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I intend to have epidural anaesthesia for pain relief during labour. I would like to know more about it. Is it effective? Any side effects or risks? What can be done if the pain relief is not complete? Answer: Epidural anaesthesia is done by anaesthetist for pain relief during labour. It is done by introducing a fine tube (epidural catheter) into a space at the back of the spine called epidural space. A local anaesthetic agent is then given via this epidural catheter and can be topped up intermittently or continuously, with the dosage adjusted accordingly, till the baby is delivered. If Caesarean section is required, the dosage can be topped up to provide anaesthesia throughout the operation. The side effects and risks of epidural anaesthesia are as follows: a) Common side effects: 1) Shivering – harmless and self-limiting. 2) Transient drop in blood pressure – correctable with intravenous infusion. 3) Nausea and vomiting – short term. b) Less common side effects 1) Infection – This is very rare as epidural and spinal procedures are done under strict aseptic conditions. 2) Puncture into vessels giving rise to haematoma (blood clot) that may press on the nerves causing persistent paralysis. This is very rare (0.001%) and will require surgical procedure to remove the clot and reverse the paralysis. If an aberrant nerve is injured during the epidural procedure foot drop may result. This will require supportive and sometimes prolonged physiotherapy. 3) Severe drop in blood pressure and difficulty in breathing when the effect of the local anaesthetic goes too far up the spine to affect the respiration. This can be damaging. 4) Delayed recovery of part of the numbness of the lower limbs caused by the anaesthesia – may take weeks or months. This incidence risk is about 0.001% 5) Puncturing of the dura membrane during the epidural procedure (0.5%). Patient will suffer severe post-delivery headache. This usually takes about a week to recover with the help of painkillers. Relief of headache can be achieved by a procedure instilling a blood patch to the same epidural space the next day to seal up the puncture in the dura membrane. 6) Persistent foetal heart rate changes requiring some intervention such as caesarean section. 7) Rapid absorption of the local anaesthetic, usually through a vein to cause a seizure – very, very rare. 8) Respiratory and cardiac arrest leading to fatality has been reported but is again extremely rare. 80% of patients who have had an epidural successfully inserted will get complete nerve block and pain relief. 15% of patients may get one-sided or partial nerve block and about 5% may not get any pain relief at all. This may be due to some anomaly of the patient’s spine, causing the epidural to be deviated to one side or even be displaced in the course of labour. Sometimes when the labour is too advanced or cervical dilatation is too rapid, epidural anaesthesia given at this stage may not act in time to alleviate pain. If the pain relief is not complete, the following steps can be taken to try to rectify it: 1) Adjust the posture of the patient, e.g. turn the patient to one side or sit the patient in a more upright position. 2) Adjust the epidural catheter, and 3) If above procedures fail the final solution is to re-do the epidural at a new space. This usually gives good results but still there is no guarantee of 100% success.

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? Answer: 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.

M could not control her emotions. She gave me a big hug. With tears rolling down her cheeks, she exclaimed, “Doc, thank you for presenting me with such a wonderful gift.”  This was the first time she was pregnant after a first attempt on intrauterine insemination, an assisted reproductive technique. M ,a 38 year-old lawyer  had been married for 8 years and trying to conceive naturally but unsuccessfully for the past 7 years. She had a mild degree of endometriosis, a condition where there is a back flow of menstrual blood in the pelvic cavity. The endometriosis was treated with laparoscopic surgery, in which a telescope is introduced into the abdomen. She  had medications subsequently for 3 months. Her husband’s sperm  count was normal except for a slight decrease in the sperm motility.After numerous failed attempts with fertility drug treatment and timed sexual intercourse at the ovulation period, the couple decided on the regime of superovulation and intrauterine Insemination (SO-IUI) What Is SO-IUI? It is an assisted reproductive technique in which two to three ovarian follicles (watery sacs in the ovary containing the eggs) are stimulated and brought to maturation and ovulation. A sample of prepared sperm is then placed directly into the uterus for the sperm to swim up the fallopian tube and fertilize the egg. This procedure will enhance conception for couples with mild endometriosis and mild sperm problem as in M’s case. It is also suitable for the patient whose cervix (neck of the womb) does not secrete good mucus during ovulation. The patient must have normal and patent fallopian tubes Fertility drugs are usually given for 10 days or more to produce between two to three mature follicles. These drugs(gonadotrophins) are given as injections alone or in combination with oral fertility drug such as Clomiphene. Ultrasound scans are done at intervals to determine the number and size of the follicles before another injection (HCG) is given for final maturation and subsequent ovulation of these follicles. On the day of the insemination, the semenis prepared in the laboratory and the motile fraction harvested and placed into the uterus using a fine catheter through the cervix. Occasionally, the procedure may be discontinued because of poor response or over response of the ovary. Whilst M was jubilant with the pregnancy, I warned her about the risks of miscarriages, foetal abnormalities and premature birth which are increased in older mother. She is now in her second trimester and the pregnancy is normal so far. The couple feel reassured every time I show them the baby moving inside the womb using the ultrasound machine.

