Bartholin glands disorders (Bartholin cyst / Bartholin abscess)

The Bartholin gland is located on either side of the vaginal opening, on the inner aspect at about 5 and 7 o’clock position. The glands secrete a fluid (mucus) that keeps the vagina moist and helps lubricate the vaginal area during sexual activity. The gland is not visible or palpable unless it is swollen.

Common disorders of the Bartholin glands are:

  • Bartholin cyst – this is a swelling of the area at the Bartholin gland, usually due to a blocked duct. The obstruction results in the accumulation of glandular secretion and cystic dilation of the duct. This usually occurs on one side. Sometimes, both sides can form cysts at the same time but is uncommon. It can vary from a small pea to a large egg-like size.
  • Bartholin abscess – Bartholin abscess is an infection of the Bartholin gland, with a collection of pus.

Causes of Bartholin cyst and abscess 

Causes include infection; congenital causes, and trauma such as a laceration or after episiotomy.

Symptoms and signs

  • Bartholinitis – the common symptom is usually pain, especially during intercourse. There will be redness and tenderness over the area. Swelling is usually minimal.
  • Bartholin cyst – the cyst, as opposed to the abscess, is generally not painful. Depending on the size of the cyst, some women may not be aware of the cyst at all. Large cysts may cause discomfort or pain and are easily palpable. The examination will reveal a cystic, unilateral (usually), non-tender mass. The cyst may burst and the discharge may be clear, cloudy, or yellow in colour.
  • Bartholin abscess – most abscesses develop over a period of a few days. The collection of pus inside the swelling will cause pain. The pain can be severe enough to interfere with walking, sitting or intercourse. In severe cases, there may be fever and feelings of unwell. The skin around the opening of the gland may be red and swollen. The abscess is usually hot, swollen, and tender. If ruptured, pus discharge will be seen. The inguinal lymph node may be swollen and the area will be painful.


The diagnosis is obvious, with the presence of a swelling in the lower half of the labia corresponding to the area of the Bartholin gland. The size varies from 1 cm to a few centimeters.


Specimens for cultures and sensitivity testing should be obtained from all draining cysts to help identify the organisms and to guide appropriate antibiotic therapy.


  • Bartholinitis – needs antibiotics therapy.
  • Bartholin cyst- if the cyst is small, it can be left alone since there is a possible chance that the cyst may resolve when the duct becomes unblocked. If the cyst is large or causes symptoms, then a surgical procedure is required. This usually involves opening the cyst wall, removing the content, and then placing a few absorbable sutures at the opening to keep the cyst open to drain the remaining contents. This is called the marsupialization procedure and preserves the function of the gland. This is usually done in the operating theatre.
  • Bartholin abscess – surgical drainage is required for relief. Sometimes spontaneous rupture of the abscess may occur but recurrence is higher in such instances. The procedure is marsupialization, similar to the cyst. Antibiotics are usually given.

Post marsupialization advise:

  • Avoid intercourse or use of tampons for  3 to 4 weeks. The wound usually takes 2 to 3 weeks to heal.
  • Soaking in warm water is helpful. Sitz baths (two to three times a day) can ease discomfort, promote drainage of the cyst fluid, and aid the healing process. Alternatively, applying a warm compress to the area several times a day can be helpful.
  • Treatment in the acute phase should consist of bed rest, and medication to relieve pain.
  • Most women feel better within 24 hours after a Bartholin’s abscess has drained.
  • If antibiotics have been prescribed, the full course must be completed.


The outcome is excellent. There is usually no lasting effect from it if adequately treated. You should be able to resume your daily activities after 24 to 48 hours. However, the recurrence of cysts or abscesses is still possible in some women.

Complications of Bartholin gland infection

  • Persistent chronic inflammation may cause blockage of the duct and leads to cyst formation. Although complications after marsupialization are rare, they can include:
  • Approximately 5 to 15 percent of Bartholin’s cysts or abscesses recur after marsupialization.
  • Rarely, there may be bleeding, hematoma (blood collection), infection, and dyspareunia (painful sex).


