Common Causes of Vaginal Discharge

When a female has symptoms of abnormal vaginal discharge & odor, vaginal pain & itchiness, and/or burning sensation when passing urine, she may be infected by one of these organisms: bacteria, fungus or protozoa parasite.

Bacteria infection in the vagina is called bacterial vaginosis. It is most commonly caused by Gardnerella vaginosis, or less commonly by Bacteroides, Fusobacterium, Ureaplasma, Mycoplasma etc, when the balance of good & bad bacteria in the vagina is disrupted. Besides vaginal irritation, bacterial vaginosis typically produces fishy-smell thin gray/white homogenous vaginal discharge which is adherent to the vaginal wall. It is not considered as a sexually transmitted disease as sexually inactive female can still be infected. However, the risk of infection increases with multiple sexual partners and douching.

      Bacterial vaginosis: white thin discharge, with fishy smell

Vaginal candidiasis is a fungal infection in vagina usually caused by yeast Candida albicans. Certain amount of yeast live in the normal vaginal tract with other bacteria. When the amount of yeast overgrow other bacterias, such as when broad-spectrum antibiotics are taken or poor immunity, vaginal candidiasis can occur. The vaginal discharge is white and curd-like but lack odor. It is quite common and is not considered a sexually transmitted disease.

      Candidiasis: White thick curd-like discharge

Trichominiasis is caused by infection of a protozoa called Trichomonas vaginalis. It typically produces greenish & yellowish foul-smelling vaginal discharge and causes significant pain during sexual intercourse. It is a sexually transmitted disease and can affect male as well. It is said that 70% of infected female have no symptoms though.

      Strawberry Cervix: typical in Trichomoniasis

All three types of infection can occur during pregnancy, and are known to increase the risk of preterm labour and low birth weight. To know what type of organism it is, vaginal fluid/discharge can be taken and study under a microscope. 

Bacterial vaginosis is the commonest cause of vaginitis, followed by candidiasis and trichomoniasis. Sometimes it is not easy to differentiate them without lab tests.

These infection can be treated when the type of culprit is identified or suspected:

• Bacterial vaginosis: 
• oral metronidazole 500mg twice a day for 7 days OR
• oral metronidazole 2g as single dose OR
• oral clindamycin 300mg twice a day for 7 days OR
• topical clindamycin (cream/suppository) at bedtime for 3 nights

• Vaginal candidiasis: all types of anti-fungal (oral OR topical - in the vagina)
• oral fluconazole 150mg single dose OR
• oral itraconazole 200mg twice a day for one day OR
• anti-fungal cream/suppository at bedtime usually for 3-7 days

• Trichomoniasis: 
• oral metronidazole 500mg twice a day for 7 days OR
• oral metronidazole 2g as single dose

Most infection can recur after treatment. Sometimes sexual partners have to be treated as well. For treatment during pregnancy, please consult your doctor.

Urethral Discharge: Is it Urethritis?

Urethritis is typically a sexually transmitted infection, but not always. It can be divided into gonococcal urethritis (GU) and non-gonococcal urethritis (NGU).

Gonoccal urethritis is caused by the bacteria Neiserria gonorrhea, while NGU can be caused by other bacterias include Chlamydia, Ureaplasma, Mycoplasma and even syphilis etc.

Both GU and NGU usually produce similar symptoms, though some infected people does not have any complains. The most common symptoms are:

• urethral /vaginal discharge
• urethral/ vaginal itchiness / pain
• dysuria (pain when passing urine)

Due to certain sexual practice, patients may also have symptoms (pain and discharge) at the pharynx, anus or rectum.

Sometimes the infection may spread to the adjacent organs such as bladder (cystitis), testis (orchitis), epididymis (epididymitis), cervix (cervicitis), ovary (oophroritis) etc.

     Urethral discharge from tip of penis

Useful investigation:

• urethral discharge swab
• gram stain (GU - intracellular gram negative diplococci)
• culture & sensitivity (modified Thayer Martin culture)
• nucleic acid amplification test (NAAT)
• urine
• FEME/culture (not very useful)

Treatment (CDC 2010 guidelines):

Since GU and NGU commonly co-exist. It is preferable to cover both condition when treatment for urethritis is give.

Uncomplicated GU

• IM ceftriaxone 250mg single dose OR
• T cefixime 400mg single dose OR
• T cefuroxime 1g single dose

Plus (for NGU)

• T azithromycin 1g single dose OR
• T doxycycline 100mg bd for 7 days

Contact tracing should be done. Those who has recent sexual contact with patients should be treated, even if they are asymptomatic.

Various Types of Hair Loss

Normal human hair grows in a cycle consists of 2 phases: growth phase and rest phase.

In growth phase (anagen) which lasts for 2-3 years, the hair grow about 1cm a month. After that, it enters rest phase (telogen) which lasts for 3-4 months. During rest phase, hairs stop to grow. At the end of rest phase, the hairs will fall and a new cycle of growth phase will begin. A person normally shed 50-100 hairs a day.

Causes of hair loss:

• aging
• 40% of men by 35 years old and 65% of men by 60 years old have noticeable hair loss
• 50% of women by 50 years old have noticeable hair loss

• genetic 
• more prone to develop hair loss if one of your immediate family has it

• poor nutrition
• iron, zinc or protein deficiency

• medication
• warfarin, fibrates, anti-acne, ACE-inhibitor, calcium-channels blockers, allopurinol, anti-thyroid drugs, epilepsy drugs, birth control pills etc

• male-pattern baldness (androgenic alopecia)
• hair loss at both temporal areas & the top
• treated with oral finasteride / topical minoxidil

• female-pattern baldness (androgenetic)
• hair thinning at the mid-line top
• treated with oral anti-androgen / topical minoxidil

