The Heart in Menopause

Menopause does not cause cardiovascular disease. However, certain risk factors increase around the time of menopause, and this compounds the risk of heart disease.

CARDIOVASCULAR disease (CVD) is a term that describes any disease of the heart or blood vessels. It includes heart attack (myocardial infarction, MI), heart failure, high blood pressure (hypertension) and stroke. MI and strokes are usually caused by blocked arteries.

There is no shortage of focus on women’s worry about cancer, especially breast cancer. However, the reality is that there are more women who die from coronary heart disease (CHD) than from breast cancer.

Many women think that CHD is a man’s disease. It is not. CHD is the most common cause of death in women. About half of all deaths in women after the age of 50 years are due to some form of CVD.

The most common cause of death in women in Health Ministry hospitals is CVD, which comprises about 25 in 100 of all deaths as compared to that of all cancers, which comprise 11 in 100 of all deaths. More women die of CHD than stroke, with about 15 and 10 in 100 deaths respectively.

The misperception of the incidence of CVD in women has led to inadequate information and health promotion to the public; inadequate screening for risk factors; lower rates of diagnosis; and lower usage of appropriate medications and interventions for treating women with CVD.

The problem is compounded by the fact that the symptoms of CHD in women are often not typical, resulting in delay in diagnosis and treatment.

Another misperception is that CVD in women is less threatening than in men. It is not. In-hospital and early post-MI mortality in women (9%) is more than double that of men (4%). The mortality rate a year after an MI is about 32% higher in women than in men.

Likewise, after a stroke, women are more likely to die than men (16% vs 8%). Women survivors after a stroke have a poorer long term outcome and a lower quality of life.

Menopause and CVD

Women who have not reached the menopause have a much lower risk of CVD than men. The risk to a woman increases significantly after the menopause when the oestrogen levels fall so much so that the risk of MI is twice or thrice that of women of the same age who have not reached the menopause.

Within a decade after a woman reaches the menopause, her risk of CHD is the same as that of a man.

Women who reach the menopause before the age of 50 years, whether spontaneously or after removal of the ovaries, have an increased risk of CVD. The risk is mainly that of CHD, not stroke.

The extent to which lowered oestrogen levels may lead to an increase in CVD risk is still not well determined. There is on-going research into this aspect.

Risk factors

Menopause does not cause CVD. However, certain risk factors increase around the time of menopause, and conditions and habits like hypertension, diabetes and smoking increase the risks.

There are several cardiovascular risk factors. Some cannot be changed, but others can be controlled or modified to reduce the risk. The former include increasing age, family history and post-menopause, especially if the menopause is premature (below the age of 40 years).

The risk of CHD is increased if a woman’s father or brother had a heart attack before the age of 55 years; the mother or sister had a heart attack before the age of 65 years; the higher the number of family members with CHD; younger family members with CHD; or if a family member had a stroke.

The findings in the National Health and Morbidity Survey (NHMS) 2011 are worrying. Apart from the increase in cardiovascular risk factors since NHMS 2006 and 1996, many of the risk factors were undiagnosed or poorly controlled.

Excess weight, especially when it is 30% above ideal weight, increases the risk of CHD. Obesity is associated with physical inactivity and both contribute independently to an increased risk of CHD.

The NHMS 2011 reported that the prevalence of overweight and obesity was 29.4% and 15.1% respectively. Abdominal obesity (more than 80cm for women) was found in 43%. Women, Indians and people aged 50 to 69 years were at increased risk of abdominal obesity.

Hypertension increases the risk of MI and stroke. Every 7.5mmHg increase in diastolic blood pressure increases the risk of stroke by 46%. The likelihood of death from CHD, stroke and other CVDs is doubled with an increase in systolic blood pressure of 20mmHg.

Most studies have shown that before the age of 60 years, women have lower blood pressure than men. After the age of 60 years, women have a much steeper rise in systolic blood pressure.

The NHMS 2011 reported that the prevalence of hypertension in adults was 32.7%, with an increasing trend with age, ie from 8.1% in the 18-to-19 years age group to 74.1% in the 65-to-69 years age group.

There were no significant differences between males and females, and between the various ethnic groups.

Diabetes increases the risk of CVD. Women with diabetes have twice the risk of having an MI than those who are not diabetic. The risk of dying from an MI in diabetic women is two to five times that of non-diabetic women.

The NHMS 2011 reported that the prevalence of diabetes in adults was 15.2%, with an increasing trend with age, ie from 2.1% in the 18-to-19 years age group to 36.6% in the 65-to-69 years age group. There were no differences between males and females.

Women who have a family history of diabetes, diabetes when they were pregnant, are obese, or of Indian and/or Malay ethnicity, are at increased risk of diabetes.

Raised cholesterol levels (hypercholesterolaemia) increases fatty deposits on the inner walls of arteries (atherosclerosis), decreasing blood flow, and eventually blocking the artery entirely. If it affects an artery supplying the heart, an MI can occur. If it affects an artery supplying the brain, a stroke can occur.

The NHMS 2011 reported that the prevalence of hypercholesterolaemia in adults was 35%, with an increasing trend with age, ie from 11.3% in the 18-to-19 years age group to 57.2% in the 65-to-69 years age group. The prevalence was higher in females, Malays and Indians.

Bearing in mind that the prevalence of CVD is considerably less in menstruating women, this means that women after the menopause have an increased risk of CVD. This is because of the increase in total cholesterol and low density lipoproteins, which may exceed that of men of the same age, both of which increase risk.

Cigarette smokers, both males and females, have twice the risk of MI than non-smokers. This risk factor is dose-related, with consistently higher risks in women than men, and is independent of age.

Tobacco induces an unfavourable lipid profile, increases inflammation and “encourages” thrombosis. This results in menstruating women losing their “natural” protection against atherosclerosis.

The Global Tobacco Survey 2011 reported that one in four Malaysians smoke, with the vast majority being males. However, about four in 10 Malaysians are exposed to secondhand smoke at work and/or at home. The effects of secondhand smoke are not very different from smoking itself.

Physical inactivity is almost as important a risk factor as smoking because of decreased circulation and weight gain. CHD is almost twice as likely to affect the inactive, compared to those who exercise regularly.

The NHMS 2011 reported that 64.3% of Malaysian adults were active, with the most active in the 40-to-44 years age group, with a gradual decrease after that. Males were more active than females.

Reducing risks

A healthy lifestyle goes a long way in preventing and reducing the risk of CVD. The following lifestyle approaches and/or modifications may help in reducing and/or managing the various risk factors before, during and after the menopause.

The identification and management of CVD risk factors should be an integral component of the periodic health examinations of all women, in addition to their gynaecological and breast examinations.

Of all the cardiovascular risk factors, smoking cessation and avoidance of secondhand smoke has the greatest impact on saving lives.

When a woman ceases smoking, however much or long she has been smoking, her risk of CHD decreases by 50%.

Apart from that, there is a decreased risk of lung disease, including cancer, and many other conditions.

The maintenance of a healthy body weight goes a long way in decreasing the workload of the heart.

Activity and regular exercise improves heart function and reduces risk factors like hypertension and hypercholesterolaemia, maintains a healthy weight, and reduces stress.

A balanced diet that is high in grains, fish, fruits and vegetables, with adequate water, vitamins and minerals, but low in saturated and trans-fats contributes significantly to good health.

The intake of sweets and fatty food should be limited. Fat intake should be less than 30% of daily calories.

Medical conditions like hypertension, diabetes and hypercholesterolaemia have to be diagnosed, treated and controlled. As these are chronic conditions, it is essential that there is strict compliance with medical advice.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

The different types of hormone therapy

Hormone replacement therapy (HRT) is a treatment used to relieve symptoms of the menopause.

