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Health Corner

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Chest pain does not necessarily equate to heart pain. Chest pain refers to any discomfort or pain at the front of the body between the neck and the upper abdomen. It is quite common, with up to 25% of people experiencing it at some point in time of their lives. It can manifest in different forms ranging from sharp pain to dull ache, localised at a spot to radiation to neck/ arms/ back.

CAUSES OF CHEST PAIN

HEART CAUSES

Chest pain due to heart disease may have the following characteristics -

  • Tightness / pressure / fullness / crushing pain at chest area
  • Pain may radiate to jaw, neck, arms, back
  • Worse with exertion
  • May be associated with difficulty breathing, cold sweats, dizziness, nausea, vomiting


Risk Factors

  • Age - >45 years for men, >55 years for women
  • Chronic medical problems – hypertension, diabetes, high cholesterol, obesity
  • Lifestyle factors – unhealthy diet, sedentary lifestyle, smoking
  • Family history of heart disease, high cholesterol


Typical Causes

  • Heart Attack – no blood flow to heart muscle
  • Coronary heart disease, Angina – poor blood flow to heart muscle due to plaque formation in the arteries that supply the heart muscles.
  • Aortic Dissection – tear in wall of aorta
  • Pericarditis – inflammation of sac surrounding the heart
  • Myocarditis – inflammation of heart muscle
  • Hypertrophic Cardiomyopathy – genetic disease with thickened heart muscle
  • Mitral Valve Prolapse - failure of heart valve to close properly


LUNG CAUSES

Chest pain due to lung disease may have the following characteristics -

  • Sharp pain associated with breathing, sneezing, coughing
  • May be associated with fever, chills, cough, difficulty breathing


Risk Factors

  • Chronic medical problems – hypertension, diabetes, heart disease, obesity, cancer
  • Recent surgery
  • Lifestyle Factors – sedentary lifestyle


Typical Causes

  • Pneumonia (lung infection)
  • Pulmonary Embolism – blood clot from deep vein thrombosis travel into lungs
  • Pneumothorax – part of lung collapses resulting in release of air into chest cavity
  • Asthma and Bronchitis


BREAST CAUSES

Chest pain due to breast disease may have the following characteristics -

  • Sharp pain or tenderness before menses
  • May be associated with breast lumpiness


Risk Factors

  • Personal medical history of breast problem e.g. breast nodule/ cyst
  • Family history of breast cancer


Typical Causes

  • Breast Cyst – fluid filled sac in breast
  • Fibrocystic breast disease – build-up of cysts and fibrous tissue
  • Mastitis – painful infection of the breast
  • Breast Cancer
  • Medications e.g. oral contraceptive pill, hormone replacement therapy


MUSCLE AND BONE CAUSES

Typical Causes

  • Costochondritis – inflammation of the cartilage of ribcage
  • Fibromyalgia – sore muscles
  • Muscle strain
  • Rib fracture


DIGESTIVE CAUSES

Chest pain due to digestive disease may have the following characteristics -

  • Burning sensation in chest or throat, may be worse after eating or at night
  • May be associated with sour taste in mouth, difficulty swallowing, sensation of lump in throat, black stools, appetite change, weight loss


Risk Factors

  • Chronic medical problems e.g. obesity
  • Pregnancy
  • Medications e.g. aspirin
  • Lifestyle Factors – smoking, alcohol, tea, coffee, carbonated beverages, spicy / fatty foods, large meals, late night meals


Typical Causes

  • Gastroesophageal Reflux Disease (GERD) – reflux of stomach contents, acid into the oesophagus (food tube)
  • Oesophagus disorders
  • Peptic Ulcer Disease – sore in stomach lining, which may be related to Helicobacter pylori bacteria infection and painkiller medicines.
  • Stomach cancer
  • Gallstones
  • Pancreas problem e.g. pancreatitis – inflammation of pancreas


OTHER CAUSES

Typical Causes

  • Panic attack – symptoms may include sharp chest pain for short duration that is not related to exertion, heart beating fast, difficulty breathing, tingling sensation hands
  • Shingles – viral nerve infection that may cause chest pain before painful blistering rash


What will the doctor do?

Besides a thorough medical history, family history, the doctor will do a physical examination and recommend relevant investigations. Management will be dependent on the most likely cause of the chest pain.

Investigations

  • Heart – Electrocardiogram, 2D Echocardiogram (scan to look at heart structure, valves and function), Treadmill Stress test (check for reduction in blood supply to heart muscles) , CT coronary angiogram (non-invasive scan to look at heart arteries for plaques) , blood test for cardiac enzymes (check for heart attack)
  • Lungs, Bones – Chest and ribs x-ray, CT thorax
  • Digestive system – Urea breath test (simple test for Helicobacter pylori), Ultrasound Abdomen (scan for liver lesion, gallstones, pancreas lesion), Gastroscopy (day surgery procedure to visualise the oesophagus and stomach via a thin tube with camera)
  • Breasts – Mammogram, Ultrasound Breasts


Self Care

  • Seek immediate medical attention 995 if you have chest tightness/squeezing sensation, associated with difficulty breathing, cold sweats, dizziness. When in doubt, err on the cautious side as treatment in the first hour following a heart attack is crucial to improve the chance of survival. Women – do be aware that symptoms of heart attack may be less typical.
  • Diet - Eat small regular meals that is less spicy, fatty and greasy. Reduce citrus fruits, coffee, tea and carbonated beverages. Sit upright during meals and do not lie down 1 hour after meals. Avoid late night meals.
  • Avoid alcohol consumption and smoking.
  • Avoid clothes that are tight fitting around the belly area.
  • Elevate the head of bed by 20cm with use of wooden blocks under the mattress
  • Adopt stress relaxation techniques e.g. deep breathing.
  • Maintain healthy weight.
  • Go for health screening every 1 to 2 years to check for chronic medical conditions e.g. hypertension, diabetes, high cholesterol, heart disease so that early intervention can be instituted. Ensure good control of these medical conditions.



“I need Panadol, I have a HEADACHE!”—Sounds familiar?

It has been estimated that almost half of the population have had a headache at least once within the past year. Headache is a worldwide problem, affecting people of all ages, races and socioeconomic status. Headache can affect our quality of life, family life, social life and work performance and productivity. Headache can also impose financial cost on companies. And because it is a subjective complaint, others may not be able to appreciate how debilitating it may be.

CAUSES OF HEADACHE

BRAIN

Problem Typical Features
Cluster Headache One sided side around the eye, head, face, may be associated with eye redness, stuffy nose.

Headache attack of short duration, about same time each day.