There is no proven effective method to prevent Bartholin cysts or abscesses. It is important to maintain good personal hygiene and practice safe sexual practices using adequate precautionary methods to reduce the chance of infection or trauma to the area. The use of lubricant during sexual activity can help reduce friction and prevent irritation or trauma to these areas. Avoid using harsh soaps or douches as these can disrupt the natural balance of the area around the vaginal opening.


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Healing a Broken Relationship

Understanding a Relationship

Article contributed by Dr Ong Tien Kwan (Klinik Ong)

Before we talk about healing a relationship, it is important that we understand what a relationship is, or rather, what makes a good relationship.

  1. A relationship is a mutual responsibility. A relationship can only happen when there are at least 2 people involved in it. A relationship is like a clap. It can only occur when two hands clapped. One hand alone cannot produce the clap. Therefore, a relationship is a mutual responsibility.
  2. A relationship is a privilege. It is a privilege because one can always choose not to have a relationship. One always has this freedom of choice. A relationship is not one-sided, coerced, or compelled. One must be free to enter into or walk out of a relationship.
  3. A relationship must be mutually beneficial. We choose to have a relationship because we see its potential to enrich our lives, to make it better, and to flourish together. Therefore, both sides must benefit from it. Without these mutual benefits, the relationship will eventually fail.
  4. A relationship is a mirror. We like someone or fall in love with someone because that person mirrors something in us that we like, admire or want. At the same time, we must bear in mind that he or she will also mirror our fears, insecurities, weaknesses, and limitations. This is not necessarily a bad thing. In fact, this offers us ample opportunities to recognize, acknowledge and heal our own fears and limitations, that may otherwise go unnoticed, unacknowledged, and therefore unable to be healed. It is here that you can turn a crisis into an opportunity for growth. Use it well.
  5. In a relationship. honesty is the best policy. At any time, a relationship can go bad, go sour or become broken. This often happens because one or both in the relationship fails to or is unwilling to face his or her own inner fears, and therefore ends up unable to communicate truthfully or effectively with each other. In fact, the most common reaction is one that looks for someone to place the blame on. Most ego understand this but cannot seem to help itself. Unfortunately, this is not only unhelpful but often worsens an already bad situation. It is here that honesty is the best policy. For any relationship to flourish, truth must be the foundation of that relationship. Honesty is needed for truth to be upheld.

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Dysmenorrhea (period pain / menstrual cramps / menstrual pain)

Dysmenorrhea refers to lower abdominal pain felt during menstruation. It is divided into two broad categories, which are primary and secondary dysmenorrhoea.

  1. Primary dysmenorrhea refers to the presence of pain during menses without any obvious gynaecological disease that could account for these symptoms. The pain is typically recurrent, crampy pain that starts just before or with the onset of menses and then gradually reduces over the next 24 to 72 hours. It is more often seen in adolescents and young females. Physical examination and an ultrasound scan of the pelvis is usually normal.
  2. Secondary dysmenorrhea refers to the pain before and/or during menstruation in females with a gynaecological disease that could explain the symptoms. These could be endometriosis, adenomyosis, or uterine fibroids. The cramping pain can be in the lower abdomen, lower back or radiates to the inner thighs. The pain may even persist after menstruation has stopped.