Hormone replacement therapy (HRT) is the replacement of the female hormones, oestrogen and progesterone, which the ovaries do not produce any more at the menopause.

Oestrogen is usually taken in HRT unless there are contraindications. Most products contain oestradiol or conjugated oestrogen. Oestradiol is sourced from soy and yam, and conjugated oestrogen from pregnant horse urine. Both are considered natural compounds.

Prolonged exposure of the uterus to only oestrogen increases the risk of cancer of the lining of the uterine cavity (endometrium).

The addition of progesterone or its synthetic version – progestogen – for at least 12-14 days per month reduces the risk of endometrial cancer to nearly the same level as that of women not using oestrogen.

As such, oestrogen-only (ET) products are prescribed in women whose uterus has been removed surgically (hysterectomy). All other women on HRT will be prescribed an oestrogen-progestogen combination (EPT).

There are different types of progestogens. They have similar effects on the endometrium and bone. However, they have different metabolic and vascular effects. Thus, the type of progestogen used may be important for appropriate management of HRT.

The side effects of the different progestogens are different; thus, tailoring of the appropriate progestogen is essential for continuance of HRT.

The treatment regimens may be cyclical or continuous. Women who have had a hysterectomy are usually prescribed continuous oestrogen. Women who have a uterus may take HRT either cyclically or continuously.

Cyclical HRT may be monthly or three-monthly. Monthly HRT is usually prescribed for women with regular periods and three-monthly for women with irregular periods.

In perimenopausal women with a uterus, cyclical EPT (monthly or three-monthly) with daily oestrogen plus progestogen in the latter part of the cycle is preferred. There is a predictable withdrawal bleed unlike continuous HT, which often cause irregular bleeding.

It is more convenient for combined EPT to be taken. If taken separately, it is easy for the progestogen, which causes more side effects, to be omitted.

As such, it is important to remember the endometrial-protective effect of progestogen, if oestrogen and progestogen are taken separately.

In post-menopausal women with a uterus, cyclical EPT (monthly or three-monthly) will produce a predictable withdrawal bleed. Continuous EPT is also suitable as it causes endometrial atrophy and does not produce a withdrawal bleed. However, irregular bleeding or spotting may occur in the initial four to six months of treatment.

Tibolone is a selective oestrogen receptor modulator (SERM) with mixed oestrogenic, progestogenic and androgenic actions. It is prescribed for post-menopausal women and has to be taken continuously. It is used to treat vasomotor, psychological and libido problems, and is an alternative no-bleed regimen for post-menopausal women.

HRT can be taken in various ways. It is advisable to have a discussion with the doctor who can advise on the appropriate route.

The choice of delivery route depends partly on patients’ preference, but there are also certain advantages for different routes.

Non-oral preparations have less effect on clotting factors, reduce triglycerides, and are more suitable for women who experience nausea with oral preparations.

They are also better for those with liver disease, gallstones, migraine or diabetes; those who are at risk of thrombosis; or those who are taking enzyme-inducing medicines.

Oral preparations are in the form of tablets of ET alone, EPT or progestogen alone.

Oral oestrogens are more likely to cause nausea. The oral route is usually avoided in women taking hepatic enzyme-inducing medicines. The progestogens in EPT are 17-hydroxyprogesterone derivatives or 19-nortesterone derivatives. Progestogen-only tablets are taken when the oestrogen component is taken through another route, eg transdermal or nasal.

Transdermal patches and gels contain ET or EPT. These reservoir or matrix patches are usually placed on the buttocks. They may cause a skin reaction sometimes, more so in reservoir patches.

Some patches contain different strengths of oestrogen, thereby permitting dose titration.

The levonorgestrel-releasing intra-unterine device plus oestrogen component may be used if there are side-effects with other progestogen preparations and delivery routes, contraception is still needed, or there is persistent heavy bleeding on cyclical EPT and normal investigations.

Nasal oestrogen spray is available and has been reported to be as effective as oestrogen delivered by other routes. Progestogen needs to be added if the uterus is intact.

The common side effects are nasal symptoms like running nose, sneezing, nosebleeds and breast tenderness (mastalgia).

Oestrogen-only implants can be inserted below the skin under local, general or regional anaesthesia. As oestradiol is released over several months, there is no need to remember to take medicine. However, implants may cause scars, and sometimes, may not be easily removed.

Vaginal oestrogen preparations are in the form of creams, tablets or pessaries. They are useful for vaginal and urinary symptoms, but do not provide total HRT. There is very low systemic absorption. If vaginal oestrogens are used for the short term, progestogen need not be added.

If vaginal oestrogens are used for the long term, an oral progestogen is usually prescribed for 12-14 days each month for endometrial protection because systemic absorption is higher.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of organisations that the writer is associated with.

Menopausal Skin Changes

At the menopause, the ovary stops producing hormones, so there are effects felt in many parts of the body, including the skin.

THE ovarian hormones exert its effects on the reproductive tract by playing a significant role in ovulation, implantation, maintaining pregnancy, childbirth and breastfeeding. Oestrogen also plays important physiological roles in the urinary tract, cardiovascular, central nervous and immune systems, and bone.
Its biological effects are found in cells that have oestrogen receptors, e.g. reproductive and urinary tracts, breast, heart, brain, and skin.

At the menopause, the ovary stops producing these female hormones. So there are effects felt in many parts of the body because of the ubiquitous effects of the hormones. The effects on the skin are described in this article.

The physical appearance of a woman, especially of the face, exerts an important influence on human interactions. Because of its psychosocial role, the condition of women’s skin can affect their quality of life. As such, there are psychological benefits in the preservation of women’s physical appearance with age, which is the foundation on which the cosmetics industry thrives.

The skin has the largest surface area in the body and is described by skin specialists (dermatologists) as the largest organ in the body. It has a thin outer layer (epidermis), a thicker deeper layer (dermis), hair follicles, sebaceous and sweat glands.

The dermis provides a matrix for blood vessels, nerves and appendages.

The dermal connective tissue comprises collagen and elastin, with the former comprising 80% of the dry weight of adult skin. Collagen provides the skin with a high tensile strength and prevents it from being torn by overstretching.

On the other hand, elastin, which comprises about 5% of the dermis, and is closely linked to collagen, provides the skin with elasticity and resilience.

The skin is the primary barrier against environmental damage, dehydration and invasion by micro-organisms. Its structure and function changes with age, and is influenced by genetic, environmental and hormonal factors. Time, photo-ageing, hormonal deficiency, environmental factors and metabolic changes all interact and contribute to a deterioration of skin quality.

During the reproductive years, the oestrogens keep in check the effects of the male hormone, testosterone, which is produced by the adrenal glands (which is adjacent to the kidneys). However, when the oestrogen levels decrease during the menopausal years, there is no hormone to check the testosterone from exerting its effects.

The effects of menopausal oestrogen deficiency on the skin include thinning (atrophy), decreased collagen and water content, decreased sebaceous secretions, loss of elasticity and features of male hormones (hyperandrogenism).

Oestrogen deficiency may hasten skin ageing. However, it is difficult to distinguish between the changes due to ageing from that due to oestrogen deficiency.

Menopausal oestrogen deficiency correlates strongly with skin collagen loss, with up to 30% of collagen lost in the initial five years after the menopause. There is progressive increase in skin extensibility and reduction of its elasticity in postmenopausal women.

Women who reach the menopause before the age of 40 years (premature menopause) have been found to have degenerative changes in skin elastin. Hormone therapy (HT) has been found to delay the increased skin extensibility, leading to a slowing of the loosening of the skin after the menopause.

Skin thickness increases up to 35 to 49 years of age, after which it thins out (atrophy). The atrophy increases in the initial 15 to 18 years after the menopause. The atrophy is due to decreases in skin collagen and water. Most clinical trials report that postmenopausal women on HT have greater skin thickness when compared with women who were not.