More common in people who smoke / drink alcohol.
Migraine One sided throbbing pain associated with nausea, vomiting, sensitivity to light, sound, smell.

Headache may last for hours to days.

May have aura before headache e.g. bright spots/flashes of light, vision loss, pins and needles sensation in limbs.

Common triggers include stress, fatigue, weather change, bright light, strong smell, menstruation, foods e.g. MSG, food additive, caffeine and alcohol.

More common in women and those with family history of migraine.
Tension Headache Dull aching pain/pressure at forehead/side of head/ back of head, may be associated with tenderness of neck and shoulder.

Headache may last for minutes to days and may be triggered by stress.
Brain aneurysm, arteriovenous malformation, tumour Aneurysm is a bulge in the blood vessel. Arteriovenous malformation is an abnormal tangle of blood vessels connecting arteries and veins. Tumour can be non-cancerous or cancerous with origin in the brain or spread from elsewhere.

Ruptured aneurysm and arteriovenous malformation as well as brain tumour can cause severe headache associated with weakness, numbness, confusion, loss of consciousness, seizure, vision problem.
Stroke Stroke occurs when blood supply to part of brain is reduced. Besides headache, other symptoms include paralysis/ numbness of face, arm and leg, slurred speech, confusion, vision problem.

Risk factors include obesity, hypertension, diabetes, high cholesterol, heart disease, obstructive sleep apnoea and smoking.
Concussion, Intracranial hematoma These are caused by trauma to the head. Concussion is usually temporary but post-concussion syndrome may last for more than a year. Intracranial hematoma occurs when the blood vessel in the brain ruptures resulting in blood collection within the brain or pressing on the brain.

The headache is associated with dizziness, nausea, vomiting, vision problem, slurred speech, loss of memory &/or consciousness.
Meningitis, Encephalitis This refers to infection of the brain caused by viruses and bacteria e.g. pneumococcus (bacteria that causes pneumonia), meningococcus, herpes simplex virus (virus that causes cold sore), varicella zoster virus (virus that causes chicken pox and shingles).

The headache is associated with fever, stiff neck and fatigue. There may be seizure, speech problem, confusion and loss of consciousness.

HYPERTENSION

Problem Typical Features
Hypertension Most cases of hypertension do not have symptoms.

During a hypertensive crisis whereby the blood pressure is 180/110mmHg, symptoms such as headache, blurring of vision, confusion, seizure, chest pain, shortness of breath can present.

EYES, EARS, NOSE

Problem Typical Features
Glaucoma Acute closed angle glaucoma occurs when the flow of fluid out of eye is blocked and the eye pressure increases rapidly suddenly, resulting in severe headache, eye pain and redness, blurred vision, halos, blindness, nausea and vomiting.
Middle Ear infection Associating symptoms include ear pain, ear discharge, difficulty hearing.
Sinus infection Headache at forehead is accompanied with pain around eyes, cheeks, nose and associated with nasal congestion and thick green yellow nasal discharge. There may be fever, cough and sensation of ear pressure.

FEBRILE ILLNESS

Problem Typical Features
Upper respiratory tract infection e.g. flu, common cold Associating symptoms include fever, cough, runny nose, sore throat, bodyache.
COVID-19 Associating symptoms include fever, cough, runny nose, sore throat, bodyache, loss of smell/taste.

ACTIVITIES

Problem Typical Features
Cough Headache Headache is sharp and localised at front or sides of head, of short duration and triggered by coughing, sneezing, laughing, crying.
Exercise Headache Throbbing headache at both sides of head that occurs during or after strenuous exercise.
Sex Headache Dull or throbbing pain that occurs before or during orgasm, more common in males.
Ice cream Headache Sharp stabbing pain in forehead triggered by eating/ drinking cold food/drink.
Medication overuse Headache/ Rebound Headache Long term overuse of painkillers e.g. Panadol, NSAIDS, codeine medicine, medicine with caffeine and sleeping pills can cause daily headache that wakes a person from sleep and may be associated with nausea, irritability, concentration and memory issues.
Hangover This occurs in the morning after night of heavy drinking. The headache is associated with dizziness, nausea, vomiting, thirst and sensitivity to light & sound.

Headache may be a symptom of a serious life-threatening condition.

Do consult a doctor if you have sudden, severe headache or headache associated with –

  • High Fever
  • Stiff neck
  • Vision problem
  • Slurred speech
  • Numbness / weakness face or limbs
  • Confusion
  • Seizure
  • Trauma


What will the doctor do?

  • Thorough personal medical history
  • Details about the headache and associating symptoms
  • Family history
  • Travel history
  • Physical Examination – temperature, blood pressure, eye and ear exam, respiratory exam, neurological exam
  • Investigations
    • Blood test for infection
    • Eye tests such as tonometry to check for glaucoma
    • CT brain, MRI brain – to check for brain aneurysm, brain arteriovenous malformation, brain infection, brain tumour, intracranial hematoma and stroke
    • Blood test for infection
  • Treatment is dependent on the cause of the headache. For short term pain relief – painkiller medications can be used. For chronic frequent headache, preventive medications e.g. blood pressure pills, antidepressants, anti-seizure medicine can be considered.


Self Care

  • Healthy Eating, regular meals, keep a food diary to track food triggers and avoid suspect foods.
  • Regular Exercises
  • Adequate Sleep with regular sleep time and minimize distractions before bedtime.
  • Stress management –
    • Stay Positive, Active and Motivated
    • Manage your time with prioritisation of work
    • Take regular breaks to relax and provide time for yourself to recharge
    • Communicate and socialize, do not keep troubles bottled up
    • Adopt relaxation techniques e.g. deep breathing
    • Seek professional help e.g. counselling hotlines, psychologist, psychiatrist




Women have a love hate relationship with menses. We are worried about too much menses and too little menses. We complain about how we hate the cramps during our menses and yet we long for menses as menopause is dreadful. As a female physician with experience in gynaecology, I have seen many ladies with troubling menstrual problems. In this article I will share insights on common menstrual issues.

HEAVY /PROLONGED MENSES & BLEEDING BETWEEN MENSES
BLEEDING AFTER SEX OR MENOPAUSE

It is important to understand your menstrual cycle. Keep track of your menses using a calendar – document the 1st day of menses and keep track of the flow and duration. Normal menstrual cycle ranges from 21 to 35 days – this refers to the number of days between 1st day of current menses and 1st day of next menses. Normal menstrual flow lasts 2 to 7 days.

What is considered as heavy/ prolonged menses?

