Hormones are chemicals that are produced by the endocrine system of the body to maintain the body’s equilibrium known as homeostasis. Hormone levels can fluctuate either physiologically (natural biologically) or due to external factors, such as infection, environmental factors, drugs etc. Interestingly, our hormone levels can affect allergies or predispose a person to allergic symptoms.
In this article, we explore the effects of common hormones, such as sex hormones, thyroid hormones, stress hormones and insulin on common allergies like eczema, allergic rhinitis and asthma.
Sex hormones fluctuate physiologically throughout our reproductive age of life. We may notice our allergy symptoms becoming more prominent or worsen during certain times of our life. Here, we discuss the role of common sex hormones, such as oestrogen, progesterone and testosterone, in affecting a person’s allergy symptoms.
In asthma, oestrogen can bind with oestrogen-receptors on the lung tissues, stimulating inflammation and activation of immune cells in the lungs. Oestrogen regulates chemical protein (chemokine) production, causing mast cells (a type of allergy cell) to degranulate (breakdown), leading to airway cells and airway muscles to be inflamed and becoming overreacting towards allergens. Progesterone hormone prevents mucus clearance from the airway.
In atopic dermatitis (eczema), one is more susceptible to the sex hormones in comparison to those without atopic dermatitis. Oestrogen generally has a positive effect on the skin barrier, reducing the risk of eczema flare ups. Contrarily, both progesterone and testosterone can be detrimental in maintaining a good physical skin barrier, leading to more predisposition of flare up of skin condition under the influence of both hormones.
In allergic rhinitis, the nose tissues and secretory glands can interact with sex hormones, such as estrogen. This, in turn, leads to blood vessels growth, tissue swelling, inflammation and an increased response to allergies and mast cells degranulation. This cascade of activities within the body result in the clinical manifestation of upper respiratory allergy symptoms of rhinitis.
Allergic Asthma | Atopic Dermatitis | Allergic Rhinitis | |
Effects of Sex Hormones on allergies | Due to the influence of oestrogen and progesterone, asthma can be exacerbated during peri-menstrual period, pregnancy phase and the exacerbation decline after menopause. Testosterone has an anti-inflammatory effect in asthma conditions. | Due to physiological fluctuation of sex hormone levels during the menstrual cycle, one may notice exacerbation of skin condition just before period or during pregnancy. | Symptoms of allergic rhinitis can be worsened during ovulatory period or during pregnancy period. |
Cortisol, our body’s stress hormone, is produced by a pair of adrenal glands that reside on the tip of both kidneys. The stress hormone is controlled by the brain — hypothalamus and the pituitary.
Stress can result in worsening of allergic symptoms. Generally, stress causes general inflammation of the body. In asthma, stress is responsible for causing lung inflammation and dysregulation of the immune system, leading to susceptibility to allergens and asthma exacerbation. Interestingly, mood disorders such as depression, anxiety and attention deficit hyperactivity disorders are associated with worsening of allergic rhinitis or atopic dermatitis symptoms — hence termed ‘allergic mood’.
Due to the physiological day-night fluctuation of stress/ neuro-hormones, one with atopic dermatitis may notice worsening itch at night.
The thyroid gland is a symmetrical, butterfly-shaped gland situated in front of a person’s neck. The thyroid gland produces thyroid hormones that play essential roles in a person’s overall metabolism. The thyroid levels can fluctuate due to physiological causes, stress, infection, and even autoimmune or brain/pituitary disorders. When the thyroid levels are too high, it is termed “hyperthyroidism”. Conversely, “hypothyroidism” is used to describe thyroid levels that are too low.
Imbalance of the thyroid hormones can exacerbate asthma symptoms. An overproduction of thyroid hormones can cause inflammation, leading to high levels of immune cells and asthma exacerbation. In hypothyroidism, due to slower overall metabolism, there is reduced oxygen usage in the lungs, and slower lung tissue/muscle clearance of air/allergens leading to predisposition of asthma symptoms. Managing thyroid levels back to normal levels can alleviate and aid the overall management of asthma treatment.
Low thyroid level is associated with allergic rhinitis due to reduced mucous/nose tissue clearance of infection/ allergy particles, increased predisposition to various sinus infections and allergies.
While thyroid disorders do not have a direct relationship with atopic dermatitis, low thyroid levels can worsen existing dermatitis as hypothyroidism can cause itching and skin dryness.
Diabetes Mellitus is a chronic endocrine disorder due to dysregulation of the glucose in the body resulting from insufficient or ineffective insulin in the body to process the blood glucose. We discussed the relationship of type 2 diabetes mellitus and allergies.
Type 2 diabetes mellitus is the result of ineffective insulin to break down blood glucose due to insulin resistance over time. Frequently, type 2 diabetes mellitus can be associated with other metabolic disorders such as obesity, which both conditions impair lung function leading to exacerbation of asthma. A good control of type 2 diabetes mellitus can improve a person’s overall asthma symptoms.
The relationship between type 2 diabetes and atopic dermatitis/allergic rhinitis remains much to be elucidated, and clinical literature remains contradictory.
While the association between hormones in our body and allergic symptoms remains an area not commonly discussed, understanding the link between them can potentially ameliorate and manage allergies more effectively resulting in better quality of life.
Importantly, learning the association between hormone fluctuations and allergy symptoms allow both patient and physician to strive towards a more personalised, holistic health management plan to control allergies.
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Over the years, there has been evidence of the development of antibiotic-resistant STDs. This is rather alarming, as the cases of STDs are not reducing at any rate. In fact, it is continuously on the rise. A healthy genital microbiome is our first line defense against external pathogens, including STDs.
There are clinical studies showing the good bacteria that constitutes the healthy genital microenvironment have an immune mechanism, and may provide protection against STDs. Treatment targeting the genital microbiome may potentially reduce the risk of acquiring STDs.
In this article, we would wish to enlighten the readers on the female and male microenvironment, the importance of maintaining a good baseline genital health and reducing one’s risk against STDs.
The vaginal environment is mainly covered with healthy anaerobic bacteria — lactobacillus spp. In an equilibrium, the lactobacillus spp keeps the vagina sterile, lubricated, and able to clear off common pathogens.
Unfortunately, this healthy state is easily tempered with the depletion of healthy lactobacillus spp and overgrowth of bad anaerobic bacteria. One of the commonly heard pathogenic vaginal bacteria is gardnerella vaginalis which plays a vital role in a recurring female vaginal infection known as bacterial vaginosis (BV).
BV is known to be associated with poor quality of life due to the uncomfortable symptoms of BV, and association with poor reproductive outcome such as preterm labour and low birth weight of infants. Furthermore, the persistence presence of bad anaerobic bacteria predisposes one towards contracting STDs and spreading STDs to others.
The actual mechanism of the destabilisation of the vagina flora remains unknown.
Factors that can shift the microflora to bad anaerobic bacteria rather than lactobacillus spp include:
Intriguingly, the male genital region is less discussed. In comparison to the female genital anatomy, the male genitalia are ‘externally’ seen. Yet, the male genital also has its own healthy microflora.
The penis is mainly covered with similar bacteria seen on our normal skin such as Corynebacterium spp and staphylococcus spp. Occasionally, bad anaerobic bacteria (that can be associated in BV in females) can be found in the male genital region as well.
As predicted and logically, men with female partners with BV infection tend to have genital microenvironments that have more bad anaerobic bacteria, such as gardnerella vaginalis, while men with female partners without BV are likely to carry normal skin bacterias such as, Lactobacillus spp, Corynebacterium spp and staphylococcus spp on the penis.
The male foreskin can also affect the microbiome in the penis. As the foreskin provides a physical layer, it can also house many bad anaerobic bacteria. In a circumcised man, as the penis is exposed, the quantity of bad anaerobic bacteria is lesser, with predominantly skin bacteria found on the penis surface. It is known that circumcised men have lower risk of acquiring HIV, herpes infection, HPV infection and lower risk to trigger BV in their female partners.
The actual mechanism of how the female genital microbiome can protect one against STDs has been a common clinical research topic though there remain gaps in the knowledge.
The healthy vaginal lactobacillus spp provides a more acidic sterile environment that prevents pathogens from replicating as they thrive better in alkaline environments. Additionally, the lactobacillus spp can protect women from STDs by:
In males, the role of genital microbiome against STDs are not as straightforward. Nonetheless, there are medical studies that show susceptibility of contracting HIV with higher numbers of bad anaerobic bacteria in the male genital region.
Bad anaerobic bacteria can be pro-inflammatory and they can create an environment that is easily succumbed to external pathogens. Men with skin flora bacteria predominant over the genitalia and less anaerobic bacteria may have lower risk of contracting STDs and triggering BV in their female partners.
You may have higher risk of STDs if
As a female, the general risk of contracting STDs is higher than males due to:
You may have higher risk of STDs if
Although STDs can be associated with abnormal genital symptoms, very often, STDs can be insidious without any tell-tale signs. You are advised to seek medical advice with your doctor if you are concerned of possible exposure to STDs and contracting the infections from your partner(s). STDs do not resolve on their own and will require the right medication and right dose to clear off the infection(s).
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Cow’s milk allergy can occur in anyone, including adults. However, it is a condition that more commonly affects the paediatric population. Diagnosis for cow’s milk allergy can be difficult and can often be confused with cow’s milk/ lactose intolerance.