Healthy skin contains a substantial amount of water, which is affected by evaporation and hydration. There is a decrease in hydration with increasing age. Dry skin is one of the commonest complaints in post-menopausal women. Oestrogen has been found to be associated with a significant decrease in the incidence of post-menopausal dry skin. This may be related to oestrogen-stimulated increases in the water content of the dermis, which may also be associated with an increase in skin thickness.

The sebaceous glands produce less sebum with age. Furthermore, the sebum produced is thicker compared to the more fluid sebum in the reproductive years. This gives rise to an oily skin and acne in some women.

Post-menopausal women on HT have been found to have an increase in sebum production when compared with women who were not on HT.

There may be increased hair growth in areas where hair follicles are more sensitive to the testosterone produced by the adrenal glands, i.e. upper lip, chin, and cheeks. It has been estimated that about three quarters of menopausal women have a slight increase in facial hair. Sometimes, this can be distressing.

The menopause can also lead to hair loss. This may involve the front of the head or baldness that is widespread or male type (androgenic alopecia). There may also be a decrease in body and/or pubic hair.

There is loss of connective tissue of the skin with ageing. This leads to an increase in distensibility and loss of skin tone, which in turn leads to facial creases and wrinkling.

At the same time, body fat deposits are redistributed to the abdomen, buttocks and thighs. The reduction in fat deposits of the breasts leads to its sagging and flattening.

The production of the skin pigment called melanin (melanocytes), which protects the skin from the environment and the sun, is under the control of oestrogens. Such control is gone in the menopausal years, resulting in the skin being more prone to damage from sunlight, with the appearance of increased pigmentation (age spots) on the parts of the body exposed to the sun’s ultraviolet rays over the years, i.e. face, neck, arms, hands and chest. The risk of a skin cancer (melanoma) is also increased,

The skin changes also lead to an increased risk of infections, which are also likely to take a longer time to heal.

The cells lining the lower urinary tract and vagina are similar in structure to the skin. As such, there are similar changes in the lining of the urethra, bladder and vagina at the same time that there are changes in the skin.

In short, the structural changes of the skin in the menopausal years include thinning, loss of elasticity and laxity, dryness, scaliness, pigmentation, hair loss, hair colour changes and wrinkling. The functional changes include reduced barrier function, reduced wound healing ability, reduced thermoregulatory ability and increased risk of melanoma.

While it is not possible to reverse the changes, much can be done to slow them down and even control some of the changes. There are general and specific measures.

Various lifestyle measures are beneficial to the skin. They include a healthy diet containing omega-3 fatty acids, vitamins (especially B, D and E), proteins, drinking plenty of water to keep it well hydrated, exercise, getting adequate sleep, avoiding hot showers which can dry out the skin (unlike cold showers which may help increase blood flow and can be helpful when there are hot flushes) and avoiding stress.

Cessation or reduction of tobacco smoking and avoidance of exposure to second-hand smoke will reduce considerably the severity and rate of damage.

Other measures include avoiding harsh soaps and conditions which lead to itching. The use of an effective sunscreen to protect the skin from the sun’s harmful ultraviolet rays, when going out, is helpful.

The application of moisturising creams can keep the skin moist. It may be helpful to change to brands designed for an individual’s age group. Some products contain collagen, but it is still unclear whether the topical application of collagen has any effect.

Prudence is needed when choosing make-up. The objective is to avoid skin irritation with chemicals and to hide lines, wrinkles and dryness. There are cosmetic products available with sun protection factor (SPF) and moisturising effects.

There are various specific measures to address specific menopausal skin conditions.

A doctor should be consulted immediately if there is any dark mole or changes in one, or if there is excessive hair loss or growth. While many family doctors can deal with these problems, the expertise of a dermatologist would be helpful.

Combined contraceptive pills containing drospirenone, which suppresses the male hormones, is prescribed in women in the menopause transition.

HT is prescribed for vasomotor symptoms and vaginal atrophy in menopausal women. Oestrogens have also been found to prevent skin collagen loss, increase skin thickness and restore skin moisture.

In addition, there are reports that oestrogen could improve and prevent fine wrinkles, aid wound healing and prevent ulcers.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Lifestyle at the Menopause and Beyond

Good nutrition and lifestyle changes can contribute to a healthy, contented menopause.

KEEPING healthy with a positive lifestyle has a significant impact on health. Women in their late 30s and 40s can make lifestyle changes that will lower their risk of health problems when they get older.

The menopausal years are a time of transition when fertility gradually ends. Every woman’s experience is unique. The decline or absence of oestrogen can lead to changes in bone, heart, urinary, sexual health, memory and energy levels.

Good nutrition and lifestyle changes can contribute to a healthy menopause. They can make a real difference to how you feel and can help to maintain health during and after the menopause.

The perimenopause is a good time to pay more attention to health if you have not been doing so.

Healthy diet

Women at the menopause and beyond should be concerned about their diet as it influences cardiovascular disease and thinning of the bone (osteoporosis).

A balanced diet that is high in grains, fruits and vegetables, with adequate water, vitamins and minerals, but low in fat, contributes significantly to good health.

The intake of sweets and fatty food should be limited. Fat intake should be less than 30% of daily calories.

The recommended daily consumption of elemental calcium in premenopausal and postmenopausal women is 1,000mg and 1,500mg respectively. This can come from leafy green vegetables, calcium-rich dairy products (low fat or non-fat), as well as calcium-fortified foods and juices.

If this is not sufficient, calcium supplements may be used.

The body’s absorption of calcium is increased by vitamin D, which can be found with about 15 minutes of daily exposure to the sun without any sunscreen, certain fortified foods like milk, tuna and liver, or vitamin D supplements.

It is advisable to eat plenty of fresh fruits and vegetables, especially dark leafy vegetables, legumes, nuts and seeds; complex carbohydrates, like oats, wholegrain bread and brown rice; and essential fatty acids (good fats) from oily fish, like sardines and pilchards.

You should limit or reduce the intake of salt, saturated fat, stimulants like alcohol, coffee and tea, sugary food and junk food.

Supplemental vitamins and minerals may or may not be required, depending on whether the diet is balanced or not. A discussion with your doctor or nutritionist would be helpful.


Physical inactivity is a risk factor for many conditions.

Exercise is a remedy for many menopausal complaints and helps prevent future disease.

It can help a person lose weight and maintain it.

It protects against cardiovascular disease and prevents osteoporosis.

It gives a person more energy, helps with better sleep, and it stimulates the brain’s production of endomorphin, which gets rid of negativity and depression, thereby relieving stress.

It improves circulation, lowers blood pressure and increases muscle strength.

The benefits of exercise are well-documented. Colpani et al reported in the journal Menopause in May that: “Habitual physical activity, specifically walking 6,000 or more steps daily, was associated with a decreased risk of cardiovascular disease and diabetes in middle-aged women, independently of menopause status.”

There are three types of exercises: aerobic, weight-bearing, and flexibility. A moderate aerobic exercise regimen of at least 30 minutes each day, like a two-mile walk, has the greatest effect on heart and lung health.

Weight-bearing exercise, like fast walking or working with weights, can delay or prevent bone loss.

Flexibility exercises, like yoga and stretching, help maintain muscle function and joint flexibility, and may also improve balance, which can decrease the risk of fractures due to falls.

Each exercise session should start with a 10-minute warm-up, and at the end, a five- to 10-minute cool-down.

In a good workout, a person will need to exercise at the target heart rate for at least 30 minutes three times a week. Your doctor will be able to provide advice on the target heart rate, which is dependent on a person’s age.

If there is difficulty in fitting exercise into your schedule, there are things that can be done to be more active, for example, walking rather than driving, and/or wherever possible, taking the stairs instead of the lift.

