Have you been feeling discomfort in your lower abdomen, leaking a bit when you laugh or cough, or even struggling with a nagging sensation of pressure sensation “down below” that just won’t go away? These are symptoms which many women experience but often brush aside, thinking it’s just a normal part of ageing or life after childbirth. But what if it’s more than that?

Your pelvic floor is a powerful, yet often overlooked, set of muscles that play a crucial role in supporting your pelvic organs, which consist of your bladder, uterus and rectum. When functioning properly, these muscles help you control urination, bowel movements and even sexual function. However, when the pelvic floor is weakened or damaged, it can lead to a variety of issues that fall under the category of pelvic floor disorders or pelvic floor dysfunction (PFDs).

Despite being common, many women go years without realising they’re suffering from a pelvic floor disorder as the symptoms can be subtle, slow to develop, or mistaken for other conditions. In this article, we will highlight five key signs that you might have a pelvic floor disorder—so you can stop guessing and start seeking the right help.

What is Pelvic Floor Disorder?

A pelvic floor disorder (PFD) occurs when the muscles and connective tissues in the pelvic area weaken, become overly tight or lose their ability to support the pelvic organs effectively. The pelvic floor is a complex network of muscles and ligaments that forms a hammock-like structure at the base of your pelvis. Its primary function is to support organs like the bladder, uterus and rectum and ensure they function properly. The pelvic floor muscles are also responsible for controlling bladder and bowel movements, as well as playing a key role in sexual function.

When these muscles are compromised—either through weakening, excessive strain or damage—they may not be able to perform their role efficiently leading to a pelvic floor disorder. This can result in issues like urinary incontinence, pelvic organ prolapse (when the organs drop and push against the vaginal walls) and chronic pain in the pelvic region.

Common Causes of Pelvic Floor Disorders

Some of the most common causes of pelvic floor disorders include:

• Childbirth: Vaginal deliveries, particularly difficult or multiple births, can place significant strain on the pelvic floor muscles, leading to long-term weakening or damage [1]. Assisted vaginal deliveries (i.e. vaccum or forceps; particularly the latter) can also result in significant trauma to the pelvic floor during the process of childbirth. 
• Ageing: As women age, particularly after menopause, the body naturally loses muscle tone and elasticity which makes the pelvic floor muscles more susceptible to dysfunction [2].
• Obesity: Carrying extra weight puts additional pressure on the pelvic floor, leading to its weakening over time [3].
• Chronic Coughing: Conditions such as asthma or chronic bronchitis that cause frequent coughing can stress the pelvic floor [4], especially when coughing is forceful or prolonged.
• Chronic constipation: Chronically or habitually straining on the toilet bowl to force bowel movements can also stress the pelvic floor muscles over time. 
• Heavy Lifting: Regularly lifting heavy objects—whether it’s due to physical labour or weightlifting—can strain the pelvic muscles if not done properly, contributing to pelvic floor dysfunction [5].

While it’s true that pelvic floor disorders are more commonly diagnosed in older women, they are not exclusive to this group. Women of all ages can experience pelvic floor issues, particularly those who have gone through childbirth, are overweight or engage in activities that put stress on the pelvic region. Young, active women can also suffer from pelvic floor disorders due to high-impact sports or improper lifting techniques. 

5 Signs You Might Have a Pelvic Floor Disorder

Recognising the signs of a pelvic floor disorder (PFD) can help you seek treatment early and improve your quality of life. Here are five common symptoms that may indicate a problem with your pelvic floor:

• Sign 1: Leaking Urine or Bowel Movements

One of the most common signs of pelvic floor dysfunction is urinary or bowel incontinence, particularly stress incontinence. This happens when the pelvic floor muscles fail to adequately support the bladder or rectum, leading to accidental leaks. You might notice this during simple activities like sneezing, coughing, laughing, jumping or exercising.

For many women, a little leakage here and there might seem harmless—perhaps you may be laughing with friends or lifting weights at the gym when it happens. However, even occasional leaks can indicate a weakened pelvic floor. While this may be brushed off as a “normal” part of ageing or post-childbirth life, it is a sign of stress incontinence and should not be ignored. Treatment options can significantly reduce/eliminate this symptom and prevent this from getting worse with time. 

• Sign 2: A Feeling of Pressure or Fullness in Your Pelvis

Another common symptom of a pelvic floor disorder is a persistent feeling of pressure or heaviness in the pelvic area. This can be a sign of pelvic organ prolapse, where one or more organs (bladder, uterus, or rectum) begin to slip out of place and push against the vaginal walls.

Women often describe this feeling as a sensation of “something falling out” or a heaviness that worsens after standing for long periods or towards the end of the day. This symptom is frequently ignored because it may come and go, but pelvic organ prolapse is a serious condition that can lead to further complications if left untreated. Early recognition can help prevent the need for surgical intervention.

• Sign 3: Painful Intercourse

If you experience pain during intercourse, known as dyspareunia, this could be another sign of pelvic floor dysfunction. Tight or overactive pelvic floor muscles can cause discomfort or pain during penetration, which makes sex unpleasant or even unbearable for some women.

The emotional toll of painful intercourse can be significant, leading to feelings of embarrassment, frustration or guilt. Over time, this may strain relationships or pose challenges in trying for pregnancy. Some women may feel ashamed to talk about it, fearing it’s an issue they have to live with. However, this is a common and treatable condition. Pelvic floor physiotherapy and other medical interventions can help alleviate the pain and restore a fulfilling sexual experience.

• Sign 4: Trouble Emptying Your Bladder or Bowels

Another red flag for a pelvic floor disorder is difficulty in completely emptying the bladder or bowels. You may feel like you need to strain or push harder than usual to urinate or have a bowel movement, or experience a constant urge to go, even when your bladder or bowel is not full.

These issues can be frustrating and disruptive to daily life. Imagine being out at a social event, constantly feeling the need to visit the restroom, or experiencing the discomfort of never quite finishing a bowel movement. These symptoms not only affect physical health but also cause emotional stress. Treatment can address these issues and provide relief.

• Sign 5: Lower Back or Abdominal Pain

Pelvic floor dysfunction can also manifest as chronic lower back or abdominal pain, especially when other potential causes (like injury or muscle strain) have been ruled out. Because the pelvic floor muscles are interconnected with the muscles in your lower back and abdomen, any dysfunction can cause tension and discomfort in these areas.

Many women may not immediately associate their back or abdominal pain with pelvic floor issues, often assuming the pain is due to poor posture or normal muscle fatigue. However, chronic or unexplained pain in these regions may be a sign that your pelvic floor muscles are struggling to support your pelvic organs properly.

When Should You See a Doctor?

If you’re experiencing any of the signs mentioned earlier—whether it’s leaking urine during a laugh, feeling pressure in your pelvis, or dealing with lower back pain that you can’t quite explain—it’s essential to seek medical advice. While it may feel tempting to brush these symptoms aside as “just part of getting older” or something that will resolve on its own, these are often early indicators of pelvic floor dysfunction that can worsen over time if left untreated.

The good news is that pelvic floor disorders are highly treatable, especially when addressed early. Seeking help from a urogynaecologist can lead to effective treatment options, whether through pelvic floor therapy, lifestyle modifications, medications, or in more severe cases, surgical intervention. Early intervention not only helps manage the symptoms but can prevent further complications and help you regain control over your overall health and well-being.

How to Start the Conversation

Opening up about pelvic floor issues can feel awkward or uncomfortable, but it’s important to remember that your doctor is there to help, and these are common issues they address regularly. Here’s how you can begin the conversation with your urogynaecologist:

• Be Direct About Your Symptoms: When describing your symptoms, be as clear and specific as possible. For instance, you might say, “I’ve been experiencing urinary leaks when I cough or sneeze,” or “I feel a heaviness in my pelvis, especially after standing for long periods.”
• Ask for a Pelvic Floor Evaluation: If your symptoms align with a pelvic floor disorder, ask your doctor for an evaluation. This might include a physical exam or a referral to a pelvic floor specialist/urogynaecologist (if your healthcare professional isn’t one) who can offer more targeted assessments and treatment options.
• Discuss All Treatment Options: Don’t hesitate to ask about all the available treatment options, from non-invasive therapies to surgical solutions. Your doctor can guide you toward the most appropriate treatment based on your specific condition and lifestyle.
• Bring Up Emotional or Intimate Concerns: If your pelvic floor issues are affecting your intimate life or causing emotional stress, don’t shy away from mentioning these concerns. Your doctor can offer support and may refer you to resources like allied healthcare professionals such as pelvic floor physiotherapists or sex therapists, which can address both physical and emotional aspects of the disorder.

Common Treatments for Pelvic Floor Disorders

Once you’ve identified the signs of a pelvic floor disorder, the next step is exploring treatment options. The good news is that pelvic floor disorders (PFDs) are highly treatable and the range of available treatments can be tailored to your individual needs. From non-invasive therapies to more advanced surgical interventions, treatment plans are designed to address the specific symptoms you’re experiencing and the underlying causes of your pelvic floor dysfunction.

• Pelvic Floor Therapy

One of the most common and effective treatments for PFDs is pelvic floor physical therapy [6]. This specialised therapy focuses on strengthening or relaxing the pelvic floor muscles, depending on your condition. Although watching videos etc can sometimes be helpful, the connection between the brain and pelvic floor muscles can sometimes be difficult for women to establish reliably. A physical therapist trained in pelvic health will guide you through exercises like Kegels, which target the pelvic muscles and help improve control over bladder and bowel function. They may also use techniques such as biofeedback, electrical stimulation, or manual therapy to enhance muscle coordination and relieve pain.

Pelvic floor therapy is particularly effective for women with stress incontinence, pelvic organ prolapse, or dyspareunia (painful intercourse). It is a non-invasive option that can yield significant improvements with consistent practice and professional guidance.

• Lifestyle Changes

For many women, making lifestyle changes can greatly improve pelvic floor health. Maintaining a healthy weight, for instance, reduces the strain on the pelvic muscles, especially in women who are overweight or obese. Adopting a fibre-rich diet can help manage constipation, which is a common cause of pelvic floor strain. Avoiding heavy lifting or learning proper techniques to minimise pressure on the pelvic muscles can also prevent further damage.

In addition to dietary and activity modifications, practising good posture and engaging in pelvic floor-friendly exercises (such as low-impact activities like walking, swimming or yoga) can help prevent symptoms from worsening.

• Medications

In some cases, medications may be prescribed to manage symptoms of pelvic floor disorders. For instance, women with overactive bladder or urge incontinence may benefit from bladder relaxants that help reduce the urgency and frequency of urination [7]. Hormonal treatments, such as topical oestrogen, can also be useful, particularly for postmenopausal women whose symptoms are linked to hormonal changes affecting pelvic tissue strength and elasticity.

These medications can offer relief, but they are often used in combination with other treatments, such as pelvic floor therapy, to address the root cause of the dysfunction.

• Vaginal pessaries

Vaginal pessaries can be particularly helpful for women who are experiencing bothersome pelvic organ prolapse – they are inserted into one’s vagina and act as mechanical support to alleviate symptoms of pelvic organ prolapse(without the need for surgery) and do not interfere with one’s daily routines. These come in many different shapes and sizes and fitting is done by a trained healthcare professional. Women can be taught how to self-manage and incorporate these to complement various activities/ exercises they may engage in as part of their lifestyle.  

• Surgical Intervention

For women with more severe cases of pelvic organ prolapse or incontinence – surgery may be necessary. Surgical options vary based on the type and severity of the pelvic floor disorder. Common surgeries include sling procedures to support the bladder [8], colporrhaphy to repair weakened vaginal walls [9] or hysterectomy in extreme cases of uterine prolapse.

Surgery is typically reserved for when non-invasive treatments have not been effective. The decision to undergo surgery should be made after careful discussion with your healthcare provider. While surgery can offer a more permanent solution to severe PFDs, it’s important to weigh the risks and recovery time involved.

It’s important to remember that no two pelvic floor disorder cases are the same. The treatment that works for one woman may not be effective for another. This is why personalised care is crucial. Your gynaecologist will develop a treatment plan based on the specific symptoms you’re experiencing, your medical history and your lifestyle.