In this article, we’ll highlight the differences and similarities between milk allergies and milk intolerance, the underlying causes of a cow’s milk allergy, common questions that one may encounter, and practical ways to deal with cow’s milk allergy.
No, a milk allergy and milk/lactose intolerance are different.
Milk allergy is an immune response to milk proteins. The body mistakenly identifies these proteins as harmful, producing specific antibodies against it. Upon repeated exposure to these proteins, the immune system triggers an exaggerated antibody response, leading to a cascade of chemical immune reactions, which manifest as signs and symptoms of milk allergy.
A lactose intolerance occurs due to the lack of the enzyme lactase, which is needed to digest lactose — a sugar found in milk. A milk protein intolerance is a non-allergic sensitivity to milk proteins, such as casein or whey.
In milk/lactose intolerance, one develops unpleasant gastrointestinal symptoms when they are unable to digest lactose effectively due to reduced amount of lactase.
The poorly digested lactose in the gut is subsequently being fermented by gut bacteria causing uncomfortable irritable-bowel-syndrome-like symptoms such as:
Contrary to milk or lactose intolerance, an individual with a true milk allergy will not be able to tolerate any amount of milk, while in the case of lactose intolerance, one may still be able to tolerate a small amount of milk.
This type of allergy can occur very fast within seconds to minutes upon consumption of cow's milk. In IgE related allergy response, once the body is exposed to the 'allergen' protein, there will be an immediate trigger of a cascade of inflammatory allergic response and release of IgE antibodies, leading to an acute allergic reaction.
This type of allergy tends to occur slower over a period of hours up to 3 days after consumption of cow’s milk. The immune response tends to develop progressively over time, and usually this is non-IgE related, immune response can often drag on with symptoms for days to even weeks. One commonly confused the symptoms of delayed response with milk/lactose intolerance.
Milk allergy symptoms can occur within the first few months of human life (within the first 6 months of life), though less commonly symptoms can occur in adulthood. There is a spectrum of severity of milk allergy symptoms, making nailing the diagnosis difficult.
Within hours after consumption of milk. Symptoms include:
From hours to days after consumption of milk. Symptoms include:
An immediate, dangerous fulminant allergic response within seconds to minutes after consumption of milk. Symptoms include:
Cow’s milk is a rich source of nutrients for the body, with over 20 beneficial proteins.
In milk allergy, the body's immune system reacts to protein that is found in the milk, particularly in 2 types of proteins — casein and whey.
Casein protein is the main emulsifier in milk and it makes up 80% of the protein in cow’s milk and 20-60% of proteins in human milk. Casein is also found in high quantities in cheese, and can be used as a food additive/ emulsifier to stabilise processed food.
Whey protein is the left over from milk when it is coagulated during the formation of cheese. Whey protein makes up 20% of cow’s milk, and about 60% of human milk. Whey protein is made up of 2 major proteins known as alpha-lactalbumin, beta-lactoglobulin.
Whey protein is commonly seen in yoghurt and protein supplement (in building muscle mass). Whey protein can also be used as a food thickener.
Common foods with milk protein include:
Reading food labels is important to pick up any cow’s milk protein content. If you are eating out, beware of possible milk in the food content.
Extra caution should be taken if eating out in coffee shops, pizza shops and ice cream places. If in doubt, it is worth highlighting any history of food allergy or food restrictions to the restaurant staff.
A good history with a clear timeline of exposure to milk allergens and presentation of the allergic symptoms is suggestive of cow’s milk allergy. Nonetheless, in the practical world, this can be much more difficult as one may be exposed to other food substances or environmental allergens or symptoms can be confounded with underlying intolerance.
Allergy tests may not be foolproof either, but may facilitate the history of presenting complaints:
You are advised to discuss any concerning symptoms with your doctor so that they can provide guidance on which tests can be offered to you to evaluate your condition further.
As there are no antidotes for cow’s milk or food allergies, the treatment is by eliminating the culprit allergen — milk from the diet.
In situations when one has inadvertently consumed milk, medication such as antihistamine and steroid can reduce or abort allergic symptoms. In severe allergic response or anaphylaxis, one will require adrenaline injection or medical emergency to reverse the allergy.
As cow’s milk allergy is commonly seen in children, it is imperative to ensure the child still receives a healthy balanced diet and is taking supplements to replace the common nutrients that are found in milk.
Breastfeeding is encouraged especially if the infant has cow’s milk allergy.
As cow’s milk protein can be passed from mother who consumed it to the child through breast feeding, the mother should avoid food that contains cow’s milk protein if the infant has cow’s milk allergy.
Alternative options such as soy formula milk may not be useful as some children may also have soy protein allergy. Due to high protein allergy cross-reactivity, those with cow’s milk protein are usually not suitable to take goat’s milk as well.
Understanding and determining the allergic components in milk proteins can aid prudent food selections to avoid allergy.
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This is a possible scenario that can be seen when a couple undergoes STD screening tests together and notice their results are “not the same”. Often, such medical results can create disharmony and distress between couples.
What does it mean when a couple’s STD results are different, and how can we proceed with such results?
Understanding the possibilities of a different STD results in comparison to your partner(s) is key to determine the next course of actions. Here we list down some of the common causes of discordance STD results.
This is unfortunately the commonest cause of discordance STD results. Commonly the tests results are different between the couple due to an increased risk of exposure to the infection in a couple or another, leading to the results differences.
This is a dicey situation where, arguably, it may mean that there is an 'unfaithful' polygamy going around, someone cheated in the relationship — which is possible. However, it is worth to note that STD infection can live in the body for years unless it is effectively treated with the right medication. Hence, discrepancies in results experienced by couples may merely mean that their partner may have had a 'past' rather than being 'unfaithful' in his or her current relationship.
One may not necessarily acquire STDs from intercourse with a person with STD, though the risk of contracting STDs is higher in those with a positive contact history. Some people can become infected and naturally clear off the infection due to better general immunity. One may have received treatment from another health condition (tooth infection/surgery etc) and inadvertently treated the STDs without realising it. In such scenarios, screening tests on the couples may result in different results.
While this is a possibility, generally, laboratory errors are not common as accredited and regulated medical laboratory has to undergo very stringent laboratory processing to ensure delivering accurate and quality results as this can affect the treatment plan of a patient . In Singapore, the medical laboratories need to be licensed, accredited and regulated by the Ministry of Health (MOH).
If you do get different STD results from your partner, here are some things you can do:
Having an open conversation without being judgmental and accusative is key in dealing with the situation of unexplained STD results. It is useful to always use logical approach than emotional impulsive approach in dealing with such results. It is worth finding proper time and space to discuss such results with your partner(s), rather than over text message or phone call leading to further misunderstanding and communication breakdown.
Exploring partner(s) current and previous sexual relationship can be useful in correlating the results and the past history of exposure. Rather than blaming, focusing on solution-based approach, consider to treat any infection(s) if need to avoid further co-spread of disease to one another.
If there remain unexplained answers to the differences in STD tests, you are advised to consult your physician/ clinic who offered the screening tests. Sometimes, bringing your partner along for the consultation may be useful to 'clear the air' on the spot.
Getting the right medical information regarding STDs is very important in correlating the clinical history and the tests results. This is advisable rather than doing self-research and over-reading on online platforms, causing unnecessary distress and alarm.
It is always important to correlate the test results and a person's clinical pictures. In this instance, you will require the expertise of your kind trusted healthcare providers. While most of the STD results, we can interpret ourselves based on 'normal' or 'abnormal' or 'reactive' or 'non-reactive', some of the STD results may not be as simple as a 'yes' and 'no' answer. Having a discrepancy results in comparison to your partner's results may be due to a previously treated or exposed infection.
In view of the possibilities of a false negative results as the tests may be done within the window period of the STD infection, one may consider repeat the tests again at a later date. It is prudent to check with your healthcare providers on the sensitivity and the time frame required for a particular test to ensure the results are reflecting a true clinical picture.
Different laboratories may offer different test kits with different sensitivity and window period. Some of the newer generation tests may be able to pick up an infection much earlier from the time of exposure.
While convenience is key, self-performing testing runs a risk of false results due to multiple reasons explained above. One may opt to head down to a physical clinic for proper consultation, evaluation, and appropriate sample test collection (if need) by your health providers. Currently, in Singapore there are a number of convenient, discreet, fuss-free clinics that can offer such services. Getting tested by your physician reduce the risk of inaccurate results due to sampling error.
Furthermore, your physician may be able to guide you on what are the relevant infectious tests to address your individual concerns, as STD tests are not merely just ‘HIV testing’.
Some may consider regular 3-6 monthly sexual health screening tests. Such practices are good as this will:
This article strives to facilitate patients who have results that differ from their sexual partner and are struggling to make sense of the results. We hope the article is able to help one way or another! Take care!
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The skin is the largest organ of the human body. Beyond the naked eyes, the skin is the home to millions of bacteria, fungi and viruses that are beneficial to us. When the skin is covered and colonised by these microorganisms, they behave as a protective barrier against invasion of external insults and pathogens.
When there is a disequilibrium of the microenvironment of these commensal microorganisms, the physical skin barrier can be disrupted, following more growth and invasion of pathogenic microorganisms. This can result in chronic inflammatory skin conditions or even more severe systemic medical conditions.
In this article, we discuss skin microbiomes and their associated with common skin conditions, making sense with current existing clinical treatment and exploring the potential role of understanding skin microbiomes in future treatment of skin diseases.