If a person is not used to strenuous activity, it would be prudent to check with the doctor before commencing an exercise programme, especially if you are above 40 years or are overweight.

Pelvic floor exercises strengthen the pelvic floor, which is composed of layers of muscle that stretch like a hammock, from the pubic bone in front to the end of the back bone. If the pelvic floor muscles are weak, urine may leak when a person coughs, sneezes or laughs (incontinence).

The pelvic floor can be strengthened by closing up the back passage as if trying to prevent a bowel movement. At the same time, the urethra is drawn in, as if trying to stop the flow of urine, and the vagina is also drawn in, as if trying to grip a tampon.

This is held for five to 10 seconds. The exercise is repeated in sets of five about 10 times a day.

Exercise is a remedy for many menopausal complaints and helps prevent future disease. –Filepic

Weight Management

Weight gain is not due to the menopause. As one ages, the body’s metabolism slows down so that it takes a longer time to burn up food that has been consumed.

This means that taking the same amount of food (like when a person was younger) would increase the weight.

An overweight person is more likely to have cardiovascular disease, high blood pressure, raised cholesterol, diabetes, arthritis and back problems.

The most dangerous form of body fat for heart health is located around the waistline.

It would be wise for all menopausal women to reassess their dietary intake and exercise levels to reach a balance that maintains a healthy weight.

Being too thin is not healthy. Women who diet or exercise excessively can become so thin that their menstrual periods stop temporarily.

It would be best not to exceed the weight for one’s height. If you have to lose weight, a discussion with the doctor and dietitian would be helpful. A healthy rate of weight loss is 0.5 to 1kg per week. It is not advisable to go on crash diets.


Alcohol exerts a greater impact on women than men as their bodies contain less water to dilute the alcohol, and the enzyme that digests alcohol is less abundant in women.

Alcohol slows reflexes, and affects judgement and memory. It also interferes with calcium absorption and bone growth.

A drink or two a day is alright. Larger amounts have been associated with menstrual problems, early menopause, damage to heart muscles, high blood pressure and some cancers.

Prolonged excessive consumption results in liver cirrhosis, which can lead to liver failure, and eventually, death.


Tobacco causes and increases the risk of many diseases. It is the single most preventable cause of illness and premature death.

Women who smoke shorten their lives by five to eight years.

The risk of heart disease, osteoporosis, cancer of the cervix and vulva, and Alzheimer’s disease is doubled.

The risk of lung cancer is increased 12 times.

Smokers also reach the menopause up to two years before non-smokers do. Family members exposed to second-hand smoke also suffer.

Any time is the right time to stop smoking. The earlier smoking is stopped, the more benefits there are. The circulation improves, and breathing is easier within three months. The risk of a heart attack is decreased by 50% within a year. The risk of other serious smoking-related diseases drops to that of a non-smoker within a few years.

There are various smoking cessation techniques and aids – reducing and limiting the number of cigarettes smoked, nicotine gum or patch, antidepressants, hypnosis and support groups. If you are unable to stop smoking, seek help from your doctor.

A combination of behaviour modifications and medicines appear to be the most successful approach. Many smokers make more than one attempt to successfully cease smoking. As such, persistence and continuing to try is vital.

Reducing Stress

Prolonged stress impacts upon health. Although the menopause has not been shown to increase stress, many women at this age face life situations that may be stressful, thereby affecting health.

Exercise has been proven to reduce stress. Deep, slow, abdominal breathing can increase relaxation and may reduce hot flushes.

There are also reports of fewer hot flushes and just feeling better with meditation, yoga, massage, or even a bath. It is beneficial to spare some time to relax every day.

Prevention of Falls

It is important to eliminate factors in the environment that can result in falls, thereby reducing the risk of fractures.

Measures to avoid falls indoors include keeping rooms free of clutter, keeping floors smooth but not slippery, installing grab bars and using a rubber bath mat in the tub or shower, avoiding obstacles that one might trip over, and switching on the lights if getting up at night.

Some measures to avoid falls outdoors include wearing rubber-soled shoes, avoid walking on slippery surfaces, and using a walker or cane if it is needed for added stability.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Implants and Injections: The Doctor Says

Contraceptive implants contain either levonorgestrel or etonogestrel. The implant is inserted by the doctor just below the skin of the upper arm under local anaesthesia. These are two useful contraceptive methods that can be used by most healthy women.

CONTRACEPTIVE implants and injections are hormonal contraception. Unlike the combined oral contraceptive (COC) pill, they contain only progestogens that are similar to the hormone, progesterone, produced by the ovaries. They are long-acting, effective contraceptive methods.

These implants and injections release progestogens continuously and steadily into the bloodstream, which thickens the mucous in the cervix, thereby preventing sperm from entering the uterus.

The progestogens also make the lining of the uterus thin, thereby making it less receptive to the implantation of a fertilised egg on it. It also prevents the release of an egg from the ovaries (ovulation).

They are a reliable and reversible contraceptive method that is suitable for women who want to use hormonal contraception but do not want to take oestrogens, or who have conditions which make them unsuitable for the COC.

The implants and injections are very effective as they are more than 99% reliable, ie less than one in 100 women who use it will get pregnant each year.


The primary advantage of contraceptive implants and injections is that they provide protection against pregnancy soon after the implant is inserted (or the first injection is given).

They are long-acting, and fertility returns to normal after its use is stopped.

Implants are effective for about three or five years, and each injection for eight or twelve weeks.

The advantages of implants and injections are that they do not affect the sexual act, and are options for those who are cannot use contraceptive methods that contain oestrogen, ie COC, contraceptive or vaginal ring. Implants and injections can be used during breastfeeding as it does not affect the latter. They may provide some protection against cancer of the endometrium and pelvic inflammatory disease, due to the thickening of the cervical mucous (which may prevent bacteria from entering the uterus).

Implants may reduce heavy or painful periods after about a year of use. Injections may reduce heavy, painful periods, and relieve premenstrual symptoms in some women.


There may be some disadvantages of contraceptive implants and injections that have to be considered.

They do not provide protection against sexually transmitted infections (STIs). They may cause periods to change significantly in the first year of use, becoming irregular, heavy, light and short, or stopping altogether (amenorrhoea).

The altered periods usually settle down after about a year of use, but they can sometimes continue for as long as the implant is fitted, or the injected progestogen remains in the body.

These changes are not harmful, but some women do not find them acceptable. Additional medicines may be prescribed if there is prolonged bleeding.

The effects on periods usually resolve soon after the removal of the implant.

However, it usually takes between eight to 12 weeks for injected progestogens to leave the body, so disrupted periods will continue during this time, and for some time afterwards. It can take between three months and a year for the periods to return to normal.

Users of contraceptive implants and injections may also have headaches, acne and tender breasts. Users of injections may also have mood changes and loss of sex drive (libido). These side effects usually resolve after a few months, but if they persist, medical attention should be sought.

Rarely, infection may occur at the site of insertion of the implant or injection, for which antibiotic treatment may be necessary. There is also a very rare risk of allergic reaction to the injection.

Injections may be associated with weight gain of about two to three kg over a year, although some women may lose weight.

They can cause thinning of the bones, but this does not increase the risk of bone fracture. The bone replaces itself when the injections are stopped, so it is unlikely that the injections will lead to long-term problems.

Women who are at increased risk of developing osteoporosis will usually be advised to use another contraceptive method.

Implants and injections are unsuitable for women who may be pregnant, want to have regular periods, or who have bleeding between periods or after sexual intercourse. They are also unsuitable for women who have had a clot in a blood vessel (thrombosis), breast cancer (currently or previously), migraine or liver disease.

The injection is unsuitable for women who have diabetic complications, liver cirrhosis, or who are at increased risk of developing osteoporosis.


Contraceptive implants contain either levonorgestrel or etonogestrel.