How to Prevent Pelvic Floor Disorders

While pelvic floor disorders (PFDs) are common, there are several steps you can take to help prevent them or reduce the risk of worsening symptoms. Prevention starts with maintaining the health and strength of your pelvic floor muscles, along with making smart lifestyle choices that minimise strain on this crucial part of your body. Here are some practical and effective ways to protect your pelvic health:

• Practice Kegel Exercises Regularly

One of the simplest yet most effective ways to prevent pelvic floor dysfunction is by incorporating Kegel exercises into your daily routine. Kegels specifically target the pelvic floor muscles, which helps in strengthening them and maintaining their ability to support your pelvic organs. 

To perform a Kegel exercise, imagine you’re trying to stop the flow of urine midstream or trying to stop a fart from coming out. Squeeze and hold the muscles for a few seconds, then relax. Repeat this several times a day. The great thing about Kegels is that you can do them anywhere (except whilst on the toilet bowl to avoid confusing your bladder/rectum) —whether you are sitting at your desk or relaxing at home. Over time, consistent practice can reduce your risk of incontinence and pelvic organ prolapse.

• Maintain a Healthy Weight

By maintaining a healthy weight, you can reduce the strain on your pelvic muscles and improve overall pelvic health. This does not mean you need to aim for rapid weight loss. Instead, focus on sustainable lifestyle changes, such as eating a balanced diet rich in fruits, vegetables and whole grains, and engaging in regular physical activity. Managing your weight not only supports your pelvic floor but also contributes to your overall well-being.

• Use Proper Lifting Techniques

Many women unknowingly strain their pelvic floor when lifting heavy objects, which can lead to dysfunction over time. To protect your pelvic floor, always use proper lifting techniques:

• Bend your knees and squat down when picking up heavy objects, rather than bending at the waist.
• Hold the object close to your body and use your leg muscles to lift, rather than relying on your back or pelvic muscles.
• Avoid holding your breath while lifting; instead, exhale as you lift to reduce pressure on your pelvic floor.

These simple adjustments can make a big difference in protecting your pelvic muscles from unnecessary strain.

• Prevent Chronic Constipation

Chronic constipation can be a significant contributor to pelvic floor disorders. To avoid this, focus on maintaining good bowel health by:

• Eating a diet rich in fibre, including fruits, vegetables, and whole grains. Probiotics can sometimes be helpful as well. 

• Drinking plenty of water to stay hydrated and promote regular bowel movements.
• Engaging in regular physical activity to stimulate digestion.

If constipation is a recurring issue, it’s important to address it early by consulting a relevant specialist and avoid prolonged straining, which can damage the pelvic floor over time.

• Stay Active with Pelvic Floor-Friendly Exercises

Engaging in regular physical activity is essential for overall health, but not all exercises are pelvic floor-friendly. High-impact activities like running or heavy weightlifting can sometimes place excessive strain on the pelvic floor. Instead, focus on low-impact exercises that are gentle on your pelvic muscles while still keeping you active.

Swimming, walking and yoga are excellent examples of pelvic floor-friendly exercises that promote overall fitness without placing undue stress on the pelvic region. These activities can help you maintain strong muscles, reduce your risk of injury, and support your pelvic floor’s health.

By incorporating these preventive measures into your lifestyle, you can significantly reduce the risk of developing pelvic floor disorders. Preventing PFDs is all about staying mindful of how you use and care for your body—strengthening your muscles, avoiding unnecessary strain, and making smart choices that support your long-term pelvic health.

Conclusion—Taking Control of Your Pelvic Health

Recognising the early signs of a pelvic floor disorder is the first step toward regaining control of your health and well-being. By being aware of the symptoms and seeking medical advice early, you can address these issues before they progress. With proper treatment, whether through pelvic floor therapy, lifestyle changes, or other interventions, it’s entirely possible to manage and even resolve pelvic floor dysfunction.

Remember, you don’t have to live with discomfort, pain or embarrassment. With the right support and care, you can significantly improve your quality of life and enjoy a more active, comfortable, and fulfilling day-to-day routine.

If you’re experiencing any of the signs mentioned in this article, don’t hesitate to reach out. Contact our clinic today to schedule an evaluation and take the next step toward restoring your pelvic health. We are here to help answer your questions and guide you on your journey to wellness.

References 

1. DeLancey, John O. L., and Fernanda Pipitone. “Pathophysiology and Effects of Pregnancy on the Pelvic Floor.” Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth: Diagnosis, Management and Prevention, edited by Abdul H. Sultan et al., Springer International Publishing, 2024, pp. 17–35. Springer Link, https://doi.org/10.1007/978-3-031-43095-4_2. 
2. Fenner, Dee E., and Yvonne Hsu. “Pathophysiology of the Pelvic Floor: Basic Physiology, Effects of Ageing, and Menopausal Changes.” Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management, edited by Giulio Aniello Santoro et al., Springer Milan, 2010, pp. 25–32. Springer Link, https://doi.org/10.1007/978-88-470-1542-5_3. 
3. Chilaka, Chioma, et al. “Pelvic Floor Dysfunction and Obesity.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 90, Aug. 2023, p. 102389. ScienceDirect, https://doi.org/10.1016/j.bpobgyn.2023.102389. 
4. Scime, Natalie V., et al. “Association between Chronic Conditions and Urinary Incontinence in Females: A Cross-Sectional Study Using National Survey Data.” Canadian Medical Association Open Access Journal, vol. 10, no. 2, Apr. 2022, pp. E296–303. www.cmajopen.ca, https://doi.org/10.9778/cmajo.20210147. 
5. Forner, Lori B., et al. “Symptoms of Pelvic Organ Prolapse in Women Who Lift Heavy Weights for Exercise: A Cross-Sectional Survey.” International Urogynecology Journal, vol. 31, no. 8, Aug. 2020, pp. 1551–58. Springer Link, https://doi.org/10.1007/s00192-019-04163-w. 
6. Quaghebeur, Jörgen, et al. “Pelvic-Floor Function, Dysfunction, and Treatment.” European Journal of Obstetrics & Gynecology and Reproductive Biology, vol. 265, Oct. 2021, pp. 143–49. ScienceDirect, https://doi.org/10.1016/j.ejogrb.2021.08.026. 
7.  Bladder Relaxant Medications. https://mft.nhs.uk/app/uploads/2021/05/Bladder-Relaxant-Medications-Knowbots.pdf. Accessed 23 Sept. 2024. 
8. Dumain, Teresa. “Sling Surgery for Incontinence.” WebMD, https://www.webmd.com/urinary-incontinence-oab/sling-surgery-incontinence.  Accessed 23 Sept. 2024. 
9. “Colporrhaphy | Treatment for Prolapse | CU Urogynecology | Denver.” University of Colorado Urogynecology, https://urogyn.coloradowomenshealth.com/treatments/pelvic-reconstructive-surgery/colporrhaphy.  Accessed 23 Sept. 2024. 

Your first gynaecological visit is an essential step in taking charge of your reproductive health. While it’s normal to feel a bit anxious or unsure, understanding the significance of this visit can help you approach it with confidence. This isn’t just a routine check-up; it’s an opportunity to establish a baseline for your health, address any questions or concerns, and build a relationship with a healthcare provider who can support you through all stages of life.

Many young women worry about what will happen during the visit, often fearing pain, discomfort, or embarrassment. However, it’s important to know that gynaecologists are trained professionals who prioritise your comfort. Your first visit may involve a conversation about your health history, menstrual cycle, and any specific concerns you have. Physical exams, if necessary, are usually straightforward and will be explained to you every step of the way.

Remember, this visit is a normal and essential part of women’s healthcare, regardless of whether you’re experiencing issues or are sexually active. Starting early with regular gynaecological visits can help you stay informed and proactive about your health. By making this first appointment, you’re taking a positive step toward a lifetime of well-being.

In this article, we will discuss why you shouldn’t delay your first gynaecological visit, what to expect during the exam, how to prepare, and what questions to ask, so you can approach your first visit with confidence and ease.

Why You Shouldn’t Delay Your First Gynae Appointment

Delaying your first gynaecological appointment can have significant implications for your long-term health. Early gynaecological care is essential not only for addressing immediate concerns but also for establishing a foundation of proactive and preventive health practices that can benefit you throughout your life.

Common Reasons Young Women Put Off Their First Visit

Despite the importance of early care, many young women delay their first gynaecological visit for various reasons. One of the most common reasons is fear or anxiety about the unknown—worrying that the visit will be painful, embarrassing, or uncomfortable. There’s also a widespread misconception that gynaecological care is only necessary once a woman becomes sexually active, leading some to postpone their first visit unnecessarily.

Others might delay because they feel that their symptoms are not serious enough to warrant a visit or because they feel embarrassed discussing intimate health issues with a doctor. Additionally, cultural or familial beliefs may play a role in postponing the first appointment, as some young women may receive mixed messages about the importance of reproductive health care.

It’s crucial to recognise that these fears and misconceptions, while common, shouldn’t prevent you from taking charge of your health. Gynaecologists are trained to handle these situations with care and professionalism, and they ensure that you feel comfortable and informed throughout the process.

Health Benefits of Starting Regular Gynaecological Check-Ups Early

Early gynaecological care is a vital part of maintaining your overall health and well-being. A gynaecologist can help you manage various aspects of reproductive health, from understanding your menstrual cycle to discussing birth control options and screening for potential health issues. Starting these visits early allows your gynaecologist to identify any underlying conditions that may not present symptoms immediately but could lead to complications if left untreated.

For instance, conditions like polycystic ovary syndrome (PCOS), endometriosis, or sexually transmitted infections (STIs) might not always have obvious symptoms in their early stages but can impact your reproductive health if not addressed promptly. Regular visits also provide an opportunity for cancer screenings, such as Pap smears and HPV tests, which can detect precancerous changes in the cervix long before they develop into more serious conditions.

Moreover, early visits also provide an opportunity to establish a relationship with your gynaecologist, which can make it easier to discuss sensitive topics openly. This trust and familiarity can make future visits less intimidating and more productive, as your gynaecologist becomes a trusted partner in your health care.

Additionally, early gynaecological care helps you establish healthy habits that can support your overall well-being. Whether it’s understanding how to manage your menstrual cycle, learning about safe sexual practices, or exploring contraception options, these early conversations lay the groundwork for a lifetime of informed health decisions.

When Should You Schedule Your First Gynaecological Visit?

Deciding when to schedule your first gynaecological visit is a crucial step in taking charge of your reproductive health. While the timing can vary depending on individual circumstances, there are general guidelines and recommendations from leading health organizations that can help you determine the right time for your first appointment.

Ideal Age and Circumstances for the First Visit

The American College of Obstetricians and Gynaecologists (ACOG) [1] recommends that young women schedule their first gynaecological visit between the ages of 13 and 15. This initial visit often serves as an introductory meeting rather than a full physical exam, which allows you to build a rapport with your gynaecologist and gain valuable information about your reproductive health. At this age, the focus is typically on education and guidance, addressing topics such as menstrual health, sexual development, and preventive care.

ACOG’s recommendation for the first visit between ages 13 and 15 is widely supported by other health organisations, including the American Academy of Pediatrics (AAP) [2]. These organisations emphasise the importance of early education and preventive care as a foundation for lifelong reproductive health.

In some cases, parents or guardians might hesitate to schedule a gynaecological visit for their adolescent daughters, fearing that it implies sexual activity. However, these early visits are not necessarily focused on sexual health alone; they are a key part of overall health care, providing a safe space for young women to learn about their bodies and ask questions in a confidential setting.

Signs That It’s Time to Book Your First Appointment

While the age guidelines provide a general framework, there are specific signs and circumstances that indicate it’s time to book your first gynaecological appointment:

• Menstrual irregularities: if you experience irregular periods, extremely heavy bleeding, or severe menstrual cramps that interfere with your daily life, it’s important to see a gynaecologist. These could be signs of underlying conditions such as polycystic ovary syndrome (PCOS) or endometriosis.
• Sexual activity: if you have become sexually active, it’s crucial to have a gynaecological visit to discuss contraception, STI testing, and safe sexual practices. This ensures that you are informed and protected as you navigate your sexual health.
• Vaginal health concerns: unusual vaginal discharge, itching, or odour can be signs of infections or other health issues that require medical attention. A gynaecologist can diagnose and treat these conditions, preventing potential complications.
• Breast health: if you notice lumps or changes in your breast tissue, it’s essential to have them evaluated by a gynaecologist. While breast cancer is rare in young women, early detection of any abnormalities is important for your overall health.
• Reproductive health questions: if you have questions or concerns about your reproductive health—whether related to menstrual cycles, contraception, or sexual health—it’s a good idea to schedule a visit. Your gynaecologist can provide the answers and guidance you need.