Our skin is made up of two main layers: the epidermis (the external layer) and dermis (the inner layer). The epidermis is made up of keratinocytes that are crosslinked together to function as a physical barrier against the external world.
We can sub-classify the skin areas broadly into 3 areas:
Common bacteria that can be seen in the oily area of a normal skin include propionibacterium acne spp. Fungi such as Malassezia spp and Candida spp can be found in oily regions of the skin as well. In moist areas, bacteria such as Staphylococcus spp and Corynebacterium spp can be seen. In dry areas of the skin, Staphylococcus spp can also commonly be seen.
Interestingly our skin microbiomes change from birth to puberty/adulthood. Newborns that are delivered through C-section tend to have skin microbiomes of normal skin while newborn that are delivered vaginally tend to have skin microbiomes that are also found in the vaginal lining. The prepubertal skin microbiomes have a greater population of Staphylococcus spp and Streptococcus spp. The population of microbiomes shifts and remodels during pubertal period as the skin becomes oilier following hormonal stimulation of the sebaceous glands. With that, in pubertal and adult skin, there are more thriving Propionibacterium spp, Corynebacterium spp, Malassezia spp etc.
What factors change the normal skin microbiome?
The skin microenvironment is kept in equilibrium by multiple factors such as temperature and humidity, pH, UV exposure, sebaceous oil production, etc. The accessorial tissues around the skin such as the sweat glands, sebaceous glands and hair follicles ensures the microenvironment is being maintained.
Unfortunately, over time with the process of ageing, immunity changes, external insults such as strong contactant, allergies and etc, disruption of the skin microbiomes equilibrium can happen, with more ‘bad’ bacteria and less ‘good’ bacteria colonising the skin, resulting in various skin diseases.
Acne vulgaris is the most common chronic skin inflammatory disease after atopic dermatitis in the world. Acne occurs when there is inflammation of the skin resulting from blockage and excessive sebum production on the skin follicles. While the actual mechanism remains much elucidated, it is documented that one with acne has more colonisation of bacteria Propionibacterium acne (also known as cutibacterium acne). It is believed that Propionibacterium acne plays a role in comedone formation and the inflammatory process in acne.
Decreasing the amount of Propionibacterium acne has been shown to be beneficial in many acne patients and the idea is used as a target mechanism in the treatment of acne. Treatment options such as benzoyl peroxide, azelaic acid, antibiotics such as doxycycline, clindamycin and erythromycin can reduce the colonisation and inflammation caused by Propionibacterium acne.
Rosacea is a chronic adult skin condition presented with recurring facial flushing, redness, pimple-like bumps. While the actual cause of rosacea remains unknown, microbiome mite- Demodex folliculorum is implicated in rosacea. Studies have shown that skin biopsy samples of rosacea patients have a high load of Demodex on inflamed affected skin, suggesting the link of the mite and the skin condition. Permetrin cream or oral ivermectin are offered as part of management of rosacea to reduce the colonisation of demodex mites on rosacea skin.
Atopic dermatitis- presenting with chronic relapsing itchy, dry, red rashes is the most common skin condition worldwide which has a major negative impact on a person’s quality of life. The condition can be associated with other atopic conditions such as allergic rhinitis and asthma. While there is genetic predisposition and family history in atopic dermatitis, the distribution of skin microbiomes in atopic dermatitis may have its effect on a person’s clinical outcome.
Staphylococcus aureus has been well documented as a colonizer in atopic dermatitis. There is a correlation between the amount of the bacteria and the severity of the disease. The higher the density of the colonization of Staphylococcus aureus, the graver the inflammation. There is disruption of the normal microbiome skin environment in atopic dermatitis due to excessive colonization of Staphylococcus aureus. This results in impairment of skin barrier and susceptibility to other infections.
In order to reduce colonization of Staphylococcus aureus, antibiotics (in the form of oral or topical) and bleach baths are used to manage eczema. Such treatment regimens can synergize the treatment outcome with conventional treatment of emollient, topical anti-inflammatory and systemic oral medications.
Seborrheic dermatitis is a skin relapsing inflammatory condition affecting areas that are rich in sebaceous glands such as the face, scalp and body. One may notice the common exacerbating triggers such as hot weather, increase humidity, emotional heighten- which may all increase further production of sebaceous oil.
Fungi such as Malassezia spp are found in oily skin surfaces, and play a role in inflammatory response in seborrheic dermatitis. Antifungal treatment is used in combination with anti-inflammatory medication to effectively manage seborrheic dermatitis.
Probiotics are live microorganisms that when being introduced into the body sufficiently, produce a positive health outcome to the person. Prebiotics on the other hand are non-digestible food substances that can encourage the person to produce selectively certain ‘good’ bacteria in the body. Over the past decades, both probiotics and prebiotics are being marketed for their potential benefits in a person’s health for a wide range of diseases including gut symptoms such as irritable bowel syndrome, diarrhoea, to even treating vaginal infections.
For the context of skin, there is medical literature looking into the role of probiotics and prebiotics in atopic dermatitis, focusing more on children rather than adults. Studies for the role of these potentially beneficial supplements are still lacking for other common skin conditions such as psoriasis, acne, rosacea, etc.
At this stage, probiotics and prebiotics are not considered a medical intervention for skin conditions. As a consumer or patient, one should be prudent in considering probiotics and prebiotics to avoid spending unnecessarily for non-clinically proven treatment due to marketing gimmicks.
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Douching is the physical act of washing the internal vagina with water or ‘mixed liquid’. Feminine douche is commonly available over the counter. They are usually made up of mixed water and iodine, baking soda, vinegar, fragrant or other chemicals etc. Feminine douche are administered by squirting the douche mixture upwards through a bottle nozzle into the vagina to ‘clean’ the vagina.
Some ladies may have the habit of douching, in order to feel ‘cleaner and fresher’. One may douche in hope to take away unpleasant vaginal smell, leftover menstrual blood, or even hoping to prevent STDs and pregnancies after intercourse.
In this articles, we discuss about the cons of douching, and many reasons why you should avoid douching.
The healthy vaginal microenvironment is slightly acidic with abundant hydrogen peroxide (H202) producing lactobacilli. By constantly producing lactic acid to keep the vaginal pH less than 4.5, these ‘good’ lactobacilli bacteria avoid the growth of ‘bad’ bacteria and fungi. The lactobacilli also attached themselves to the surface lining of the vagina, competing with the ‘bad’ organism from adhering onto the vaginal wall, and secrete protective mucus and discharge for the vagina.
Douching can alter the microenvironment of the vagina which is made up good vaginal bacteria under an acidic environment. Healthy good vaginal bacteria protect the vagina from external insults such as infections. The act of douche can wipe out the good bacteria leading to overgrowth of bad bacteria and fungus leading to recurring vaginal infections.
Aside from removing the normal vaginal flora and causing overgrowth of ‘bad’ bacteria, douching can act as a ‘pressurised fluid transporter’, allowing external bacteria/viruses (pathogens) to ascend from the vagina to the cervix, uterus, fallopian tube, ovaries or even the abdominal cavity. This can eventually lead to pelvic inflammatory disease.
It is clinically documented that frequent douching is associated with bacteria vaginosis, recurring vaginal yeast infection, HIV and STDs infection, pelvic inflammatory disease, ectopic pregnancy, pre-termed labour and infertility.
Strangely but rightfully, the vagina cleans itself automatically. The vagina produces mucous accordingly to flush out the unwanted ‘bacteria’, menstrual blood, semen, or discharge and ensure the vaginal microenvironment and pH are maintained.
The external of the vagina can be rinsed with water and mild soap. If you have sensitive skin, chemical soap/bath may cause external vagina (vulva) irritation and dryness. Scented pads, tampons, sprays or powder should be avoided as these can cause vaginal irritation or even infection, in more severe cases.
No, douching before and after intercourse does not prevent STDs. On the contrary, douching can increase risk of contracting STDs including HIV as it washes away the ‘good’ bacteria in the vagina, leading to the vagina susceptible to external bacterial STDs and virus STDs.
Regular douching is associated with female related vaginal infection such as bacterial vaginosis and vaginal candidiasis (fungal infection). Those who douche weekly has a 5 times increase risk of developing bacterial vaginosis. Due to a significant reduction of H202 lactobacilli, the vagina environment is tempered with a hostile overgrowth of ‘bad’ bacteria such as Gardnerella spp, Mycoplasma hominis and etc.
Bacterial vaginosis though is not a STD, increases the risk of a women acquiring STDs, and frequently is associated with womb lining infection, pelvic inflammatory disease, pre-termed labour and low birth weight in babies.
It is a ‘chicken-and-egg’ situation whether women with abnormal vaginal symptoms engage in douching in hope to ease the symptoms, or women who engage in douching subsequently develop abnormal vaginal symptoms. Regardless of the chronological causative link, there is a strong association of douching and female-related vaginitis.
Douching is unlikely to resolve vaginitis and may exacerbate the symptoms further by ‘over-cleansing’ and causing greater susceptibility of contracting other infections. If you have abnormal vaginal symptoms, you are advised to see your female health care professional for further treatment and management of your condition.
With the act of douching, reducing the amount of ‘good’ vaginal bacteria, the vagina is even more susceptible to STDs such as Chlamydia trachomatis, Neisseria gonorrhea, Trichomoniasis and other bacterial STDs.