The levonorgestrel implant comprises six small silicone rods that are inserted, by the doctor, just below the skin of the upper arm under local anaesthesia. The small wound is then covered with a dressing, usually without the need for stitches.

The rods, which are left in place for up to five years, constantly release a small amount of levonorgestrel into the bloodstream. It is immediately effective if inserted on the first day of the period.

The etonorgestrel implant is a single rod that is inserted in a similar manner as the levonogestrel implant. The rod, which is effective for three years, releases etonorgestrel in a steady and controlled manner during this time. Its insertion and removal is faster than that of levonorgestrel implants.

Implants may be used until menopause, the average age of which is about 50 years.

As long as the implants are used in accordance with their duration of action, there is very effective protection against pregnancy, with 0.1 pregnancies in 100 women in one year of use.

An implant can be removed at any time by a doctor. The removal takes a few minutes under local anaesthesia. Upon removal, there is no longer any protection against pregnancy and the normal menstrual cycle is usually restored rapidly.


Contraceptive injections contain either depot medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN). There are other injections that contain both oestrogen and progestogen, but these are not available in Malaysia.

The site of the injection is usually the muscle of the buttock, or sometimes, the upper arm.

DMPA injections are given every twelve weeks. The first three NET-EN injections are given at eight-weekly intervals, after which the injections are given every 12 weeks.

Disruptions of the period are not uncommon. There is amenorrhoea in about 45 to 50 in 100 women after the injections have been used for more than a year.

It may take up to a year for periods to start again in some women. This may be acceptable to some women, but others, especially those who want a pregnancy at a later date, may find this unacceptable.

As long as the injections are used in accordance with the prescribing directions, there is very effective protection against pregnancy, with 0.3 pregnancies in 100 women in one year of use.

About 70% of women gain weight with DMPA, with an average of 2.5kg after one year of use. About 20% of women gain weight with NET-EN, with an average of 5kg after one year of use.

About 70% of women conceive within a year of stopping DMPA or NET-EN.

There have been concerns raised about the link between DMPA and cancer. However, data from the World Health Organization suggest that there is no long-term increased risk of breast, cervical and ovarian cancer.

On the other hand, there is a marked reduction in the risk of endometrial cancer.

Timing it

Contraceptive implants or injections can be inserted or given at any time in the menstrual cycle, provided the user is not pregnant.

Implants and injections that are inserted or given during the first five days of the onset of periods, or within 21 days of childbirth in non-breastfeeding mothers, provide immediate protection against pregnancy.

If inserted or injected at any other time of the menstrual cycle or after 21 days of childbirth, there will be no protection for the following seven days; so another contraceptive method, eg condoms, will have to be used during this time.

There are reports of heavy and irregular bleeding when injections are given within the first few weeks after childbirth.

Injections are usually given six weeks after childbirth for breastfeeding mothers.

Implants can be inserted immediately after a miscarriage or abortion, with immediate protection against pregnancy.

Implants and injections are useful contraceptive methods. They provide excellent protection against pregnancy when used in accordance with the prescription directions. They can be used by most healthy women except those who have conditions which render them unsuitable.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. 

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Hope in HPV Vaccine

As HPV infection is a major cause of cervical cancer, vaccination offers the hope of a reduction in the incidence of this cancer.

HUMAN papilloma virus (HPV) is a common sexually transmitted infection.

The HPV virus needs to infect cells in order to survive. Once inside a cell, it directs the cell to make copies of it and to infect other healthy cells. The infected cells eventually die and are shed from the body. When the virus is shed, it can infect another person.
There are different types of HPV. The low risk types, such as HPV6 and HPV11 cause benign genital and respiratory warts, while persistent infection with high-risk types such as HPV16 and HPV18 is associated with increased risk of high grade cervical intraepithelial neoplasia (CIN), which is a precursor of cervical cancer.

The genital warts (condylomas) may appear on the outside or inside the reproductive tract. It can spread to nearby skin or to a sexual partner.

Genital warts are more likely to occur in people who have more than one sexual partner or whose sexual partner has more than one partner. Other reproductive tract infections are often associated with genital warts.

HPV is a major cause of cancer of the cervix. HPV infections by the high risk types are common in young sexually active women. Most clear spontaneously without ever causing cervical intraepithelial neoplasia while some develop a persistent infection.
Hence, cervical cancer can be considered a rare consequence of persistent infection with one or more high risk types, with other as yet undefined factors playing a role.

Studies suggest that HPV may also cause cancer of the vulva, vagina, anus, some cancers of the oropharynx (middle part of the throat that includes the base of the tongue and tonsils).

The more sexual partners a person has, the more likely he or she will get HPV infection. The vast majority of HPV infections go away without treatment. Certain factors like smoking, multiple sexual partners, having many children, oral contraceptive use and HIV infection are associated with an increase in the risk of developing cervical cancer.

As HPV may have no symptoms, it may be more common than is thought.

Most genital warts may appear within a few weeks or months after sexual contact with an infected person or they may not appear at all.

The warts are flat, abnormal growths in the genital area including the cervix. Sometimes, the warts are extensive with a cauliflower-like appearance.

There is no published data on the disease burden of HPV infection in our country as HPV is not a notifiable infection.

However, cervical cancer is the second most common cancer in women here.

The National Cancer Register for 2003 shows the incidence in Peninsular Malaysia as 13.4 and 62.9 per 100,000 women in the age groups 15 to 49 and 50 to 69 years respectively.

HPV vaccines

Women who had previously been infected by a particular HPV type are unlikely to get re-infected by the same HPV type because of the antibodies produced.

There are two types of HPV vaccines: a bivalent (HPV16 and HPV18) and a quadrivalent vaccine (HPV 6, 11, 16 and 18).

Both vaccines provide protection against 70% of the HPV types that cause cervical cancer.

In addition, the quadrivalent vaccine provides protection against 90% of the HPV types that cause genital warts.

The vaccines do not provide protection against HPV types that a person has been exposed to.

However, a person who has had HPV may still benefit from the vaccine because most people are not infected with all the types of HPV contained in the vaccine.

The vaccines do not provide protection against other sexually transmitted infections (STI).

Information about some aspects of HPV vaccines is yet to be clarified. This includes the duration of protection although current data indicates that the protection after vaccination lasts at least five years.

The vaccines are given by injection in the upper arm. The second and third doses are given two and six months later.

The optimal age for HPV vaccination is between the age of nine and 26 years.

Effectiveness and safety

The HPV vaccines are effective. Studies of both vaccines, to-date, have reported near 100% efficacy.

HPV vaccines are generally well tolerated and reactions are minimal. It is usually limited to some pain, swelling, itching and redness at the injection site, fever, nausea, vomiting, dizziness and fainting.

Other side effects reported include swollen glands in the neck, armpit, or groin, headache, skin rashes, joint pain, aching muscles, unusual tiredness or weakness, and a general feeling of being unwell.

Allergic reactions have been reported. They include difficulty in breathing, wheezing and rashes. Some of these reactions are severe.

It is important to inform your doctor if you or your child has had an allergic reaction to the vaccine; has a bleeding disorder; is immunocompromised, such as with HIV infection; is pregnant or is planning to get pregnant, as the vaccine is not recommended for use in pregnant women; has a fever more than 37.8°C; and is taking or intends to take any medicines including over the counter medicines.

HPV vaccination is no substitute for Pap smear screening. Those who have received HPV vaccines should continue Pap smear screening.

An abnormal Pap smear does not mean that a person has HPV infection or any other condition, including cancer.

It does mean that you have to be examined with a procedure called colposcopy. This involves using a magnifying instrument to look at the cervix, vagina, vulva and anus.

If there are areas that appear suspicious, a biopsy, in which a small sample of tissue is removed for microscopic examination, will be performed.

