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Cervicitis: A condition poorly understood, neglected, and carries more repercussion than we think
Cervicitis is a medical condition where the cervix is inflamed. This can result from an infection or even an irritant. It is defined when there is evidence of mucous-pus discharge from the cervix and possible spotting from the cervix due to a fragile, inflamed cervix. When cervicitis occurs acutely, one can have uncomfortable noticeable symptoms. However, when the cervicitis runs a more chronic journey, symptoms become more tolerable. One can potentially ignore the symptoms as they can be mild.
Cervicitis is not a new medical condition. Yet, it is not commonly discussed of, one may even ignore the condition in hope of spontaneous resolution of symptoms.
Good awareness, understanding, early screening and treatment of cervicitis are imperative in halting further irreversible pelvic scarring and obstetric complications
One with cervicitis can have non-specific mild vaginal symptoms to no symptoms at all, making it a difficult diagnosis to pick up without screening tests.
One who are experiencing symptoms of cervicitis can present with
If you have potential exposure to genital infection(s), abnormal lower genital symptoms above, you are encouraged to speak to your healthcare providers for further evaluation of your condition.
Cervical smear such as pap smear is used to screen for early cervical cell changes or cervical cancer. Pap smear can be useful in guiding patients and physicians on whether a person may potentially have cervicitis. Pap smear showing inflammatory cells may be a clue of underlying cervicitis or lower genital infection that has not been taken care off.
Pap smear test alone is not conclusive of a cervicitis diagnosis, but the abnormal results can be a telltale sign of infection(s) around the lower genital area.
One should consider a follow-up high-vaginal swab to evaluate specific potential pathogen(s) that can cause vaginal and cervix infections. This is important in subsequent targeted treatment to eradicate the infection(s).
Inflammation of the cervix is frequently due to underlying infection, such as STDs. Infective pathogens - bacteria and viruses can be contracted during sexual intercourse. Persistent infection of the lower reproductive area such as the vaginal canal can eventually lead to cervicitis or even ascending infection (pelvic inflammatory disease).
Untreated STDs that can result in cervicitis include
Interestingly, non-STD related bacteria such as Gardnerella vaginalis (which is associated with bacterial vaginosis) can also result in inflammation of the cervix.
Observational studies over the years reveal interesting trend of infection types in women with cervicitis. Chlamydia and gonorrhea bacteria remain the top common causative pathogens that are responsible of cervicitis.
However emerging data shows
This shift in pattern of pathogens in cervicitis can be explained by human behavior, modern dating, earlier age of becoming sexually active, multiple sexual partner(s), engaging in various sexual orientations, use of oral contraception and not using barrier contraception, resulting in a predisposition of co-infections in the lower reproductive organs.
In addition, sexual health clinical services may not be widely available to everyone. In particular, screening tests may not be fully available in non-sexual health clinic. In return, this explains the rise of multiple lower reproductive organ infections, missing diagnosis, delay of right treatment, persistent cervicitis and complication such as pelvic irreversible inflammation and scarring.
While bacterial vaginosis is not considered a STD, it is more commonly seen in those who are sexually active or who have multiple sexual partner(s). Bacterial vaginosis is a common female lower reproductive organ infection due to disruption and disequilibrium of the healthy pH vaginal microflora, leading to depletion of healthy lactobacillus microflora and overgrowth of bacterial vaginosis related bad bacteria. At a glance, this may seem a benign condition with mild vaginal abnormal symptoms (or even no symptoms at all). However, there is increasing medical evidence showing the causative relationship between bacterial vaginosis, cervicitis and pelvic inflammatory disease. To make things worse, presence of bacterial vaginosis increases risk of contracting STDs including HIV, HPV, Herpes, chlamydia and many more.
With the knowledge above, blind treatment with broad-spectrum antibiotics or pessaries may be a hit-and-miss treatment for lower genital infection. There is a role to consider pro-active measures such as regular women checkup with appropriate vaginal test panels to capture these pathogens that can affect our cervical health.
Douching/wash agents, contraceptive materials such as spermicides, diaphragms, tampons or even condom can lead to irritation of the cervix in some women, resulting in cervicitis.
Infective cervicitis, if not treated, will result in more serious health morbidities. The infection can spread upwards towards the rest of the reproductive organs, affecting the uterus, fallopian tubes, even the ovaries, leading to chronic inflammation and scarring. One can develop chronic pelvic pain, discomfort, infertility, and even risk of ectopic pregnancy.
To make things worse, untreated cervicitis is a risk factor of contracting HIV infection. One is also more susceptible of contracting other STDs if cervicitis left untreated. If the untreated cervicitis is due to STDs, one can also infect their loved ones through intercourse.
Cervicitis itself is generally not life threatening though it can be associated with long term health complications such as infertility, and obstetrical complications. Cervicitis secondary to high-risk HPV infection can potentially lead to cancer.