As mentioned above, as the act of douching provides a vacuum-transport-pathway for the untreated STD bacteria, one can be predisposed to ascending infection of the womb, fallopian tube, ovaries, leading to pelvic inflammatory disease, chronic pelvic scarring and infertility.
It is understandable that some women douche following experiencing abnormal vaginal symptoms such as itching, abnormal discharge, pain or irritation, discomfort down below. Unfortunately douching does not resolve the symptoms, in fact it may even exacerbate the underlying problem. You should see your medical professional staff whom you are comfortable with to further evaluate your symptoms. STD tests may be offered accordingly to one’s exposure risk and symptoms. Only via testing, the right medication can be offered to treat and resolve the symptoms.
Interestingly the healthy acidic vaginal environment is able to partially inactivate viruses including HIV (human immunodeficiency virus). The vaginal flora changes when a personal douche the vagina, with an obliteration of acidic lactobacilli and vaginal protection layer, a rise of vaginal pH and production of inflammatory cells. These inevitably encourages the ‘bad’ bacteria such as bacterial vaginosis or external pathogens (STDs), HIV to thrive more easily.
No, douching does not prevent pregnancy. It is not medically proven to control and avoid unwanted pregnancies. While douching can wash away the semen in the vagina, the sperm inside the semen can travel quickly into the cervix, uterus, fallopian tube to fertilise the ‘egg’. Douching is unable to halt the progressive journey of the sperm.
If you are concerned of pregnancy after unprotected sex, you can consider emergency contraception to prevent becoming pregnant. You can consider long term contraception methods if you have recurring risk of unwanted pregnancy. You can understand more on various contraceptive options by consulting your health care provider.
One may consider douching out of ‘hygiene’ purpose, amelioration of vaginal odor, resolution of vaginal discomfort, avoidance of STDs or even pregnancy. Nonetheless, there is no clinical proof to support the use of douche for the above roles.
If there are abnormal vaginal symptoms and concerns of vaginal infections including STDs, douching will not help the underlying condition. One will need appropriate medical attention and treatment. In some cases, vaginal swab testing, urine test, blood tests, STD tests may be required to evaluate for the underlying vaginal infection.
Using douching as a mode of preventing pregnancy is ineffective and medical contraception is advised.
There is no sufficient medical data to prove the benefits of douching and good evidence to show that douching can be detrimental to health. It is hence, advisable to avoid douching.
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In this article, we explore the difficulties encountered in delivering adequate cervical cancer screening and HPV preventive care to patients. The article also aims to debunk some of the common misconceptions about HPV, cervical cancer, and HPV vaccination. It is written to increase awareness of the importance of proactive measures in screening and preventing HPV infection and HPV-related cancers.
Cervical cancer is a preventable medical condition, yet hitherto remains the 10th most common cancer affecting females in Singapore. We now understand cervical cancer is due to a chronic infection of the cervical cells from human papillomavirus (HPV). While there are over 150 strains of HPV, high-risk HPV that can be associated with cancer includes HPV type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.
Through proper regular screening, early detection, and treatment of pre-cancerous stages of cervical cancer, this is a type of cancer that we can avoid. HPV vaccinations have proven effective by more than 90% in protecting against HPV infection and HPV-related cancers such as cervical cancer.
HPV vaccination is encouraged and offered to BOTH women and men from the age of 9 to 45 years old.
Following the introduction of the Cervical Screen Singapore programme in 2004, there had been a steady initial decline in the incidence of cervical cancer up until 2015, when the incidence of cervical cancer plateaued. Unfortunately, in recent years, there has been evidence of a possible rise in cervical cancer incidence.
In an attempt to eliminate cervical cancer by 2030, the World Health Organization (WHO) advocates a target goal of 90-70-90 where:
Currently, our local cervical cancer screening rate is only 48%, way below our national target rate of 70%.
Local awareness of cervical cancer screening and prevention in the younger adult group (age 25-29) is only 76.5%, while awareness is better at 91% in the older adult group (age 30-69).
The poor uptake of pap smear and HPV testing is multifactorial, involving the obstacles faced by patients, health care providers, and the health system as a whole. In this article, we focus mainly on issues faced by patients.
Three key points that will determine whether a patient will opt for the screening test:
Misinformation about HPV infection and cervical cancer is common. Although the majority of women have heard of a pap smear, the purpose of the test and the screening frequency of the tests remain uncertain to most patients. Patients also may deem screening against cervical cancer unnecessary as they ‘feel fine’, asymptomatic, or feel the test is not required due to ‘lack of sexual activity’.
Furthermore, the uptake of cervical cancer screening tests is correlated to a person’s educational background, personal beliefs, and cultural barriers. Patients tend to confuse HPV with other STDs (such as chlamydia, gonorrhoea, HIV, etc) and may view HPV testing as taboo. Additionally, one may have the wrong impression that HPV infection only occurs in a person who is promiscuous in their sexual habits. The stigma associated with HPV infection can dissuade a person from getting screened for cervical cancer.
Reluctance to get cervical cancer screening is often due to fear, embarrassment, and potential discomfort from the procedure. As cervical cancer screening is usually performed by health care providers involving examination of a female’s genital region, this can be a turn-off for females to undergo pap smear or HPV testing.
Other reasons for poor uptake of cervical cancer screening include the financial burden of regular medical screening, missed appointments, unable to find time for screening, and generally uninterested in screening.
The lack of HPV vaccination uptakes can be multifactorial. A few common reasons include:
The move towards better uptake of HPV vaccination and cervical cancer screening will require concerted effort from all parties, including the health care system, the government and legislation, the allocation and availability of resources, and the participation of patients and the community.
As a community and as a patient, we can each play our part as below:
Sexually transmitted diseases (STDs) are an umbrella term for infections that can be acquired through sexual intercourse. Based on the local epidemiological studies in Singapore, STDs affected 201.6 per 100,000 of the population in 2017.
This leads us to the following questions:
We will explore the above points in this article.
STDs can have a detrimental effect on male hormones and can result in prostatitis and sexual dysfunction.
Testosterone is an essential male sex hormone that regulates the male libido, sperm production, general energy level, fat and muscle mass distribution, and red blood cell production. Testosterone hormone is produced mainly in the testicles, and the level can fluctuate. Common causes of reduction of testosterone hormone include ageing, diabetes, trauma, thyroid disease, hormonal disorders, tumour, and infection.
STD Infections can cause inflammation of the testicles (this is known as epididymitis), leading to impairment of the production of testosterone. Common STDs that are associated with low testosterone include HIV, chlamydia, gonorrhoea, and syphilis.
The prostate gland is a small chestnut organ located at the neck of the bladder, just in front of the rectum, and at the base of the urethra (the urinary tube that delivers urine). It is an important organ in the male reproductive system and aids in the production of semen to ensure the sperm is viable and able to move. Due to its location, the prostate gland can easily become infected by pathogens such as STDs.
Untreated STDs, such as HIV, gonorrhoea, and chlamydia, can infect the prostate, leading to prostatitis – inflammation of the prostate. When the prostate is inflamed, the surrounding blood circulation to the genitals can be compromised; there will be lesser blood flow to the penis which can result in difficulty in sustaining an erection.
Urethritis is a type of urinary tract infection that affects the urethra. The urethra is the opening tube that allows urine to flow from the bladder to the external body. Due to the proximity to the external environment, it is easily infected by STDs. Chlamydia and gonorrhoea remain two of the most common STDs associated with urethritis. However, there are other bacteria, such as syphilis, trichomonas, mycoplasma spp, ureaplasma spp, candida, etc that may contribute to urethritis symptoms.
Abnormal urinary symptoms such as painful urination, itching or burning sensation, and discharge over the urethral can occur in untreated urethritis. Untreated STD-related urethritis can be associated with the further spread of the disease to the surrounding reproductive organ, resulting in peri-pelvic infection or abscess, urinary tract scarring, inflammation of the testicles and prostate, etc. These can all lead to penile discomfort, pelvic pain, and inflammation and again affect a person’s sexual function.
Thankfully, most STDs that affect male sexual function are treatable with the correct diagnosis and medications.
STDs have been known to have a negative role in menstrual cycle and PMS.
Although STD infections do not affect the female hormonal axis, they can be associated with abnormal vaginal discharge and spotting symptoms. One may notice spotting from light to dark brown/red discharge when they are not having their usual period or after intercourse. Less commonly, STDs can be associated with irregular periods or missed periods, though other causes such as pregnancy, PCOS (polycystic ovarian syndrome), or thyroid disorder should be considered as possible differentials as well.
In chronic untreated STD infections, one may develop more severe complications such as inflammation and scarring of the pelvis and reproductive organs, including the uterus, fallopian tubes, and ovaries. In such instances, the ovulation or menstrual cycle can cease to function, leading to clinical presentation of irregular or missed periods.
Common bacterial STDs can be associated with abnormal menstrual cycle or vaginal symptoms. STDs bacteria including chlamydia, HPV, gonorrhoea, trichomonas, and mycoplasma genetalium, are common culprits. Unfortunately, as most symptoms of abnormal vaginal discharge or abnormal menstrual spotting tend to be mild, one may delay seeking medical treatment. If it is a case of an untreated STD, delaying treatment increases the risk of long-term complications such as pelvic inflammatory disease and can affect future fertility.