What to Expect During Your First Gynaecological Exam

Your first gynaecological exam can feel daunting, but understanding what to expect can help ease any anxiety and ensure you feel more comfortable during the visit. A gynaecological exam is a routine procedure designed to assess your reproductive health and provide you with the care and information you need. Here’s a detailed walk-through of what typically happens during the exam, so you can be prepared and informed.

When you arrive for your appointment, you’ll first check in at the reception and may be asked to fill out some forms regarding your medical history. This information is crucial for your gynaecologist to understand your overall health and any specific concerns you might have.

A nurse or medical assistant will likely measure your weight, height, and blood pressure. The exam usually starts with a general discussion about your health. Your gynaecologist may ask about your menstrual cycle, sexual activity, any symptoms or concerns, and your medical and family history. This conversation is an important part of the exam, as it helps your gynaecologist provide personalised care tailored to your needs. You’ll then be asked to get changed in privacy for the physical examination. Your gynaecologist will inform you before entering the room to ensure your privacy and comfort.

It is understandable that you might feel the need to groom or shave before your gynaecological visit (or even postpone it until the aforementioned is done), but it’s actually not necessary. Your gynaecologist is primarily focused on your health and well-being, and they won’t be concerned about grooming.

Explanation of the Different Parts of the Exam

A typical gynaecological exam is composed of several key components, each serving a specific purpose:

• General health check: your gynaecologist may begin with a general health check, including questions about your overall well-being, diet, exercise, and lifestyle. This part of the exam may also include a routine physical check of your abdomen to assess your general health.
• Breast exam: the breast exam may be performed if there are any issues concerning the breast, for early detection of breast abnormalities. During this exam, your gynaecologist will gently examine your breasts for lumps, changes in texture, or other unusual signs. You may also be taught how to perform a self-breast exam at home, which is an important tool for the early detection of breast issues.
• Pelvic exam: the pelvic exam is perhaps the most anticipated part of the visit, and understanding what happens can alleviate much of the anxiety. You’ll be asked to lie back on the exam table and place your feet in stirrups, which allows your gynaecologist to examine the pelvic area more easily. The exam begins with an external visual inspection of your vulva to check for any visible abnormalities, such as irritation, swelling, or signs of infection. 
• Speculum exam (this is only performed for women who have had sex before): next, the gynaecologist will perform a speculum exam [3]. A speculum, which is a smooth, duckbill-shaped instrument, is gently inserted into the vagina to hold the walls of the vagina open, allowing your gynaecologist to see the cervix (the lower part of the uterus that opens into the vagina). This part of the exam might feel a little uncomfortable, but it should not be painful. Your gynaecologist will check the cervix for any irregularities and might take a sample of cervical cells for a Pap smear or HPV test, which screens for cervical cancer.
• Pap smear/HPV test: if you’re at the appropriate age and have been sexually active, your gynaecologist may perform a Pap smear and/or HPV test during the pelvic exam. This involves collecting a small sample of cells from your cervix using a soft brush or spatula. The sample is then sent to a lab to check for any precancerous or cancerous changes. These tests are quick procedures and should be performed on a regular basis as they are essential for the early detection of cervical cancer.
• Bimanual exam: after the speculum is removed, your gynaecologist may perform a bimanual exam [4]. This involves inserting one or two fingers into your vagina while pressing down on your abdomen with the other hand. This allows your gynaecologist to feel the size, shape, and position of your uterus and ovaries, and to check for any tenderness or abnormalities.
• Pelvic ultrasound: depending on the clinical history and findings of the physical examination, your gynaecologist may need to perform a pelvic ultrasound to check on the structure of your female reproductive organs (i.e. uterus and ovaries). This is typically best done transvaginally (with an empty bladder) for women who have been sexually active before. For women who have never had sex before, this is usually done either trans-abdominally (with a full bladder) or transrectally (with an empty bladder) depending on the clinical indications. The pelvic ultrasound scan typically takes a few minutes and may sometimes feel a little uncomfortable, but should not feel painful unless there are gynaecological pathologies. In certain select cases, the pelvic ultrasound may need to be performed in a specialised scan centre.   

How Long the Visit Typically Lasts

The entire gynaecological visit, including the time spent discussing your health, typically lasts between 30 minutes to an hour. The actual physical exam portion may only take about 10 to 15 minutes. The length of the visit can vary depending on whether it’s your first appointment, the complexity of your health history, and any specific concerns you have.

Your gynaecologist will also take time at the end of the exam to discuss any findings, answer your questions, and guide you on your next steps, such as when to return for follow-up visits or how to manage any health issues that were identified.

While your first gynaecological exam might feel a bit intimidating, it’s an essential step in maintaining your reproductive health. Knowing what to expect can help you feel more at ease and ensure that you’re prepared to take full advantage of the care and advice your gynaecologist provides.

What Questions Should I Ask My Gynaecologist During My First Visit?

Your first gynaecological visit is not just about undergoing a physical exam—it’s also an opportunity to ask questions and gain a deeper understanding of your reproductive health. Preparing a list of questions beforehand can help ensure that you leave the appointment feeling informed and confident about your health. Here are some essential questions every young woman should consider asking during her gynaecological visit.

“Is my menstrual cycle normal?”

Understanding what’s typical for your menstrual cycle is key to recognising when something might be off. Ask your gynaecologist about what constitutes a normal cycle, and discuss any irregularities, such as heavy bleeding, severe cramps, or missed periods. This can help you determine if your experiences are within the normal range or if further investigation is needed.

“What can I do to manage menstrual pain and PMS symptoms?”

If you experience significant discomfort during your periods, your gynaecologist can provide strategies for managing pain and premenstrual syndrome (PMS). This may include lifestyle changes, over-the-counter medications, or hormonal treatments. Discussing these options can improve your quality of life and help you manage your menstrual cycle more comfortably.

“What contraception options are available, and which one is right for me?”

Contraception is a critical aspect of reproductive health, and there are many options available, each with its own benefits and potential side effects. Your gynaecologist can help you understand the various methods, including birth control pills, intrauterine devices (IUDs), implants, patches, and more. Together, you can discuss your lifestyle, health conditions, and preferences to find the method that best suits your needs.

“What should I know about sexually transmitted infections (STIs)?”

If you’re sexually active, it’s essential to understand how to protect yourself from STIs and what steps to take if you think you’ve been exposed. Ask your gynaecologist about routine STI screening, symptoms to watch for, and the best practices for prevention. Open communication about your sexual health is crucial for maintaining your overall well-being.

“What should I do if I notice changes in my vaginal health?”

Changes in vaginal discharge, odour, or itching can be concerning and might indicate an infection or other health issue. Discuss with your gynaecologist what’s normal and when you should seek medical advice. Understanding your body’s signals is vital for catching potential problems early.

“Are there any vaccines I should consider?”

Certain vaccines, like the human papillomavirus (HPV) vaccine [5], are important for preventing infections that can lead to more serious health issues, such as cervical cancer. Ask your gynaecologist about recommended vaccines for your age and health status.

“How can I maintain a healthy lifestyle that supports my reproductive health?”

Your gynaecologist can provide guidance on how diet, exercise, and stress management can impact your reproductive health. This is a great time to discuss any concerns you have about your lifestyle and receive personalised advice.

Topics to Cover: Menstrual Health, Sexual Health, Contraception Options, and Personal Concerns

During your visit, it’s important to cover a range of topics that are relevant to your overall reproductive health. These include:

• Menstrual health: understand what is normal for your cycle, how to manage symptoms, and when to seek help for irregularities.
• Sexual health: discuss safe sex practices, STI prevention, and any concerns about sexual activity.
• Contraception options: learn about the different methods available, their effectiveness, and which might be the best fit for your lifestyle.
• Personal concerns: don’t hesitate to bring up any other concerns, whether they relate to your body, mental health, or relationships. Your gynaecologist is there to support your well-being in a comprehensive manner.

One of the most important aspects of your gynaecological care is establishing open and honest communication with your gynaecologist. This relationship is built on trust, and being transparent about your concerns, habits, and lifestyle will allow your gynaecologist to provide the best possible care. Remember, your gynaecologist is a trained professional who is there to support your health, not to judge you. The more open you are, the more personalised and effective your care will be.

Don’t be afraid to ask questions, no matter how small or personal they may seem. Your gynaecologist has heard it all and is there to help you navigate your reproductive health with confidence and knowledge.  

Conclusion 

Your first gynaecological visit is more than just a medical appointment; it’s a crucial step in taking control of your reproductive health and well-being. By understanding the importance of this visit and what it entails, you’re empowering yourself with the knowledge and confidence needed to make informed decisions about your body.

Regular gynaecological care is a cornerstone of preventive health, which can help you stay ahead of potential issues and ensure that you receive the guidance and support you need at every stage of life. From menstrual health to contraception options and beyond, these visits provide the foundation for a lifetime of proactive care.

If you haven’t scheduled your first gynaecological visit yet, now is the time to do so. Don’t let fear or uncertainty hold you back from taking this important step. Embrace the journey of caring for your reproductive health, and make your well-being a priority today.

References 

1. Should My Teen See an Ob-Gyn? Here’s What I Tell Parents. https://www.acog.org/womens-health/experts-and-stories/the-latest/should-my-teen-see-an-ob-gyn-heres-what-i-tell-parents. Accessed 21 Aug. 2024. 
2. Gynecologic Examination for Adolescents in the Pediatric Office Setting, AAP. https://publications.aap.org/pediatrics/article/126/3/583/66218/Gynecologic-Examination-for-Adolescents-in-the?autologincheck=redirected. Accessed 21 Aug. 2024 
3. “Speculum: Design, Purpose, Types, Exams & What To Expect.” Cleveland Clinic, https://my.clevelandclinic.org/health/drugs/24238-speculum. Accessed 21 Aug. 2024. 
4. “Bimanual Pelvic Examination.” Patient Information, https://patients.uroweb.org/tests/bimanual-pelvic-examination/.  Accessed 21 Aug. 2024.
5. Human Papillomavirus (HPV) Vaccines – NCI. 15 Aug. 2024, https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-vaccine-fact-sheet. 

As its name suggests, hormone replacement therapy (HRT) replaces the hormones that decline during the perimenopausal and menopausal periods. But what is menopause, and how does it impact women’s health? What is the significance of hormone replacement therapy (HRT), and is it even necessary? In this article, we delve into the world of menopause and HRT, giving you the knowledge to help you make the right decision. 

What is menopause?

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It typically occurs in middle age, usually in a woman’s late 40s to early 50s, although this varies between individuals. One is deemed to have reached menopause if there is cessation of menstruation (periods) for one year, and women typically undergo a perimenopausal transition prior to that. This whole process may also be associated with a range of physical and hormonal changes in a woman’s body.

The main hallmark of menopause is a decline in the production of certain hormones, particularly estrogen and progesterone, by the ovaries. This hormonal shift can lead to a variety of physical and emotional symptoms.

What are the symptoms of perimenopause/menopause?

Common perimenopausal/ menopausal symptoms include: 

• Irregular periods: Intervals between menstrual cycles may become shorter or longer, with varying degrees of flow.
• Hot flashes: Sudden and intense feelings of warmth that may occur randomly, often accompanied by sweating.
• Night sweats: Hot flashes that occur during the night, which can disrupt one’s sleep quality.
• Vaginal dryness: Thinning and dryness of the vaginal tissues, which can lead to discomfort during intercourse.
• Mood swings: Changes in mood, including irritability, anxiety, and depression.
• Sleep disturbances: Difficulty falling asleep and staying asleep.
• Changes in sexual desire: Some women may experience a decrease in libido.
• Changes in skin and hair: These can include thinning hair, dry skin, and changes in skin texture.
• Weight gain: Due to a decrease in metabolic rate, many women may find it more challenging to maintain their weight.
• Changes in bone density: A decrease in estrogen levels typically leads to a loss of bone density over time, increasing the risk of osteoporosis.

If you are experiencing any of the symptoms stated above, you are not alone, as this is a physiological process that every woman needs to go through eventually. Make an appointment with your gynaecologist to understand what you are going through and learn how to navigate the next chapter of your life, especially if you find that your quality of life is being adversely affected.  