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Infertility treatment

Treatment for infertility will depend on the underlying cause. Unfortunately, not all causes can be treated by surgery, medications, or both. Even if the suspected underlying cause of infertility has been treated, not all women will conceive. In about 10% to 15% of infertile couples, the cause is usually not found after a standard clinical and laboratory evaluation. This is term as unexplained infertility. Deciding what to do, if anything, when a fertility evaluation is completed may not be easy. Any treatment for conceiving is actually “maximizing fertility potential” rather than “curing infertility.” There is no guarantee that any of them will result in the successful birth of a baby. Ultimately, if conventional therapies do not achieve the desired pregnancy, then the last resort will be assisted reproductive technology (ART). This refers to procedures such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

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Infertility investigations

The woman and her partner should be present at the initial evaluation for infertility. The doctor will obtain a full clinical history from the couple and then proceed on to a physical examination. The initial investigations that need to be performed will be based on these assessments. Sometimes, the cause of the infertility may be found at this visit. Further evaluation and clinic visits may be necessary for other couples. It may take several weeks. This is because some of the tests may have to be repeated for verification at different specific times in her menstrual cycle. The initial workup of a man usually can be done faster, because men have no monthly cycles and because there are fewer tests for men.


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Stress and hormonal imbalance in women

Life is full of stress. It is common to everyone. Some people are able to handle stress better than others while many cannot cope with the stress that comes with everyday modern living. Stress can affect the well-being of both one’s physical and mental health. Physical stress occurs when a person does not have enough rest, engaging in exercises to the extreme limit of bodily endurance, has a poor diet, or suffers from illness and disease. Mental stress may arise from worries about matters such as money, jobs, retirement, marriage, or the death of loved ones. Sometimes the stress that arises is subtle, and a person may not even realize she is experiencing it. For example, one may feel tired and overwhelmed after a hard day’s work. This fatigue may be a result of either physical or mental stress or a combination of both. Either way, the body is taxed to some degree.

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Premenstrual Syndrome (PMS)

Premenstrual syndrome (PMS) involves symptoms that begin 7 to 14 days prior to the next menses and usually disappear when men­struation flow begins. A significant proportion of women experience PMS at some point in time; some more frequent than others. The severity can range from mild only to very severe form. Luckily, this is only seen in a small proportion of women. For some women, it may get worse as they age and will disappear once they reach menopause. However, during this transition period, it may overlap with the menopause symptoms.

 Symptoms and signs

  •  Physical changes such as fatigue, lack of energy, tender and/or swollen breasts, fluid retention causing puffiness in ankles, hands, and face.
  • Dizziness or fainting, headaches.
  • Digestive issues such as constipation, diarrhoea, bloating, heartburn, food cravings, increased appetite or overeating.
  • Psychological symptoms – such as mood changes, pronounced tension, and anxiety, sleeping difficulty, depression, difficulty concentrating, less interest in work or the usual activities.
  • Skin changes such as acne outbreaks.
  • Sexual issues.

These are the common ones and there are many other symptoms that may be attributed to PMS as well. If you think you have PMS, you should keep track of your symptoms and assess the severity for at least 2 months. The use of the PMS symptoms diary is very useful and you can show this diary to the doctor during the consultation. It is a useful aid for the diagnosis and for assessment of response to treatment. You can download one example from this link.


 The cause is unknown but may be due to fluctuations in the circulating level of hormones in the regular menstrual cycles (especially oestrogen and progesterone). These fluctuations cause retention of sodium in the blood­stream, resulting in oedema in body tissues and contributing to some of the physical symptoms. There may be other contributing factors such as psychiatric, endocrinologic, diet, and changes in the chemical’s levels in the body (endorphin, sero­tonin, prostaglandin).

Risk increases with:

  • Increased levels of stress.
  • Caffeine and high fluid intake seem to worsen symptoms.
  • Smoking may also intensify or increase symptoms.
  • PMS increases with age.
  • PMS can occur with other disorders such as depression.


A physical examination and other investigations will be done to rule out other disorders. Diagnosis usually depends on a history of symptoms and their relationship to the menstrual cycle. Keeping a menstrual diary to monitor and record symptoms severity is helpful. This is also essential for diagnosis and assessment of improvement to treatment.


No specific preventive measures but you can try to avoid stressful situ­ations at the expected time of PMS. Support from close friends or spouse will be helpful.