As mentioned, cervicitis is commonly caused by STDs including viruses such as HPV. High-risk HPV strains infection can lead to inflammation of the cervix tissues. If a person's immune system is unable to clear off the HPV infection, over time, there can be chronic cervicitis changes, progressive cervix cells inflammation and changes, leading to abnormal cervical cells formation, precancerous changes and eventually lead to cancer cells over the cervix.
It is worth understanding these 3 facts:
HPV-related cervicitis and cancer risk can be mitigated. We should always encourage our female family members, friends, colleagues for regular cervical cancer screening to pick up early abnormal changes, get HPV immunization vaccine if age-eligible and without contraindication, and seek medical assistance early if any abnormal cell changes detected.
If there is concern of cervicitis, one should consider arranging a medical checkup with your healthcare provider.
Your doctor will offer you a physical examination involving a pelvic and vaginal checkup. A sterile speculum will be introduced gently into the vagina to visualize the cervix. A cervix with mucous discharge, red dots, bleeding spots, ulcers may be suggestive of cervicitis. Having said that a normal physical review does not rule out cervicitis.
In those with risk factors or possible exposure to genital infection and cervicitis, your doctor may obtain vaginal, cervical swab samples, urine samples for further screening of infections.
If you are experiencing symptoms of cervicitis or have concerns about your reproductive health, accurate diagnosis and prompt treatment are essential. Take control of your health with a confidential consultation and effective care from our experienced medical team. Schedule your appointment today.
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Our human body is covered with billions of micro-organisms. From the skin, nose, mouth, intestine, to the genital areas, we are covered with bacteria colonies which play pivotal impact on our overall health. It is increasingly known that a healthy microbiome over our genital region protects one against various infectious diseases including STDs.
In this article, we want to explore further the relationship of genital microbiome and fertility, potential long term effect of genital microbiome in conception- both naturally and in assisted reproductive treatments.
A healthy vagina is predominantly covered with Lactobacilli spp bacteria. Lactobacilli spp produces lactic acid in the vaginal canal, keeping the pH in an acidic level, preventing bad bacteria, fungus or even viruses from thriving.
The healthy Lactobacilli spp vaginal flora serve functions as:
The vaginal ecosystem can turn into a hostile environment with depletion of healthy Lactobacilli spp, making the pH of the vaginal canal higher and conducive for pathogens to grow. In an abnormal vaginal canal, the bacteria colonies are more diversified with the presence of bacterial-vaginosis-related bacteria (Gardnerella vaginalis), and fungus (Candida spp).
The alteration of the vaginal flora also leads to the loss of innate vaginal mucosal barrier, resulting in an unstable vagina susceptible to external insults such as infection and inflammation.
A diversified vaginal bacteria flora also predisposes one to form biofilm- which is a layer of diversified micro-organism colony that is resistant towards treatment and difficult to eradicate them.
Vaginal microbiome can change due to
Changes of estrogen and progesterone levels can be associated with changes in the vaginal microbiome.
| Hormonal Phase | Vagina flora | Health Impact |
| Follicular phase | Lactobacillus levels getting more
Overall flora getting stable |
Generally feeling well, minimal vaginal discharge |
| Ovulation phase | Lactobacillus levels high
Stable flora |
Reproductive environment is suitable for fertilization, ideal for sperm movement and survival |
| Luteal Phase | Lactobacillus starts to deplete
Flora becomes more diversified |
Noticeable heavier vaginal discharge, Susceptible to infection and inflammation |
| Menstruation | Lactobacillus depletedMore alkaline pH
Flora diversified |
Susceptible to infection and inflammation |
Unhealthy lifestyle such as chronic stress, smoking, poor dietary intake, certain intense exercises such as biking/ cycling, tight clothing can result in vaginal microbiome disruption. Also, medications such as antibiotics can also inadvertently disrupt the healthy vaginal flora by stripping off the good lactobacillus bacteria as well.
Untreated STDs are known to cause persistent inflammation in the lower genital tract, resulting in disruption and displacement of the normal healthy vaginal flora. Overtime, one can develop permanent scarring of the reproductive organs.
Frequent unprotected intercourse, different and multiple sexual partner(s) tend to diversify the vaginal microbiome. This is due to changes of the microbiome pH, leading to depletion of healthy lactobacillus and increase the overgrowth of bad bacteria. Without the innate vaginal mucosal barrier protection, one is also susceptible to various STDs.
The uterus is long believed to be a sterile, internal part of the human body. Increasing evidence has shown that the uterus has its own micro-ecosystem, and this is not a carry-over ecosystem from the vaginal microbiome.
Similar to vagina microenvironment, lactobacilli spp can be found in abundance in the uterus healthy lining. Contrary to vagina flora, the uterus normal flora also consists of non-lactobacilli bacteria such as bacteroides spp, pseudomonas spp, acinetobacter spp and etc.