What is Hormone Replacement Therapy (HRT)?

Hormone replacement therapy is used to alleviate the symptoms of menopause by effectively replacing the hormones (oestrogen and progesterone), which levels decline during the perimenopausal/menopause period. 

There are different types of hormone therapy, these are:

• Systemic hormonal therapy: systemic HRT consists of either oestrogen-only or oestrogen and progesterone therapy and is used to help alleviate perimenopausal/menopausal symptoms such as hot flashes, mood swings, night sweats, etc. Oestrogen-only therapy is typically recommended for women who have had their uterus removed (hysterectomy), whilst oestrogen and progesterone therapy is used for women who still have their uterus intact. The function of progesterone is to protect the uterus, as oestrogen-only therapy in women with an intact uterus can increase the risk of endometrial (uterine) cancer. Systemic HRT comes in many forms, including oral pills, transdermal patches, topical creams/gels, vaginal rings etc. The choice of administration should be individualised, considering one’s preferences and clinical situation. 
• Local hormonal therapy: local Hormone Replacement Therapy (HRT) primarily involves the use of hormonal medications (namely, oestrogen) to address specific symptoms that are related to the vaginal and urogenital area. Unlike systemic HRT, which delivers hormones throughout the body, local HRT has a more localised effect on a targeted area and aims to alleviate vaginal atrophy, dryness, burning sensation/discomfort, and painful intercourse as well as to help with urinary symptoms (e.g. urinary frequency, urgency, incontinence, recurrent urinary tract infections that can occur during the perimenopausal/menopausal period). Local HRT is usually administered topically and comes in the form of either a vaginal cream or vaginal tablets, or both, which help to restore the health, elasticity and moisture of the urogenital region. As it is usually low dose with a localised effect, it is generally considered to have lower risks compared to systemic HRT; however, it does not typically help in alleviating other perimenopausal/menopausal symptoms such as hot flashes, mood swings, etc. 

What are the benefits of hormone replacement therapy (HRT)?

• Alleviating menopausal symptoms: HRT can effectively alleviate menopausal symptoms, which can sometimes be debilitating and improve one’s quality of life and interpersonal relationships. It can also help prevent osteoporosis and may have a beneficial effect on heart health when started relatively early in menopause.
• Improving bone health: HRT can help delay the onset/development of reduced bone density, which eventually may lead to osteoporosis; however, HRT is not typically started as the primary indication for osteoporosis prevention in perimenopausal/menopausal women.  
• Potential cardiovascular benefits: The relationship between HRT and cardiovascular benefits is complex and has been the subject of extensive research. The effects of HRT on cardiovascular health can vary depending on several factors, including the type of HRT, the timing of initiation, and the individual’s health profile. A woman’s individual health profile and risk factors play a significant role in how HRT may affect her cardiovascular health. It is hence essential to assess an individual’s cardiovascular risk factors, such as blood pressure, cholesterol levels, smoking history, and family history, before considering HRT, and the decision to use HRT made on a case-by-case basis; HRT is not typically started for the primary indication for cardiovascular health in perimenopausal/menopausal women. It is important to note that lifestyle changes such as a healthy diet, regular exercise, and smoking cessation are just as (if not more) effective in promoting cardiovascular health without the need for HRT.

What are the risks and side effects of hormone replacement therapy (HRT)?

As much as hormone replacement therapy (HRT) can offer benefits, there can be potential risks/side effects involved, which also depends on the type of HRT, duration of use, individual’s health profile and other considerations. 

• Cardiovascular Risks: HRT can increase the risk of blood clots in the legs (deep vein thrombosis), which can migrate to the lungs (pulmonary embolism).
• Breast Cancer Risk: Systemic HRT (estrogen and progesterone) is associated with a slightly increased risk of breast cancer, especially with long-term use.
• Endometrial Cancer Risk: Women who have a uterus and take oestrogen without progesterone (or progestin) are at an increased risk of developing endometrial cancer.
• Ovarian Cancer Risk: Some studies have suggested a possible increased risk of ovarian cancer with long-term HRT use, although the evidence is not conclusive.
• Stroke: HRT, especially when initiated in older postmenopausal women, has been associated with an increased risk of stroke.
• Vaginal Bleeding: Irregular or unexpected vaginal bleeding can occur with HRT, especially in women who still have their uterus – this should be flagged up to your gynaecologist promptly to see if further evaluation is required.

The decision to use HRT should be individualised, taking into account a woman’s medical history, age, risk factors, and the severity of her menopausal symptoms. It’s essential to have a thorough discussion with your gynaecologists to weigh the potential benefits and risks. The optimal duration of HRT also varies from person to person. Regular follow-up with your gynaecologist is crucial to monitor the effects of HRT and adjust the treatment plan as needed.

Who is hormone replacement therapy (HRT) suitable for?

Hormone replacement therapy is not for everyone. There are also several contraindications to consider before even considering this treatment. This is why a thorough consultation with a specialist is essential if you plan on going on hormone replacement therapy.

• Factors to consider
  • Age and menopausal stage: HRT is best suited for women who are perimenopausal and/or newly menopausal, with the aim of the lowest effective dose for the shortest duration; starting HRT for older women who are many years past menopause and/or continuing on HRT for many years beyond the age of menopause entail increased levels of risk. 
  • Medical history: HRT is generally not advisable for women with hormone-dependent cancer, e.g. breast cancer, endometrial cancer, ovarian cancer, etc. It is also not suitable for women with a medical history of clotting disorders. 
  • Uncontrolled cardiovascular risk factors: e.g. poorly controlled hypertension, can increase the risk of adverse events, such as stroke. 
  • Severe liver disease: As the liver metabolises HRT, individuals with severe liver disease may need to avoid using HRT.
  • Undiagnosed vaginal bleeding: Unexplained vaginal bleeding should be investigated and diagnosed before considering HRT. It can be a sign of underlying medical conditions that may need treatment.

What are the alternatives to hormone replacement therapy (HRT)?

There are several alternatives to Hormone Replacement Therapy (HRT) for managing the symptoms of perimenopause and menopause. The choice of alternatives depends on an individual’s specific symptoms, preferences, and medical history. Here are some common alternatives to HRT:

• Lifestyle Modifications:
  • Diet: A balanced diet rich in fruits, vegetables, whole grains, and lean proteins can help manage menopausal symptoms and promote overall health.
  • Exercise: Regular physical activity can help reduce hot flashes, improve mood, and maintain bone health.
  • Stress Reduction: Techniques like mindfulness, yoga, meditation, and deep breathing exercises can help manage stress and reduce mood swings.
  • Smoking Cessation: Quitting smoking can improve overall health and reduce the risk of heart disease and lung problems.
  • Dietary Supplements: Some women find relief from menopausal symptoms by taking certain dietary supplements, such as:
  • Calcium and Vitamin D: These supplements can help maintain bone health.
  • Black Cohosh: This herbal supplement may alleviate hot flashes and other menopausal symptoms in some women.
  • Soy Isoflavones: Found in soy products, these compounds may have a mild oestrogen-like effect and help with menopausal symptoms.
    
• Prescription Medications: Non-hormonal prescription medications can be used to manage specific symptoms. For example:
  • Selective Serotonin Reuptake Inhibitors (SSRIs): These can help reduce hot flashes and improve mood.
• Vaginal Moisturisers and Lubricants: For vaginal dryness and discomfort, over-the-counter or prescription non-hormonal vaginal moisturisers and lubricants can provide relief during sexual activity.
• Behavioural Therapies: Cognitive-behavioral therapy and other forms of counselling can help women manage emotional and psychological symptoms associated with menopause.
• Acupuncture: Some women have reported relief from hot flashes and other symptoms through acupuncture treatments.
• Herbal Remedies: Herbs like red clover, evening primrose oil, and dong quai have been used by some women to alleviate menopausal symptoms. However, scientific evidence supporting their effectiveness is limited, and their safety varies.

What long-term considerations should I consider before going on hormone replacement therapy (HRT)?

Before considering HRT, there are several important factors and considerations. 

• Individual Health Profile: Your gynaecologist will assess your individual health history, including any medical conditions, medications, and family history. This evaluation is crucial in determining whether HRT is a safe and suitable option for you.
• Symptoms and Needs: Consider the severity of your menopausal symptoms and how they affect your quality of life. HRT is typically recommended for individuals with moderate to severe symptoms, but the decision should be tailored to your specific needs.
• HRT Type and Formulation: Discuss with your healthcare provider the type of HRT (systemic or local) and the specific formulation that may be most appropriate for you. The choice can depend on whether you have a uterus, your risk factors, and the nature of your symptoms.
• Duration of Use: Decide how long you wish to try HRT – it is typically for the shortest effective duration for symptom management. Your healthcare provider can help you establish a treatment plan with clear goals.
• Regular Monitoring: If you choose HRT, expect regular follow-up appointments with your gynaecologist. Monitoring is essential to assess the benefits and risks of HRT over time and make necessary adjustments.
• Potential Risks: Be aware of the potential risks associated with HRT, such as an increased risk of blood clots, heart disease, breast cancer, and stroke. Your gynaecologist will help you assess these risks based on your health profile.
• Alternatives: Consider alternative approaches to managing menopausal symptoms, such as lifestyle modifications, non-hormonal medications, and complementary therapies. Discuss these options with your healthcare provider to determine the most suitable treatment plan for you.
• Side Effects and Tolerability: Pay attention to any side effects or discomfort related to HRT. Share these concerns with your healthcare provider to ensure the best treatment experience.
• Discontinuation: Discuss the process and potential effects of discontinuing HRT if and when it becomes necessary or desirable.

Conclusion

The decision to use HRT should be based on an individualised assessment of benefits and risks in consultation with a healthcare provider. HRT is not a one-size-fits-all solution. It should be tailored to an individual’s specific needs, considering their medical history, health profile, and menopausal symptoms – i.e. its use should be informed, individualised, and closely monitored. Ultimately, the decision to use HRT is a personal one that should be made in collaboration with your gynaecologist to optimise health and well-being during and after menopause.

A high-risk pregnancy can be challenging for expectant mothers and their healthcare teams, as it comes with an elevated probability of complications that can impact both the mother and the developing foetus. 

This article will discuss what constitutes a high-risk pregnancy and the factors behind it. From maternal age and multiple pregnancies to pre-existing medical conditions, gestational complications, and a history of previous issues, we’ll explore the various elements that healthcare professionals consider when assessing pregnancy risk. 

What is a high-risk pregnancy? 

A high-risk pregnancy, also known as a high-risk gestation or high-risk obstetric pregnancy, is a pregnancy that has a higher likelihood of complications for the mother, the foetus, or both compared to a typical pregnancy. 

What causes high-risk pregnancy? 