• telogen effluvium 
• hair growth enters into telogen phase prematurely, triggered by body insult / stress such as: emotional/physical stress, surgery, starvation, high fever, serious illness, extreme diets, childbirth etc
• hair loss starts 3-4 months after the stress event
• reversible after the stress factors subside

• anagen effluvium
• caused by chemotherapy drugs where actively growing hairs at anagen phase are most affected

• tinea capitis (scalp fungal infection / ringworm)
• itchy red scaly scalp with patchy hair loss
• treated with topical anti-fungal 

• alopecia areata
• autoimmune disorder with exact cause unknown
• non-scarring patchy hair loss
• may regress (hair grow back), recur or progress to total baldness
• treated with topical steroids/minoxidil or monthly steroid injection

• cicatricial alopecia (scarring)
• caused by inflammation and damage to hair follicles
• patchy and permanent hair loss
• associated with SLE and lichen planus

• traction alopecia
• caused by regular use of hairstyles that tightly pulling the hair
• patchy hair loss and non-permanent hair loss

• hormonal changes
• hyper- or hypothyroid
• diabetes
• childbirth / menopause

• excessive hair styling
• chemicals used & over-styling

• trichotillomania
• a mental disorder with irresistible hair-pulling
• patchy bald areas

Abnormal Menstrual Bleeding

An ideal menstrual cycle lasts for 28 days, with the first day calculated from the onset of menstrual bleeding and ovulation is at day-14 of the cycle. Normal menstrual cycle has a mean interval of 21-35 days, with a duration of 2-7 days and 30-80ml menstrual bleeding. 

Anything outside these range may be viewed as abnormal. These can be:

• menorrhagia: excessive (>80ml/day) or prolonged (>7 days) bleeding
• polymenorrhea: menstrual bleeding interval <21 days
• oligomenorrhea: menstrual bleeding interval >35 days
• metrorrhagia: irregular and more frequent menstrual bleeding
• metromenorrhagia: irregular, more frequent and excessive bleeding
• dysmenorrhea: excessive menses pain
• amenorrhea: absent of menstrual bleeding for >6 months
• intermenstrual bleeding: bleeding/spotting in between regular menstrual cycles
• postmenopausal bleeding: bleeding after >6 months menopause

Important causes of abnormal menstrual bleeding that need to be ruled out:

• Pregnancy and its related complication

• Gynecological pathology

• Benign lesion
• uterine fibroid/polyp
• cervical polyp
• adenomyosis
• polycystic ovary syndrome

• Non-benign lesion
• uterine cancer
• ovarian cancer
• cervical cancer
• vaginal cancer
• endometrial cancer
• endometrial hyperplasia

• Pelvic inflammatory disease
• cervicitis
• salpingitis
• endometritis

• Trauma
• cervix
• vagina
• vulva

• Endocrine disorders
• Hyperthyroidism
• Hypothyroidism
• Hyperprolactin

• Blood clotting disorders
• Thrombocytopenia
• Von-Willebrand's disease
• Coagulopathy

• Iatrogenic
• Oral contraceptive pills
• Intrauterine contraceptive devices
• Medication
• anti-coagulants

• Dysfunctional uterine bleeding (diagnosis of exclusion in the absence of organic disease)
• Stress / Excessive exercise etc.

Dysfunctional uterine bleeding is more common in the extremes of reproductive age, which are the first 2 years after the onset of menses (menarche) and a few years before the termination of menses (menopause). About 90% of the abnormal bleeding is anovulatory, in which there is no ovulation within the cycle because of certain disruption in the hypothalamus-pituitary-ovary axis.

Important investigations for abnormal uterine bleeding

• pregnancy test
• pelvis ultrasound scan
• blood test: platelet, coagulation, thyroid function, prolactin
• hysteroscopy
• endometrial sampling/biopsy

     Endometrial biopsy

The treatment depends on the underlying cause of abnormal bleeding. If no organic disease can be found (dysfunctional uterine bleeding), treatment available includes:

• Tranexemic acid
• NSAIDs
• Danazol (ethisterone)
• GnRH agonists
• Combined oral contraceptive pills
• Progesterone only pills
• Intrauterine devices with progesterone
• Endometrial ablation (if future pregnancy not wanted)
• Hysterectomy (if future pregnancy not wanted)

Why is My Platelet Count Low?

Sometimes you just go for a routine blood test and you are told that your platelet count is abnormally low. The doctor may ask you whether you have easy bruising, red dots on your skin (petechiae), delayed blood clotting or spontaneous bleeding. You may or may not have these problems. What actually cause your platelet to be low?

Platelet is one of the 3 major types of blood cells produced in the bone marrow, besides red blood cells and white blood cells. Platelet is important in the process of blood clotting. If your platelet count is too low or not functioning, then you may have easy bleeding problem. The medical term of low platelet is thrombocytopenia.

      red cell, platelet, white cell

Normal range of platelet count is between 150,000-450,000/mcL. If you find that your platelet count is low for the first time and you do not have any symptoms, you can repeat the test as sometimes during blood taking and processing, the platelets may clump. If 10 platelets clump together, the machine may read it as only one platelet.

Though platelet count <150,000/mcL is considered low, it usually will not cause bleeding problem as long as their function is not affected. Spontaneous bleeding may be a concern if the count is <20,000/mcL.

There are many possible causes of thrombocytopenia. They can be classified into 3 large groups.

1. Reduced production in bone marrow
2. Increased destruction (by immune system or not)
3. Splenic sequestration (due to enlarged spleen)

The list below are not comprehensive, only the important and common ones listed.