Studies have shown that there may be a link between untreated STDs and worsening premenstrual symptoms (PMS). Premenstrual symptoms such as headache, sadness, and longer period of cramps are exacerbated by untreated STDs (such as chlamydia, herpes, HPV) based on a clinical study in Oxford using a period-tracker app for smartphones.
The hypothesis suggests that with the associated inflammatory phase and falling of progesterone level prior to menses, STDs can worsen further this inflammation, hence, exacerbating PMS symptoms.
Aside from the physical complications from STDs, these infections are also associated with negative psychological impacts. The way general society stigmatizes STDs, a person’s upbringing and cultural background may affect a person’s mental outlook against STDs.
Emotional responses such as anger, depression, guilt, shame, and isolation can occur. This can be followed closely with reduced self-worth, low self-esteem, anxiety, and depression when one is dealing with STD conditions. Over time, constant mental stress against STDs can be associated with restlessness and reduced sexual desire or satisfaction.
One may be scared of contracting STDs to the extent of being unable to be aroused sexually. In males, psychogenic erectile dysfunction can occur out of fear of STDs. In females, one can experience sexual dysfunction symptoms such as vaginismus, reduced libido, painful intercourse, etc.
This will depend on the underlying cause of sexual dysfunction. If the root of the medical condition is due to underlying STD infections, treating or managing the underlying culprit STD infections is likely to improve a person’s overall sexual function. However, bear in mind that most cases of sexual dysfunction can be multi-factorial, and it may benefit to discuss your concerns with your doctor to address any other causes.
Based on the WHO diagnostic criteria, diabetes mellitus is defined as a fasting serum glucose level equal to or more than 7 mmol/L or 126 mg/dl. In diabetes, a person has chronically high sugar levels in the bloodstream due to a defect or reduced insulin production.
Diabetes is infamously associated with long-term health complications such as increased risk of heart attack, stroke, kidney disease, nerve complications, blindness, poor wound healing, various disabilities, and even death. According to the International Diabetes Federation, 1 in 10 people lives with diabetes worldwide. Based on the National Population Health Survey 2022 Singapore, the prevalence of diabetes (between the age group 18 to 75) in Singaporean is 8.5%.
In this article, we aim to discuss the correlation and overlapping symptoms of both medical conditions.
A person with diabetes tends to have a weaker general immune system, and this predisposes the person towards various forms of infections, including sexually transmitted diseases (STDs).
Interestingly, an untreated STD, just like any form of infection, may increase the blood sugar level in a diabetic person. This can create a vicious cycle for a diabetic patient with STDs- predisposition to high risks of infection and is more complicated to treat.
There is no direct causative effect between diabetes and STDs. Diabetes does not cause STDs, and vice versa. Both conditions are due to completely different underlying physiology. STDs are due to sex and infection. Diabetes is due to the ineffective breakdown of sugar by insulin in the body, leading to a long-term hyperglycaemic state in the circulation.
It is imperative to note that STDs, as the name has suggested, sexually transmitted diseases, are transmitted through sexual encounters. STDs occur due to exposure to unsafe unprotected oral, vaginal, or anal intercourse. A person with diabetes without a history of sexual encounters is, hence, unlikely to acquire an STD.
Nonetheless, people tend to be confused by both medical conditions, as their presentations are similar, and we strive to iron them out in simpler terms.
In both diabetes and STDs, a patient (both men and women) can present with itching over the genital region.
In diabetes, chronic high blood sugar and a low immune system cause a person to have a poorer skin barrier, which increases the risk of fungal and bacterial infection. Itching can be a symptom of a skin infection.
On the other hand, STDs such as Chlamydia, Gonorrhoea, Trichomoniasis, Mycoplasma Genitalium, HPV/warts, and Herpes Simplex Virus infection can present with itching over the genital region.
A rash over the genital region is always a concern of a possible STD. STDs such as herpes infection and HPV infection can present with a rash and are commonly mistaken as eczema or sensitive skin.
A rash over the lower pelvic, groin, or even anal region can also be non-STD related. In the case of diabetes, a combination of a weakened immune system and environmental factors such as increased sweating/ hygiene/ humidity of surroundings, one can present with a bacterial or fungal-related skin infection over the moist area below.
Furthermore, patients with diabetes may be more commonly seen with skin tags. Skin tags are small appendages, stalk-like skin bumps that can be confused with STD skin bumps such as HPV viral warts.
Abnormal vaginal discharge is characterised by unusual excessive volume (compared to baseline), colours such as yellow to green or greyish in appearance, and foul-smelling vaginal discharge. There can be occasional associated painful urinary symptoms, lower pelvic pain or, in more severe cases, even fever.
This abnormal symptom invariably always rings a red flag alarm on a possible underlying STD (as long as there is a sexual history involved). Bacterial STDs such as Chlamydia, Gonorrhoea, Trichomoniasis, Ureaplasma spp, Mycoplasma spp, etc, are common culprits that are involved in the abnormal symptoms.
Nonetheless, abnormal vaginal discharge can be seen more frequently in diabetic patients due to recurring fungal/yeast infections.
Urinary tract infection is frequently seen in a person with diabetes due to high blood sugar levels in the body. Confusingly, in bacterial STDs, one can present with similar symptoms such as urinary tract infection- painful urination, discharge from the urethral, burning sensation upon peeing, urinary urgency, etc.
In a person with a urinary tract infection that is not caused by an STD, the urinary tract is infected due to migration or contamination of the bacteria from the surrounding genital region. In the case of diabetes- it is due to an underlying poor immune system, poor skin integrity, and a higher risk of general infection.
In STDs, the causative bacteria, such as chlamydia and gonorrhoea, come from an external source- such as an infected sexual partner.
Pain during intercourse should not be ignored. Reversible and manageable causes such as STDs or diabetes should be addressed to avoid irrevocable complications such as chronic discomfort and infertility.
As diabetes can affect the blood vessels and nerve supplies of the body, in females, it can be associated with vaginal dryness due to reduced lubrication as a result of diabetic neuropathy. In diabetic males, the blood flow to the penis can be impaired, leading to sexual dysfunction. In both circumstances, sex can be painful and uncomfortable.
Painful sex can be an indicator of an untreated STD. Over time, an undiagnosed STD can cause chronic inflammation and scarring of the reproductive organs and chronic pain during intercourse. STDs are important to treat, not just to address sexual discomfort but, more importantly, to prevent the infection from causing scarring and eventual infertility.
High-risk pregnancies are commonly seen in a person with diabetes or untreated STDs.
In diabetes, the pregnant mother is at higher risk of miscarriage, pre-term labour, stillbirth, and serious birth defects in babies (congenital heart, brain, and spine defects).
Vertical transmission of STDs from mother to unborn foetus is possible. Infections such as HIV, hepatitis, syphilis, chlamydia and gonorrhoea can be passed on to the foetus during pregnancy. STDs in newborns can be associated with neurological defects, meningitis, blindness, deafness, chronic infection in the babies, failure to thrive, or even death. STDs are one of the preventable causes in newborns if screening and early treatment are offered to pregnant mothers.
1. Diabetes and STDs are two medical conditions of different entities and underlying causes.
2. A person can have both diabetes and STDs.
3. A person with underlying diabetes can be more susceptible to STDs.
4. Diabetes clinical presentation can be similar to STD symptoms, though the treatment for both are completely different.
5. As diabetes and STD presentations can be confusing, a review with your healthcare professional can be beneficial to diagnose the symptoms correctly.
6. Both diabetes and STDs can be screened accurately, and there are effective treatment options in managing both conditions to minimise long-term complications.
With the recent hype over skin food for luscious hair and longer, stronger nails, biotin is becoming a common supplement in our multivitamin drug cupboard. Have you ever wondered how safe biotin is and whether it has any long-term implications for our health?
In this article, we explore the role of biotin in the human body and the benefits and potential drawbacks of this supplement.
Biotin, also known as Vitamin B7, Vitamin H, and Coenzyme R, is a water-soluble protein that facilitates the production of energy for the body by acting as a catalyst in the metabolism of protein, carbohydrates, and fats.
It can be found in meat, salmon, eggs, innards such as liver, dairy products, cereal and grains, soy flour, fruits and vegetables such as bananas, carrots, cauliflower, etc. Biotin, when consumed, is absorbed in the small intestine and stored predominantly in the liver.
Currently, there are no blood tests that enable us to monitor the level of biotin in our body.
Biotin plays an essential role in the growth of skin, hair, and nails. Biotin deficiency is known to be associated with brittle nails, skin rash, or hair loss. Furthermore, low biotin can be associated with cardiovascular consequences such as high cholesterol and heart disease.
There are ongoing medical studies and research on the role and benefits of biotin in skin conditions such as seborrhoeic dermatitis, acne, or eczema and neurological conditions such as multiple sclerosis. However, there is insufficient clinical evidence to prove its efficacy in these conditions.
Patients who are on anti-convulsants (epilepsy medication) can be associated with lower biotin levels in their bodies.
Biotin deficiency is uncommon in healthy people with a regular, varied diet.
Biotin can be lower in chronic alcohol drinkers or pregnant or lactating mothers. Rarely, one can be genetically predisposed to biotin deficiency due to biotinidase enzyme deficiency (an enzyme that allows the release of free biotin in the body).