Various factors can contribute to a pregnancy being categorised as high-risk, including:

• Maternal age: pregnant women who are of advanced maternal age are at higher risk of having babies with chromosomal abnormalities such as Down syndrome, developing gestational diabetes, pregnancy-induced hypertension/pre-eclampsia, preterm labour, etc [1]. 
• Multiple pregnancies: multiple pregnancies, such as twins or triplets, have a higher likelihood of foetal anomalies, intrauterine growth restriction/low birth weight and growth discordance [2]. They are also more likely to end up with premature birth. These factors can lead to complications such as respiratory distress syndrome, jaundice, etc, requiring admission to neonatal intensive care units. Women who are carrying multiple pregnancies also have a higher chance of developing anaemia, gestational diabetes, pregnancy-induced hypertension/pre-eclampsia and needing caesarean sections as their mode of delivery [3]. They are also at a higher risk of experiencing postpartum haemorrhage (afterbirth bleeding) as well as postpartum depression [4,5]. 
• Pre-existing medical conditions: women with pre-existing medical conditions such as diabetes mellitus [6], hypertension [7], heart disease [8], kidney disease [9], autoimmune conditions (such as lupus) [10], epilepsy [11], thyroid or blood disorders [12], neurological conditions [13], etc. who become pregnant will be considered as high-risk pregnancies. 
• Gestational conditions: certain antenatal conditions/complications can change a low-risk pregnancy to a high-risk one. These include poorly controlled gestational diabetes [14], pregnancy-induced hypertension/pre-eclampsia [15], antepartum haemorrhage [16], placenta previa/abnormally adherent placenta [17], etc. 
• Lifestyle factors: lifestyle factors such as smoking, alcohol/substance abuse, poor nutrition, extremes of body mass index (underweight and obesity), high caffeine consumption, high stress levels, presence of domestic violence, and lack of social support can result in a high-risk pregnancy [18].
• Obesity: pregnant women who are obese are at higher risk of various pregnancy complications [19]. Their babies are also at increased risk of congenital disabilities and macrosomia (large birth weight). 
• History of preterm birth/cervical surgeries: women with a history of preterm birth or history of cervical surgeries (e.g. cervical cone for cervical dysplasia) are at higher risk of having another preterm delivery [20]. Preterm babies are at increased risk of respiratory distress syndrome, intraventricular haemorrhage (bleeding into the brain), necrotising enterocolitis (gut inflammation/tissue death), retinopathy of prematurity (which can lead to visual impairment/blindness), jaundice, temperature dysregulation, feeding difficulties, infections, growth/development delays, cerebral palsy, and downstream long-term health issues. 
• Rh incompatibility: Rh incompatibility occurs when mothers who are rhesus-negative have a baby with a partner who is rhesus-positive; there are situations where the mother’s immune system produces antibodies against rhesus-positive blood cells, which can then cross the placenta and attack the rhesus-positive blood cells of the developing foetus. This immune response can cause haemolysis (breakdown of red blood cells) and result in a condition known as haemolytic disease of the newborn (HDN). HDN can lead to severe anaemia, jaundice, and, in more severe cases, hydrops fetalis, which is characterised by severe swelling and fluid accumulation in the foetus’ body. In severe cases, HDN can be life-threatening for the baby.
• Genetic disorders: genetic disorders that can result in a pregnancy being high risk, such as chromosomal abnormalities, e.g. Down Syndrome (Trisomy 21), Trisomy 18 (Edwards Syndrome), Trisomy 13 (Patau Syndrome), Turner’s syndrome, neural tube defects (such as spina bifida and anencephaly), cystic fibrosis, sickle cell disease, thalassaemia major, inborn errors of metabolism can all contribute to a high-risk pregnancy.  

If you have a high-risk pregnancy, it is crucial for you to consult a highly professional obstetrician and gynaecologist and to ensure regular monitoring throughout your pregnancy. This approach greatly enhances the likelihood of a healthy pregnancy and safe delivery for you and your baby.

What is the significance of prenatal care in high-risk pregnancies?

Prenatal care is essential for the health and well-being of expectant mothers and their developing babies. Regular prenatal care involves a series of medical check-ups, screenings, and guidance throughout the pregnancy. Here’s why prenatal care is so important:

• Early detection and prevention: early and consistent prenatal care is crucial in identifying, accessing, and managing risk factors and complications. Experienced obstetricians can tailor care plans to address specific needs and risks associated with high-risk pregnancies.
• Optimising maternal health: this is typically achieved through a multidisciplinary approach. 
• Monitor baby’s growth to prepare for labour and delivery: you will likely require more frequent foetal ultrasounds to monitor your baby’s development and well-being; depending on the findings, your obstetrician can then plan the next steps and advise on the timing/mode of delivery to reduce possible complications.
• Emotional and psychological support: high-risk pregnancies can be physically, emotionally, and financially straining. It is essential to provide expectant mothers with the utmost support and care. 

How do I manage a high-risk pregnancy? 

Managing a high-risk pregnancy requires close collaboration between you, your healthcare team, and, sometimes, specialists. Here are some key steps to help manage a high-risk pregnancy:

• Choose a skilled healthcare provider: high-risk pregnancies typically benefit from multidisciplinary care and may require the involvement of a high-risk maternal-foetal specialist throughout the pre-conception, antenatal, and postnatal stages. 
• Regular prenatal care: high-risk pregnancies require closer monitoring, and this, in turn, translates to frequent appointments with your obstetrician, particularly in the run-up to your estimated due date. 
• Follow medical advice: the management of a low-risk pregnancy differs from a high-risk one, so if you have a high-risk pregnancy, your friends’ experiences may not apply to you – follow your obstetrician’s medical advice closely to ensure optimal outcomes for you and your baby. 
• Manage pre-existing conditions: poorly controlled pre-existing conditions, such as diabetes, lupus, etc., can adversely impact your pregnancy. It is vital to keep them under control whilst you are trying to conceive and throughout your pregnancy – this may require you to see multiple specialists during this journey. 
• Lifestyle modifications: having a healthy lifestyle has never been so important – eat healthy foods, engage in physical exercise (as advised by your obstetrician), avoid smoking/alcohol/excessive caffeine intake, and modulate your stress levels. 
• Medications: make sure all the medicines you take during pregnancy are pregnancy-safe. If you are obtaining any medications from doctors other than your obstetrician, be sure to inform them that you are currently pregnant so that the appropriate ones can be prescribed. 
• Specialised testing: certain specialised tests are required during pregnancy, including Down syndrome screening (if one opts for it), detailed foetal anomaly scans, growth ultrasound scans, etc., and these are typically time-sensitive, i.e. to be done at certain weeks of the pregnancy. Keep to your scheduled appointments to attend all necessary testing. 
• Stay informed: don’t be shy to ask your obstetrician questions, particularly if you have any concerns or are unclear about anything. This is a learning process for you and your partner, and it is important to gain as much information as possible to make the journey smoother. 
• Emergency plan: know what red flag symptoms you should look out for, e.g. contractions or leaking of water bag before you hit 37 weeks of pregnancy, vaginal bleeding, reduced foetal movements, etc. Keep the emergency contacts of your obstetrician and nearby hospitals with you at all times. It would also be good to keep a file containing all your antenatal information and investigations for easy reference and access.  
• Foetal movement monitoring: most women will start to feel foetal movements from about 20 weeks. However, this varies between individuals – some may feel foetal movements earlier (particularly if they have prior experience and are more sensitive to baby movements). Foetal movements may also be perceived later, especially if the placenta position is anterior (i.e. front of the uterus). 
• Postpartum care: pregnancy care does not end at childbirth; the “fourth” trimester involves postpartum care and consists of both mother and newborn care. Care of the mother involves assessment of vaginal bleeding (lochia), pain management, healing of incisions (e.g. episiotomy, caesarean section wound), breastfeeding support (if applicable), emotional well-being, discussion of exercise, sexual health, and contraception. Care for the newborn involves checking for congenital conditions, feeding,  jaundice, overall development, vaccinations, etc. 

Remember that each high-risk pregnancy is unique, and the management plan will be tailored to your circumstances. Always consult with your doctor for guidance and support throughout the pregnancy. The goal is to optimise the health and safety of both you and your baby.

What preparations should be made for delivery in high-risk pregnancies?

In high-risk pregnancies, some essential preparations should be made for the delivery to ensure the safety and well-being of both the mother and the baby. These preparations include:

• Birth plans and preferences: discuss and create a birth plan with your healthcare provider, outlining your preferences and any specific requirements or concerns related to labour and delivery. This is particularly important if you have a high-risk pregnancy, as some common birth plans may interfere with the care your baby needs. 
• Emergency preparedness: be prepared for potential emergencies during labour, such as premature birth or complications. Know when and how to seek immediate medical attention.
• Cesarean sections vs vaginal births: be informed about the implications of both delivery methods and which one is more suitable for your situation 

What should be considered in postnatal care and beyond in high-risk pregnancies?

• Neonatal Intensive Care Units (NICU): be aware of the potential need for neonatal intensive care if the baby is born prematurely or with health complications. This can be particularly costly if the stay is projected to be extended. 
• Long-term monitoring and follow-up: recognise the importance of ongoing healthcare and follow-up appointments for mother and child after delivery, as high-risk pregnancies may have a lasting impact.
• Contraception and family planning: discuss contraception and family planning options with your healthcare provider to make informed choices about future pregnancies. 

Conclusion

The goal of managing high-risk pregnancies is mitigating risks by optimising maternal and foetal health. This is done through medical interventions, lifestyle modifications, or both. In conclusion, it is safe to say that the management of high-risk pregnancies requires a team approach, personalised care, and a focus on early detection and intervention.

Work closely with your obstetrician and follow their advice and guidance. This way, you can increase your likelihood of a healthy pregnancy and the birth of a healthy baby.

References

1. Rosaly Correa-de-Araujo, S. S. (2021). Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. Journal of Women’s Health, doi: 10.1089/jwh.2020.8860.
2. SingHealth. (2021). Multiple Pregnancy: Managing the Higher Risks​. Retrieved from HealthXchange.sg: https://www.healthxchange.sg/women/pregnancy/multiple-pregnancy-managing-higher-risks
3. María De la Calle, J. L.-C. (2021). Women Aged over 40 with Twin Pregnancies Have a Higher Risk of Adverse Obstetrical Outcomes. International Journal of Environmental Research and Public Health, doi: 10.3390/ijerph182413117.
4. Giulia di Marco, E. B. (2023). Multiple Pregnancy and the Risk of Postpartum Hemorrhage: Retrospective Analysis in a Tertiary Level Center of Care. Diagnostics (Basel), doi: 10.3390/diagnostics13030446.
5. Yoonjoung Choi, D. B. (2009). Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics, doi: 10.1542/peds.2008-1619.
6. Abourawi, F. I. (2006). Diabetes mellitus and pregnancy. Libyan Journal of Medicine, doi: 10.4176/060617.
7. Ellen W. Seely, J. E. (2014). Chronic Hypertension in Pregnancy. Circulation, https://doi.org/10.1161/CIRCULATIONAHA.113.003904.
8. Uri Elkayam, S. G. (2016). High-Risk Cardiac Disease in Pregnancy: Part I. Journal of the American College of Cardiology, doi: 10.1016/j.jacc.2016.05.048.
9. David Williams, J. D. (2008). Chronic kidney disease in pregnancy. BMJ, doi: 10.1136/bmj.39406.652986.BE.
10. Waltraut Maria Merz, R. F.-B. (2022). Pregnancy and Autoimmune Disease. Deutsches Arzteblatt International, doi: 10.3238/arztebl.m2021.0353.
11. Dr. Yi Li, K. J. (2023). Epilepsy and Pregnancy. Continuum (Minneap Minn), doi: 10.1212/CON.0000000000001056.
12. Leo A. Carney, J. D. (2014). Thyroid Disease in Pregnancy. American Family Physician, 273-278.
13. Sandya Renukesh, L. R. (2016). Neurological Disorders Complicating Pregnancy – Focus on Obstetric Outcome. Journal of Clinical and Diagnostic Research, doi: 10.7860/JCDR/2016/19839.8955.
14. Badurudeen Mahmood Buhary, O. A. (2016). Glycemic control and pregnancy outcomes in patients with diabetes in pregnancy: A retrospective study. Indian Journal of Endocrinology and Metabolism, doi: 10.4103/2230-8210.183478.
15. Nir Melamed, J. G. (2014). Gestational Hypertension and Preeclampsia: Are They the Same Disease? Journal of Obstetrics and Gynecology Canada , DOI:https://doi.org/10.1016/S1701-2163(15)30545-4.
16. Charlotte B. Oguejiofor, C. D. (2023). A Five-Year Review of Feto-Maternal Outcome of Antepartum Haemorrhage in a Tertiary Center. International Journal of Innovative Research in Medical Science, doi: 10.23958/ijirms/vol08-i03/1637.
17. Eric Jauniaux, I. D. (2019). The Impact of Placenta Previa with Placenta Accreta Spectrum Disorder on Fetal Growth. Ultrasound in Obstetrics & Gynecology, doi: 10.1002/uog.20244.
18. Office of Communications. (2018, June 11). What are some factors that make a pregnancy high risk? Retrieved from National Institute of Child Health and Human Development: https://www.nichd.nih.gov/health/topics/high-risk/conditioninfo/factors
19. Lucilla Poston, L. F. (2011). Obesity in Pregnancy: Implications for the Mother and Lifelong Health of the Child. A Consensus Statement. Pediatric Research, 175-180.
20. Amaya Wittmaack, D. D. (2019). Maternal History of Cervical Surgery and Preterm Delivery: A Retrospective Cohort Study. Journal of Women’s Health, doi: 10.1089/jwh.2018.7457.

What is birth control and how do they work?

The myriad of birth control methods can sometimes prove confusing for many especially when considering different lifestyle factors. Contraception, commonly known as birth control, comes in various forms that are used to prevent unplanned or unwanted pregnancies. Before we learn about how birth control works, it is important to understand that birth control is only efficient when used properly, correctly, and consistently. A poor lapse of judgement may not only result in an unplanned or unwanted pregnancy but may also bring about a sexually transmitted infection (STI). 