• Reduced production in bone marrow

• some viral infection (HIV, EBV, parvovirus, mumps, rubella, varicella, dengue)
• some medication (thiazides, phenytoin, valproate)
• alcohol
• chemotherapy
• radiation to the marrow
• leukemia
• lymphoma
• cancer infiltrating the bone marrow 
• vitamin B12/Folic acid deficiency

• Increased destruction

• Idiopathic Thrombocytopenic Purpura (ITP)
• Autoimmune diseases (Systemic Lupus Erythemathosus)
• Drugs-induced (heparin, sulfonamides antibiotics, quinine, quinidine, carbamazepines, digoxin, paracetamol / acetaminophen)
• Sepsis (severe systemic infection)
• Disseminated Intravascular Coagulation (DIVC)

• Platelet sequestration

• chronic liver disease (cirrhosis)
• leukemia
• lymphoma

If you have thrombocytopenia, you should check the numbers of your red and white blood cells. If they are normal, then it is less likely that the whole bone marrow is affected. The doctor will ask you some questions to find out any relation to the causes listed above, such as the medication you take, whether you have recent infection, your alcohol consumption, hepatitis status and other associated symptoms etc. 

      petechiae can be a sign of low platelet

A peripheral blood film / full blood picture should be done to see the size, shape and characteristic of all 3 types of blood cells. Sometimes a bone marrow aspiration may be done to rule out abnormality in the marrow. If no cause can be found after extensive investigation, and the platelet count is persistently low, steroid treatment may be given as a trial. If the platelet count increase significantly after steroid treatment, then it is likely to be idiopathic thrombocytopenic purpura, where the low platelet count is caused by immune system mediated platelet destruction.

Urticaria: A Common Problem

Urticaria, hives or wheals are raised, pink or red skin lesion that are usually associated with allergy. The lesion can be generalized or localized at certain body parts. It is a fairly common problem that everyone will experience in their lifetime. Some are mild, but some can be serious.

When the mast cells are stimulated by allergens, they release certain chemical mediators such as histamine etc. These mediators result in the dilation of the small blood vessels in which fluid will leak out from the vessels into the tissues under the skin, causing the swelling in urticaria and the itchiness.

       Urticaria rash

Urticaria can be classified into a few types depends on its clinical manifestation

• acute (last<6 weeks)
• chronic (last>6 weeks)
• episodic (acute & intermittent)

Common causes of acute urticaria are allergy to certain foods or medication, insects bite and viral infection esp in children. The urticaria emerges within few minutes to few hours after the contact with allergens and typically goes away within a day.

If the urticaria does not really goes away and persist for more than 6 weeks, then it is called chronic urticaria. The causes for chronic urticaria are more complex and may overlap with causes of acute urticaria. 

Causes of chronic urticaria include:

• Physical
• dermatographism
• pressure
• cold
• heat, exercise, stress (cholinergic)
• sunlight
• water (aquagenic)
• vibration

• Food consumption (milk, nuts, eggs, seafood etc)

• Insects bite/sting (scabies, bedbugs, fleas etc)

• Contact urticaria (latex, animals, foods etc)

• Medication and drugs
• aspirin
• NSAIDs
• ACE-inhibitors
• opioids
• alcohol

• Autoimmune conditions 
• urticarial vasculitis
• systemic lupus erythematosus (SLE)
• autoimmune thyroid disorders
• rheumatoid arthritis

•  Infection
• hepatitis B
• mycoplasma
• streptococcus
• herpes simplex virus
• helicobacter pylori
• mycobacterium tuberculosis

• Chronic idiopathic urticaria (no cause can be found)

The actual cause for chronic urticaria is not easy to determine accurately. History from the patients is important and it can suggest physical, medication and food related urticaria. For example if the urticaria rash appears after a hot bath, then it is likely a cholinergic urticaria. Physical challenge can be done if physical cause is suspected.

       Papular urticaria

Laboratory tests are mainly done to rule out the presence of autoimmune disorders in chronic urticaria. Acute episode usually does not need any test. Tests that can be done include complete blood and differential count, ESR, CRP, IgE, ANA, RF, complement, thyroid function and its autoantibodies. Skin biopsy is beneficial only if urticarial vasculitis is suspected. 

The type of tests to be done depends on clinical evaluation by the doctor. If no cause can be found after thorough examination and investigation, the urticaria is referred to as chronic idiopathic urticaria.

Most common and useful treatment for urticaria is oral non-sedating anti-histamine (2nd or 3rd generation). If anti-histamines do not work well, other types of medication can be tried. If you know what is the most likely precipitating cause, then try your best to avoid it. Sometimes chronic urticaria may improve after a few years.

Blood Blister In The Mouth

Sometimes you wake up in the morning and notice a black dot inside your mouth. You look closely into the mirror and notice that it looks like a blood-filled blister. Is it a serious problem?

It may be the first time you notice it, or it may have come and go for a few times before. Most likely the blood blister is caused by break of small blood vessels (capillaries) on the inner side of the mouth. If the bleeding continue, the lesion may enlarge. When the bleeding stops, the lesion will usually disappear within few days time. There may be slight pain or no pain at all.

       blood blister at inner cheek

This condition is usually benign, and is said to caused by minor trauma or injury to the oral mucosa. The trauma can be from chewing hard food, hot food, dentistry, brushing teeth, oral treatment, accidental self-biting during sleep etc. This condition is also called "angina bullosa hemorrhagica".

Nevertheless, you need to rule out whether you bleed abnormally easily or not. You need to check whether you have blood blisters elsewhere in the body other than inside the mouth. If you have easy bruising, easy bleeding from gum or nose and your wound is slow to clot after injury, you might need to check your blood for platelet count and coagulation profile. Low platelet (thrombocytopenia) can cause easy bleeding, which is not very uncommon.

Sometimes the blood blister could be "pyogenic granuloma", which is actually a bunch of abnormal capillaries present as a red nodule and can bleed easily. Compare to angina bullosa hemorrhagica, pyogenic granuloma can occur on the skin all over the body. Its size can be large and may not heal even within weeks. Pyogenic granuloma is more common in children while angina bullosa hemorrhagica is more common in older adult. 

       pyogenic granuloma

If the blood blister in your mouth come and go within few days, and you don't have any other problems such as fever or easy bleeding elsewhere, then it is probably angina bullosa hemorrhagica and is completely benign. If you are still worry, you should see a doctor and perhaps check your platelet and coagulation profile.