➢ Need to change soaked pad / tampon every hour for a few consecutive hours

➢ Need to use double sanitary protection

➢ Need to wake up in middle of night to change sanitary protection

➢ Pass large blood clots

➢ Bleeding for more than a week

What is considered as bleeding between menses?

➢ Any bleeding or spotting out of the usual menses

What is considered as bleeding after menopause?

➢ Any bleeding or spotting after menopause. Menopause is defined as absence of menstrual period for more than a year, usually in age group 45 to 55 years old.

Why do you need to see a doctor?

Excessive bleeding can lead to anaemia (low blood count). Anaemia can cause symptoms eg giddiness, fatigue, breathlessness and hair loss..

There are benign conditions such as mid cycle spotting due to ovulation, trauma from rough sex, atrophic vaginitis due to menopause as well as stress and lifestyle factors that may lead to the abnormal menses / bleeding.

But there are also serious medical conditions that can contribute to abnormal menses / bleeding – What will the doctor do?

The doctor will ask you about your medical history and menstrual cycle – hence a menstrual calendar is useful for you to jot down the dates and amount of flow.

Recommended tests may include the following -

1) Pelvic examination and PAP smear – to check for endocervical polyps, precancer (CIN) and cervical cancer

2) Vaginal swab for infection such as HPV, chlamydia, gonorrhoea, trichomonas

3) Ultrasound pelvis – to check for uterine fibroids, adenomyosis, endometrial polyps, ovary cysts, uterine cancer, ovary cancer

4) Urine or blood test for pregnancy

5) Blood test for full blood count, CA125 (ovary cancer marker), thyroid function, liver function, kidney function, female hormones

6) Endometrial biopsy, hysteroscopy, dilatation and curettage – to check for uterine cancer

7) Colposcopy – to check for precancer (CIN) and cervical cancer

Depending on the medical condition, severity, childbearing plans and personal preference, the doctor will then recommend the most appropriate treatment.

Conservative approach is the usual first line treatment for benign conditions such as uterine fibroid. Fibroids are non-cancerous growths in the womb that can cause heavy or prolonged menses. Surgery is only recommended if the fibroids are large or causing severe bleeding or pain in spite of medical therapy.

In general, to regulate menses, medications such as NSAIDS painkillers, tranexamic acid, oral contraceptives, progesterone-based medicine as well as hormonal IUCD can be considered. Nutritional supplement with iron may also be required if the blood count is low.

NO MENSES

There are 2 types of medical conditions – those who have not had menses by age 16 years old and those who have no menses for 3 consecutive months. We will focus our discussion here to the latter.

Causes

1) Stress and lifestyle factors e.g. extreme weight loss, underweight, poor nutrition, over exercise

2) Natural factors e.g. pregnancy, breastfeeding, menopause

3) Medications e.g. depo provera injection for birth control, antidepressants, chemotherapy

4) Hormonal issues
• Polycystic ovary syndrome
• Pituitary tumour
• Hypothyroidism
• Premature menopause

5) Structural issue e.g. uterine scarring

6) Chronic medical condition e.g. depression

What will the doctor do?

Besides a thorough medical history & physical examination, the doctor will recommend some tests –

1) Urine or blood test for pregnancy

2) Blood test for hormones- FSH, LH, estrogen, progesterone, testosterone, prolactin and thyroid function

3) Ultrasound pelvis for structural abnormalities and signs of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common hormonal disorder in women of reproductive age group. Ovaries develop small follicles and fail to release eggs regularly. Besides irregular menses, other issues include acne, excess hair growth, weight gain, insulin resistance, increased risk of hypertension, diabetes, high cholesterol and infertility.

Lifestyle management for polycystic ovary syndrome includes healthy diet with low carbohydrates combined with regular exercises for weight reduction. If you are not planning for baby soon, medication to regulate menses with use of oral contraceptives and metformin improvement of insulin resistance can be considered. If you have fertility issue, medication to promote ovulation can be considered.

PAINFUL MENSES

Most women experience menstrual cramps at some point in their lives. Menstrual cramps can range from a mild nuisance for a day to severe intolerable pain that lasts for days and interferes with daily activities. The cramps usually start a day or two before the menses, peak 24 hours upon onset of menses and subsides in 2-3 days. It can be a dull ache or throbbing pain at the lower abdomen and back. It can be associated with dizziness, nausea, headache, fatigue and loose stools.

What will the doctor do?

The most common cause of painful menses is due to womb contractions due to prostaglandin chemical. The strong contractions can press the nearby blood vessels. This may temporarily cut off oxygen supply to the womb muscles, thus resulting in pain. This type of menstrual cramp usually starts once a girl has her menses, and becomes less painful with age and after giving birth.

Do see a doctor if you have never had menstrual cramps before and you start having painful menses after 25 years old. You should also see the doctor if the menstrual cramps worsen or disrupt your daily activities every month. This is because the painful menses may be caused by diseases of the female reproductive organs.

Causes

1) Endometriosis
This condition affects about 10% of women in reproductive age group worldwide. This is an estrogen dependent disease whereby the endometrial tissue from the womb consisting of blood, gland and connective tissue, migrates to other areas e.g. ovaries and fallopian tubes, instead of being expelled during menstruation.
Besides painful menses, endometriosis may cause painful intercourse and can result in complications such as ovary cysts, scar tissue, adhesions, infertility, intestinal and bladder complications and increased risk of ovary cancer.

2) Uterine fibroids
This refers to non-cancerous growth of smooth muscle cells in the womb. This condition affects about 20% of women in reproductive age group worldwide. Fibroids can result in anaemia from heavy bleeding, problems with urination and bowel movement and infertility. They usually regress after menopause.

3) Adenomyosis
This is a condition whereby the endometrial tissue that lines the womb grows into the muscular wall of the womb, resulting in the enlargement of the womb. Adenomyosis can result in chronic pelvic pain and anaemia from heavy bleeding.

4) Ovary cyst
This refers to a fluid filled sac in the ovary. Most ovary cysts are functional and may disappear. Some cysts may grow to become cancerous, or may twist or rupture resulting in severe pelvic pain.

5) Pelvic inflammatory disease
This is an infection of the reproductive organs, usually caused by sexually transmitted bacteria. It can cause fever, abdominal pain, vaginal discharge and painful urination. Complications include infertility, ectopic pregnancy, tubo-ovarian abscess and chronic pelvic pain.

What will the doctor do?

The doctor will ask you about your medical history, menstrual cycle, flow and associated symptoms.