Beads of cold sweat dripped from her forehead. Her face was as white as a sheet. Her extremities were cold and clammy.  Her pulse was rapid and blood pressure was low. She was bleeding profusely from the vagina. L, a 43 year- old housewife was rushed to the hospital by her husband in a state of ” shock”. She had been having “menstrual bleeding” on and off for a month and had passed out clots for the past 5 days. She felt very weak and collapsed at home. After resuscitation with intravenous fluid and blood transfusion, L’s condition improved.  Ultrasound examination of her uterus showed a huge fibroid about 10 cm in diameter. “Doc, I should have it removed 4  years ago when it was only 5 cm," she sighed. “ I was so scared of having an operation that  I avoided seeing the doctor after that and  only took some Chinese herbal  tonics every month after my menses.” When her condition stabilized, I discussed various options of treatment with her and her spouse. She finally decided to have her womb removed with conservation of the ovaries. This was performed successfully by key-hole surgery.  She was discharged well on the third day after operation. Removal of the womb or hysterectomy is a common gynaecological operation. It is done for the following conditions: •             Cancer of the uterus, cervix, or ovaries •             Uterine fibroids: These are non-cancerous growths in the muscle wall of the womb causing pain, bleeding, or pressure symptoms •             Uterine prolapse: The womb protrudes out of the vagina causing severe discomfort •             Endometriosis: Backflow of menstrual blood into the pelvic cavity causing severe menstrual cramps and/or pain during sexual intimacy •             Chronic pelvic infection: Usually from sexually transmitted diseases- with severe menstrual pain and pain during sexual intimacy •             Adenomyosis: This occurs when the lining of the womb grows into its muscular wall and causes severe menstrual pain and heavy bleeding TYPES OF HYSTERECTOMY There are 3 types of hysterectomy: 1.   Total hysterectomy: The whole womb is removed together with the neck of the womb (cervix) 2.   Subtotal hysterectomy or partial hysterectomy: Only the upper part of the womb is removed, leaving the cervix behind 3. Radical hysterectomy: The whole womb, tissue on the sides of the womb, the neck of the womb (cervix) and the top part of the vagina are removed. This operation is done when cervical cancer is present. APPROACHES OF HYSTERECTOMY Hysterectomy can be done through the abdomen or vagina depending on the surgeon’s experience, previous history of abdominal surgery, the reason for the hysterectomy, and the overall health of the patient. 1. Abdominal approach: This can be done through open surgery or key-hole surgery. Open surgery is the traditional approach. An incision of 10 to 20 cm is made either vertically or horizontally across the abdomen. The pelvic cavity is entered and the uterus removed. The hospital stay is about 3-4 days if there are no complications. Key-hole surgery is done using a laparoscope ( a telescope with a lighted camera) and delicate surgical tools. These are inserted through several small cuts, measuring 0.5 cm to 1 cm in diameter, in the abdomen. The surgeon performs the operation from outside the body, viewing through a video screen or a sophisticated robotic system. Key-hole surgery offers a number of benefits compared to the traditional open surgery. Recovery is faster with shorter hospital stays. Scars are smaller and post-operative pain is much less. There are less chances of wound infection and adhesions from the intestines and other abdominal organs 2.Vaginal approach: The surgeon makes a cut in the vagina and removes the uterus through the incision which is then closed, leaving no visible scar. RISKS OF HYSTERECTOMY Most women who undergo hysterectomy have no serious complications. However, as with any surgery, complications may arise in a small minority of women. These include: •             Excessive bleeding •             Wound infection •             Adverse reaction to anaesthesia •             Damage to the urinary tract, bladder, rectum or other pelvic structures during surgery, which may require further surgical repair •             Urinary incontinence •             Vaginal prolapse (part of the vagina "prolapsing" out ) •             Chronic pain in the abdomen •             Pulmonary embolism from blood clots in the veins of the pelvis If the ovaries are removed together with the womb, the patient will experience menopausal symptoms straight away. She may require hormone replacement therapy or alternative treatment to manage her menopause. If the ovaries are conserved, studies have suggested that the patient may enter menopause earlier. Full recovery usually takes several weeks. Activities such as lifting heavy objects should be avoided.