Biotin deficiency can be associated with hair loss, brittle nails, and skin rash, particularly over the mouth, eyes, nasal hole, and perianal region). In more severe cases, one can develop neurological symptoms such as seizures, numbness in the limbs, and psychiatric symptoms such as depression and hallucination.
Thankfully, no major side effects have been reported for overdosing on biotin. However, informing your healthcare provider before starting the supplement is still good practice.
As high biotin intake can lead to falsely high or low biochemistry laboratory test results, which can lead to misdiagnosis and mismanagement of a person’s health condition, it is always prudent to check with your doctor about your biotin dose.
There is slowly emerging medical evidence of biotin interference with laboratory test results. Most laboratory immunoassays (tests) use the biotin-streptavidin system to run samples, as this system allows high affinity and sensitivity (the ability of chemical proteins to bind together and pick up abnormalities). It is found that a high amount of biotin (>1mg/day) can cause false test readings.
Abnormal thyroid hormone blood tests and Vitamin D serum levels are found in patients who consume high biotin levels. There have been reports of false hyperthyroidism or inappropriate diagnosis and treatment of Grave’s disease in patients who are taking high-dose biotin (30-100 mg biotin/day). Aside from this, some reports reveal biotin can interfere with blood markers for heart failure (such as pro-BNP {brain natriuretic protein}), both female and male hormones, cortisol, parathyroid hormone readings, folate, vitamin B12, iron readings, etc.
The concern and danger here:
You are encouraged to inform your doctor on the supplement(s) that you are taking prior medical tests to ensure the tests is run and interpreted appropriately.
Thought for the day…
The interference of biotin with our daily biomarkers raises a few new questions to ponder:
A more pragmatic approach is to educate ourselves as both patients and consumers on the supplement that we are delving into. On the other hand, physicians have a role in screening patients' drug and supplement lists. Those who are on biotin should be counselled on the potential interference with laboratory results before blood testing.
1. Gifford JL, Sadrzadeh SMH, Naugler C. Biotin interference: Underrecognized patient safety risk in laboratory testing. Can Fam Physician. 2018 May;64(5):370.
2. Elston MS, Sehgal S, Du Toit S, Yarndley T, Conaglen JV. Factitious Graves’ disease due to biotin immunoassay interference—a case and review of the literature. J Clin Endocrinol Metab. 2016;101(9):3251–5.
3. Piketty ML, Polak M, Flechtner I, Gonzales-Briceño L, Souberbielle JC. False biochemical diagnosis of hyperthyroidism in streptavidin-biotin-based immunoassays: the problem of biotin intake and related interferences. Clin Chem Lab Med. 2017;55(6):780–8.
4. https://ods.od.nih.gov/factsheets/Biotin-HealthProfessional/#ref
A sudden noticeable swelling over the vulva region is always a cause for concern. Furthermore, painful swelling in the vulva region is a particularly concerning symptom that warrants medical evaluation. Often the question arises “Doctor, is this an STD (Sexually Transmitted Disease)?”
Due to the acute presentation and discomfort of a Bartholin’s cyst, people tend to turn up in the consultation room with concerns of possible infection and seeking treatment. In this article, we explore this medical condition, the possible triggers, and how we can manage it.
Over the lining opening of the vulva (external vagina), there are small glands known as the Bartholin’s glands. These glands serve to produce healthy fluid to lubricate your vagina. However, the opening of the gland can develop blockages, leading to the accumulation of fluid in the gland and the formation of a cyst. Bartholin’s cysts are usually painless, but they can be palpable and swollen over the opening of the vagina.
Occasionally, Bartholin’s cysts can become infected with bacteria, leading to a painful abscess that requires medical attention.
Bartholin’s cyst or infection commonly affects women of reproductive age. The incidence decreases once a woman reaches menopausal age. Bartholin’s cyst cases make up approximately 2% of gynaecological cases seen annually.
Bartholin’s cysts generally do not cause symptoms as they tend to be small. However, when it gets infected, one may experience the following:
The actual cause of Bartholin’s gland becoming blocked is still unclear. Bartholin’s cysts tend to occur during reproductive years and become less common after menopause. A Bartholin’s gland can potentially get blocked due to:
It can be useful to evaluate the possible triggers with your trusted healthcare providers. Modifiable triggers, such as lifestyle that irritates the vulva, can be avoided, and infection can be treated to prevent the further occurrence of Bartholin’s cyst.
Risk factors for developing Bartholin’s cysts include:
Although the majority of the cause of Bartholin’s cysts or abscesses remains unknown, there is an association of Bartholin’s cysts/abscesses with sexually transmitted infections (STIs), particularly chlamydia and gonorrhoea. It may be worthwhile to consider screening for bacterial STIs if there is evidence of recurring Bartholin’s cyst infections and if you are sexually active.
Non-STI-related bacteria such as E coli (bacteria from the colon/anorectal region), Streptococcus pneumoniae, and Haemophilus influenza are pathogens that can potentially block the Bartholin’s glands and lead to infection and abscess formation.
If the STI-related bacteria are not treated, Bartholin’s infection may not recover. In the long run, one may risk developing chronic vaginitis, pelvic inflammatory disease (PID), and infertility, and one can spread the infection to one's partner(s). Thankfully, infectious Bartholin’s cysts are treatable with proper antibiotics.
If you are concerned about a Bartholin’s cyst, reach out to your healthcare provider. Your doctor will offer a physical examination involving the vaginal area to look for any abnormal lumps and infections over the area. In certain circumstances where there are concerns of infection, your doctor may offer swab tests to send off fluid discharge samples to the laboratory for further testing.
If the infected Bartholin’s cyst is left untreated, there is a possibility that the cyst may burst spontaneously over time, causing pain and discomfort. Sometimes, the infected cyst may progress and become an abscess (a pocket collection of pus); one can be unwell with fever and vulva pain. In such circumstances, oral treatment may be insufficient, and surgery may be required to manage the symptoms.
Small and painless Bartholin’s cysts do not require treatment. Nonetheless, if the cyst becomes painful and infected, medical treatment is advised.
Treatment for a Bartholin’s cyst usually involves:
Avoid possible triggers such as repeated friction or trauma to the vulva region. If this is a risk factor in your circumstances, consider a regular STI screen. In the case of a mild Bartholin’s cyst without evidence of infection, you can consider a regular Sitz bath method to allow spontaneous resolution of symptoms.
Have you ever had an episode where you had to cross and uncross your legs in public due to the itchy sensation below? Or an episode of urgent need of the bathroom to scratch the itchy genitalia? The symptom may sound trivial, but it can profoundly impact our lives, affecting our daily routine and causing embarrassment when socialising with others.
Genital itch is a common medical symptom that can occur in anybody. It is a non-discriminative symptom, regardless of your educational or socioeconomic background.
Genital itch symptoms can be broadly categorised into dermatological versus infectious/sexually transmitted disease STD-related causes.
Some various bacteria or parasites can cause symptoms of itch over the genitalia when the infection is left unattended. This includes chlamydia trachomatis, Neisseria gonorrhoea, Mycoplasma Genetalium, Gardnerella bacteria, Trichomonas parasites, etc. These are commonly associated with sexually active people. If you are having trouble with genital itching and you are in a sexual relationship, do discuss it with your doctor and consider further screening for sexually related infections. These bacterial/parasitic-related sexually transmitted infections are treatable, and they do not resolve on their own unless treated with the correct medications.
A genital itch can be an embarrassing symptom to present to your doctor. Nonetheless, the condition is manageable if the right cause is determined and dealt with.
You are encouraged to see your doctor when your symptoms persist and cause impairment and nuisance to your daily routine.
Further red flags to note and consider seeing your doctor if you have:
Although 'itch' is a generally benign symptom, it may be a tell-tale sign of a more serious medical condition that requires treatment. Do see your doctor if the genital itch symptoms are not improving or if you develop any of the red flags discussed above.
As genital discomfort or itch can be a private and embarrassing condition, you are encouraged to see a doctor that you are comfortable with.
Your doctor will obtain a relevant history of your symptoms and relevant social/sexual histories. Your doctor will then physically examine your genitalia region for skin integrity. In females, your doctor may request, with your consent, a vaginal examination. In males, your doctor may request, with your consent, to examine your scrotal and penis region. Depending on individual conditions, your doctor may examine the rest of the body for other relevant body signs associated with your symptoms. Your doctor may also offer various tests in the form of blood, swab, scrape, or even urine tests depending on the working differential diagnosis.
The treatment and management of itchy genital symptoms depend on the cause. In dermatological causes, your doctor may offer topical medicated cream as a steroid, antifungal, or antibacterial to manage the symptoms. In more severe cases of concern with fungal infections, your doctor may prescribe oral antifungals to manage the symptoms. Lifestyle advice to reduce triggers that irritate dermatological symptoms will be discussed.
If the underlying cause is an untreated infection, you may be offered targeted treatment through oral medication, cream, or even procedures such as cryotherapy or electrocautery.
Discuss your symptoms with your doctor, allow your doctor to examine your condition, and discuss the treatment options available to manage your genital itch symptoms with your doctor.
Although itch can be a completely benign symptom that potentially resolves spontaneously, if the symptom is not addressed appropriately, one may miss or delay diagnosing an underlying medical condition. In the event of dermatological-related itchy genitalia, if the underlying skin condition is not addressed, one may have recurring symptoms in the near future. In the event of infectious-related itchy genitalia, one will have an untreated infection and be at risk of developing complications from the infection and spreading the disease to people around you.