Recommended tests may include the following –

1) Pelvic examination – to check for any signs of endometriosis, pelvic inflammatory disease

2) Vaginal swab for infection such as HPV, chlamydia, gonorrhoea, trichomonas

3) Ultrasound pelvis – to check for uterine fibroids, adenomyosis, ovary cysts

4) Blood Test for CA125 ovary cancer marker

5) Laparoscopy – keyhole surgery with camera to look for any scarring, adhesions, ovary cysts, endometriosis. During the surgery, removal of endometriotic tissue and scar tissue can also be done.

Depending on the cause of the painful menses, severity and childbearing plans, the doctor will recommend the most appropriate management.

First line treatment is pain control with use of simple analgesia – off the counter painkiller, NSAIDS group of painkillers. Do make sure that you are not allergic to the medicine and take the painkiller as soon as you have your menses, preferably before the pain starts.

The next line of treatment would be hormone therapy with either oral contraceptive pills or progesterone-based medicine. Depo provera injection and Hormonal IUCD can also be considered.

Last line of medical treatment for endometriosis is the use of short course Gonadotropin releasing hormone analogue which causes the ovaries to stop producing estrogen thereby causing the endometriotic tissues to shrink. This results in temporary menopause.

Surgery is recommended in 3 scenarios -

1) Endometriotic lesions are big, more than 5cm
2) Medical therapy fails
3) Fertility issue

What can you do?

1) Heat therapy with use of heat pad, hot water bottle

2) Regular exercises

3) Supplements e.g. omega 3, magnesium, vitamin B and E may be useful

4) Acupuncture



Vaginal discharge is part and parcel of a woman’s life, regardless of age group. It consists of fluid made by glands in vagina and cervix. It has a role to play by keeping the vagina clean and protecting it from infection.

Most of the time, vaginal discharge is normal. The amount, consistency and colour of the vaginal discharge may vary with factors such as menstrual cycle, arousal, pregnancy, breastfeeding. In general, normal vaginal discharge can be clear or white, thick and sticky or slippery and wet. It usually doesn’t have a strong or unpleasant smell.

When should I see a doctor?

1) Colour or consistency or smell of the vaginal discharge changes

2) Itch or burning sensation at the genitals

3) Pain during intercourse

4) Pain during urination

5) Associating symptoms of fever and pelvic pain

Causes of Abnormal Vaginal Discharge


What will the doctor do?

The doctor will ask you about your medical history, sexual history, nature of vaginal discharge and any associating symptoms.

Recommended tests may include the following -

1) Pelvic examination and PAP smear – to check for characteristics of vaginal discharge and evidence of ulceration, vaginitis, cervicitis and pelvic inflammatory disease

2) Vaginal swab for infection such as HPV, chlamydia, gonorrhoea, trichomonas

3) Urine test – to check for urinary tract infection

4) Blood test – to check for diabetes in recurrent yeast infections

Presumptive treatment based on the initial assessment will be instituted by the doctor first while waiting for the lab results.

For yeast infection, oral antifungal medicine or suppository will be useful

For bacterial vaginosis, trichomonas, chlamydia and gonorrhoea infection, course of oral antibiotics will be required. Screening for concomitant sexually transmitted diseases will be advisable. Partners should also be screened.

Prevention

1) Wear cotton underwear as it does not retain heat and moisture. Avoid tight fitting pants/jeans/ pantyhose. Minimize usage of pantyliners as yeast thrives in damp environments.

2) Practise good personal hygiene – always clean from front to back after visiting the bathroom to avoid transmitting germs from the anus to vagina.

3) Avoid staying in wet clothes / swim wear for prolonged period.

4) Avoid scented wash and spray, scented tampons and pads, vaginal douches as these may affect the balance of yeast and bacteria in the vagina.

5) Consider probiotic feminine wash and oral probiotics to replenish healthy bacteria.

6) Supplement with oral probiotics when you are on a course of antibiotics. Avoid unnecessary antibiotic use.

7) Eat a well-balanced diet that is low in sugars. Curcumin supplement may also be useful.

8) Manage diabetes well.

9) Always practise safe sex with use of condoms, unless planning for pregnancy. When using sexual lubricants, choose water-based ones.



For most women, finding a lump in the breast is frightening as breast cancer is the top thing that comes to mind. The fear stems not just from the diagnosis of cancer but also the treatment process and side effects. The danger arises when some women are so overwhelmed by fear and anxiety that they postpone doctor consultation and tests, hoping for the breast lump to go away. This fear is understandable but do make sure that it does not interfere with your health and delay the precious time for early intervention and better outcome. A breast lump deserves medical attention.

BREAST SELF EXAMINATION

Stay in tune with your body, listen to the body’s signals. Mark on your calendar - Make it a point to check your breasts once a month. By doing so, you will develop an eye for anything unusual. Being familiar with how your breasts look and feel will make it easier for you to pick up any changes.

Step 1

Choose a date for breast self-exam – after menses is preferred. For pregnant and menopausal women, you can assign your favourite day of the month.

Step 2

Look at your breasts in front of the mirror for any puckering, dimpling, changes in size, shape or symmetry. Do this in different positions - hands on hip, and arms above head.

Step 3

Lie down on your back. Use the finger pads of your 3 middle fingers with circular motion and varying level of pressures to examine all levels of breast tissue. Follow a pattern e.g. clockwise or anticlockwise – from outer part to inner part of the breasts. End with examination of the armpits.

WHEN SHOULD I SEE A DOCTOR?

1) Lump in breasts or armpits
2) Change in the way your breasts look or feel
3) Puckering or dimpling or rash of the breasts
4) Pain or redness or swelling of the breasts
5) Change in nipple e.g. nipple inversion
6) Nipple discharge

Do not panic yet, do schedule a date with your doctor for a clinical breast examination. Remember, most breast lumps are not cancerous, but it is still important to have a check as soon as possible.

Radiation dose from an 8 hr airplane flight = 0.04mSv
Radiation dose from mammogram = 0.4mSv
Radiation dose from chest XR = 0.1mSv
Accumulated dosage to cause fatal cancer years later in 5% of people = 1000mSv
Based on this, a lady will have to undergo at least 2000 mammograms to accumulate a cancer-causing radiation dose.

IMAGING TESTS

1) Mammogram

Mammogram is a non-invasive screening tool that utilizes low-dose xray to examine the breasts. The machine works by compression of the breasts for a few seconds to flatten the breast tissue so that abnormalities can be clearly visualized. From the mammogram, we are able to detect cancerous as well as benign calcifications. We do not routinely do mammogram for women under 40 years of age since their breast tissue tends to be denser and this can affect the accuracy of the mammogram. Hence for women under 40 years of age with breast symptoms, it is advisable to consult a doctor for further advice and investigation.