Q. I am 35 years old with 2 children. For the past 6 months, my menses are getting very heavy with the passage of large blood clots.  Is it normal? What are the causes? I consulted my family physician, who gave me iron supplements. How does iron help?A. If you notice a change in the amount of menstrual bleeding and pass out large blood clots, you probably realise  that something is not right.There are many causes of heavy menses. Common causes include: Hormonal  imbalance. In a normal menstrual cycle, there is a balance between 2 hormones secreted by the ovary, namely oestrogen and progesterone. These hormones regulate the lining of the womb (endometrium), which is shed during menstruation. If hormonal imbalance occurs -which may be due to the ovary not producing and releasing the egg (anovulation), the endometrium grows in excess and finally sheds by way of heavy bleeding. Uterine fibroids. These are common noncancerous growths of the womb, being present in 25% of women age 35and above.   They can cause heavy or prolonged menstrual bleeding by increasing the surface area of the endometrium. Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, causing enlargement of the uterine cavity. Endometriosis: This condition is due to the backflow of the menstrual blood into the pelvis. Chronic pelvic infection: This  condition usually results from sexually transmitted diseases Polyps: These are small, non-cancerous growths on the  endometrium, usually a result of high hormone levels. Intrauterine device (IUD). Heavy menses is a side effect of the non-hormonal intrauterine contraceptive device. Cancer. Uterine cancer, ovarian cancer and cervical cancer are occasional causes of excessive menstrual bleeding. Other  medical conditions including thyroid problems, bleeding disorders, liver and kidney diseases may be associated with heavy menses Iron supplements will not relieve heavy periods. You were given the supplements because the doctor suspected that you might have anaemia, a condition in which you don't have enough red blood cells to carry adequate oxygen in your body. With heavy periods and blood loss over a long time, your body’s iron stores would be depleted. The iron supplements rebuild your body's iron stores. You may also want to take vitamins containing folic acid, vitamin C, and vitamin B-12 to help build red blood cells. Please consult your doctor for further investigations and treatment.

My wife is feeling anxious during her pregnancy. This is our first pregnancy. Is this normal? Any other symptoms I should look out for?Anxiety and even some moodiness  are normal emotions that all mothers experience during and after pregnancy. But some women may have an increased risk of depression if the anxiety is left unrecognized. The warning symptoms  are as follows: Physical symptoms: Poor appetite Disturbed sleep, Low energy levels Breathlessness Chest discomfort Headaches Mental or Emotional symptoms Poor concentration Irritability Feeling weepy Gloominess Worrying and obsessing over things Thinking of worst-case scenarios Source: Dr. Adrian  Wang, Consultant Psychiatrist

Cervical mucus (CM) is the secretion produced by the glands in the cervix, the neck of the womb. It is important for conception as it is the entry point for the sperm to swim up the womb and fallopian tube in search of the egg. It usually forms a thick plug preventing the sperm from entering the womb. But during ovulation, instead of being a barrier, it helps accelerate the passage of the sperm through the cervix and prolong the life of the sperm, allowing them to live for up to five days. CM also helps screen the sperm allowing the active and apparently “normal” sperm to pass through.  In addition, it acts as an anti-bacterial barrier for the cervix. Distinct from other vaginal discharge, CM is odourless, colourless and does not cause any vaginal irritation. In response to the ovarian hormones, the amount, consistency and composition of CM show cyclical changes throughout the menstrual cycle Women can see and feel CM when it moistens their underwear, or when they wipe themselves with toilet paper. Soon after the menses, the vaginal discharge is scanty with no visible mucus. As ovulation approaches, the vagina feels moist with increasing amount of sticky, white or creamy discharge .The mucus is slightly stretchy but breaks easily when stretched. During ovulation, the vagina feels slippery, wet and lubricated. The mucus is copious, thin, stretchable and transparent like the raw egg white.  After ovulation, the mucus becomes scanty, thick, opaque and sticky again. By observing these changes in the CM, women can boost their chances of conception by timing intimacy during ovulation.