As HPV infection is a major cause of cervical cancer, vaccination offers the hope of a reduction in the incidence of cervical cancer.

However, other measures are needed to eradicate cervical cancer. They include widespread Pap smear screening and safe sexual practices.

One should also remember that HPV vaccines prevent HPV infections. It cannot be extrapolated to the prevention of cervical cancer as there are, apart from HPV infection, other as yet undefined factors playing a role in the genesis of cervical cancer.

Dr Milton Lum – is member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Flush These Symptoms Away

Helpful general measures for hot flushes and night sweats include regular exercise, wearing light clothing, sleeping in a cool place and avoidance of stress. Hot flushes and night sweats are often unwelcome consequences of menopause.

MENOPAUSE is the permanent cessation of periods as a result of the loss of ovarian activity, and can be said to have occurred only after 12 months without spontaneous menstruation.

The average age of this natural event is 50 years. Women who are at or near the menopause often experience vasomotor symptoms – hot flushes and night sweats.

A hot flush is a feeling of intense heat involving the face and body. Whilst it may be attributed to the hot tropical weather, hot flushes are difficult to ignore.

Women who experience them often switch on the fan and/or air conditioner even when the ambient temperature is low.

The hot flushes may not be apparent to an observer, but are very real to the person experiencing it. Its duration varies from a few seconds to 10 minutes, with an average of about four minutes.

The frequency of the flushes ranges from hourly to a few times a week.

During the flush, the blood vessels open up (dilate), resulting in a slight decrease in the body’s core temperature. After it goes away, there is no other bodily change. Such symptoms are also called vasomotor symptoms.

Night sweats can be troublesome. Some women who experience them complain that it is as if their clothes were drenched by the rain. Sleep disturbances are common when there are night sweats.

Hot flushes and night sweats are often associated with poor concentration and memory. Frequent flushes and sleep disturbances may lead to mood changes, which are common. Depression is not uncommon.

Why it occurs

Why hot flushes and night sweats occur is not well understood. They appear to be related to markedly high levels of hormones called gonadotrophins, which are produced by the brain to stimulate the ovaries when ovarian hormone production fails.

Vasomotor symptoms do not usually occur in men as there is no similar rapid decrease in hormones. The gradual decrease in hormones in older men is not accompanied by high levels of gonadotrophins.

However, men who are treated for prostate cancer with medicines that suppress production of the male hormone, testosterone, can experience hot flushes that are similar to that in menopausal women.

The reported prevalence of vasomotor symptoms varies with different studies. However, certain generalisations can be made.

For one, the frequency and severity of the symptoms are much more at or near the menopause.

The symptoms occur in about half of menopausal women, with some finding it more distressing than others.

They resolve spontaneously in many women within a few months, but persist in others for several years after menopause.

There are studies that report of persistent hot flushes in about three in 10 women aged 60 years.

The prevalence of menopausal symptoms in Malaysian women have been published in medical literature. Dhillon et al reported on the “Prevalence of menopausal symptoms in women in Kelantan” (Maturitas. 2006 Jun 20; 54(3):213-21).

The most common number of menopausal symptoms was eight, with night sweats occurring in 53% and hot flushes in 44.8%. There was tiredness in 79.1%; reduced level of concentration in 77.5%; mood swings in 51%; sleep problems in 45.1%; loneliness in 41.1%; anxiety in 39.8%; and crying spells in 33.4%.

Similar findings were reported by Syed Alwi Syed Abdul Rahman et al in their publication “Assessment of menopausal symptoms using modified Menopause Rating Scale (MRS) among middle age women in Kuching” (Asia Pacific Family Medicine 2010, 9:5).

The common symptoms were physical and mental exhaustion in 67.1%; sleeping problems in 52.2%; hot flushes and sweating in 41.6%; irritability in 37.9%; anxiety in 36.5%; and depressive mood in 32.6%.

Certain factors increase the likelihood of vasomotor symptoms.

They are more severe in women whose body weight is low, who do minimal or no exercise, and those who smoke.

Caucasians and Negroes experience them more often than Asians.

The symptoms are more severe if the menopause is sudden or early, e.g. surgical removal of the ovaries; following chemotherapy or radiotherapy.

Managing vasomotor symptoms

Vasomotor symptoms are not life-threatening, but they affect quality of life, especially when they are frequent and severe.

They usually resolve with the passage of time. However, when they are present, it is vital that the spouse and family members are sympathetic and tolerant. At the same time, the sufferer has to approach it positively.

Helpful general measures include regular exercise; the wearing of light clothing; sleeping in a cool place; and avoidance of stress.

However, some studies report that exercise and diet are of little benefit. Avoidance of factors that precipitate vasomotor symptoms, e.g. tobacco smoke, alcohol or certain foods is helpful.

Vasomotor symptoms are treated specifically with hormones. Both oestrogen (ET) and combined oestrogen-progestogen (EPT) are effective for relief of hot flushes and/or sweats.

ET and EPT are effective in reducing the frequency and severity of hot flushes and/or sweats. Both low and standard dose ET and EPT are effective.

The dose refers to the oestrogen concentration in E and EPT. The standard dose contains either conjugated equine oestrogens 0.625mg or estradiol valerate 2mg. The low dose contains either conjugated equine oestrogens 0.3mg or 0.46mg; or estradiol valerate 1mg.

In short, the quality of life of a menopausal woman with vasomotor symptoms can be improved with a medical consultation.

Dr Milton Lum – is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Ectopic Pregnancy

Early detection and treatment of ectopic pregnancies will produce better outcomes.

Ectopic pregnancy is a condition in which the fertilised egg (embryo) is implanted outside the uterine cavity. Its occurrence varies in different countries but it is estimated to occur in about one in 100 pregnancies.

Unseen: About 50% of ectopic pregnancies do not exhibit any specific symptoms.

About 95% of ectopic pregnancies occur in the fallopian tubes. It can also occur in other sites like the ovary, cervix or abdominal cavity.

An ectopic pregnancy is life-threatening as it can rupture, causing bleeding into the abdominal cavity. The earlier an ectopic pregnancy is treated, the better the outcome. Delay will lead to further damage to the fallopian tubes or other sites and if left untreated, the blood loss can result in death.

Risk factors

When an egg is released by the ovary, it travels along the fallopian tube where it is fertilised by the sperm. The lining of the fallopian tubes contain hair-like structures, called cilia, which push the embryo along into the uterine cavity where it gets embedded. If there is damage to the fallopian tubes, the cilia may be unable to perform its function, resulting in the embryo embedding in the fallopian tube itself.

These factors increase the likelihood of ectopic pregnancy:

Pelvic inflammatory disease (PID) in which the ovaries, fallopian tubes and uterus have been or are infected.

Intra-uterine contraceptive device especially when it is associated with PID.

Previous surgery on the fallopian tubes like sterilisation, its reversal or other surgery.

Previous abdominal surgery like caesarean section and fibroid removal (myomectomy).

In-vitro fertilisation (IVF). Although the embryo is placed inside the uterine cavity, it may still attach itself to the fallopian tube.

Previous ectopic pregnancy. The risk of an ectopic pregnancy increases from 1% to 10% after an ectopic pregnancy has occurred.

The risk in women aged 44 years or more is increased from 1% to 8%.

It should be noted that these risk factors are not present in many women who have an ectopic pregnancy.


About 50% of women with an ectopic pregnancy have no specific symptoms apart from those associated with pregnancies such as missed period, nausea and sore breasts.

The symptoms include:

Vaginal bleeding that differs from that of the normal period in that it is lighter or darker.

Abdominal pain which is usually on one side. The pain may be severe and persistent.

Shoulder tip pain which is due to the blood in the abdominal cavity irritating the diaphragm, which has the same nerve supply as the shoulders.