Some centres offer breast thermography as an alternative. This uses infrared technology to detect temperature changes on the skin surface. When a cancerous growth develops, there may be excess production of blood vessels resulting in elevated skin temperature. There is a high rate of false positive and false negative – it can show changes that are not cancerous and it can also fail to detect cancerous changes. Hence it has not been shown to be an effective screening tool for breast cancer.

2) Ultrasound Breasts

Ultrasound breasts is a non-invasive test that uses high frequency sound waves through the breasts to convert into images. There is no radiation involved. It is a good test for breast lumps- to ascertain the nature of the breast lumps. Breast calcifications cannot be seen via ultrasound.

3) MRI Breasts

MRI breasts is a non-invasive test that involves magnet and radio waves and use of contrast injection to take pictures of the breast tissues. This is usually reserved for women with breast implants or when the diagnosis is inconclusive using standard modalities.

Based on the medical history, physical examination as well as the imaging test results, the doctor will discuss the possible action plans with the patient in the shared decision making for the most appropriate course of action.

Based on the breast lump’s characteristics in ultrasound, we can determine how likely it is to be benign. Features commonly seen in non-cancerous lumps – smooth, well circumscribed, few lobulations, more echoes.

Possible causes of non-cancerous breast lumps include the following:

1) Breast cyst
2) Fibrocystic disease / change
3) Fibroadenoma
4) Breast abscess
5) Lipoma

If the factors suggest the breast lump is likely benign, your doctor may recommend close follow-up with monthly breast self-exam and follow-up mammogram and/or ultrasound breasts at closer intervals e.g. 6-monthly.

If there are features such as ill-defined borders, spiculated margins, posterior acoustic shadowing, less echoes, branch pattern, punctate calcifications, microlobulation – the breast lump may be indeterminate or malignant (cancerous). Follow-up with a breast specialist will be highly recommended with a view for biopsy for confirmation.

GENETIC BLOOD TEST

Genetic blood test using DNA analysis to identify mutations in breast cancer susceptibility genes – BRCA1 and BRCA2 is available. People with such mutations are at increased risk of developing breast cancer and ovarian cancer.

This blood test is NOT routinely offered as the results are not always clear-cut. A Positive result means that you have a gene mutation and the breast cancer risk is higher and close action plan with your doctor is required.
A Negative result means that you do not have the gene mutation or you may have a gene mutation that has not been discovered yet.
An Inconclusive result / Gene Variant means you have a genetic change which has not been previously associated with cancer in others – hence the cancer risk is unclear.

Therefore, this test is only recommended for those with personal or family history of breast or ovarian cancer.

BREAST BIOPSY

This is a procedure done by the breast specialist whereby a tissue sample is removed and examined under the microscope for presence of breast cancer. Based on the appearance, size and location of the breast lump, the specialist will recommend the best type of biopsy.

Breast biopsy options include-

1) Fine needle aspiration biopsy - use of thin needle attached to syringe
2) Core need biopsy – use of a larger needle
3) Stereotactic biopsy – needle biopsy with assistance of mammogram images from different angles
4) Vacuum assisted biopsy – use of a probe connected to vacuum device eg mammotome
5) Surgical biopsy – a small cut is made in the skin and breast tissue to remove part or all of the lump

Do bear in mind that even if the breast lump is proven to be non-cancerous by breast biopsy, regular follow-up is still essential as changes may still occur. Living with benign breast condition may be emotionally hard because of a small risk of a non-cancerous lump turning into cancer.



With the government’s circuit breaker measure instituted from 7th April 2020, most people in Singapore are required to stay at home except those working in essential services. People can only go out masked up to buy groceries, food, exercise (limited to brisk walking, jogging, cycling) and seek medical attention.

This would mean that most people are cooped up at home either alone, or with their spouse, children and parents almost 24/7. This is a useful measure to curb transmission of COVID-19. But it can also pose strains to one’s physical and mental health as well as relationships.

In this article, I hope to share with all of you – some steps you can adopt to stay strong, sane and safe in this stressful COVID-19 situation.

HEALTH TIPS

HEALTHY EATING AT HOME

1) Shopping for the kitchen

Make a shopping list to minimize time spent at the supermarket / market. If you are a novice cook, do stock your kitchen with ingredients for easy to prepare meals.

Go supermarket / market shopping once a week instead of daily.

During grocery shopping, keep at least 1 metre distance from others and refrain from touching your face and mask. If possible, sanitise the handles of the shopping trolleys or baskets before use. If possible, go cashless. Sanitise your hands after using self-checkout counters.

Once home, wash your hands thoroughly with soap and water. Clean the external surfaces of all the grocery items. Change into ”indoor’’ clothes and wash the “outdoor” clothes.

Stock your fridge with fruits for snacking, fresh and frozen vegetables. Broccoli, brussel sprouts and sweet potatoes can be kept for a long time outside the freezer.

Brown rice and whole grains are healthy options.

When buying canned / frozen / dried foods, choose those with lower fat, salt and sugars.

2) Cooking and eating at home

Search for healthy recipes. Create meals with carbohydrates, protein as well as fruits and vegetables to ensure a balanced diet.

Separate raw and cooked food. Cook thoroughly and keep food at safe temperatures. Wash fruits and vegetables thoroughly with clean water.

Avoid unhealthy cooking techniques eg deep frying. Cut back on salt, sugar and oil.

Avoid stress eating especially binging on unhealthy snacks eg potato chips, cookies, cakes, desserts.

Ensure sufficient hydration with lots of water in this hot weather.

3) Takeaway food

Make healthy choices when ordering takeaway food.

Wash the disposable cutlery before use.

WORK FROM HOME

1) Keep to a structured daily schedule with normal sleep cycle – as per your usual work hours.

2) Choose a dedicated and comfortable space for work, preferably a place with good natural lighting. Do not work on your bed as this may affect productivity and your sleep regime.

3) Change out of your pyjamas. Taking care of your appearance will boost your self-esteem.

4) Consider standing up to work to burn some calories. When seated, do simple exercises such as leg lifts, knee lifts, toe curls.

5) Stay sane by taking regular breaks to recharge and refresh. Set alarm to remind yourself about activity breaks – walking / stretching breaks. Dance in the house with some music in the background. Go out of your house and climb some stairs. Consider yoga and meditation.

6) Socialize with co-workers via text, video calls, zoom. Communication helps one feel connected to others. This helps to minimize feeling of isolation and loneliness.

7) Have a buffer to signal the end of work day so that your brain can transition into non work mode, eg a nice shower, a walk with your dog. Relax at the end of work day with other activities eg games, TV.