Q. I am 54 year old and menopausal. Recently I had some vague lower abdominal discomfort.  I went for a gynaecological check-up. My gynaecologist suggested CT scan of the pelvis. Is it safe? I heard that the scan may increase my risk of cancer. A. CT scan is one of the common medical imaging techniques. It helps create images of structures in your body by using a small, targeted amount of ionizing radiation. It provides much clearer and more detailed images than traditional X-rays do. It helps doctors diagnose and detect growths and many medical conditions. With such low doses of radiation used in a CT scan, your risk of developing cancer is small. But according to the American College of Radiology, this imaging examination should be done with good medical reasons. Since minimal radiation is used when performing CT scan, the benefits outweigh the small potential risk of cancer.

If you use nail polish and the remover once in a while, the chemicals probably would not have any negative impact. Studies so far have not revealed any adverse outcome in the baby.Many of the chemicals are organic solvents which are volatile and can be toxic if inhaled in high concentration. The extent of the exposures varies greatly, depending on the ventilation available and care taken in the application of the nail products. A recent report from the FDA, United States indicates that these chemicals can cause skin irritation, allergic rashes and death.If you are working as a nail technician in a busy nail salon, repeated exposure at work may pose a risk.    You can reduce your exposure by the following measures: Keep the place well ventilated before you put on the nail polish. Dry the polish by keeping the client’s arms away from you. Do not blow on the nails. This will minimize breathing in the fumes. After painting the nails or removing nail polish, always wash your hands with soap and water to remove any chemical residue.

I am 40 years old and have been married for 10 years with 2 children. Recently, I experienced some difficulty in erection. Will any change in lifestyle help me overcome this problem? I am not keen on taking medicine? You are suffering from erectile dysfunction (ED) or 'impotence.' This is the inability to keep the penis erect or firm enough for sexual intercourse. Don’t ignore it as this can be an early warning sign for more serious health problems such as diabetes and cardiovascular disease. There are many causes of ED. But the most common lifestyle-related causes are smoking, obesity and stress. Making lifestyle changes may improve ED and your overall health. These include: 1. Exercise regularly: A study from Harvard University showed that a 30- minute walk a day would reduce the risk of ED by 41%. Other studies suggested that moderate exercise helped obese men with ED improve their sexual performance. Kegel exercises, by strengthening the pelvic floor muscles, can improve erection. 2. Eat a well-balanced diet: In the Massachusetts Male Aging Study, eating a diet rich in fruit, vegetables, whole grains, and fish and reducing the intake of red and processed meats and refined sugar, lessened the likelihood of ED. Food fortified with vitamins, especially Vitamin B12, helps ED in older people. 3. Regular medical check-ups: Reduction of blood sugar, cholesterol, triglycerides and blood pressure have been known to help lower the risk of ED. 4. Maintaining a healthy weight: This is a good strategy for avoiding ED. Obesity raises risks for vascular disease and diabetes, the two major causes of ED. 5. Stop smoking and avoid excessive alcohol consumption. 6. Reduce stress: Learn how to relax. Give yourself some "quiet time "and get enough rest and sleep. This will help your body recover from stressful events and ED.