There are effective treatments to manage the itch in the genital region. Understanding the possible differentials and having the courage to seek medical help are paramount steps to take to take control of your health and your overall quality of life.
Breast lumps are uneven bumps and growths you can feel over your breasts. It is commonly found in women but can occur in men as well, though less common.
More than 25% of women will encounter breast lumps in their lifetime. Thankfully, most of these breast lumps are benign (non-cancerous). In Singapore, according to the Singapore Cancer Registry Annual Report 2021, breast cancer remains the most frequent type of cancer occurring in women over the past 5 years. From 2017 to 2021, this occurrence comprised nearly 30% of all types of cancer.
You should see a doctor if you notice any of the following:
As these symptoms may be red flags suggestive of breast cancer, early evaluation and treatment are paramount as they can be life-saving.
Your doctor will obtain a history to understand the timeline and progression of the breast lump(s), a family history of any medical conditions related to breast issues, and will physically examine both your breasts and armpit region. Depending on individual symptoms, risk factors, and concerns, your doctor may recommend imaging scans to evaluate the breast lump(s).
Common screening/imaging options for breast lumps include:
The modalities of screening for breast lumps may differ from patient to patient as this depends on the patient’s symptoms, age, risk factors, and general medical background. You are advised to consult your doctor first to understand your symptoms and, secondly, to examine the area of concern physically. This will allow your physician to guide you on the screening option that is best suited for your individual needs.
As mentioned, thankfully, the majority of the breast lumps are benign. The 2 common causes of non-cancerous breast lumps are breast fibroadenoma and breast cysts. However, occasional breast lumps can be due to a more sinister cause, such as breast cancer. Hence, it is important to get yourself checked if you have any breast lumps.
Breast fibroadenoma is a common non-cancerous breast finding that usually presents with palpable lumps. They typically develop during puberty or early reproductive ages due to the exposure and sensitivity of oestrogen hormones. The breast tissues, under the influence of oestrogen, will then grow, intertwining with the breast glands and ducts, leading to the formation of a solid nodule (lump).
Breast cysts are common benign breast condition. Breast cysts are lesions that are fluid-filled in nature. Breast cysts may come and go over any part of the breast(s), which can be influenced by the level of oestrogen hormone in a person. Big cysts can cause pain and discomfort in some women. Small breast cysts are usually left alone with regular monitoring by your doctor. In large, uncomfortable cysts, your doctor may offer a procedure to drain out the fluid of the cysts.
Cancer happens when the cells in a person’s body cannot stop growing. If the cell growth is out of control and occurs in the breast cells and tissues, you can develop breast cancer. The breast cancer cells can grow bigger with time and spread to the surrounding tissues through the bloodstream and lymphatic drainage. Over time, they can disseminate to other organs of the body.
Although most breast lumps are not dangerous, a breast cancer diagnosis should not be delayed and missed as early detection and treatment can be potentially life-saving. In the late stages of breast cancer, the cancer cells can affect other parts of the body, eventually developing into cancer.
Please see a doctor if you have a breast lump!
Below are the factors that determine your risk for breast cancer:
It is worthwhile speaking to your doctor about lifestyle measures to reduce your risk of exposure to breast cancer.
Although there is no absolute way to prevent breast cancer, early detection with appropriate screening may be life-saving. Treatment for early stages of breast cancer is curative. Hence, don’t wait and take a chance; screen and treat early.
Monthly breast self-examination should be performed at home regularly. Your doctor can guide you on how to examine your own breasts and the pitfalls to look out for. You are advised to consider routine mammogram screening annually from age 40 to 49 and two yearly routine mammograms from age 50 and above.
As guidelines are used for the recommendation of the general population, it is still good practice to discuss with your physician which are the suitable breast tests or imaging for you.
Breast lumps are common, and most of the findings are not dangerous. However, breast cancer can present as lumps; hence, breast screening is vital for early detection and treatment!
Vaginitis is an umbrella medical term for ‘inflammation of the vagina’. It is commonly associated with abnormal vaginal discomfort symptoms such as itch, abnormal discharge, burning or pain sensation over the vagina. Chronic vaginitis occurs when the unusual vaginal symptoms occur more than 6 months.
Chronic vaginitis can be a frustrating journey for both patients and physicians. The condition brings in its wake frequent clinic attendees and a cost burden to patients and the healthcare system. With unresolved clinical symptoms, patients often default to medical follow-up at some point, leading to further poor diagnosis and management of the condition.
This article strives to highlight the medical condition of chronic vaginitis that significantly affects many women’s quality of life and discuss the common practical pitfalls we face in the management of chronic vaginitis. It seeks to empower both patients and physicians to be more insightful of the condition and be proactive and compliant in treating the chronic condition.
We can broadly subdivide the causes of chronic vaginitis into infection-related causes versus non-infection-related causes. The top 3 common infectious causes of chronic vaginitis seen in child-bearing-aged ladies are:
It is important to be cautious of possible concurrent infection with sexually transmitted diseases such as chlamydia, gonorrhoea, mycoplasma genetalium, herpes, HIV and etcetera.
Non-infectious causes of chronic vaginitis are usually associated with background dermatological issues such as irritation secondary to topical use of chemical or douche materials, underlying health issues such as eczema and lichen planus, and hormonal changes secondary to menopause.
As each patient may have a different trigger or cause(s) for chronic vaginitis, it is worth seeing your trusted physician for further evaluation.
Every female’s vaginal discharge may differ. It is worth noting your baseline (usual) discharge colour, consistency and volume since you were young. Vaginal discharge will be present in every woman. Generally, the discharge is usually colourless to whitish, with no abnormal odour and a healthy normal baseline volume. The discharge consistency can be more ‘albumin-like’ or ‘milky’ during the mid-cycle or ovulatory phase and slowly becomes slightly thicker towards the end of the menstrual cycle.
Symptoms such as vaginal itchiness, vaginal odour, excessive vaginal volume discharge, yellow to greenish copious amount of vaginal discharge, painful intercourse, painful urination, pelvic or lower back pain, and fever may be suggestive of an underlying health condition yet to be addressed.
In the long run, unattended chronic vaginitis may develop complications of pelvic inflammatory disease with womb and fallopian tube inflammation and scarring, leading to infertility and chronic pelvic pain presentation.
Please seek medical attention before chronic vaginitis progresses into long-term health complications.
This is one of the major common scenarios seen in chronic vaginitis or unresolved vaginitis. It is important to consider clinical vaginal swab tests to cast a broader net of diagnostic screening. Without swab testing, there may be a missed opportunity and a time lag in arriving at the correct diagnosis. Furthermore, a person can simultaneously have a few types of vaginal infections, which clinical swab testing can detect at early stages.
It is unfortunately common for patients to repeatedly visit clinics in hopes of seeking a resolution to no avail. They are usually given various options of medications ranging from tablets to topicals to intravaginal pessaries during clinic visits, only to have their symptoms wax and wane.
Blind treatment may ease the symptoms temporarily by treating the surface infection, while the remaining infection(s) may linger and cause further recurrence of vaginal symptoms. If your symptoms are not recovering, do let your doctor know and consider vaginal swab testing to ensure the condition is managed appropriately.
With the evolution of time, relationships may not work out how we wish to. The new partner that you engage with may be carrying an undiagnosed infection from their previous partner without knowing- unless regular screenings have been done.
An unresolved history of vaginitis may be due to underlying concurrent infection, including sexually transmitted infection(s) that has yet to be addressed. In this situation, with appropriate testing and receiving proper treatment, the vaginitis will resolve. Sexual partners must be screened and treated to avoid reinfection between the couple.
Fortunately, it is becoming common practice to conduct medical checkups between couples and consider regular sexual health screening to address and treat any asymptomatic STIs.
This is another common scenario seen in the community. A patient may see Dr A due to convenience for her condition. Subsequently, when there is a resurfacing of similar symptoms, the patient will then consult Dr B, and if the symptoms are not better, a further consult with Dr C.
The unspoken issue here: whenever the patient sees a new doctor, unless a proper history or examination is taken, the patient may be treated for that ‘snap-moment’ without taking into consideration the previous symptoms, tests that were offered or treatment that was received. This leads to poor patient care as there is no continuity of care. The constant change of medical providers reduces their ability to fully comprehend patients’ conditions, subsequently failing to provide the comprehensive care that patients deserve.
It is ideal and advisable to stay with the same doctor you are comfortable with for the long-term management of the vaginitis condition. This will ensure better overall patient care and allow the best possible treatment to be offered to the patient.
Given recurring and unresolved vaginal symptoms, a patient may opt for various complementary treatment methods. With the rise of social media and digital resources, there is a wide variety of street medications – that promise and guarantee a cure for vaginitis.
It is important to discuss with your doctor before embarking on self-treatment, as complementary medications may lack clinical evidence and may not work. This may lead to spending excessively and unnecessarily on treatment that is not beneficial at all. Besides, certain over-the-counter products may even serve as an irritant and exacerbate further the symptoms of vaginitis.
Vaginitis is a medical condition frequently encountered in females. It is one of the causes that lead to frequent attendees in primary care or outpatient clinic settings. Poor management, poor patient insight, wrong diagnosis, and polypharmacy bring in its wake cost and time burden to patients and health care. Furthermore, without resolution of the symptoms, it can create stress and anxiety for the patient and tension in the relationship between couples as well.