EXERCISES AT HOME

Regular physical activity benefits both the mind and body. Exercise has been proven to reduce blood pressure, reduce weight and reduce risk of diabetes, heart disease, stroke and osteoporosis. It also helps to improve muscle strength, flexibility, energy and fitness. In addition, it is vital for our mental health – to reduce risk of depression, cognitive decline and early dementia. It also enhances your mood and sleep.

1) Incorporate 30 minutes of moderate intensity exercises into your timetable daily.

2) Strengthen muscles with weights – improvise with 1 litre water bottles. Do squats, sit-ups and push-ups.

3) Do household chores eg mop or vacuum at a faster pace, ironing of clothes, gardening.

CLEANING OF YOUR HOME

Research suggests that the COVID-19 virus may live on surfaces for some time.

For disinfection of areas likely to be contaminated eg door knobs, railings, faucets, worktables, keyboard and mouse, telephones, do consider household cleaning products with suitable active ingredients eg accelerated hydrogen peroxide, benzalkonium chloride, chloroxylenol, ethyl alcohol, isopropanol, iodine, sodium hypochlorite and sodium chlorite. Examples of brands include Bleach, Chlorox, Dettol, Lysol and Walch etc.

Wash hand towels frequently. Remove shoes and outdoor clothes once home and take a bath to decontaminate.

HEALTH CARE

Do keep in mind that COVID-19 is not the only medical illness that we can succumb to. There is a multitude of medical problems ranging from the common cold, gastric flu to chronic medical conditions such as hypertension, diabetes, heart disease and cancer.

Health screening and vaccinations are considered as non-essential services during this circuit breaker period. However, if you do feel unwell, do seek medical attention at the nearest clinic / polyclinic / our medical centre.

Symptoms that you should not ignore

1) Respiratory symptoms eg running nose, sore throat, cough, breathing difficulty

2) Fever

3) Gastrointestinal symptoms eg vomiting, abdominal pain, diarrhoea, blood in stools, change in bowel movements

4) Persistent headache, giddiness

5) Frequent bleeding from nose

6) Chest pain

7) Breast lump

8) Urination symptoms eg painful urination, blood in urine

9) Menstruation problems eg abnormal vaginal bleeding or vaginal discharge

MEASURES TAKEN AT ASIA HEALTHPARTNERS

1) The medical centre is cleaned and sanitised regularly. Seats are spaced 1 metre apart.

2) All patients are screened by health declaration form and temperature check. Accompanying visitors are advised to wait outside premise.

4) Patients with travel history in past 14 days OR respiratory tract symptoms eg fever or cough or runny nose or itchy/sore throat are advised to defer the review / followup procedures.

5) Patients with respiratory tract symptoms will be able to consult doctor in isolation room only.

6) Appointment scheduling helps ensure that minimal patients are at our centre at each point in time.


DEFINITION OF COUGH

Cough is a voluntary or involuntary action that clears your throat of mucus, fluids, microbes, foreign particles and irritants.

There are 3 phases involved in a cough –

1) Breathing in

2) Vocal cords closed with increased pressure in throat and lungs

3) Vocal cords open with explosive release of air resulting in a cough with a sound

Cough can be classified into 3 categories

1) Acute – duration less than 3 weeks

2) Subacute – duration 3 to 8 weeks

3) Chronic – duration more than 8 weeks

COMMON CAUSES OF ACUTE COUGH

1) Common Cold

This is caused by a variety of respiratory viruses eg rhinovirus. Symptoms are usually of gradual onset and less intense.

Symptoms = low grade fever, runny/stuffy nose, sore throat, mild to moderate cough

2) Flu (Influenza)

This is caused by influenza viruses. Symptoms are usually abrupt and worse.

Symptoms = high fever, headache, body ache, chills, dry persistent cough, sore throat, runny/ stuffy nose

This can result in complications such as pneumonia, bronchitis, asthma attacks, ear infection, heart problem.

3) COVID-19

This is caused a novel coronavirus 2019-nCoV.

Symptoms = fever, cough, sore throat, runny nose

This can result in complications of acute respiratory distress syndrome (fluid leak into lungs), acute respiratory failure (failure of lungs to pump oxygen to blood), pneumonia, acute liver injury, acute injury to heart and sepsis (infection into the bloodstream)

4) Bacterial Upper Respiratory Tract Infection & Pneumonia

Pneumonia refers to infection of the lungs which can be caused by viruses, bacteria or fungi.

Common bacteria causes include Streptococcus pneumoniae/Pneumococcus, Haemophilus influenzae, Staphylococcus aureus, Klebsiella and Mycoplasma.

Symptoms = fever, chills, cough, chest pain associated with breathing / coughing, shortness of breath

This can result in complications such as fluid in lungs (pleural effusion), pus in lungs (abscess), bacteria in blood stream (sepsis), difficulty breathing requiring use of ventilator.

5) Whooping cough (Pertussis)

This is caused by the Bordetella pertussis bacteria.

Symptoms = coughing fits with severe hacking cough followed by a high-pitched whoop sound, runny nose, watery eyes, low grade fever

COMMON CAUSES OF CHRONIC COUGH

1) Postnasal drip / Allergic rhinitis / Vasomotor rhinitis (sensitive nose)

Rhinitis is a condition with inflammation of nose lining. Allergic rhinitis is triggered by allergens eg dust mite, pet dander. Vasomotor rhinitis is induced by temperature fluctuations and air pollutants. Symptoms include runny nose, congested nose, sneezing, itchy eyes, cough, headache.

One of the common characteristics of chronic rhinitis is postnasal drip. Mucus produced by the nose lining glands can run down the back of the nose to the throat, resulting in one feeling the need to clear the throat and trigger cough which is worse at night. Postnasal drip can be caused by excessive mucus secretions or impaired clearance of mucus from the nose and throat.

2) Asthma

Classic asthma presents with symptoms of cough, difficulty breathing and wheeze. Patients tend to have other allergic conditions such as eczema and sensitive nose. Family history also plays a role. Common triggers include infections eg cold and flu, environmental allergens, smoking, stress, exercise and temperature changes.

Cough variant asthma is a type of asthma with the main symptom of chronic dry cough without wheezing or breathlessness. The cough can occur during day or night and may be worse with triggers such as dust, dust mite, mould, pet dander, pollen, cold air, exercise. It may occur after an upper respiratory tract infection.

3) Gastroesophageal reflux disease (GERD)

GERD occurs when the stomach acid flows backwards into the oesophagus (food tube). This usually occurs due to faulty lower oesophageal sphincter- damage caused by overeating, late night eating, unhealthy diet and obesity.

