Post-menopausal bleeding

Postmenopausal bleeding is defined as unexpected vaginal bleeding that occurs during the menopausal years. Menopause is the permanent cessation of menstruation and is normally diagnosed after 1 year of absent menstrual flow.

Symptoms and signs

  • Vaginal bleeding, which may be a light-brown discharge or heavy, red bleeding (with or without clots). Mucus may accompany the bleeding. Bleeding episodes may vary in length.
  • Women who are on hormonal replacement therapy may have some bleeding and this can be normal, depending on the type of hormone that she is taking. Please consult your doctor about the types of bleeding to be concerned about.
  • Presence of excessive bleeding, progressive abdominal distention, pain and feeling
    unwell usually signify a more serious problem.

Read morePost-menopausal bleeding

Cervical cancer screening (Pap smear, Thin Prep)

The cervical cytology smear was previously referred to as Pap smear. It is a test carried out to detect pre-cancerous and cancerous cell changes in the cervix.
Worldwide, cervical cancer is the fourth most common cancer in women. In Malaysia, cervical cancer is the third most common cancer among women and the seventh-highest among the entire population (Malaysia National Cancer Registry report (MNCRR), 2007 – 2011). The good news is that it can be prevented via widespread vaccination with Human Papilloma Virus (HPV) vaccine among the younger age groups and regular screening for precancerous lesions of the cervix with cervical cytology smear. Pre-cancerous lesions of the cervix can be treated easily and this will prevent further development into cancer and can save lives.

Reasons for the test

  • As part of routine cancer screening.
  • Investigate the cause of abnormal vaginal bleeding or discharge.
  • Bleeding after sexual intercourse

How is it done?

It is a simple and relatively painless office procedure. Sometimes, some discomfort or pain may be felt and you should tell the doctor who is performing it so that the speculum can be adjusted to ease the discomfort.
The examination is performed in the clinic. It usually takes about 10 minutes. You will need to lie on your back on the examination bed, with knees bent and legs are apart. The external genital will be examined visually for abnormalities (abnormal lumps, sores, skin discoloration or inflammation)
A well-lubricated speculum is placed inside the vagina and opened. The speculum is an instrument that holds the vaginal walls apart and allows the examiner to see the cervix and vagina and check for inflammation, infection or growths. There may be some feeling of pressure on the bladder or rectum with the speculum in place. With A small brush, a collection of cells is taken from the cervix and transferred to a small container with a preservative fluid. This type of collection is called liquid-based cytology (LBC). This has replaced the old conventional method of smearing the collection onto a slide. Currently, the LBC cervical cancer screening method is better and more accurate compared to the conventional Pap smear test.
If you have an infection or there are signs of infection present, a sample of vaginal or cervical discharge may be taken for laboratory analysis at the same time.

How frequent?

It is recommended that women should go for a cervical cytology smear once they are above the age of 21 and already sexually active. The interval is every 3 to 5 years. A more frequent screening (every 6 to 12 months) may be necessary if the women are at high risk of developing cervical cancer or had an abnormal smear in the past. Some doctors still recommend annual smears as a routine. The basis for a 3 to 5 years smear is that cervical cancer is a slow progressive condition and usually takes 10 to 15 years to transform into full-blown cancer. Therefore, a 3 to 5 years smear will be sufficient to detect the pre-cancer stage. The cost-benefits ratio is also taken into consideration for this extended recommendation. Those who favour a once-a-year smear argue that the test is not 100% accurate and it depends on so many factors such as the person taking the sample and the laboratory which analyses the sample. Yearly smear can minimize the risk of inaccurate results since it is rare to get a false negative test 2 or 3 years in a row. Furthermore, once-a-year testing makes it easier for women to remember. Many women will find it difficult to remember when the last time smear was done, was it 2, 3 or even 5 years ago. This increases the risk of skipping the test and missing out on the early diagnosis.
In the future, the inclusion of the HPV DNA testing into the cervical cancer screening program will make the testing more accurate to pick up precancerous change of the cervix. Studies have shown that if the cervical cytology smear is normal and/or there is no HPV infection, then the risk of pre-cancerous or cancer of the cervix is extremely low and the screening interval can extend for as long as 3 to 5 years.

How to prepare for the test?

Women should not be menstruating or have sperm present in the vagina from recent intercourse. Therefore, women should avoid sexual intercourse within a period of 24 hours prior to the procedure.
Do not douche, use tampons, or use vaginal medications for at least 24 hours before having the test.
The smear can be done during pregnancy. However, it is not routine and only done when there is an indication for it.

What to expect after the test?

  • There may be some slight bleeding or discharge following the test. Use a tissue to wipe or wear a panty liner.
  • The results of the smear testing may take a few days to two weeks to be available to you.
  • A positive test may indicate that there are some cells changes that need further investigations but do not necessarily indicate a pre-cancerous or a cancerous condition of the cervix. Further testing or a colposcopy or even a biopsy may be indicated to confirm the abnormality.
  • Sometimes the smear report may indicate the presence of infection and treatment may be given.
  • One must be aware that the cervical cytology smear is not 100% accurate and the need for regular repeat smear as per recommended interval is important to ensure that the precancerous changes are not missed in the future.
  • You can drive or return to work immediately if you wish.
  • There is no dietary or activity restriction.