Expected outcome

Lifestyles and behavioural modifications, with or without medications can adequately control PMS symptoms.


Physical and psychological symptoms may be severe enough to disrupt a woman’s life.



  • Treatment steps involve education and understanding of the problem faced by the woman. Begin a regular, aerobic exercise program (such as walking, biking, swimming etc) and learn relaxation techniques. These are beneficial in general and both are encouraged as part of stress reduction. Meditation or yoga may be helpful. If feasible, reduce activities during symptomatic days if it helps.
  • Stop smoking.
  • Get regular sleep.
  • Cognitive behavioural therapy (CBT) may provide some relief for some women. This can be done concurrently with other therapy for more effective relief of PMS.

Dietary changes

  • Decrease salt intake during the premenstrual phase.
  • Eat a balanced diet with plenty of fiber (fruits and vegetables), whole grains varieties, and food rich in calcium and vitamins B.
  • Eat regular meals and snacks throughout the day. Skipping a meal may make you more miserable due to low blood sugar or hungry pang.
  • Limit or abstain intake of alcohol, caffeine, and sodas.
  • Keep well hydrated


These are used with varying degrees of success. Treatment should be individualized, based on the main presenting symptoms and the woman’s reproductive needs at that point in time.

  • Complementary medicine such as Vitex agnus castus (chasteberry) can be tried in mild PMS and can be effective in some women. There are also many vitamins and supplements that are popular as a treatment for PMS such as primrose oil (for breast tenderness), vitamin B6, calcium and vitamin D. These may be helpful in relieving a few symptoms but may not work for everyone. It is generally not prescribed as a routine. If you are taking any complementary medicine or supplements, please inform your doctor about it because some of these may interact with the prescribed medications. The role of acupuncture is still uncertain.
  • Diuretics pills can help you to pass out more urine to reduce fluid retention.
  • Pain medications such as paracetamol, ibuprofen or celecoxib.
  • Medications are used to suppress the cyclical hormonal change and these include the combined oral contraceptive pills (COCs) and gonadotropin-releasing hormone agonists (GnRH agonist). COCs pills will be a good option for those who require contraception as well. Drospirenone-containing COCs are effective and licensed to be used for PMS. GnRH agonist injection will suppress the ovarian hormone production, leading to a state of low oestrogen or pseudo-menopausal state. However, for long term use, the oestrogen-progestin combinations pills need to be given as add-back therapy to avoid menopausal symptoms and estrogen-deficiency complications such as bone loss
  • Selective serotonin reuptake inhibitors (SSRIs) are a group of drugs that target the serotonin system by increasing the level in the brain. Serotonin is one of the chemicals that is important in the transmission of signals between brain nerve cells (neurons). Elevated levels will improve the transmission of signals among the neurons in the brain and help to improve mood and sense of well-being.


Surgery is the last resort. This is rarely required because generally, medical therapy is usually effective in relieving symptoms of PMS. This type of surgery is a major operation and will involve the removal of both ovaries and the fallopian tube, usually in conjunction with the removal of the uterus (hysterectomy).

You should see your doctor immediately if you have:

  •  You or a family member has symptoms of PMS that interfere with normal activities or relationships.
  • Symptoms do not improve, despite treatment.
  • New or unexplained symptoms develop. Medications used in treatment may produce additional new side effects.

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Bacterial vaginosis (BV)

Bacterial vaginosis (BV) is caused by an overgrowth of certain types of bacteria, which results in vaginal inflammation.  With BV, there is a shift in the bacterial ecosystem, favouring the “not so good or healthy” type such as Gardnerella vaginalis, Mycoplasma hominis and Mobiluncus species and a corresponding reduction in the healthy types such as lactobacillus. There is also a disturbance of the vaginal pH. Bacterial vaginosis most often occurs during reproductive years. It is not regarded as a sexually transmitted infection, but sexual activity has been linked to the development of this infection.

Symptoms and signs

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