Hepatitis B in Pregnancy

If you are a female and you are a hepatitis B carrier, is it alright to become pregnant?

The answer is yes. However, you need to take extra precaution during pregnancy and delivery.

Hepatitis B is mainly transmitted through contact with blood, where it is present in high concentration. Other body fluids like saliva, semen, vaginal discharge etc contain less concentration of the virus.

First of all, the spouse of hepatitis B carrier need to check his hepatitis B virus and antibody status. If he is not a carrier and does not have the antibody, then he needs to get the 3 doses of hepatitis B vaccination at the interval of 0, 1, 6 months. When he gets the antibody, viral transmission during sexual intercourse with his carrier wife can be prevented. However, the antibody level may wean off with time and he should check its level regularly.

When a woman who is also a hepatitis B carrier conceive, pregnancy is to continue as usual. Examination and blood test are done to make sure that she does not already reach the stage of chronic liver damage.

If a woman with no known hepatitis B status first found to be infected during pregnancy, then the possibility of an acute infection need to be ruled out. If acute infection occurs in the first trimester, there is a 10% risk of transmission of virus to the baby. If it occurs in the third trimester, the risk is 80-90%. The incubation period of hepatitis B can range from 6 weeks to 6 months.

Generally, the risk of transmission of hepatitis B virus from a carrier mother to her baby is about 10-20%. If immunoprophylaxis (hepatitis B immunoglobulin - HBIG) is given to the baby soon after birth, the risk can be significantly reduced. Thus, every baby born by a hepatitis B carrier mother will receive a dose of HBIG and a dose of hepatitis B vaccine within 12 hours after birth. The vaccine need to be continued for another 2-3 doses later.

Normal vaginal delivery does not significantly increase the risk of hepatitis B virus transmission to the baby compare to Cesarean section. Breast feeding should be allowed and encouraged, as long as the baby get the HBIG and vaccination.

    Hepatitis B virus

If unfortunately the newborn is infected with hepatitis B virus, there is a high chance (90%) that the baby will become a carrier. Not everyone infected will become a carrier. For children between 1-5 years old, the chance to become a carrier is 30%, while for adults, the chance is about 5%. Nevertheless, hepatitis B virus usually does not cause other problems such as malformation or organ malfunction to the infected baby.

If you are not a hepatitis B carrier and would like to get  hepatitis B vaccination during pregnancy, you can do so as the vaccine is reported as safe when given during pregnancy.

Herpes Simplex 1 & 2

Herpes simplex is often regarded as a sexually-transmitted infection, but it is not necessarily so. There are 2 types of herpes simplex virus (HSV): HSV type 1 and HSV type 2.

HSV-1 is associated with infection around the mouth and face region, and is also referred to as "oral herpes" or cold sores. It is estimated that about 50% of population in the US has been exposed to HSV-1. Whereas HSV-2 mainly cause infection around the genital area called "genital herpes", and it is sexually-transmitted.. Nevertheless, sometimes HSV-1 can cause genital infection and HSV-2 can cause oral infection. 

     HSV-1: Cold sores

The signs of HSV infection are painful blisters around the skin/mucosa surface of the mouth (oral herpes) or genitalia (genital herpes) which can last 1-2 weeks, often associated with fever. These blisters will break and become ulcers. About 80% of herpes simplex infection however, are asymptomatic (no signs and symptoms).

HSV is transmitted through contact with infected oral or genital secretion, either through kissing, touching, sharing towels, sexual activity etc. Most people are infected with HSV-1 during childhood by close skin contact with infected adults. HSV-2 is mainly transmitted through sexual act. HSV-2 can also spread from an infected mother to the new born during vaginal birth. 

Once a person first get the infection (primary infection), the virus will stay dormant in his/her body forever and it can't be cured. However, the dormant (sleeping) viruses do not cause any problem unless they are "activated". When the viruses are activated, they can spread to other people who come into close contact with the sufferer. The virus reactivation is referred to "recurrence" or "outbreak". The recurrence may or may not produce visible skin lesion thus the sufferer may not even know that he/she has a recurrence. Pain in the skin usually precedes the eruption of skin lesion.

     HSV-2: Genital herpes

The frequency of recurrence varies, sometimes once a month, sometimes once in a few years. Generally the recurrence will be less severe, less frequent with shorter duration over the time as our body get the antibody against it. That means the first or primary infection should be the most severe. HSV-2 causes more frequent recurrence (typically 4-6x a year) compared to HSV-1. Some factors which may trigger the recurrence are emotional stress, fever, illness, sunburn, trauma, surgery and menstruation.

Diagnosis of HSV infection is often made from the history and skin lesion. It can be confirmed by taking swab from the lesion for culture or viral DNA (PCR) test. 

When there is no symptoms or lesions, measuring antibody level (IgG & IgM) through blood test can be done. The presence of IgM means recent or current infection whereas IgG means previous or past infection. Once infected, IgG will only appear in the blood after 2-12 weeks and will persist for life. Thus, it is wise to repeat a negative IgG result after 8-12 weeks if the exposure is there. IgM cannot distinguish HSV-1 and HSV-2 accurately and may cross react with other viruses, thus giving false positive results. The glycoproteinG based antibody test can distinguish both types of virus. However, generally HSV antibody tests do not give very accurate results.

    HSV blisters / vesicles

The blisters caused by HSV can disappear by itself without any treatment. However, anti-viral treatment (oral or cream) may lessen the severity and duration of the signs and symptoms. The anti-viral (eg. acyclovir 400mg tds / 200mg 5x/day) is best given early at the first sign of recurrence or within the first 5 days, for a duration of 5-10 days. Some doctors suggest daily low dose anti-viral medicine (suppressive therapy eg. acyclovir 400mg bd) to reduce the frequency and severity of recurrence, especially for those with recurrence more than 6 times a year.