Pain on passing motion or urine.

The diagnosis is made by clinical examination in most instances. A transvaginal ultrasound is helpful in diagnosis. This involves inserting the ultrasound probe into the vagina to visualise the uterus and its surroundings.

Sometimes, the diagnosis is made at laparoscopy, which is an operative procedure that involves direct visualisation of the pelvic organs through small incisions in the abdomen. This procedure is useful especially when there are no specific symptoms. After making the diagnosis at laparoscopy, a decision will be made on the mode of management.


The management is influenced considerably by whether the diagnosis is made before the ectopic pregnancy has ruptured or not. The gynaecologist will discuss the various treatment options with the patient.

Surgery to remove the embryo from the abdominal cavity is the most common treatment. If there is no indication of shock, the laparoscopy approach is usually preferred. If there are changes indicating shock, a laparotomy is preferred, in which the larger incision will facilitate an expeditious stopping of the bleeding.

The part of the fallopian tube in which the embryo is located (salpingectomy) is removed or the embryo is removed through an opening in the tube (salpingotomy). If the other tube appears normal, there is no evidence that a salpingotomy is preferable to a salpingectomy. If the other tube appears diseased and there is a desire for future fertility, a salpingotomy is preferred, as a salpingectomy would mean that IVF or other assisted reproduction would be required for the next pregnancy.

Medical treatment can be provided if the ectopic pregnancy is diagnosed early. Methotrexate may be prescribed to stop the pregnancy from continuing. The women who are most suited for methotrexate treatment are those with minimal or no symptoms and a serum human chorionic gonadotrophin (hCG) below 3,000 IU/l.

The side effects of methotrexate include nausea, vomiting, sore mouth and sore eyes. About 75% of those given methotrexate will experience abdominal pain which may be difficult to differentiate from that of tubal rupture.

Expectant treatment (“Wait and see”) refers to situations where there are minimal symptoms and the pregnancy’s location is unknown.

This situation occurs when the hCG is less than 1,000 IU/l and no pregnancy, whether inside or outside the uterine cavity, is visible on transvaginal ultrasound.

Up to 60% of such pregnancies resolve spontaneously without any treatment. Regular examinations and blood tests are mandatory with expectant management, until the hCG levels are below 20 IU/l.

Surgery will have to be resorted to at any time during medical or expectant treatment should the clinical situation warrants it. Anti-D immunoglobulin will be given to all rhesus negative women with suspected or confirmed ectopic pregnancy.


Ectopic pregnancies cannot be prevented. However, one of its major risk factors, pelvic inflammatory disease (PID), can be prevented. The primary cause of PID is sexually transmitted infections (STI), which is preventable. Regular use of the condom can prevent STIs. Knowing one’s sexual partner and having one sexual partner can also prevent STIs. Regular sexual health checks are helpful particularly if one suspects one’s sexual partner has STI and/or PID.

Dr Milton Lum – is member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Contraception and menopause

Even if a woman has menopausal symptoms, it does not mean that she cannot get pregnant.

A WOMAN is considered to have reached menopause if she has not had a period for 12 consecutive months. This is a retrospective diagnosis. Although the average age of the menopause is 50-51 years, the time at which the menopause is reached varies between women.

The menstrual periods become irregular before they stop altogether. As long as a woman has a period, the ovary will still produce some eggs (ovulate). As such, the possibility of pregnancy exists, although the chances get increasingly remote nearer to the menopause.

Even if a woman has menopausal symptoms, it does not mean that she cannot get pregnant. About 75% of pregnancies in women above the age of 40 years are unplanned. It has been reported that 93% of women aged 40 to 55 years with regular menstrual cycles appear to ovulate each cycle.
As such, although there is a natural decline in fertility after the age of 37 years, effective contraception is still necessary to prevent an unplanned pregnancy.

There are various birth control options (contraception) available. Contraceptives are either hormonal (e.g. the Pill) or non-hormonal (e.g. condoms).

Hormonal contraceptives are often featured disproportionately in the media, usually with frightening headlines. Mature women are more likely to be sensitive to these negative messages, and therefore, often abandon effective contraceptive methods.

The reality is that the contraceptive methods available are very safe. In addition, many methods have significant non-contraceptive benefits to the user.

The doctor can help a couple choose an appropriate method depending on medical history, sexual habits, the method’s effectiveness and possible side effects, lifestyle and preferences.

Contraceptive pill
Hormonal oral contraceptives (the Pill) containing one hormone (progestogen) or two hormones (oestrogen and progestogen), provide effective birth control. Fertility is restored rapidly on discontinuation.

In general, the Pill is not prescribed in pregnancy, suspected pregnancy, smokers above 35 years, or those with a history of uncontrolled high blood pressure, blood clots, coronary artery disease or breast cancer.

The low-dose combined Pill (COC) is safe and effective for perimenopausal women who have no medical conditions. It is not prescribed for women above 35 years who are smokers, or those above 40 years with cardiovascular disease like angina, or those with a history of stroke or migraine.

The progestogen-only Pill (POP) is safe for women at risk of blood clots, or who have had a heart attack or stroke. However, it is less effective than the COC in preventing pregnancy.

The added benefits of the Pill include a reduced risk of endometrial and breast cancer, with the reduced risk persisting for 15 years or more after stopping. There is also less fibrocystic changes in the breasts, better regulation of periods, and reduced postmenopausal bone loss.

There is a very slight increase in the relative risk of breast cancer in all current users of the COC. As the incidence of breast cancer increases with age, this may become more significant in those above 40 years of age.

The side effects of the Pill are few, and may include nausea, bleeding between periods, breast tenderness, fluid retention, and new or worsening headaches.
The use of the Pill may make it difficult to know when menopause is reached.

Contraceptive patch and vaginal ring
The contraceptive patch and ring are like the COC, except that the hormones are delivered continuously through a patch stuck on the skin or through a ring inserted into the vagina.
They are effective and easy to use. There is no need to consume a tablet daily. The periods are lighter, more regular and less painful. However, some users may complain of skin irritation.
The conditions for use are the same as the COC.

Intra-uterine contraceptive device
An intrauterine contraceptive device (IUCD) is inserted into the uterine cavity by the doctor. Most devices contain copper and are effective for three to five years. Fertility is rapidly restored on removal.
The IUCD string must be checked periodically to confirm that it is in place by placing a finger into the vagina. The doctor will usually arrange a pelvic examination at least once annually.

An IUCD cannot be inserted in pregnancy, suspected pregnancy, those who have a history of pelvic inflammatory disease, sexually-transmitted infections (STI), anaemia or abnormal vaginal bleeding, or those in a polygamous relationship.

The side effects may include spotting, irregular, prolonged or heavier periods, or uterine cramps. These usually occur soon after insertion, which may be uncomfortable.

An IUCD inserted before reaching the menopause has to be kept in place for one year in women aged above 50 years, or two years if the periods stop below 50 years of age.

Contraceptive injections
A single injection of a depot progestogen provides effective contraception for one to three months, depending on the brand. Fertility returns within a year after discontinuation.
It is not prescribed in pregnancy, vaginal bleeding of undetermined origin, liver disease, blood clotting conditions and breast cancer.

The side effects may include menstrual cycle changes and weight gain. Regular visits to the doctor’s clinic for the injections are required.
The conditions for use are the same as the POP.

Contraceptive implants
The progestogen implant system contains capsules, each about the size of a match, which are inserted under the skin of the inner aspect of the upper arm. It is effective and fertility is rapidly restored on removal. The implants must be removed after five years of use.
It is not prescribed in pregnancy, undetermined vaginal bleeding, liver disease, breast cancer or blood clots.

The side effects may include nausea, weight change, acne, vaginal dryness, irregular uterine bleeding and headaches, especially in the first year after insertion.
The conditions for use are the same as the POP.