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Menopause – symptoms and treatment options

Menopause is the permanent cessation of menstruation. It can occur as early as age 40 or as late as nearly age 60s. The average age of menopause is usually about 49 to 51. It is normally diagnosed in females after 1 year of absent menstrual flow. Menopause does not occur suddenly. It is a slow transition and peri-menopause usually begins a few years before the last menstrual period. Menopause is only one event in the transition period involving changes in the female body between the mid or late 40’s, when the production of female hormones (estrogen and progesterone) begins to decline. Most of the signs and symptoms of menopause arise from this decrease in estrogen production even before periods stop altogether. Menopause occurring before age 40 is termed premature and may need medical evaluation for the cause. However, if menopause is delayed beyond the age of 55 (meaning a woman is still experiencing menstrual bleeding), there is an increased risk of breast, ovarian, and uterine cancer. This is due to the increased amount of time a woman’s body has been exposed to the estrogen. Therefore, regular mammograms and gynaecological review by specialist is important for women experiencing late-onset menopause.

Read moreMenopause – symptoms and treatment options

Loop Electrosurgical Excision Procedure (LEEP/LLETZ) for CIN

Loop electrosurgical excision procedure (LEEP), also known as large loop excision of the transformation zone (LLETZ), is a procedure for further diagnosis and treatment of cervical intraepithelial neoplasia (CIN). CIN lesion is an abnormal growth in the cervix. The CIN lesion is usually diagnosed during a routine Pap smear (or called Thin Prep) test. LEEP is a very safe way to remove abnormal tissue from the cervix that might otherwise progress to cancer. It minimizes the amount of tissue removed in order to preserve childbearing ability.

Reason for the procedure

• Presence of CIN lesions from the colposcopy evaluation and confirmed via cervical biopsy. Some types of CIN can progress to cervical cancer if not treated. This can be used as a treatment for CIN lesions.
• Unsatisfactory colposcopic evaluation whereby the whole transformation zone cannot be visualized or the cervix appeared abnormal and requires a bigger tissue specimen for a more accurate diagnosis to exclude cancer changes.

Read moreLoop Electrosurgical Excision Procedure (LEEP/LLETZ) for CIN

Endometrial biopsy (Endometrial sampling or curettage)

Endometrial biopsy is a procedure that involves the removal of tissues from the endometrium, which is the inner lining of the uterus.

Reason for the procedure

It is done to diagnose endometrial cancer or hyperplasia (with or without atypia). Endometrial hyperplasia is a potentially precancerous condition. This procedure is indicated in a woman with abnormal uterine bleeding. This includes bleeding between menstrual periods, excessive bleeding during a menstrual period, or bleeding after menopause. It is also done to exclude endometrial cancer in post-menopausal  women with abnormal endometrial finding on ultrasound scan of the uterus.

Read moreEndometrial biopsy (Endometrial sampling or curettage)

Pre-Pregnancy Care for Woman with Type 2 Diabetes Mellitus

Article contributed by Ms Yong Lai Mee

The prevalence of Type 2 Diabetes Mellitus (T2DM) among women in childbearing age is increasing. Pre-existing T2DM in pregnancy increased the risk of maternal and neonatal complications such as macrosomia big baby), miscarriage, stillbirth, eclampsia (high blood pressure and its complications), and preterm labour. The American College of Obstetricians and Gynaecologists and the American Diabetes Association emphasized the importance of achieving optimum diabetes control for promoting the well-being of maternal and reduced prenatal fetus and baby adverse outcomes. Below are some tips to achieve optimum pre pregnancy diabetes care.

Blood Glucose Control

  • Keep pre pregnancy HbA1C < 6.5% to avoid complications during pregnancy.
  • Fetal mortality rate increased 4 folds in those with HbA1C >6.6%.
  • Poorly controlled pre pregnancy diabetes increases congenital heart diseases by 3 folds, neural tube defects increase by 4 folds and spontaneous miscarriages in 30-60% of all pregnancies.
  • Plan 4-6 months before pregnancy to ensure diabetes control is within target range.

Read morePre-Pregnancy Care for Woman with Type 2 Diabetes Mellitus

Uterine Prolapse (pelvic organ prolapse)

This refers to the descend of the uterus into the lower half of the vagina and beyond. In its most severe form, the whole uterus may be outside the vagina. Besides the uterus, other pelvic organ may descend as well such as bladder (cystocoele), rectum (rectocoele) and the small intestines (enterocoele).

Symptoms and signs

  • A lump is seen or felt at the opening of the vagina. It may be seen protruding outside of the vagina.
  • Vague discomfort or pressure in the pelvic region.
  • Backache that worsens with lifting.
  • Urination problems such as frequent and painful urination, difficulty in urination. occasional stress incontinence (urine leakage when laughing, sneezing or coughing), inability to control urination (uncontrollable urine leakage).
  • Difficulty in defecation.
  • Pain during or difficulty with sexual intercourse.
  • Abnormal per vaginal bleeding, usually arising from the exposed vagina wall and cervix.

Read moreUterine Prolapse (pelvic organ prolapse)

Lower Urinary Tract Infection (Lower UTI, cystitis)

Infection of the lower urinary tract occurs when the inner lining of the bladder becomes infected and the urine is full of bacteria. In pregnancy, 5 – 10% of women have bacteria in their bladder and some will have no symptoms at all.

How common?

Up to 40 – 50% of women will have at least one attack in their lifetime and 25% will have recurrences.


  • Bacteria can reach the bladder from the genital and anal area, or through the bloodstream.
  • Injury to the urethra or the bladder.
  • Prolonged use of a urinary catheter to empty the bladder, such as during childbirth or surgery.

Risk factors

  • Sexual activity.
  • Infection in other parts of the genitourinary system.
  • Pregnancy.
  • Poor hygiene.
  • Menopause.
  • Diabetes mellitus.
  • Underlying abnormalities of the urinary tract, such as tumours, calculi (stones), and strictures.
  • Incomplete bladder emptying.
  • During or after major surgery

Read moreLower Urinary Tract Infection (Lower UTI, cystitis)