To reduce the risk of spreading to others, avoid close personal contact and sexual activity during recurrence. The problem is, sometimes recurrence may not produce any skin lesion and no one will be aware of it. Thus, it is advisable to always use condom during sexual intercourse to minimize the transmission of genital herpes. The risk cannot be eradicated totally even when using condom because skin around the genitalia not covered by condom may also spread the virus.

HSV infection cannot be cured but can be controlled or prevented. It is not life-threatening if you are infected with it, unless you are immunocompromised (extremely low immunity).

Pap smear: When to start and What to expect?

Pap smear/test is a screening test used to detect early changes in cervical cancer. "Pap" is named after Dr George Papanicolaou. Before the cells in the cervix turn into cancer cells, they undergo a few pre-cancerous changes. If these changes can be picked up early, then treatment can be given and cervical cancer can be prevented.

The precancerous cell changes are called dysplasia or cervical intraepithelial neoplasia (CIN). CIN can be divided into mild (CIN 1), moderate (CIN 2) and severe (CIN 3). CIN 1 usually can go away on its own but it still can progress to CIN 2/3. CIN 2 and 3 are more serious and need further test.

Through Pap smear, a brush is used to sample cells around the cervix and viewed under a microscope. Liquid-based cytology is more accurate compared to the conventional Pap smear. It is best to do pap smear between 10-20 days after the first day of menstruation.

Pap smear schedule:

Start: Age 21, or 3 years after first vaginal intercourse

Stop: Age 70, and with 3 consecutive negative tests, and no abnormal test in prior 10 years.

Post total hysterectomy: discontinue if benign reasons & no high grade CIN

Interval:

• Conventional pap test: annually
• Liquid-based cytology (LC): every 2 years
• LC with negative HPV test: every 3 years

•  For conventional and LC, if age >= 30 years old with 3 consecutive negative Pap smears, can repeat in 2-3 years.

 Updated Oct 2012

The American Congress of Obstetricians and Gynecologists has updated its 2009 practice bulletin on cervical cancer screening; its guidelines generally align with those released earlier this year (2012) by the U.S. Preventive Services Task Force, the American Cancer Society, and other groups.

Among the recommendations for routine screening:

• Women under age 21 should not be screened, regardless of behavioral risk factors. 
• For those aged 21 to 29, cytology alone should be performed every 3 years.
• For women aged 30 to 65, cytology plus human papillomavirus co-testing every 5 years is preferred; however, cytology alone every 3 years is acceptable.
• Women should not be screened after age 65 provided they've previously had sufficient negative screening results and no history of cervical intraepithelial neoplasia grade 2 or higher.
• More frequent screening may be required for women who have a history of cervical cancer or CIN2 or higher, who are immunocompromised (including HIV-infected), or who were exposed to diethylstilbestrol in utero.

    Pap smear

The Bethesda System is often used to interpret pap smear's result. In this system, the term squamous intraepithelial lesion (SIL) is used instead of CIN. 

Pap smear result can either be:

• Negative (normal)

• Atypical squamous cells of undetermined significance (ASC-US)
• most common result
• usually indicate HPV infection which may normalize if infection is cleared

• Squamous intraepithelial lesion - low grade (LSIL)
• equivalent to mild dysplasia (CIN 1)
• may goes away without treatment
• may indicate mild precancerous change

• Squamous intraepithelial lesion - high grade (HSIL)
• more likely to progress to cancer
• equivalent to CIN 2,3 and carcinoma in-situ

• Atypical squamous cells, cannot exclude HSIL (ASC-H)
• not clearly HSIL but could be

• Atypical glandular cells  (AGC)
• suggest precancer cells

• Cancer
• abnormal cells may have spread deeper

Abnormal Pap smear results will require further tests, either repeat Pap smear, do HPV test or colposcopy. Biopsy or other minor intervention such as conization, cryocauterization, laser therapy, large-loop excision of the transformation zone or endometiral sampling may be needed.

      Follow up test for abnormal pap smear result

HPV and Cervical Cancer

Human Papillomavirus (HPV) is a common sexually transmitted infection. If you are sexually active, there is a 50% chance that you have already infected with HPV at some point of time. Most of the time HPV infection will not produce any symptoms and our body immune system can cure it by itself within 2 years time without any treatment (median 8 months). However, some infected people may have genital warts and for female, it may lead to pre-cancerous changes in the cervix. The pre-cancerous changes need further monitoring and possibly treatment.

           Human Papillomavirus

HPV has been widely discussed now because of its link to cervical cancer, though the risk is very small. Besides, HPV is also related to other types of cancer around genital area such as vagina, vulva, penis and anus. 

There are more than 100 types of different HPVs, however, only about 40 has clinical significance to human. Base on their risk to cause cancer, they can be divided into "high risk" type and "low risk" type. HPV type 16 and 18 are the most well known high risk type and both are associated with almost 70% of cervical cancer.

HPVs can infect both male and female equally. It can be transmitted from a person to another through direct contact during sexual intercourse. So if you start to have sex at early age, have multiple sexual partners or if your partner has multiple sexual partners, your risk of getting HPV infection is higher.

Most HPV infection is transient, but about 10% of women may have persistent infection. If the persistent HPV type is HPV 16/18, then the risk of developing cervical pre-cancerous changes is higher. It may progress to cervical cancer if left untreated.

Since long time ago Pap smear has been available as a screening tool for cervical cancer in female. Now Pap smear is still the most important screening test that save lives. Its accuracy is improved with the new liquid base cytology test, which is better than the conventional "scrape and spread on slide" test.