In this article, we will delve into:

1. Different types of birth control methods 
2. The pros and cons of each birth control method 
3. Factors affecting the selection of a birth control method

Types of birth control methods

There are many different types of birth control methods such as:

 

Hormonal medications/devices

These rely on hormones to prevent pregnancy. Routes of administration vary and range from oral tablets, skin patches, vaginal rings, intramuscular injections, contraceptive implants (aka Implanon/Nexplanon), to intrauterine devices.

Types of hormonal birth control include: 

• Oral contraceptives: such as birth control pills. There are 2 types of birth control pills available in Singapore, these are combined oral contraceptive pills (COCP) and progesterone-only pills (POP). 
• Intrauterine contraceptive devices: also known as IUCDs or IUDs. The Mirena IUD, one of the most popular options for IUDs, provides long-term contraception [1].
• Birth control patches: prevent pregnancy by releasing hormones through the patch and into your bloodstream. Works in a similar way to combined oral contraceptive pills.
• Vaginal ring: a soft, plastic ring that is inserted into the vagina. It releases the hormones oestrogen and progesterone to prevent pregnancy.
• Birth control injections: progesterone injections that are injected into the arms or buttocks to prevent pregnancy.
• Birth control implant: a flexible rod that is placed under the skin of your upper arm. It releases the hormone progesterone which works to prevent pregnancy.
• Emergency contraception: typically used as a last resort when your usual birth control methods have failed, e.g., condom breaks during intercourse. An example of hormonal emergency contraception is the Morning After Pill (Postinor, Ellaone). The Morning After Pill should not be taken frequently by a woman as part of her regular contraceptive method. 

Some of these methods also serve dual functions such as menstrual regulation and relief of menstrual symptoms which include menstrual cramps/heavy period flow, etc [2]. 

 

Non-hormonal methods

These methods prevent pregnancies without the use or interference of hormones. 

Types of non-hormonal birth control include: 

• Abstinence: refraining from sex to prevent pregnancy. 

• Fertility awareness/natural family planning: this involves being aware of a woman’s bodily changes throughout her menstrual cycle, including changes in basal body temperature, monitoring of cervical mucus, tracking of the menstrual calendar, and using urine ovulation test strips (to avoid fertile times).
• Barrier contraceptives: the most easily available birth control method and is sold over the counter at most convenience shops. Examples include male condoms and female diaphragms.
• Copper intrauterine contraceptive device (Cu IUCD): this is an intrauterine device (IUD) that is similar to the Mirena IUD, except that it does not have hormones and primarily works only to prevent pregnancy. 
• Sterilisation: this surgical method is a permanent form of contraception and is generally deemed irreversible. Examples include female tubal ligation and male vasectomy.
• Emergency contraception: typically used as a last resort when your usual birth control methods have failed, e.g., condom breaks during intercourse. An example of non-hormonal emergency contraception is the copper IUCD.

The pros and cons of each birth control method

There are strengths and weaknesses for each birth control method. It is important to evaluate them to ensure you are making an informed decision. 

Birth control method	Effectiveness	Pros	Cons
Birth control pills	Perfect use: 99% Typical use: 91%	Oral administration   Helps in menstrual regulation, relief of menstrual cramps, and heavy flow   Short-term and no delay in the return of fertility after stopping	Must be taken at the same time daily Side effects include headaches, nausea, bloating, breast tenderness, etc. (usually improves after first few months)
IUCD/IUD	99%	User independent; Mirena IUD also helps in the relief of menstrual cramps and heavy flow Lasts for 5 years (but removable prior to that if keen for pregnancy, with no delay in the return of fertility)	Invasive – needs to be placed inside the uterine cavity Commonly results in erratic periods, and prolonged/unscheduled bleeding especially in the first 6 months Small risk of infection
Birth control patch	Perfect use: 99% Typical use: 91%	Skin patch administration Helps in menstrual regulation, relief of menstrual cramps, and heavy flow   Short-term and no delay in the return of fertility after stopping	Must be changed on a weekly basis  Side effects include skin irritation, headaches, nausea, bloating, breast tenderness, etc. (usually improves after first few months)
Birth control implant	99%	User independent Helps in the relief of menstrual cramps and heavy flow Lasts for 3 years (but removable prior to that if keen for pregnancy, with no delay in the return of fertility)	Invasive – needs to be inserted underneath the skin  Commonly results in irregular periods and prolonged/unscheduled bleeding especially in the first 6 months
Birth control injections	Perfect use: 99% Typical use: 94%	User independent (during 3 months post-administration) Helps in the relief of menstrual cramps and heavy flow	Commonly results in irregular periods and prolonged/unscheduled bleeding Delay in the return of period and fertility after cessation Associated with weight gain and decrease in bone mineral density
Condoms	Perfect use: 95% Typical use: 70%	No serious side effects  Widely available Helps protect against sexually transmitted infections (STIs)	May slip off/break during intercourse Penis must be withdrawn immediately after ejaculation
Vaginal ring	Perfect use: 99% Typical use: 91%	Helps in menstrual regulation, relief of menstrual cramps, and heavy flow Short-term and no delay in the return of fertility after stopping	Must be changed on a weekly basis  Side effects include vaginal discharge, headaches, nausea, bloating, breast tenderness, etc. (usually improves after first few months)
Spermicide	Perfect use: 80% Typical use: 70%	No severe side effects Widely available	Low efficacy when used alone  Usually needs to be combined with other methods e.g., condoms/diaphragm
Diaphragm	Perfect use: 95% Typical use: 70%	No severe side effects	Needs to be fitted correctly (every woman’s cervix is slightly different)  Must be combined with other methods e.g., spermicide
Fertility awareness/ Natural family planning	Perfect use: 99% Typical use: 75%	No severe side effect Can be used for pregnancy planning	Close tracking is needed to understand one’s body clock (at least a few months to learn)
Morning after pill	98% (if administered within a certain timeframe)	Can be used as a last resort should one’s regular contraceptive method fail	Not suitable as regular/long-term contraception Must be administered within a certain timeframe Side effects include nausea/vomiting, dizziness, unscheduled bleeding etc.
Abstinence	100%	High effectiveness	May not suit everybody
Tubal ligation	99.5%	Highest success rates in preventing pregnancy Does not affect periods	Invasive – requires day surgery with associated surgical/anaesthetic risks Permanent/irreversible
Vasectomy	99.8%	Highest success rates in preventing pregnancy	Invasive – requires day surgery with associated surgical/anaesthetic risks Requires follow-up sperm test to show the absence of sperm in semen Permanent/irreversible

 

These methods have varying effectiveness and different pros and cons when it comes to preventing pregnancy, however, not all birth control methods are created equal. 

Of note, only barrier contraceptives can prevent pregnancies and sexually transmitted infections (STIs) – that means if you are on another form of birth control e.g., birth control pills and also wish to protect yourself against STIs, you should combine them with the use of condoms during every sexual encounter. 

Factors affecting the selection of a birth control method

 

“So, what is the best birth control for me?” This answer will vary on a case-by-case basis. The decision will boil down to which factor you deem most important. In fact, your ideal birth control method may differ depending on which part of your life you are in. 

There are several things to consider before deciding on the most effective birth control method, including:

• Convenience: do you prefer something over-the-counter or something that requires a doctor’s prescription? Does your lifestyle/personality fit methods that require daily/weekly/monthly administration or do you prefer something more user-independent? 
• Lifespan of contraceptives: when are you thinking of conceiving– are you looking for something short-term or long-term? Perhaps something permanent as you have completed your family? 
• Affordability: although some methods e.g., IUCD may be more expensive upfront, the cost over time may prove to be more economical than short-term options such as birth control pills. 

• Side effects: which side effects are you willing to put up with? The most common reason why women are non-compliant with their birth control methods is that they are unable to cope with the side effects, e.g., if you are used to having regular, on-the-dot monthly periods, methods such as the contraceptive implant/IUCDs, etc may not be suitable for you. 
• Efficacy: what degree of “risk” are you willing to take? 

• Comfort: what options are you and your partner comfortable with? 

Bear in mind that these factors must be considered in relation to your lifestyle and whether you are able to commit to the responsibilities necessary for the birth control method to be effective.

 

Factors	Birth control method
Comfort: “I want birth control that doesn’t impede my sexual experience. I also have a monogamous relationship and sex is an important aspect of our relationship.”	Birth control pills Birth control patch/skin patch Vaginal ring  IUCD (Mirena or copper)  Contraception implant (Implanon/Nexplanon) Surgery (tubal ligation/vasectomy)
Lifespan: “I want a contraceptive that lasts long and requires minimum management.”	IUCD (Mirena or copper) – 5 years Contraception implant (Implanon/Nexplanon) – 3 years Surgery (tubal ligation/vasectomy) – forever Abstinence – as long as you can manage
Affordability: “I want a contraceptive that is cheap and will still keep me safe.”	Condoms Diaphragm + spermicide Fertility awareness/natural family planning  Abstinence
Protection against STI:  “I want a contraceptive that prevents pregnancy and protects me from STIs as I have multiple partners.”	Condoms
Convenience: “I want a birth control method that doesn’t involve visiting a health care provider.”	Condoms Abstinence Fertility awareness/natural family planning
Side effects:  “I want a birth control method that doesn’t affect my hormonal cycle.”	Non-hormonal methods of contraception

 

Is the pull-out method an effective method of birth control?

No. The pull-out method, also known as the withdrawal method or coitus interruptus, involves pulling the penis out before ejaculation occurs. It is not an effective form of birth control as sperm exists in pre-ejaculate [3,4]. Pre-ejaculate is released during arousal and may contain sperm due to previous sessions of ejaculation. This sperm can still result in pregnancy, in fact, statistics have shown that 1 in 5 couples who use the pull-out method will still end up falling pregnant [5]. 

 

How do I get birth control pills in Singapore?

 

There are two main types of birth control pills in Singapore, these are prescription-only and include the following:

• Combined oral contraceptive pills (COCP): these contain both oestrogen and progesterone.
• Progesterone-only pills (POP): these contain progesterone only.

In general, if you are thinking about going on contraception, do make an appointment to see an obstetrician who will be able to tailor and individualise your birth control options according to your needs – there is no one-size-fits-all. 

References

1. Jeffrey T Jensen, E. L.-L. (2022). Contraceptive efficacy and safety of the 52-mg levonorgestrel intrauterine system for up to 8 years: findings from the Mirena Extension Trial. American Journal of Obstetrics and Gynecology, doi: 10.1016/j.ajog.2022.09.007.
2. Sarina Schrager, M. L. (2020). Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women. Journal of Women’s Health, 937-943.
3. Stephen R. Killick, C. L. (2011). Sperm content of pre-ejaculatory fluid. Human Fertility, 48-52.
4. Ekachai Kovavisarach, S. L. (2016). Presence of Sperm in Pre-Ejaculatory Fluid of Healthy. Journal of the Medical Association of Thailand, 38-41
5. Planned Parenthood. (2023, June 21). How effective is pulling out? Retrieved from Planned Parenthood: https://www.plannedparenthood.org/learn/birth-control/withdrawal-pull-out-method/how-effective-is-withdrawal-method-pulling-out

Exercise is vital for a healthy life, pregnancy is no exception. Exercise can help maintain or improve your body’s strength, flexibility, and even boost your mood (which might be a little sensitive during pregnancy). But the age-old question remains: is exercise safe during pregnancy?

In this article, we will explore the safety of exercise during pregnancy, the benefits of exercise during pregnancy, pregnancy-safe exercises, and exercises that encourage an easy birth.

Is exercise safe during pregnancy?

In short, it depends. There are various factors that may prevent some women from safely exercising during pregnancy, which include:

• Vaginal bleeding: vaginal bleeding is not considered normal during pregnancy (although it may be frequently encountered especially during the first trimester). Vaginal bleeding may be a sign of a threatened miscarriage, cervical/placental issues, preterm labour, etc. One should stop exercising when they encounter vaginal bleeding and consult their obstetrician at the soonest.
• Placenta problems: low-lying placenta, also known as placenta previa, is a condition during pregnancy where the placenta is found to be either near or overlying the cervical OS (aka the womb neck opening or opening of the cervix); women with this condition are at an increased risk of vaginal bleeding and preterm labour and should hence avoid strenuous exercise so as to minimise the risk of triggering the fore-mentioned.