Barrier methods
Barrier methods, which include the male and female condom, diaphragm, cervical caps and spermicides, must be used during every act of sexual intercourse to be effective.
The condom is the only effective method that prevents pregnancy and protects against STI. Condoms can be used in combination with other contraceptive methods.

Fertility awareness
Some women use fertility awareness methods by abstaining from sexual intercourse at certain times in the menstrual cycle. These methods cannot be depended upon if the menstrual cycle is irregular, and indeed, irregular cycles are common during the menopausal years.

Emergency contraception
Emergency contraception (EC) is effective if used within 72 to 120 hours after unprotected sexual intercourse or condom accidents. The “morning-after Pill” must be taken within 72 hours.
An IUCD can be inserted within 120 hours. They should not be used as regular birth control methods.
Mature women need not be shy or embarrassed about asking for EC.

Double protection
A woman is exposed to STIs, including HIV/AIDS, if she has more than one sexual partner, or the sexual partner has more than one sexual partner.

In such situations, there is an additional need to prevent transmission of STIs.
Whenever there is a possibility of transmission of STI, doctors will strongly recommend dual protection, either through the simultaneous use of condoms with other contraceptive methods, or through the consistent use of condoms alone for the prevention of pregnancy and the transmission of STI.

Stopping contraception
If one is using non-hormonal contraception, it should be continued for two years after the last menstrual period in women under 50 years of age, and for a year after the last menstrual period in women more than 50 years.

If one is using hormonal contraception, one cannot depend on the periods, which are hormone withdrawal bleeds, to know if one is fertile or not.
Some women on hormonal contraceptives have irregular or no periods, but are still fertile if they stop using their contraceptives.

The COC, contraceptive patch, vaginal ring and injection should be stopped at the age of 50 years and another contraceptive method used instead.

The POP, contraceptive implant, IUCD and barrier methods can be used until the age of 55 years, after which, contraception will not be needed any more. This is because no spontaneous pregnancy has been reported after that age.

Women with premature menopause because of medical conditions, e.g. undergoing chemotherapy, may have protracted fluctuating ovarian function. This would require special attention from the attending doctor.

Hormone therapy is not a contraceptive
Hormone therapy (HT) prescribed for menopausal symptoms like hot flushes, do not provide contraception, as it does not suppress ovulation due to its low levels of hormones.
Many women commence HT before they reach the menopause. It is difficult to know when the menopause occurs and how long contraception is needed in HT users.
If one has reached the menopause (had no period for one year if aged over 50 years, or for two years if under 50 years) before commencing HT, then contraception should be used until the age of 55 years.

A method of confirming if the menopause has been reached is to stop the HT medication for six to eight weeks, and then check blood hormone levels.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with.

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Not just dryness

Vulvo-vaginal atrophy results from oestrogen loss and is often associated with various complaints in menopausal women.

THE ovaries produce the female hormones, oestrogen and progesterone, during reproductive life. These hormones exert their effects on multiple sites, including the urogenital tract.
There are numerous oestrogen receptors in the vulva, vagina, urethra, bladder and the pelvic floor, and oestrogen maintains the structure and function of the vagina and the surrounding urogenital tissue.

Menopause occurs around 50 years of age, when the ovaries stop producing any more female hormones. This means that women will spend about a third of their lives in the postmenopausal period, a state in which there is little or no oestrogen (hypoestrogenic).

During this time, the oestrogen receptors in the urogenital tract and pelvis also decline.
The hypoestrogenic state results in a loss of elasticity and hydration of the pelvic mucosa.
The vagina becomes less distensible, with shortening and narrowing. The mucosal lining of the vagina, introitus and labia become thin and dry with the decrease in secretions.
With the passage of time, the vaginal mucosa becomes friable and may bleed with minimal trauma like sexual intercourse or even a gynaecological examination.

The thin vagina also leads to a significant reduction of glycogen and a consequent reduction in the population of lactobacilli, resulting in an increase in pH and a decrease of hydrogen peroxide, thereby permitting the growth of pathogenic micro-organisms and increasing susceptibility to infections. There are similar changes in the vulva, urinary tract and pelvic floor. These changes are called vulvo-vaginal atrophy (VVA). In contrast to vasomotor symptoms like hot flushes and sweats, which usually improve over time even without treatment, VVA is chronic and progressive. The severity of its symptoms is variable, ranging from mild discomfort to pain which may reach a point where sexual intercourse is no longer pleasurable or possible.
Women who are not sexually active may be troubled by vaginal dryness and itching, which may worsen with time.

The factors which impact VVA include age, timing and type of menopause, number of births and vaginal deliveries, frequency of sexual intercourse and certain medical conditions and/or medicines. Studies report that the symptoms of VVA like poor lubrication and painful sexual intercourse (dyspareunia) affect 20% to 45% of women in mid-life, with significant impact on a woman’s sexual health and quality of life. However, only a minority seek help or are offered help by their doctors. When managing VVA, a detailed history and physical examination, including a pelvic examination, will be carried out by the doctor. The objective is to identify contributing factors, alternative causes, and therapeutic interventions that have been undertaken.

The physical and pelvic examination would identify physical signs that are consistent with VVA and exclude other pathological conditions that may cause similar symptoms. The primary goal of treating symptomatic VVA is to relieve symptoms. Non-prescription therapies include non-hormonal vaginal lubricants and moisturizers which are available over-the-counter in the pharmacy.

The regular use of non-hormonal, long-acting vaginal moisturizers can decrease vaginal pH to premenopausal levels, although there is no change in the vaginal cells. There are no published reports on the irritative potential of these products. As such, it is advisable to test them on a small patch of skin for 24 hours before inserting them into the vagina. If the product that tests successfully on the skin still causes vaginal irritation, a switch to another product is advisable.
Studies on herbal products like black cohosh, soy and other herbs have not shown any beneficial effect on VVA. The gold standard for the treatment of symptomatic VVA is oestrogen, which can be administered orally or into the vagina. The latter is the preferred mode of delivery when vaginal symptoms are the only complaint. Low-dose vaginal oestrogen provides sufficient oestrogen to relieve symptoms with minimal absorption into the blood stream.

Vaginal oestrogen is more effective than oral oestrogen in relieving VVA symptoms, with 80% to 90% of women reporting a favourable response to the former compared with 75% of women in the latter. The prescription of oestrogen is avoided in certain medical conditions, e.g. breast cancer and venous thromboembolism. Women with symptomatic VVA unrelated to sexual activity are usually prescribed non-hormonal, long-acting vaginal moisturizers and low-dose vaginal oestrogen.

A short course of between one and three months is needed for the woman to become symptom-free. However, symptoms may recur upon cessation of treatment. Women with symptomatic VVA related to sexual activity are managed according to the severity of symptoms.
Initially, non-hormonal vaginal lubricants are used with sexual intercourse together with long-acting vaginal moisturizers regularly. Non-responders to non-hormonal vaginal lubricants and moisturizers would be prescribed low-dose vaginal oestrogen.

Women with moderate to severe dyspareunia who prefer non-vaginal medicines would be prescribed transdermal or oral hormone therapy or ospemifene, a selective oestrogen receptor modulator (SERM). Some women may have vaginal narrowing or spasm, which limits penetration. Gentle stretching with lubricated vaginal dilators of graduated sizes helps in the restoration and subsequent maintenance of function. The re-initiation of regular sexual activity when penetration is again comfortable helps to maintain vaginal health. Pelvic floor physical therapy and the use of vaginal oestrogen prior to vaginal dilatation are also beneficial. VVA is a chronic and progressive condition which is under-reported, under-diagnosed and under-treated.

Patient and physician education about VVA would go a long way towards the maintenance of vaginal and sexual health as well as patients’ quality of life in their golden years.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.