Not long ago, HPV DNA test is recommended as as "add-on" to Pap smear to further help the decision making for doctors in patients with abnormal pap smear result. HPV DNA test is not recommended routinely for women <30 years old unless the Pap smear shows abnormality. It cannot substitute Pap smear as the main cervical cancer screening tool. If the HPV DNA test is positive for high risk HPV type in a patient with "borderline" Pap smear result, then it may prompt further investigation.

      

    Changes in cervix caused by HPVs

HPV infection can be prevented through vaccine. Currently there are 2 types of vaccines available: Gardasil (HPV 6, 11, 16, 18) and Cevarix (HPV 16, 18). HPV 16 & 18 are the most common high risk HPV that account for almost 70% of cervical cancer. HPV 6 & 11 are low risk HPV that can only lead to genital warts.

These vaccines are given in 3 separate intramuscular doses (0, 1-2, 6 months apart). They are found to be 100% effective in preventing pre-cancerous cervix lesion caused by HPV 16 & 18. Thus it should be able to prevent 70% of cervical cancer (as HPV 16 & 18 cause 70% of cervical cancer). It is not 100% prevention from cervical cancer. There are other types of high risk HPVs and many other possible causes for cervical cancer. So Pap smear is still mandatory even after you have received Gardasil or Cervarix vaccination.

Vaccination is best given to girls/women before they are infected with HPV 16 & 18, or in other words, before having their first sex. It can be given as early as 9 years old up to over 40 years old. However, the earlier the better it is.

 

Cloudy & Foamy Urine: Is It Proteinuria?

Normal urine is suppose to be clear, with mild yellow or straw colour. When you notice your urine is cloudy (frothy) and/or foamy (bubbles), you may be anxious and want to know whether there is anything wrong with your kidneys.

Urine contains water and all sorts of solubles waste products that are excreted by our kidneys. In common sense, when the waste products in the urine is more concentrated, or there are abnormal particles in the urine, the urine may become cloudy or foamy.

     Normal urine: clear

Here is a list of possible causes of:

Cloudy Urine

• dehydration  (more concentrated urine)
• proteinuria (protein in the urine)
• phosphate crystals (after phosphate-rich meal)
• vitamins B/C (excessive intake excreted through kidneys)
• urinary tract infection (pus from bladder/kidney infection)
• prostatitis (infection or inflammation of prostate)
• kidney stone
• vaginal discharge (contaminate the urine)
• gonorrhoea (pus contaminate the urine)
• retrogade ejaculation (only cloudy after ejaculation)

Foamy Urine

• forceful urination into toilet bowl
• dehydration
• proteinuria
• urinary tract infection

From the list above, dehydration may be the most common cause and proteinuria may be the most important cause. 

When you complain of cloudy urine, at least you need to get a urine sample to check for the presence of protein in your urine. If it is positive for protein, then you may need to have further investigation. However, not all proteinuria especially mild proteinuria is harmful. If your urine do not contain protein, then it is good but you should repeat it at other time and also look for other causes.

    Urine dipstick test: easy for self-check

If the cloudy urine is intermittent and not frequent, then the chance of significant proteinuria is less.

Dehydration, phosphate crystals and vitamin B/C in the urine are totally harmless. Infection usually produce pain when passing urine or pain at the lower abdomen or flank. Urine dipstick and microscopy can help to identify infection. Kidney stones can be diagnosed with ultrasound scan.

Food rich in phosphate include milk, cheese, beans, nuts, corn, chocolate, meat, egg yolk, mushrooms, wheat, oat etc and some processed food with additives such as soft drink, processed meat/hot dogs, biscuits, ketchup etc.

Not every cloudy or foamy urine means kidney problem. If you have this problem, you can check your urine using a dipstick or see your doctor if you are in doubt.

Raised CA-125: What are the Causes?

CA-125 is a protein found mostly in certain types of cancer cells. CA stands for cancer antigen and CA-125 is known as a tumour-marker especially for ovarian cancer.

CA-125 is traditionally done to measure the success of ovarian cancer treatment or when a pelvic mass is found. It is not suggested to be used as a screening test for ovarian cancer because it is not accurate with high probability of false positive and false negative results. CA-125 can be high in certain cancers other than ovarian cancer, and in other non-cancerous condition as well.

     Female reproductive organs

Here is a list of conditions which can cause a raised CA-125:

Cancer

• Ovary
• Uterus/endometrium
• Fallopian tube
• Breast
• Pancreas
• Liver
• Lungs
• Bowel
• Bladder
• Cancer with peritoneum involvement

Non-cancer (gynecological)

• Benign ovarian cyst
• Endometriosis
• Fibroid
• Pelvic inflammatory disease
• Pregnancy (first trimester)
• Menstruation

Non-cancer (non-gynecological)

• Pancreatitis
• Liver cirrhosis/failure
• Renal failure
• Nephrotic syndrome

The normal value of CA-125 is <35 u/ml. If you have a level higher than 35, then you should have an ultrasound scan to check your ovaries and uterus. Your doctor will take relevant history from you and examine you thoroughly. If nothing can be found, usually you are only required to repeat the test at an interval and follow up with the doctor.

If a pelvic/ovarian mass is found, depends on its characteristic, a surgery may be required to confirm whether it is cancerous or not. Sometimes it can just be a benign (non-cancerous) ovarian tumour or endometriod cyst.

However, not everyone with confirmed ovarian cancer will have an abnormal CA-125 results. Only about 50% of stage I ovarian cancer patients have raised CA-125. For stage II, III, IV ovarian cancer patients, 80% will have raised CA-125 while for the rest of 20% of these patients, their CA-125 level remain normal.