The uterus microbiome is now proven to play a vital role in the outcome of fertility. When there is a dysregulation of the ecosystem, the uterus has a significant reduction in number of lactobacilli spp and increase growth of bacterial-vaginosis-related bacteria. Overtime, the uterus mucosal lining that serves as a protective barrier can be impaired with increased risk of inflammation and infection.
A uterus with predominant lactobacilli spp has a higher success chance in natural conception and assisted reproductive treatments. Those with unhealthy uterus microbiome is associated with poorer reproductive outcome, higher risk of infertility, embryo implantation failure, miscarriages and other obstetric complications.
Vaginal flora disruption is associated with poorer reproductive outcome.
In early part of fertilization or conception, the vaginal microbiome plays a vital role in sustaining the sperm and facilitating the sperm to reach the egg. In a less conducive vaginal microbiome, the sperm is unable to move and swim in the vaginal tract and it may also unable to survive long enough in the woman's genital tract due to an abnormal vaginal environment that is hostile, inflammatory and present of pathogens.
To further insult to the reproductive process, due to susceptibility and increase risk of infection in an abnormal vaginal microbiome, one can have irreversible genital tract/ tube scarring and damage, leading to difficult fertilization of the sperm and egg.
Surfacing medical evidence shows that the imbalance of vaginal flora is associated with pregnancy complications such as recurring miscarriages, failure of implantation, pre-termed labor, low birth rate and etc. In those seeking assisted reproductive treatments/ IVF, an abnormal vaginal micro-environment has lower success rate, with more risk of failure in embryo transfer and implantation.
One may be hesitant to see or discuss such concerns with your healthcare providers. The medical checkup is usually less apprehensive than we thought. Vaginal checkup with vaginal tests and STD tests can be performed at clinic settings. A sterile speculum device is carefully inserted into the vagina to open up the vagina canal. This is followed by a gentle swab test over the vaginal and cervical walls.
Over the years, reliable vaginal smear tests, cultures and PCR tests allow patients and health care physicians to determine accurately any underlying vaginal pathogens. Do consider exploring your vaginal health with your healthcare providers.
The vaginal microbiome plays an important role in fertility and overall reproductive health. If you would like to discuss this further, consultations are available at DB Clinic to help you discuss your concerns and possible care options.
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Cervical cancer is one of the most preventable cancers in modern medicine. It is estimated of globally 600,000 new cases of cervical cancer by the World Health Organization in 2020. Persistent HPV infection is a known main cause of development of cervical cancer. While HPV vaccination significantly reduces HPV infection, thereafter risk of cervical cancer, the vaccine uptake remains slow. Able to identify and modify concurrent risk factors of persistent HPV infection can reduce risk of cervical cancer.
A common vaginal infection known as bacterial vaginosis (BV) can affect up to 30% of women. Although BV is generally a female-related vaginal infection and result from the imbalance of the vaginal microflora, it can play a pivotal role in prevention, or clearance of HPV infection.
In this article, we want to explore the relationship of BV and HPV infection- in both women and men. We strive to understanding the association between the two conditions, encourage medical management of these two pathogenic conditions to minimize the risk factors of developing cervical cancer.
The cervix and the vaginal mucous lining have their own microflora and defense immunity, serving as a main physical barrier against external insults and pathogens. A healthy woman in reproductive age’s cervico-vaginal lining is covered predominantly with Lactobacillus spp. Lactobacilus spp has antibacterial properties, producing chemicals such as hydrogen peroxide, chemo-proteins, an acidic genital pH and create an environment that is unsuitable for bad bacteria or pathogens to thrive.
An intact cervico-vaginal microbiome can act as a physical barrier against STDs including HPV infections, and facilitate with clearance of HPV if contracted.
Women with BV have higher risk of developing cervical HPV infection in comparison to women without BV.
The actual mechanism of BV affecting cervical HPV infection remains unknown, though there are some postulated hypothesis:
All in all, BV predisposes one towards HPV infection and delays clearance of the virus, potentially result in persistent HPV infection and eventually progress to precancerous and cancer of the cervix.
Risk factors of developing both conditions include:
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Vaginal microenvironment plays a vital role in a healthy woman’s sexual and reproductive wellbeing. Often, the alteration and depletion of certain vaginal microbiome such as Lactobacillus spp can be associated with vaginal infections such as recurring yeast infection or bacterial vaginosis. A stable and less diversified microflora with Lactobacillus spp predominance ensures healthy long term vaginal health.
Have you ever wonder why some ladies are more predisposed towards vaginal microflora changes? Even within a same woman, the vaginal microflora can fluctuate with time. Here, we explore on the effects of female hormones, sex, lifestyle, contraception choices on the vaginal microenvironment.