Thankfully, the treatment outcome for vaginitis is fair, and it is possible to abort and cure the symptoms. Empowering and educating female patients on the expectation of normal vs abnormal vaginal health symptoms, the possible causes and pitfall triggers may improve the outcome of this condition. In patients who have exposure to possible vaginal infections, the role of vaginal swabbing is vital to consider to nip the cause(s) in the bud in delivering the proper treatment. Lifestyle triggers can be discussed between doctors and patients to reduce the chances of recurrence of vaginal infection.
Libido, better known as sexual desire or drive, indicates an adult woman’s general health [1]. Libidos are instinctual urges, naturally present for all species to procreate and pass their genetic material to future generations. More importantly, libidos are also pertinent in maintaining a healthy relationship and sustaining a romantic bond with your sexual partner.
Multiple pieces of literature [2] have raised the occurrence of lower libido in Asian women. These are often related to conservatism in Asian society. In the case of Singaporean women, however, it may be fair to deduce that they are more sexually empowered to treat lowered libido proactively.
A recent study [3] indicated that over half of middle-aged women in Singapore are sexually active; however, many are challenged with sexual dysfunction [4], such as loss of libido. A study [5] by KK Women's and Children's Hospital also revealed low sexual desire and rarely reaching orgasm are commonly reported forms of sexual dysfunction in women. In this article, we take a deep dive into the issue of low libido and how you may overcome it.
Libido differs from one individual to another, with many factors contributing to the phenomenon. Women exhibit different levels of libido at different ages, some attributed to natural biological changes and others due to factors unrelated to bodily changes. Symptoms of low libido may include:
Biologically, changes in libido are often due to changes in hormones, such as the gonadal hormone [6], which plays a primary role in maintaining libido. Additionally, the hormones androgen [7], oestrogen [8], and testosterone [9] also play an important role in sexual function. Regulated hormone is important as it fuels a woman's psychosexual stimulation and increases sensitivity and blood flow (important in pleasure sensory).
At different ages, the levels of these hormones may fluctuate, providing some rationale for varying levels of libido in women. Below are general characteristics of libido levels at different stages.
Age group | Characteristics |
20-30 | High biological drive to reproduce but modest levels of sexual drive Women tend to be more selective about when and whom to reproduce with within these age groups (high sexual selection cognition) [10] |
31-44 | Decline of fertility begins Women’s sexual desire tends to become heightened Women tend to have more sex in these age groups |
45 and above | A decrease in sexual drive is observed as oestrogen levels begin to drop Progressive decrease in libido as women undergo perimenopausal symptoms Libido in these age groups is mostly mind-induced versus biologically driven |
While libido patterns can be explained by age group and biological change, many can testify that these do not hold true. This is because libido is not just a biological occurrence but a culmination of biopsychosocial aspects.
It is natural and expected that most women have fluctuating changes in their sexual desires throughout their lifetime. Apart from naturally occurring biological changes in your body, some factors that may affect your libido include:
Depending on the exact cause of your low libido, the approach to remedy your sexual drive varies. Low libido in women is usually a complex case. Your healthcare provider may offer multifaceted treatment and management upon understanding your condition. Below are some approaches you may take to solve libido issues:
Women must conduct routine screening and gynaecological health check-ups to truly understand if there are biological changes in their bodies. For instance, regular screening may reveal thyroid disorders as a source of hormone dysregulation and lowered libido. Similarly, you may also obtain insight into other underlying health conditions or medications masking as a lowered libido issue.
Sexual dysfunction issues can also be addressed at your nearest sexual health clinic under the surveillance of a registered medical professional. Issues may include fear of penetration, painful sex, and inability to orgasm. With a health professional such as a gynaecologist, you can reduce trial-and-error roulette and get to the crux of the issue.
Where biological issues are present, your partner may also be able to empathise if they are provided with rational justification of what is behind your lowered sexual interest. This will also avoid straining romantic relationships.
Psychological factors can be just as detrimental to your libido and need not be a life sentence. Therapies such as Cognitive Behavioural Therapy (CBT) [17] and mindfulness-based therapy (MBT) [18] have been proven scientifically efficient [19] in addressing low libido. If you have not been diagnosed with mental health conditions, one can also perceive this as an opportunity to seek psychological intervention.
It is essential for mothers with postpartum depression to seek psychological help. Whilst lower libido may strain your relationship, there are also risks to your child's development. Interventions [20] may include pharmacological, psychotherapeutic, and nonpharmacologic options.
If infidelity issues have occurred, you and your partner may attempt couple counselling or marital counselling for assistance in repairing the relationship. A study [21] has shown that whilst couples with infidelity are significantly distressed and depressed initially, couple therapy intervention induced improvement for up to 6 months posttherapy with optimistic results.
There are some lifestyle changes you may attempt to address low libido at home. We suggest implementing these changes only if no significant medical or psychological issues impact your libido. Lifestyle changes includes:
There has been a rise in women attempting to self-medicate for lowered or loss of libido. This includes an increased demand for blue pills also known as sildenafil (Viagra) [26]. Sildenafil is approved by the FDA (US Food and Drug Administration) and permitted for use for erectile dysfunction in men. However, it is not approved for use by women in Singapore due to associated risks and complications, which include:
It would be necessary for you to seek a doctor when libido loss becomes a persistent issue (over a month) and is causing you distress. Loss of libido may mean an increase in the possibility of a Hypoactive Sexual Desire Disorder [27] (HSDD) diagnosis. The key difference between low libido and HSDD is that the latter causes significant distress and lowered quality of life. Additionally, HSSD patients may even feel distressed at the thought of sex and can be averse to even self-pleasing.
If suspected of HSDD, you will be referred to a gynaecologist and sexual health clinic. Further investigations will be conducted to identify the classification of libido loss, which includes genito-pelvic pain/penetration disorder (GPP/PD), sexual interest or arousal disorder, or a female orgasmic disorder.
If you are struggling with a loss of libido, visit your nearest sexual health clinic for appropriate medical intervention. Attempting to self-medicate may worsen your condition or delay detection of serious health conditions. Remember, working to address your libido is healthy and should not be associated with guilt or shame.
We hope this article has empowered you to make the best choices for your sexual health. Our vision is that issues pertaining to lowered libido or libido loss garner greater momentum in Singapore and other Asian nations. Contrary to traditional beliefs, a great sexual life is as important to women as to men.
Pelvic inflammatory disease (PID) is a severe inflammatory infection of the female reproductive organs, which includes the uterus, ovaries, and fallopian tubes. It is related to an untreated or unresolved sexually transmitted infection of the woman’s reproductive organs and is one of the causes of infertility. If pelvic inflammatory disease (PID) is left untreated, one can develop an abscess in the pelvic reproductive area and potentially develop a generalised infection, which can be life-threatening.
In Singapore, pelvic inflammatory disease is commonly seen in women in the age group of 15-24 years old, with a general incidence of approximately 10 in every 1000 women [1].
You may not be aware of pelvic inflammatory disease symptoms in milder cases, as one can present without any symptoms. Symptoms suggestive of PID include:
If you are experiencing any of the above symptoms or you are concerned about developing PID, you are advised to see your doctor for further evaluation of your condition and seek prompt and appropriate treatment.
The cause of a person developing PID is commonly due to underlying sexually transmitted diseases (STDs) or reproductive organ infections that were left untreated.
Possible causes of pelvic inflammatory disease include [2-5]:
Speak to your doctor about ways to reduce the risk factors of developing PID, and consider STD screening if you are concerned about developing PID.
STDs are known causes that can lead to PID if the infections are left untreated, as the bacteria can ascend from the vagina to the cervix and further up to the uterus or fallopian tube of the female’s reproductive organs [6].
STDs associated with PID include:
If you have been exposed to STDs/PID, speak to your doctor, consider STD testing, and seek treatment without further delay.
Yes, a person can develop PID even without underlying STDs. Non-STD causes that can lead to PID include:
Please see a doctor if you are concerned about PID or experiencing symptoms that suggest PID.
As the STD bacteria that are left untreated can ascend the female reproductive system, areas that can eventually develop inflammation or scarring in PID include:
You can reduce the risk of acquiring PID by:
You should seek medical advice if you are presenting with PID symptoms or if you notice the following:
PID is diagnosed based on your clinical symptoms and findings from gynaecological tests and examination.
Depending on individual conditions, your doctor may offer vaginal and cervix swab tests for laboratory investigation of STD/bacterial infection. Your doctor may offer tests such as blood tests, urine tests, pregnancy tests, and an ultrasound of the pelvis region to screen further for PID.
In more severe cases, you may be advised to seek medical attention in the hospital and consider a laparoscopy procedure to investigate further for PID.
PID can be treated. However, the complications of PID, such as damage or scarring of the reproductive organ, may not be reversible with treatment. Treatment works to clear off the underlying infection(s) and avoid further irreversible complications from PID [9]. Your sexual partner(s) must also be treated to prevent re-infection of the condition.
In severe cases of PID, you may be admitted to the hospital for intravenous antibiotics treatment and monitoring.
Long term complication from PID includes:
You can consider resuming your sexual life after completing your antibiotics and resolving your symptoms. Your partner is advised to get screened and tested before resuming a sexual lifestyle with you.
PID is a treatable condition if it is managed promptly and appropriately. Hence, do not allow the infection to brew longer and worsen; consider early STD screening and treatment!