A study done in 1999 by IJ Jacobs screen about 10,000 post-menopausal women over 45 years old using the CA-125 test alone. Results of this study showed a false positive rate of about 80%. (only 20% of these women with abnormal CA-125 had ovarian cancer)

Another study screened 11,000 post-menopausal women over 45 years old with CA-125. As a result, 468 of them were found to have raised CA-125 and ultrasound scan were done. Of these 468 women, 29 underwent surgical procedure and noted:

• 6 had ovarian cancer (1.3% - 6 out of 468)
• 2 had adenocarcinoma of unknown origin
• 14 had benign tumour
• 4 had fibroids
• 3 had no abnormality

We can see that the false positive rate of CA-125 test varies from different studies, but we know that the chance of ovarian cancer with a raised CA-125 is not very high. However, this should not be the reason for us to ignore the positive result. To improve the accuracy of the test, a serial CA-125 tests should be done to see the trend, and ultrasound scan should be performed.

Testicular Microlithiasis: Can It Cause Cancer?

Testicular microlithiasis is usually diagnosed during ultrasound scan done as screening or for suspected testicular mass. Those many white dots which appear in the ultrasound image are calcium deposits. However, it has no relation with how much calcium you eat. Should a man worry if he is told to have testicular microlithiasis?

Unfortunately, though testicular microlithiasis is widely recognized and diagnosed, we still do not understand it well. The cause of it is still unknown, and its consequences are still very much debatable. The most worrying issue regarding testicular microlithiasis is its association with a type of testicular cancer called testicular germ cell tumour. 

     Microlithiasis: The "Stars" are the microliths

Opinion regarding the link between testicular microlithiasis and cancer varies between different countries and even between different doctors within the same country. However, if you have testicular microlithiasis, definitely you need to have it monitored regularly and should not just leave it alone.

For people with testicular microlithiasis, it is easier to divide them into 3 groups. How they should be followed up with their doctor depends on which group they are in.

• Testicular microlithiasis and asymptomatic (no symptoms and healthy)
• Testicular microlithiasis with symptoms of testicular dysgenesis syndrome
• subfertility (difficult to get baby)
• cryptorchidism (undescended testis)
• testicular atrophy (reduction in testis size)
• gonadal dysgenesis (abnormality in sexual organs development)
• Testicular microlithiasis with  concurrent germ cell tumour

For those who are asymptomatic and apparently healthy, you need to see a doctor to rule out the presence of testicular dysgenesis syndrome. If everything is fine, the risk of developing testicular germ cell tumour is not high. However, it is advisable to perform testicular self-examination regularly and see your doctor/urologist for examination or ultrasound scan annually. Biopsy is usually not required.

For those who have testicular dysgenesis syndrome, the risk of testicular germ cell tumour is said to be higher than others who do not have the symtoms. A condition called intratubular germ cell neoplasia with unclassified type (or testicular carcinoma in-situ), which is "pre-cancerous" condition , can be found in 11-18% of those with both testicular microlithiasis and testicular dysgenesis syndrome. In such case, you need to consult a urologist to discuss whether a testicular biopsy and further imaging studies are necessary. Monitoring of tumour markers such as AFP and hCG may be helpful.

For those who has concurrent unilateral (one-sided) germ cell tumour, the presence of microlithiasis may suggest that the risk of cancer in the other testis is higher. Thus, further management such as chemotherapy may differ.

It is wrong to say that testicular microlithiasis can cause cancer. However, it is related to testicular cancer. Having testicular microlithiasis does not mean that one will definitely develop testicular cancer in the future. As testicular microlithiasis is still considered inadequately studied, please liaise with your urologist as he/she will know the latest development regarding this condition.

Gallstones and Gallbladder Flush

There are generally 2 types of gallstone: cholesterol or pigment stones. It is believed that >80% of gallstones are caused by excessive cholesterol in the bile.

Gallstones can be easily diagnosed using an ultrasound scan. Most gallstones are diagnosed incidentally while doing ultrasound scan for screening or other purposes, as most gallstones do not produce any symptoms. When they do, the most common symptoms they produce is pain at the right upper region of the abdomen which may radiate to the right shoulder, especially after a fatty meal.

The stones can irritate the gallbladder and cause inflammation of the gallbladder referred to as "cholecystitis". Sometimes the stone can pass through the bile duct and get trapped half way. It will result in severe pain and jaundice (yellow eyes & skin). If left untreated, serious complication such as pancreatitis can occur. Both these two conditions are common gallbladder disorders and need emergency surgery to remove the gallbladder (cholecystectomy).

     Gallbladder at your right upper abdomen

If you find out that you have gallstones and you still have not experience any symptoms, then usually nothing need to be done. Some doctors may recommend surgery to remove the gallbladder straight away as when problems arise, surgery will have higher risk. Other doctors may recommend medication such as ursodeoxycholic acid to dissolve the cholesterol stones. However, this drug is not commonly given nowadays as it takes many years to dissolve the stones and the stone may reform after that.

If you have gallstones with no symptoms or only mild infrequent discomfort, you may want to try an alternative treatment called gallbladder flush. This method is not 100% effective and it depends on how well you follow the plan.

There are many version of gallbladder flush available, but their principle are almost the same. Here is an example.

2-4 weeks before:

Eat healthy diet rich in fruits & vegetables, with no meat and no refined food. Make sure there is no constipation.

Day 1-5:

Continue with the healthy diet. Drink at least 2 glasses of apple juice a day. 

Day 5:

Do not eat anything after lunch. Take 1 teaspoon of epsom salts at 4pm and then another teaspoon at 6pm.

From 8pm, take 15ml of olive oil mixed with 15ml of lemon juice every 15 minutes for 8 times (total 120ml of olive oil & 150ml of lemon juice taken in 2 hours time).

Then go to bed lying on your right side with right knee bend.

Day 6-7:

You may pass out greenish/yellowish stones if successful. To confirm it, just see your doctor to do an ultrasound scan.

    Gallstones

Plenty of fruits and vegetables help to cleanse the bowel in preparation for the stones to pass out. Apples are rich in malic acid which can help to soften or break the cholesterol gallstones. Epsom salt or magnesium sulfate helps to relax smooth muscle within the bile ducts so that the stones can pass through easily. Olive oil will make the gallbladder contract forcefully to flush out the stones, while lemon juice just make the olive oil better to drink.