The healthy colonization of vaginal microbiome can be personalized and differs from one another. It is a self-sustaining ‘micro-ecosystem’ that self-regulates, self-cleans, and dynamically change over time due to external factors such as hormone, lifestyle, sex, infections, medications etc. Not unusually, the healthy bacteria that colonizes the vagina can change even over a matter of days.
From the time of puberty into and through adulthood, a healthy vaginal microbiome is predominated by Lactobacillus spp. Furthermore, the amount of Lactobacillus spp increases during pregnancy.
Lactobacillus spp create a low pH microenvironment by production of lactic acid, making the vagina unsuitable for various pathogens and infection. Hence, Lactobacillus spp acts as a vagina defense mechanism against infections. It is currently known that the depletion of lactobacillus spp in the vagina can lead to bacterial vaginosis infections, increases the risk of contracting STDs such as HIV, herpes, chlamydial infections and etc.
Lactobacillus spp typically thrives under the influence of estrogen hormone. During menstruation, due to a cyclical drop of estrogen and rise of progesterone hormones, the amount of Lactobacilus spp decreases and the vaginal microflora becomes diversified leading to increase opportunity of various vaginal bad bacterial colonization, predisposing one towards abnormal vaginal symptoms such as vaginal itch, unusual discharge, discomfort.
Intriguingly, some women’s vaginal microbiome remains stable throughout menstrual cycle, while others may experience temporal and transient shift of the microbiome flora during menses, and bacterial population returns back to normal after period. This is why some women (not all) may experience vaginal infections peri-menstrual period.
Irregular period, due to conditions such as PCOS (polycystic ovarian syndrome) can be associated with vaginal microbiome disruption with reduced lactobacillus spp and overgrowth of bad bacteria such as gardnerella spp, mycoplasma spp and streptococcus spp. While the underlying cause remains elucidated, it is believed the abnormal amount/ratio of the sex (estrogen-progesterone) hormones, increase in testosterone in PCOS altered the normal vaginal pH and microenvironment leading to depletion of lactobacillus spp.
Menstrual blood, with the presence of iron can increase the vaginal pH leading to decrease in lactobacillus amount, resulting in dysbiosis of the vaginal microenvironment and bacterial vaginosis symptoms.
Sex activities during menstruation can affect the vaginal microbiome. The vaginal environment is unstable during period with depletion of lactobacillus spp. Sexual intercourse without barrier contraception can further disrupt the vaginal microenvironment and increase susceptibility of contracting infections including STDs and bacterial vaginosis.
Due to the increasing use of contraceptive methods to prevent pregnancy, understanding the effect of contraceptives on the vaginal microenvironment is important.
Use of spermicides can result in alternation of vaginal microflora. Similarly, physical barrier contraceptives such as condom and cervical cap may be coated with a layer of lubricant/ chemicals or spermicides- have potentials to disrupt the vaginal environment, causing inflammation. Consequently, the vaginal flora can be diversified with lesser amount of lactobacillus spp, and more amount of pathogenic bacteria such as E. coli, Enterococcus spp.
Copper IUD may affect the vaginal microbiome due to long-term presence of a foreign object leading to increase colonization of bacterial vaginosis-related bacteria and decrease in lactobacillus spp.
The clinical literature on the impact of hormonal contraceptives are contradicting although most are favorable towards a stable vaginal microbiome without tempering the amount of vaginal lactobacillus spp. Having said that, it is known that contraceptive hormones can be associated with vaginal yeast infection (candidiasis).
Contraceptive method should be chosen following a patient-physician shared decision after factoring in a person’s health background/ risk, lifestyle and desire for effective birth control and etc.
A stressful lifestyle generally puts the body under inflammation. Stress hormones such as cortisol, adrenaline can cause vaginal microbiome dysbiosis by reduction of lactobacillus spp and increase risk of vaginal infections such as bacterial vaginosis or even contracting STDs.
Lifestyle such as douching is a clinically proven cause of vaginal microbiome disruption. Douching is associated with increase vaginal pH, lesser lactobacillus spp and high association with vaginal infections such as bacterial vaginosis.
Menopause is a physiological state where a woman has completed her reproductive career. There is a significant reduction in reproductive hormones including estrogen. As a result, in postmenopausal woman, there is significant reduction in amount of lactobacillus spp, and increase in diversity of the vaginal microbiome and anaerobic bacteria including vaginosis-related bacteria such as gardnerella spp and others.
If you have symptoms as below, you should consult your doctor that you are comfortable with.
Your doctor will physically examine you and prescribe medications accordingly to treat underlying vaginal infections. Vaginal swab tests or urine tests may be offered depending on your symptoms and condition. Blood tests and ultrasound imaging can be offered if underlying hormone or menstrual disorders are suspected.
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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.
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