer or an incubator until they are larger and able to maintain body temperature without help. · Brain haemorrhage: The less developed blood vessels in the baby’s brain are delicate and more likely to break and bleed. The baby may show slow reflexes, weak suction of the mouth, fits and apnoea. Most bleeding episodes are mild and resolve with little short-term impact. But some babies may have larger bleeding resulting in permanent brain injury. · Intestinal inflammation: Preemies are more likely to have immature gastrointestinal systems, leaving them more prone to intestinal inflammation. Occasionally, serious complications such as necrotizing enterocolitis (NEC) in which the cells lining the intestine wall are injured, can occur. · Blood infection: Due to an underdeveloped immune system, preemies are more likely to get infection which can quickly spread to the bloodstream causing sepsis, a life-threatening complication.

I am overweight with a BMI of 30. My menses are irregular. My friend has advised me to try the “detox” diets. What are they? Any health benefits? Is it safe? A. “Detox” is a short form of detoxification, a process that our body performs all the time by converting “toxin” that need to be removed from the body using important nutrients from the diet. There are two main types of” toxins”: 1. Endotoxin: substances that are the by-products of metabolism e.g. urea and lactic acid. 2. Exotoxin: These toxins come from the environment e.g. Air pollutants, pesticides, heavy metals and tobacco smoke, among others. They enter the body through eating, drinking, breathing or absorption through the skin. Our body has evolved highly sophisticated mechanisms for eliminating these toxins. The liver, kidneys, intestines, skin and lungs all play a role in the excretion of these unwanted substances. If the body is unable to excrete these “toxins”, they will be stored in the fat cells, soft tissues and bone and will affect our health negatively. Nowadays, “detox diets” are very popular, comprising various programs of non-traditional diets. They are purported to eliminate toxins from the body, promote health and assist with weight loss. Typically, the program consists of a period of fasting followed by a strict diet of raw vegetables, fruit and fruit juices, and water. In some programs, herbs and other supplements are used along with colon cleansing (enemas) to empty the intestines. There is very little scientific evidence that these programs are effective in removing the toxins. On the contrary, they may be dangerous. especially the more extreme or restrictive regimens. For instance, some detox plans eliminate important nutrients, like protein, which can lead to malnourishment. A prolonged juice cleanse, also called a juice fast, over time could lead to an imbalance of electrolytes such as sodium and potassium. Colonic cleansing may lead to serious complications, including diarrhoea, perforation of the gut and life-threatening blood poisoning (septicaemia). Nevertheless, cutting back on processed foods and sugar in preference for balanced diets consisting of fish, lean meats, fruit, vegetables and whole-grains, reducing the intake of alcohol and caffeine and drinking more water will almost certainly make you get healthier. 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/.

I have been having heavy periods for the past one year. Ultrasound examination of the pelvis is normal. My gynaecologist suggested that I should have the Mirena inserted in my womb. He said this would reduce the blood flow. What is Mirena? How does it work? Any side effects? A. Mirena is a small T-shaped plastic intra-uterine device (IUD) (see figure) which is inserted by the gynaecologist into the womb for contraceptive purpose. It releases progestogen, a hormone similar to the natural progesterone produced by the ovaries and can be used in the treatment of patients with heavy menses. Every month, the lining of the womb(endometrium) thickens during the first half of the menstrual cycle to prepare for ovulation. If ovulation takes place and the egg is not fertilized, the endometrium is shed off as menstrual flow. The progestogen which Mirena releases acts on the endometrium and reduces its thickness. With less thickening of the lining, the menstrual flow is thus reduced. After a year of Mirena insertion, menstrual flow may stop completely in one out of five women.Side effects of Mirena include: · Irregular vaginal bleeding: For the first 3 to 6 months, the monthly period may become irregular. There may be frequent spotting or light bleeding. After a while, these episodes become less frequent and menses may completely stop. · Pain or bleeding may occur during or immediately after the insertion.· Ovarian cyst: About 12 out of 100 women may develop cysts in the ovary. These cysts are non-cancerous and usually disappear on their own in a month or two. Occasionally, the cysts may persist and cause pain requiring surgical removal. · Pelvic inflammatory disease (PID). IUD users may get pelvic infection which is usually sexually transmitted. If left untreated, life-threatening sepsis may occasionally set in.· Perforation. Very rarely, Mirena may go through the wall of the uterus in a condition known as perforation. This may cause abdominal pain. · Expulsion: Mirena may be expelled by the womb and may no longer prevent pregnancy. 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/.

In recent years, eating the placenta (placentophagy) after delivery appears to be a trendy affair as it has been popularized by the media and celebrities. The placenta can be eaten raw, cooked, roasted, dehydrated, encapsulated or through smoothies and tinctures. There has been no standardized method of preparation but the most frequent way appears to be encapsulation into pills after steaming and drying the placenta. What is placenta?Placenta, also known as afterbirth, is a disc- shaped organ that develops in the womb during pregnancy. It provides oxygen and nutrients from the mother to the growing baby and removes waste products from the baby's blood. (see figure). It is expelled from the womb after delivery. Almost all mammals eat their placentae raw soon after delivery but no contemporary human culture has incorporated consuming placenta postpartum as part of its traditions.Advocates of placentophagy argue that since dried human placenta (Zi He Che 紫河车) has been used for centuries in Traditional Chinese Medicine and term placenta has been found to contain various nutrients and hormones, consuming it after delivery should have positive health benefits. They claim that it can prevent postpartum depression, reduce post-delivery pain, boost energy levels, improve lactation, promote skin elasticity, enhance maternal bonding and replenish iron in the body. Recent researches have proved otherwise.Although some nutrients and hormones are found in term placenta, their maintenance and stability in raw tissue and in preparation have yet been tested.In a review published in American Journal of Obstetrics & Gynecology (2017), the authors concluded that “there is no scientific evidence of any clinical benefit of placentophagy among humans, and no placental nutrients and hormones are retained in sufficient amounts after placenta encapsulation to be potentially helpful to the mother postpartum”. In a recent case of a new-born baby who developed repeated bacterial infection after the mother had eaten contaminated placenta capsule, the Centers for Disease Control and Prevention, USA has also recommended that the intake of placenta capsules be avoided. They have issued a warning against such practice.Most women who want or expect to feel good after eating placenta do feel that way. But that may be just be a placebo effect.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/.

I have Graves' disease and my GP told me that I may be infertile. Is that true? I am in my mid-twenties and am getting married next month. Graves' disease is a medical condition when the thyroid gland becomes overactive and produces an excessive amount of thyroid hormones(hyperthyroidism). The thyroid gland is a butterfly-shaped organ situated at the base of the neck and in front of the throat. It releases hormones that play an important part in many bodily functions, including reproduction. Together with the sex hormones produced by the ovaries, thyroid hormones balance and maintain the normal function of the reproductive system. If the thyroid gland releases too much hormones, maturation of the egg and ovulation will be affected. This may result in irregular scanty periods, absent periods and infertility. Even if conception occurs, the risks of miscarriage and adverse pregnancy outcomes, such as high blood pressure in pregnancy, poor growth of the baby and premature delivery, may occur. In men, hyperthyroidism can cause a marked reduction in sperm count and abnormal sperm motility, resulting in infertility. The sperm count usually returns to normal once the thyroid condition has been treated. Since you have Graves’ disease, you should have it treated before embarking on the journey to parenthood. With treatment and careful monitoring during pregnancy, many complications can be avoided or minimised. 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/.