The acid can get past the upper oesophageal sphincter to enter the throat and voice box – resulting in hoarse voice, sore throat, stuck sensation at throat and cough. The cough tends to be worse at night or after a meal or while lying down. It may be associated with heartburn (painful sensation in the chest).

4) Tuberculosis (TB)

TB is caused by a bacteria. Symptoms of active TB include chronic cough, coughing out blood, chest pain associated with breathing/ coughing, fever, chills, night sweats, fatigue and weight loss.

5) Smoking

Smoking affects the cilia (tiny hair like structures along the airways). The cilia lose some ability to push foreign materials out of the lungs. Hence the body has to cough more to remove the chemicals from the lungs. The cough tends to be wet with mucus and phlegm and can be associated with wheeze and crackling noises.

6) Lung Cancer

Symptoms of lung cancer include chronic persistent cough, coughing out blood, shortness of breath, pain in chest / back associated with coughing, loss of appetite, fatigue and weight loss.

Risk factors include smoking, asbestos exposure and family history.

7) Certain Medications

Some high blood pressure medications may cause cough, which is reversible once the medicine is stopped.

WHAT SHOULD I DO IF I HAVE A COUGH?

1) Wear a mask to prevent droplet transmission to others

2) Consult a doctor – PHPC (Public Health Preparedness Clinic), family clinic, polyclinic, our medical centre. Do keep the doctor informed about all the symptoms, personal medical history, job nature, place of residence, contact history (family members, colleagues with similar illness), travel history in past 2 weeks and family history.

With the doctor consultation, physical examination, the doctor will be able to assess the need for further investigations

  • Swab and send home test for COVID-19 – for patients that fits the case definition of COVID-19. This involves a deep nasal swab of secretions at upper part of throat behind the nose. The test is available at polyclinics, some GP clinics, SGH Fever Screening Centre as well as National Centre for Infectious Diseases (NCID). This test is not available at Asia Healthpartners.
  • Blood test for indication of infection
  • Sputum test for type of bacteria infection
  • Chest x-ray to check the lungs for pneumonia
  • Sinus x-ray to check for rhinitis leading to sinusitis
  • CT scan of lungs to check for lung lesions and lung cancer
  • Spirometry (lung function test) to check airways for asthma
  • Nasoendoscopy to check for rhinitis, deviated nasal septum, nasal polyp

Armed with the above information, the doctor will then reach a most likely provisional diagnosis and issue appropriate medications and advice. In accordance with the Infectious Disease Act, it is mandatory for the doctor to issue a medical certificate of 5 days duration and the patient must stay at home for 5 days – can only go out for medical attention if still unwell.

PREVENTION STRATEGIES

1) Personal hygiene and care are important. Keep your hands clean and avoid touching your face, eyes and nose. Wear a mask if you are unwell or when in public places (compulsory at this time).

2) Healthy eating with a balanced diet and regular exercises are important for our immune system. Supplements can be considered. Avoid overeating and late-night snacking. Do not lie down after eating. Minimize stress and ensure sufficient sleep. Avoid smoking and moderate alcohol consumption.

3) Keep your home and work environment clean. This is especially important if you are prone to allergies. Common allergens include dust, dust mite and pet dander.

4) Consider vaccinations to prevent flu, whooping cough and pneumonia. This is especially important for those at higher risk of these ailments such as people above 50 years of age, those with chronic diseases eg hypertension, diabetes, heart disease.


DEFINITION OF FEVER

Fever is defined by a temporary increased body temperature, 37.5 degrees Celsius and above. This usually occurs as a response by our body’s immune system to combat infection. Our body temperature may vary throughout the day and may be affected by eating, physical activity and sleep. Normal temperature is usually lower in the morning and highest in late afternoon / evening.

Types of thermometers to check for fever:

1) Digital thermometer – usually used under the tongue or in the armpit. It uses electronic heat sensor. Do wait for at least 15 minutes after eating / drinking to take oral temperature.

2) Ear thermometer – measures the temperature inside the ear by reading the infrared heat. The temperature reading may be affected by earwax or a small curved ear canal.

3) Forehead thermometer – measures the temperature at the forehead (temporal artery) using infrared. Do make sure to sweep hair away from forehead and keep the forehead dry before measurement.

COMMON CAUSES OF FEVER

Common areas of viral infection –

1) Viral Infection

Common areas of viral infection –

a) Upper and lower respiratory tract infection -Symptoms = fever, runny/stuffy nose, sore throat, cough

Examples – Rhinovirus, Influenza virus, COVID-19, Dengue virus, Chicken pox virus

b) Gastrointestinal tract infection – Symptoms = fever, vomiting, diarrhoea, abdominal pain

Examples – Rotavirus, Norovirus, Adenovirus

2) Bacterial infection

Common areas of bacterial infection –

a) Upper and lower respiratory tract infection -Symptoms = fever, runny/stuffy nose, sore throat, cough

Examples – Streptococcus pneumoniae/Pneumococcus, Haemophilus influenzae, Staphylococcus aureus, Klebsiella and Mycoplasma

b) Gastrointestinal tract infection – Symptoms = fever, vomiting, diarrhoea, abdominal pain

Examples – Campylobacter, Salmonella, Shigella, E coli

c) Urinary tract infection – Symptoms = fever, painful / frequent urination

Examples – E coli, Klebsiella, Proteus

3) Parasitic infection

Malaria infection – Symptoms = fever, chills, headache, body ache, cough, vomiting. Do take note of travel history.

4) Heat stroke

This usually occurs due to prolonged exposure to or physical exertion at high temperature.

Symptoms = fever, headache, confusion, slurred speech, vomiting, flushed skin, palpitation, fast breathing, hot and dry skin

5) Cancer and Autoimmune Diseases

Fever of unknown origin can occur in some cancer such as lymphoma, leukaemia as well as solid tumour e.g. liver cancer, kidney cancer. Autoimmune diseases such as rheumatoid arthritis, lupus may also cause recurring fever.

6) Certain Vaccines

Vaccines such as influenza (flu), MMR (measles, mumps, rubella), DPT (diphtheria, pertussis, tetanus), pneumococcal can cause low grade fever.

WHAT SHOULD I DO IF I HAVE A FEVER?

1) Wear a mask to prevent droplet transmission to others

2) Monitor temperature 3 times a day and document it.

3) Stay cool - wear comfortable lightweight clothing, do not wrap yourself up with blankets.

4) Stay hydrated -drink lots of fluids and avoid alcohol. Take note of your hydration status by monitoring your urine colour and frequency. Dark yellow urine indicates insufficient hydration.

5) Take a shower with cool or lukewarm water and use cold compress/ ice cubes in towel over the forehead and neck.