  

• Pre-eclampsia during the second or third trimester: pre-eclampsia (PE) is a condition involving high blood pressure and proteinuria (protein found in the urine) that is typically diagnosed in the second or third trimester; uncontrolled hypertension in pregnancy can result in liver/kidney/blood dysfunction and even seizures in the pregnant mother; women with PE typically need close monitoring with medications and should avoid strenuous exercise to maintain a normal blood pressure range as far as possible.
• Cervical problems: a short cervix, also known as cervix insufficiency or an incompetent cervix increases the risk of preterm labour. If you have been told that you have a short cervix, either due to previous cervical operations or on the ultrasound scan, you should avoid strenuous exercise lest you trigger premature contractions.

  

• Anaemia: having a low blood count, particularly during pregnancy when you need to provide for both yourself and your foetus, can put extra strain on your vital organs and result in a higher risk of you feeling faint/light-headed/dizzy during exercise. In general, try to get your anaemia under control through appropriate supplements before engaging in strenuous exercises.
• Preterm labour: if you are at risk of going into preterm labour e.g., you have a history of preterm deliveries, a short cervix from previous surgery, repeated bleeding episodes throughout your pregnancy etc, it is generally not a good idea to engage in strenuous exercise.
• Pregnant with multiple babies: having twins (or higher order pregnancies) means that your womb is heavier, your joints/ligaments are under greater strain, and you are also overall at a higher risk of going into labour early (preterm labour); excessive exercise may put you at increased risk of ending up with premature babies.

With these in mind, it is essential to check with your obstetrician and obtain clearance before you commence exercising.

For most women however, exercise during pregnancy is safe; the bottom line is – if you are healthy and your pregnancy is normal/low risk, it is safe to exercise and you should exercise to maintain your physical stamina throughout your pregnancy journey [1-4].

Benefits of exercise during pregnancy

During pregnancy, your body goes through a plethora of changes such as a change in the centre of gravity, backaches, bloating, constipation, and weight gain. Exercise has been shown to be incredibly beneficial during pregnancy [5].

Exercise during pregnancy has been found [3] to promote the following:

• Increase energy levels: regular exercise can help combat fatigue and boost energy levels during pregnancy, making it easier to cope with the physical demands that pregnancy puts on your body.
• Improve mood and mental well-being: pregnancy or not, exercise is well known for stimulating the release of endorphins, which are natural mood-boosting chemicals. Pregnancy can be stressful and anxiety-inducing, exercise can help negate this by boosting one’s mental health overall.
• Reduce pregnancy aches and pains: pregnancy can bring about many physiological changes in one’s body, including lower backaches, bloating, water retention, and constipation; exercise serves to alleviate these symptoms.
• Regulate weight gain and reduce risk of pregnancy complications: such as gestational diabetes mellitus (GDM) and pregnancy-induced hypertension, 1 in 5 pregnant women in Singapore is afflicted with GDM; exercise can help regulate blood sugar, blood pressure, and optimise gestational weight gain during pregnancy. Exercise also allows an easier return to pre-pregnancy weight following delivery.
• Enhance overall fitness, strength, and endurance: maintaining these through exercise during pregnancy is essential as the pregnancy journey is a physically demanding one and so is the process of childbirth.
• Improve sleep quality: exercise promotes better sleep and relaxation during pregnancy.

Which month of pregnancy can I start exercising?

Once you have gotten the go-ahead from your obstetrician, you can start exercising in any month of your pregnancy. How to kick start exercising during pregnancy depends on your fitness level prior to pregnancy; if you led a largely sedentary lifestyle prior to pregnancy, start low and go slow – begin by incorporating just 10 minutes of light exercise a day, this may include walking, yoga, stretching, or swimming.

If you were generally fit and exercised regularly before conceiving, you will be able to keep to your usual exercise routine barring physical impediments e.g., as your belly grows bigger. Ultimately, you know your body best and it is important to listen to your body and the advice of your doctor.

Pregnancy-safe exercises

Depending on your fitness level, the following low-impact exercises are considered safe for pregnancy:

• Swimming
• Walking/hiking
• Jogging
• Yoga
• Pilates
• Body-weight exercises
• Light weight exercises

Exercises not considered safe for pregnancy are:

• Kick-boxing
• Hockey
• Soccer
• Volleyball
• Basketball
• Hot yoga
• Hot pilates
• Gymnastics

High-impact exercises with risks of direct or indirect trauma to your belly are a definite no-no during pregnancy. Additionally, exercises or activities that involve exposure to high temperatures like hot yoga, hot pilates, sauna, and hot tubs are also generally not advisable during pregnancy [6].

Exercises that encourage an easy birth

An easy birth or delivery is one of the most important aspects of giving birth. Fortunately, there are several types of exercises that encourage an easy birth, these include:

• Kegel exercises: otherwise known as pelvic floor exercises. Pelvic floor muscles play an important role in supporting the pelvic organs (bladder, uterus, and bowel); strengthening them during the antenatal and postpartum period can help improve your control over them as well as facilitate a smoother postpartum recovery.
• Squats: these help open up the pelvis and also strengthen and tone the hip, buttock, and thigh muscles, all of which are actively engaged during labour and childbirth.
• Stretching exercises: commonly adopted in pregnancy modified pilates/yoga, gentle stretching, maintaining core muscle strength, improving posture, and stabilising the pelvis are beneficial in improving flexibility, balance, and overall strength.
• Walking/swimming: these low-impact and easily available exercises are gentle on the joints, promote cardiovascular fitness, and can serve to increase endurance.
• Deep breathing exercises: these can help with relaxation and form part of coping techniques during labour.

In conclusion, for most women, exercise during pregnancy is safe and beneficial. Consult with your obstetrician to find out what is suitable for you, listen to your body, and listen to your doctor.

References

1. Simony L Nascimento, F. G. (2012). Physical exercise during pregnancy: a systematic review. Current Opinion in Obstetrics and Gynecology, 387-394.
2. Maria Perales, A. S.-L. (2016). Benefits of aerobic or resistance training during pregnancy on maternal health and perinatal outcomes: A systematic review. Early Human Development, 43-48.
3. Maria Margarida Ribeiro, A. A. (2021). Physical exercise in pregnancy: benefits, risks and prescription. Journal of Perinatal Medicine, 4-17.
4. Loretta Dipietro, K. R.-B., & COMMITTEE, 2. P. (2019). Benefits of Physical Activity during Pregnancy and Postpartum: An Umbrella Review. Medicine and Science in Sports Exercise, 1292-1302.
5. Lingdi Wang, L. Z. (2022). Exercise during pregnancy may have more benefits than we thought. eBioMedicine, doi: 10.1016/j.ebiom.2022.103889.
6. Justin Chan, A. N. (2014). Hot yoga and pregnancy. Canadian Family Physician, 41-42.

What are pelvic floor disorders?

Pelvic floor disorders are a group of conditions that affect the muscles, ligaments, nerves and connective tissue in the pelvic region. These disorders can affect both men and women, and include conditions such as pelvic organ prolapse and urinary/ bowel dysfunction such as urinary incontinence.

Pelvic floor disorders can have a significant impact on a person’s quality of life and require medical attention for prompt diagnosis and proper treatment.

Does giving birth weaken your pelvic floor?

Giving birth can indeed put significant strain on your pelvic floor muscles, which in turn leads to damage and weakness.

The process of childbirth, particularly vaginal delivery, can have a sizable impact on the muscles, ligaments, nerves and connective tissue in the pelvis.

Risk factors that put women at higher risk of pelvic floor dysfunction include:

• Having multiple births
• Delivering large babies
• Having prolonged labors
• Going through assisted vaginal births i.e. with the use of instruments such as forceps/vacuum extraction

Fortunately, not every woman who has undergone childbirth will go on to develop pelvic floor disorders/weakness; pelvic floor exercises (Kegels) can improve the state of the pelvic floor following delivery, although in some women, the pelvic floor weakness can persist and ultimately require treatment to improve their quality of life.

Can I avoid getting a weak pelvic floor with a cesarean section?

Although there have been studies[1] that show a lower incidence of pelvic organ prolapse for women who delivered exclusively through caesarean sections versus women who delivered vaginally, having a caesarean section does not guarantee that you will never suffer from pelvic floor weakness.

One also needs to take into account the strain on the pelvic floor muscles over the 9-month pregnancy journey, the numerous surgical risks of having a caesarean section, including:

• The intra-operative risks of injury to surrounding organs
• A longer recovery period with increased need for analgesia (which can make it more difficult for a woman to engage her both her abdominal and pelvic floor muscles effectively until much later)
• Implications on future pregnancies such as caesarean scar rupture or abnormally implanted placentas.

It is recommended that the decision on one’s mode of delivery (whether via vaginal birth or caesarean section) be individualised and discussed with your obstetrician, taking into account both maternal and fetal factors.

Does the pelvic floor go back to normal after birth?

The pelvic floor muscles can return to supporting normal pelvic functions after birth, but this depends on a number of factors such as:

• The type of delivery
• The condition of the pelvic floor before pregnancy
• The individual’s engagement of the pelvic floor muscles during the postpartum period, as well as in the long run

Physical therapy and exercises specifically targeting the pelvic floor are helpful[2] in strengthening the weakened pelvic floor muscles following childbirth, although it is important to note that this takes time and consistent effort.

If you feel that you may be suffering from a weak pelvic floor, you should seek guidance from a healthcare professional who specializes in pelvic floor rehabilitation.

Does a strong pelvic floor help with birth?

Having a strong pelvic floor may not specifically help you with the childbirth process, but can certainly counter the strain exerted on your pelvic floor from the growing baby throughout the pregnancy, and minimize the risk of pelvic floor damage sustained during childbirth – this translates to you having a lower risk of experiencing urinary/faecal incontinence as well as pelvic organ prolapse both in the short- and long-term.

I think I have a weak pelvic floor after birth – what should I do?

Symptoms of a weak pelvic floor can range from woman to woman – in some cases, it can manifest in involuntary urinary/faecal leakage, feeling pelvic heaviness or even a lump in your vagina.

The good news is that most of these symptoms will improve and/or resolve with time so there is no need to panic – just as you took 9 months to nurture a baby, do remember that it is equally important to give your body some time and breathing space to go back to its pre-pregnancy state.

Do engage your pelvic floor muscles regularly by doing Kegel exercises, and if you still feel that you may be suffering from a weak pelvic floor after some time, you should seek guidance from a healthcare professional who specializes in pelvic floor rehabilitation who can do a proper pelvic examination and determine the degree of pelvic floor dysfunction, if any.

Do you have any questions about pelvic floor dysfunction? Feel free to contact me.

References

1. Cattani, L., Decoene, J., Page, A. S., Weeg, N., Deprest, J., & Dietz, H. P. (2021). Pregnancy, labour and delivery as risk factors for pelvic organ prolapse: a systematic review. International urogynecology journal, 32(7), 1623–1631. https://doi.org/10.1007/s00192-021-04724-y
2. https://www.yourpelvicfloor.org/conditions/pelvic-floor-exercises/

What is gestational diabetes?

Gestational diabetes mellitus, or GDM for short, is a type of diabetes that occurs during pregnancy and typically diagnosed during the 2nd half of your pregnancy via an oral glucose tolerance test (OGTT).

The OGTT is a series of blood tests (usually done between 24 to 28 weeks of pregnancy) that is first performed after you have fasted, and is then repeated 1 and 2 hours after you drink a sweet drink with a fixed sugar content.

The diagnosis of GDM is ascertained if your blood sugar levels remain persistently high in any of your serial blood tests. Thankfully, the majority of pregnant women who get diagnosed with GDM do have resolution of this condition after delivery.

Who is at risk of gestational diabetes?

Risk factors of GDM include;

• Advanced maternal age
• Having a family history of diabetes or personal history of GDM in your previous pregnancies
• Having a high body mass index (BMI) at the start of your pregnancy.

Although having one or more of these risk factors does not necessarily mean that a woman will develop GDM, this condition remains very common in Singapore, with 1 in 5
[1] pregnant women being afflicted by it.

Hence, it is common practice in Singapore to universally screen for GDM in all pregnant mothers so that the condition can be diagnosed and managed on a timely basis.

What causes diabetes in pregnancy?