I am 53 years old and haven’t had a period for three years. But I suddenly got my period again last week. Is it normal? Do I need to consult a gynaecologist? Any examination required? You are having bleeding after menopause, which is not normal, even if it is just spotting.  The cause is usually minor, but cancer is always a possibility and must be ruled out. You have to consult a gynaecologist as soon as possible.The common causes are as follows: Inflammation and thinning of the wall of the vagina (atrophic vaginitis) or womb lining (endometrial atrophy) due to a very low female hormone( oestrogen) level. Non-cancerous growths of the neck of the womb( cervical  polyps) or the womb lining(endometrial polyps) Thickened womb lining (endometrial hyperplasia) : if left untreated, this can lead to development of womb cancer (endometrial cancer) Cancer of the vulva, vagina, neck of the womb(cervical cancer), womb lining(endometrial cancer) and ovary Bleeding from the urinary bladder  or rectum To find out the cause, the gynaecologist may perform the following examinations: Pelvic examination: An instrument (speculum) is introduced into the vagina to look at the wall of the vagina and cervix. Swabs may be taken from your vagina and/or cervix to rule out any infection. A pap smear will also be done at the same time. Vaginal ultrasound scan: This is performed by gently inserting a fine ultrasound probe into your vagina, to look at the lining of the womb and for tumour masses in the womb and ovaries. Hysteroscopy: This is performed by passing a thin fine telescope (hysteroscope) through the cervix into the womb to look at its lining and remove a small sample of tissue for examination under microscope(endometrial biopsy). Appropriate treatment will be given depending on the cause of your bleeding.

Sitting on the wheelchair with teary eyes and occasional sobs, she gazed patiently at her baby in the incubator at the neonatal intensive care unit (NICU). The baby weighing 1.2 Kg. looked no bigger than a kitten. It was thin and pale with loose, dry skin. It lay floppily with a number of tubes and wires attached to the monitoring machines. It cried feebly at times. M, 34 just had a Caesarean section(C-section) 2 days ago .This was her first pregnancy . It was apparently normal until at 28 weeks of gestation when the levels of the fluid surrounding the baby (amniotic fluid) were found to be low. The growth of the baby had slowed as well. The estimated weight of the baby was at the 10th percentile with the measurement of abdomen 2 weeks behind that of the head. The baby was diagnosed as having intrauterine growth restriction (IUGR) a condition in which the baby was small for the gestation.I asked M to come for frequent check-ups so that the baby’s growth can be monitored by ultrasound scans regularly. Her baby’s heart beats were also measured electronically by cardiotocograms (CTG) to ensure adequate oxygen supply. Steriod injections were also given to help improve the baby’s lung function. At the 33rd week of her pregnancy, CTG indicated that the oxygen supply to the baby was diminishing. The blood flow to the baby’s brain was reduced by Doppler flow studies.  I discussed the gravity of the situation with M and her husband and decided that the baby should be delivered by C-section. The baby was born with a low Apgar score indicating its poor physical condition at birth. It was admitted to NICU in the incubator straight away for immediate medical care.Intrauterine growth restriction (IUGR) is a condition where the unborn baby does not grow at the normal, expected rate. The estimated weight of the baby is less than that of 90% of those with the same gestational age. It occurs in about 2 to 3 percent of all pregnancies and results from diminished supply of the nutrients and oxygen to the baby.Although some IUGR babies are small because of genetic factors, majority are due to other causes which include: Mother having : Pregnant for the first time or for the fifth time or more Under the age of 15 or over the age of 35 High blood pressure Chronic kidney diseases Diabetes Heart or respiratory diseases Anaemia Infection from viruses ,bacteria or parasites Alcohol, cigarette  and drug abuse Reduced blood flow to  the womb and placenta: Minor detachment of placenta before delivery Low lying placenta with bleeding Placental insufficiency Unborn  baby  having Infection Birth defects Genetic abnormality When IUGR is severe, the foetal oxygen supply is critically compromised. This may cause foetal death. In less severe case, the baby may have problems after birth. These include: Difficulty in breathing from inhalation of the first faeces(meconium)  before or during delivery Low blood sugar Difficulty in maintaining the body temperature Low resistance to infection Increase in  red blood cells resulting in abnormal  clotting problems Developmental  and learning disorders during childhood Management of IUGR depends on its onset and severity. Careful monitoring of the growth of the foetus using ultrasound and Doppler flow studies and optimal timing for delivery are important in achieving good outcome. It was quite an ordeal for M to watch her baby suffering in the incubator.  Her face finally brightened up with smiles when it finally left the NICU after 2 weeks. When I saw her 6 weeks after the baby was born, it had put on a remarkable amount of weight and both mother and baby were doing well. “Doc, thanks for your timely intervention,” she said” thanks for letting me understand what motherhood really means.”I could see immense joy in her.