There is a possibility that the stones may trapped halfway and causes pain which may need intervention by doctors. Other than this, gallbladder flush is a safe practice for healthy adults. Even if it is not successful, your body will still benefit from a few weeks of healthy diet.

Delay Your Menstruation Period

Some female may wish to delay their menses cycle due to various reasons, such as wedding, holiday trip, taking exam etc. This can be easily achieved.

For female who are NOT taking oral contraceptive pills, you can take a pill called "norethisterone" which is a progesterone hormone. It is taken 3 days before the expected first day of the next menstrual cycle. The dose is 5mg three times a day. Just stop the hormone when you want the menses flow to start. Usually the menses will start 2-3 days after stop taking norethisterone. Side effects are not common, as it is only taken short term. Some known side effects include stomach upset and breast changes. If your menses cycle is irregular and you are not sure when will be the start of next cycle, then it's a problem. In this case you may want to start norethisterone many days earlier before the day of your trip. Don't take norethisterone continuously for more than 2 weeks.

          Example of Norethisterone. Not expensive.

For female who are taking oral contraceptive pills (OCP), you have to continue to take the pills with hormone in order to delay the menses. In a typical OCP, the first 21 pills are with hormone while the last 7 pills are "empty" without hormone. Normally when you take the pills without hormone, menses flow will start. If the period of time you don't want your menses to come falls between Day 1 to Day 21 of the pills, then just continue the OCP as usual. However, if it falls after Day 21, then after the Day 21 pill, you have to start a new strip of OCP from Day 1, without taking the "empty" Day 21-28 pills. When you want your menses flow back at anytime, just take the "empty" pills for 7 days.

     Example of OCP: Note the 7 empty pills in white

Vanishing Twin: Take it easy

Vanishing twin syndrome is when one of your twin baby just disappears in your womb during the course of pregnancy. It can also represent one or more babies lost in triplet, quadruplet or more.

This syndrome becomes more widely identified with the use of early pregnancy ultrasound scan. It occurs when an early ultrasound scan reveals 2 or more babies but a later scan shows less than that. The loss of fetus (baby in womb) can happen at any point of pregnancy. It can be in the first, second or third trimester. Generally, the earlier it happens, the better the outcome to the viable fetus and mother. Some research reveals that about 10-15% of single baby born are initially twins.

    Fetus papyraceus

 

No one knows exactly what causes vanishing twin syndrome. It is believed that the vanished fetus has some chromosomal or genetic defect and is aborted for good. The viable twin has normal chromosome and usually no other abnormality, but may have increased risk of cerebral palsy if it occurs after the second half of pregnancy. For mother side, there is some risk for complication if it happens later in pregnancy, such as preterm labour, infection of the retained material, post-delivery bleeding, obstruction of labour etc. However, if vanishing twin syndrome occurs in the first trimester (<12 weeks), these complication are very unlikely.

Vanishing twin syndrome may cause some per vagina bleeding and/or lower abdominal discomfort. The vanished fetus can “disappear” completely, form part of the placenta or become “mummified” depends on at what stage it starts to disappear. Mummified fetus need close observation during the pregnancy as it has higher risk to cause complication.

So, don't panic or feel too sad if your doctor tell you that one of your twin just disappears. It is actually good as if the disappeared baby is born, it will give you more problems as it has genetic defect. If the phenomenon occurs in the first half especially first trimester, there should not be too much worry.

Helicobacter pylori: are you infected?

If you have frequent stomach upset, you may want to check whether you are infected with Helicobacter pylori or not. Since the discovery of this bacteria in early 1980's, it has changed the belief that bacteria cannot survive in the acidic environment of the stomach.

    Helicobacter pylori

Why is H. pylori so important and why should you be treated if you are infected with it? The reasons are:

• Almost 70-90% of all peptic ulcer diseases are related to H.pylori
  • About 90% of duodenal ulcers are related to H.pylori
  • About 60% of gastric (stomach) ulcers are related to H.pylori
• If you are infected, you have 10-20% risk to get peptic ulcer disease
• If you are infected, you have a 1-2% risk of getting stomach cancer

Yes. H.pylori has been classified as class I carcinogen (cancer-causing agent) for gastric cancer, in the same class as smoking causes lung cancer.

    Gastric & duodenal ulcer

Since the bacteria stay in the digestive tract, we can get infected by taking in food/drink contaminated with the bacteria. H.pylori infection produces no symptoms in 30-35% of patients. When it does, it can cause:

• Dyspepsia (indigestion)
• Nausea/vomiting
• Abdominal pain/discomfort
• Anemia if bleeding from ulcer

It's easy to check whether you are infected or not. The screening test is usually a blood test that check your antibody level against H.pylori. If it is positive, it means that you have current or recent infection, and should be treated.

After treatment, you should check whether the bacteria are eradicated successfully by doing a urea breath test. This should be done at least 4 weeks after finishing treatment. Blood test is not recommended to be used to confirm eradication because the antibody level may remain high up to 2 years after all the bacteria died. Besides the breath test, another test that can be done to confirm eradication is stool antigen test.

If you have severe symptoms that make a doctor suspect ulcer in your stomach/duodenum, then you can straight away go for an endoscopy in which a tube with camera is inserted through your mouth into your stomach to look for the ulcer. At the same time, tissue samples (biopsy) can be taken to check for the presence of H.pylori.

Treatment for H.pylori is called triple therapy, as it is a combination of 3 types of medication (2 antibiotics and 1 anti-acid). It should be taken accordingly for at least 7 days (up to 14 days) or failure of treatment and bacteria resistance can occur easily. If treated rightly, the success rate is up to 90-95%. It is not easy to get the infection again after it has been successfully eradicated. The re-infection rate is only about 1-2%, but it is noted to be slightly higher in children and women.