Under normal circumstances, insulin (a hormone) is made by the pancreas and utilizes blood sugar for the body.
During pregnancy, your body undergoes some physiological changes that result in insulin resistance – this causes your cells to be less effective in using insulin. This in turn leads to high blood sugar levels.

What are the warning signs of gestational diabetes?

Majority of pregnant women with GDM have no specific symptoms or warning signs of their condition, which makes universal screening all the more important.
Occasionally, if the blood sugar levels are extremely high, some women may experience increased thirst and frequent urination, fatigue and hunger – however, some of these may overlap with common symptoms that pregnant women experience in general, so it is vital to check in with your obstetrician if you are experiencing any of these.

Can you have a healthy pregnancy with diabetes?

Majority of women with GDM will go on to have successful pregnancies with healthy babies, particularly if their GDM is well controlled. Good control of GDM is typically achieved by:

• Keeping a healthy diet
• Regular physical exercise
• Closely monitoring your blood sugar profile aka BSP (this can be done at home with a simple glucometer) and
• Communicating with your obstetrician regarding your BSP values.

It is important to keep blood sugar levels within a target range (this applies to both pre- and post-meal readings) to prevent high blood sugar levels to minimize the risk of pregnancy complications, and you will likely require more frequent antenatal visits and ultrasound scans to check on the well-being of the baby.

Whilst the majority of pregnant women will be able to control their GDM simply through the combination of healthy eating and exercise, some women may require additional help in the form of medication.

Depending on the severity of the condition, this may require the input of an endocrinologist (diabetes specialist) for titration of either oral medications or insulin injections to keep your BSP values stable – the medications prescribed will be safe for your pregnancy and it is extremely important to be compliant with the outlined treatment plan to ensure good pregnancy outcomes.

Poorly controlled GDM can expose the mother and child to pregnancy complications, such as;

• Pre-eclampsia (hypertension in pregnancy)
• Macrosomia (large baby, which can result in higher risks of shoulder dystocia, birth trauma and an increased risk of requiring a cesarean delivery)
• Sudden intrauterine death (IUD)
• Neonatal jaundice/ hypothermia/ hypoglycemia (low blood sugar) requiring further treatment

Even though GDM resolves in most women following childbirth, women with a history of GDM still remain at an overall higher risk of developing type 2 diabetes mellitus later on in life as compared to the baseline population, and it is advisable you keep to a healthy lifestyle with regular screening for diabetes as you get older. It may also be necessary for you to be screened for diabetes at the start of your subsequent pregnancies.

How can you prevent gestational diabetes?

You may not be able to prevent GDM if you have a genetic predisposition to it, but ways to reduce the risk of developing GDM include the following:

• Keeping a healthy body mass index (BMI) prior to pregnancy
• Keeping within the ideal gestational weight gain during pregnancy as advised by your obstetrician
• Eating healthily and keeping an eye on the sugar intake during your pregnancy journey
• Keeping physically active throughout your pregnancy – this will also help you in keeping your stamina up and achieving a smoother labor/delivery

Do you have any questions regarding your pregnancy? Feel free to contact me.

References

https://www.healthhub.sg/live-healthy/1606/gestational-diabetes-what-you-need-to-know

What is a UTI?

A urinary tract infection, or UTI for short, refers to an infection that can occur in any part of the urinary system – this includes the kidneys, ureters (pipes that carry urine from the kidneys to the bladder), bladder and urethra (tube through which urine leaves the body).

UTIs are typically caused by bacteria which enters the urinary system through the urethra and travels to the bladder. They are much more common in women than in men, owing to their shorter urethra (this makes it easier for the bacteria to enter and reach the bladder to result in cystitis i.e. bladder infection).

There are several risk factors that increase a person’s likelihood of developing a urinary tract infection (UTI). Some of the most common risk factors include:

• Sexual activity
• Pregnancy
• Inadequate hydration/ infrequent voiding
• Menopause
• Urinary tract abnormalities
• Use of certain devices
• Weak immune system
• Poor perineal hygiene
• Certain medications

What are the symptoms of a UTI?

Symptoms of a UTI may include;

• Lower abdominal discomfort
• Feeling a strong, persistent urge to urinate
• Experiencing a burning sensation when urinating
• Passing frequent
• Small amounts of urine
• Cloudy
• Foul smelling
• Bloody urine

In severe cases, fever, nausea, or vomiting may occur; some may experience either a left or right flank pain if the UTI has progressed upwards to infect the kidney.
It is important to note that you may experience one or more of the fore-mentioned symptoms, and not necessarily the full spectrum. Different UTI episodes in the same person may also present in different ways.

In some cases, people with UTIs may not present with any symptoms and are incidentally picked up when urine tests are done for other reasons e.g. during a routine health screening.

Will a UTI go away on its own?

Very mild UTIs may go away on its own, particularly if you are able to recognise it early and adopt some measures e.g. drinking more water to flush out the urinary system, or taking certain over-the-counter urinary alkaliniser, which works by raising the pH of urine.

However, once full-blown, a UTI is unlikely going to resolve on its own without treatment.

If you suspect that you may be having a UTI, you should visit your doctor as soon as possible to get some tests done. This is to reduce the risk of the UTI worsening and leading to a kidney infection, which can potentially make you extremely sick or even be life-threatening in some cases.

Your doctor will usually arrange for a urine microscopy (to check the number of red and white blood cells in your urine sample that may suggest the presence of a UTI) and a formal urine culture (to determine what bacteria is causing your UTI and which antibiotics is the most effective treatment for it).

It is not advisable to self medicate; if you have been given antibiotics by your doctor for your UTI, it is important to complete the course of antibiotics even if you feel better before the course is over, as incomplete therapy can encourage the emergence of multiresistant bacteria and make future UTIs challenging to treat.

Why does my UTI keep coming back? Do I have to be worried that I have recurrent UTIs?

The American Urological Association[1] defines recurrent UTIs as two episodes of acute bacterial cystitis within six months or three episodes within one year.

These definitions typically consider these episodes to be culture proven and separate infections with the resolution of symptoms between episodes; this is because the accuracy of clinical diagnoses can vary considerably.

If you have recurrent UTIs, it is best to consult a urologist or a urogynaecologist (if you are a female) who will need to take a detailed history and perform physical examination/ further investigations to delineate the possible causes of your recurrent UTIs.

Further investigations may include;

• Charting a bladder diary to determine your fluid intake/urinary frequency and output
• Imaging of your urinary tract to exclude abnormalities
• Screening for diabetes mellitus, and/or a cystoscopy (scope into your bladder).

Depending on the findings, there are some measures that may be suggested to reduce the risk of recurrent UTIs – these include:

• Incorporating probiotics in your diet to encourage equilibrium of your urinary/vaginal flora
• Washing up/voiding immediately after sexual intercourse
• The use of topical vaginal estrogens if you are peri-menopausal/menopausal and found to have urogenital atrophy
• Improving hygiene practices including wiping from front to back during toileting
• Avoiding chronic constipation
• Optimising control of medical conditions such as diabetes mellitus
• Increasing your daily fluid intake to keep well hydrated
• Cutting down on intake of bladder irritants such as caffeine and alcohol
• Keeping healthy bladder habits by voiding every 2-3 hourly
• Avoiding the use of certain feminine hygiene products
• Visiting your doctor early if you detect onset of a UTI for prompt diagnosis and management

Do you have any questions regarding UTIs? Feel free to contact me.

References

1. Anger, J., Lee, U., Ackerman, A. L., Chou, R., Chughtai, B., Clemens, J. Q., Hickling, D., Kapoor, A., Kenton, K. S., Kaufman, M. R., Rondanina, M. A., Stapleton, A., Stothers, L., & Chai, T. C. (2019). Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. The Journal of urology, 202(2), 282–289. https://doi.org/10.1097/JU.0000000000000296

Vaginal laxity is a poorly understood symptom of pelvic floor dysfunction, yet comes with a significant degree of bother for women with potential impact on interpersonal relationships and sexual intercourse.

Case in point – a study published in the International Urogynaecology Journal[1] stated that the associated bother of vaginal laxity was almost as high as the bother associated with conventional prolapse symptoms.

Although there is no international consensus on the exact definition of vaginal laxity, it is colloquially known as a sensation of vaginal “looseness”. Vaginal laxity can occur together with pelvic organ prolapse, whereby a woman’s pelvic organs (i.e. the bladder, uterus or rectum) droop into and/or beyond the vagina, but can also occur in isolation. A recent research article in the Journal of Sexual Medicine[2] found no correlation between vaginal laxity and physical examination findings of pelvic organ prolapse or sexual function.

Yet another study[3] showed decreasing prevalence of vaginal laxity with age, whilst symptoms of pelvic organ prolapse increase with age, concluding that vaginal laxity was not an early symptom of pelvic organ prolapse. These findings reveal the need for better quantification of vaginal laxity.

What causes vaginal laxity?

Given the “iffy” nature of vaginal laxity and its lack of standardized definition or assessment tool, it can be hard to delineate the causes of vaginal laxity. Contributory risk factors may include;

• Pregnancy
• Childbirth – particularly vaginal delivery or assisted vaginal delivery e.g. vaccum- or forceps-assisted deliveries
• Aging
• Menopause (with the associated age-related tissue and hormonal changes in vaginal wall composition)

How do I check for vaginal laxity?

Some women may report a persistent feeling of “looseness” in their vagina, which may be associated with discomfort, heaviness, a dragging sensation or even pain.

These symptoms can prove to be troubling for the woman and may even affect her body perception, self-esteem and ability to derive satisfaction from her intimate, sexual relationships.

The spectrum of symptoms and bother can be quite wide-ranging and vary between women.

Unfortunately, there is no definite way to check for vaginal laxity, and because of the lack of a globally accepted assessment tool for vaginal laxity, your gynaecologist can only check for the presence of pelvic organ prolapse on vaginal examination, which may be poorly correlated to your symptoms as mentioned earlier.

Could vaginal relaxation syndrome be an indication of underlying health problems?

Vaginal relaxation syndrome refers to relaxation of the vaginal walls, and is currently used interchangeably with the term vaginal laxity.

From a physical health perspective, unless it is correlated with findings of pelvic organ prolapse and/or urinary incontinence (due to common shared risk factors), vaginal relaxation syndrome does not pose a threat nor act as a harbinger of medical diseases; however, it may come with significant psychological burden to the woman and her partner, which can be socially debilitating.

Are there treatments available for vaginal relaxation syndrome and how effective are these options?

Studies showing definitive treatment success for vaginal relaxation syndrome in existing literature remain limited, with small sample sizes of women studied and findings still a mixed bag.

Radiofrequency therapy and laser procedures have come up recently as topics of interest and have been advocated as part of “vaginal rejuvenation” to be a safe, efficacious and non surgical treatment approach[4] for vaginal laxity with high patient satisfaction and minor adverse events.

However, much research is still needed to determine the true effectiveness of “vaginal rejuvenation” on vaginal laxity, the appropriate training, how long the treatment effects can last for, if repeat/maintenance treatment is required and at what intervals, and long-term safety concerns.

In the meantime, Kegel (pelvic floor) exercises is generally a fail-safe way to improve your pelvic floor tone and muscle strength, and should be performed as early as in your antenatal period with long-term incorporation into your daily exercises – as it has certainly been proven to help with both pelvic organ prolapse and urinary incontinence.

Do you have any questions? Feel free to drop me a message!

References

1. Dietz, H. P., Stankiewicz, M., Atan, I. K., Ferreira, C. W., & Socha, M. (2018). Vaginal laxity: what does this symptom mean?. International urogynecology journal, 29(5), 723–728. https://doi.org/10.1007/s00192-017-3426-0
2. https://www.sciencedirect.com/science/article/pii/S2050116121001239#:~:text=Vaginal%20laxity%20(VL)%20is%20a,descend%20from%20the%20normal%20position
3. Alexander, J. W., Gillor, M., & Dietz, H. P. (2022). Is vaginal laxity an early symptom of pelvic organ prolapse?. International urogynecology journal, 33(7), 1927–1931. https://doi.org/10.1007/s00192-021-04927-3
4. Juhász, M. L. W., Korta, D. Z., & Mesinkovska, N. A. (2021). Vaginal Rejuvenation: A Retrospective Review of Lasers and Radiofrequency Devices. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 47(4), 489–494. https://doi.org/10.1097/DSS.0000000000002845