6) Take a medicine to reduce fever e.g. paracetamol, if you are not allergic to it.

7) Warning signs to seek medical attention –

  • Persistent fever
  • Stiff neck
  • Bad headache
  • Delirium
  • Chest pain, palpitation, difficulty breathing
  • Giddiness
  • Minimal urination or dark coloured urine or painful urination
  • Severe abdominal pain, vomiting
  • Severe sore throat
  • Severe cough, blood in phlegm
  • Persistent ear pain
  • Rashes


8) High risk group with underlying health issues – to seek medical attention urgently

  • You are taking immunosuppressant medications e.g. steroids
  • You have chronic medical conditions e.g. diabetes, heart disease, stroke, chronic lung disease, chronic liver disease, chronic kidney disease, immunodeficiency condition.
  • You are on or recently completed treatment for cancer.
  • You are a transplant recipient
  • Chest pain, palpitation, difficulty breathing
  • You are HIV positive.


9) Consult a doctor – PHPC (Public Health Preparedness Clinic), family clinic, polyclinic, our medical centre. Do keep the doctor informed about all the symptoms, personal medical history, job nature, place of residence, contact history (family members, colleagues with similar illness), travel history in past 2 weeks and family history.

With the doctor consultation, physical examination, the doctor will be able to assess the need for further investigations

  • Swab and send home test for COVID-19 – for patients that fits the case definition of COVID-19. The test is available at polyclinics, some GP clinics, SGH Fever Screening Centre as well as National Centre for Infectious Diseases (NCID). This test is not available at Asia Healthpartners.
  • Blood tests to confirm type of infection
  • Urine test for infection
  • Stool test for infection
  • Chest x-ray to check the lungs for pneumonia

Armed with the above information, the doctor will then reach a most likely provisional diagnosis and issue appropriate medications and advice. In accordance with the Infectious Disease Act, it is mandatory for the doctor to issue a medical certificate of 5 days duration and the patient must stay at home for 5 days – can only go out for medical attention if still unwell.

PREVENTION STRATEGIES

1) Personal hygiene and care are important. Keep your hands clean and avoid touching your face, eyes and nose. Wear a mask if you are unwell or when in public places (compulsory at this time).

2) Healthy eating with a balanced diet and regular exercises are important for our immune system. Supplements e.g. Vitamin B, C, D, Zinc, Selenium, Echinacea, Propolis can be considered. Minimize stress and ensure sufficient sleep.

3) Consider vaccinations to prevent flu and pneumonia. This is especially important for those at higher risk of these ailments such as people above 50 years of age, those with chronic diseases e.g. hypertension, diabetes, heart disease.

4) Visit your family doctor or travel clinic at least 4 weeks before travel to discuss appropriate vaccines. You can also look up health information pertaining to your destination on the CDC website. Many travel related diseases are vaccine preventable.

5) Protect against mosquito bites. In mosquito prone area, wear long sleeves and pants, use mosquito repellent – ideally with DEET, use mosquito net, spray insecticide in dark corners. Prevent mosquito breeding with the 10minute 5 step Mozzie Wipeout -

  • Change water in vase alternate days
  • Turn over water storage containers
  • Remove water from flower pots alternate days
  • Cover bamboo pole holders when not in use
  • Clear blockages and put insecticide in roof gutters monthly


Diabetes is a growing burden worldwide. According to the International Diabetes Federation,there are 425 million people with diabetes in the world. The number is expected to increase to 629 million by 2045. This is due to the aging population as well as different lifestyle. Singapore has the 2nd highest proportion patients among developed nations. About 11.3% of people in Singapore have diabetes. And 1 in 3 Singaporeans have a lifetime risk of developing diabetes, hence it is a serious health concern that all of us should pay attention to.

Many people have misconceptions about diabetes. We will debunk and demystify the myths here.

Common Myths

1) Diabetes only affects overweight people.

Being overweight is a risk factor for diabetes. But diabetes is a multifactorial disease whereby other risk factors such as age, family history and lifestyle also come into play. Hence diabetes can also affect people who are lean.

2) Eating sugar causes diabetes.

There are many reasons why diabetes develops – genetic influence, unhealthy diet, sedentary lifestyle, obesity, age, hormonal disorders, autoimmune diseases, certain medications. Hence high sugar diet per se does not necessarily lead to diabetes. But for diabetes prevention, it is important to lead healthy lifestyle with good food choices and regular exercises. Do avoid desserts such as ice cream, chocolates, cakes as well as sweetened beverages eg fruit drinks, fruit punch, soda, energy drinks and sports drinks.

3) I will feel unwell if I have diabetes.

Not true! Many people can walk around with diabetes without showing any symptoms. This is especially so in early stage of the disease.

Symptoms of thirst, increased urination, fatigue, blurring of vision tend to occur in the later stage of the disease.

4) If I have diabetes, I just need to avoid sugary food. No other action is required.

A healthy eating plan with food rich in nutrients and low in fat and calories is the way to go in a diabetic diet. Eat healthy carbohydrates eg wholemeal bread, oats, brown rice, fibre rich food eg fruits, vegetables, legumes, nuts and fish.

Use the healthy eating plate method whereby carbohydrates occupy just a quarter of plate. Be careful with hidden sources of sugar – masquerading as sucrose, fructose, lactose, cane sugar, brown sugar, corn syrup, maple syrup, sugar cane syrup.

Eat lesser of high glycaemic index food as these will raise the blood sugar more than low glycaemic index food. High glycaemic index foods include white rice, corn flakes, popcorn, potato, pretzels. Artificial sweeteners can be used to sweeten food and drinks for lesser calories.

If you have entertainment that includes alcohol, do not drink on empty stomach as alcohol blocks the emergency liver production of glucose and this can result in hypoglycaemia (low sugar level) which can be dangerous. Avoid craft beers as they tend to have more calories and go for calorie free mixers eg diet soda, club soda, diet tonic water or water.

Exercise is also important in the management of diabetes. Aerobic exercises eg brisk walking, jogging, cycling, dancing, swimming will help your body use insulin better and reduce the risk of heart disease by lowering blood glucose, blood pressure and cholesterol. Aim to do moderate to vigorous intensity aerobic exercises for at least half hour per session 3 times per week. Start slowly if you have not been active. Strength training / resistance training exercises eg weights, pushups, situps, make your body more sensitive to insulin, lower blood glucose, maintain strong muscles and bones to reduce risk of osteoporosis.

5) I just need to get a home glucose meter to check for diabetes.

Diagnosis of diabetes should not be made using home glucose meter or urine glucose test. There is a significant difference in blood glucose level between finger prick/ capillary reading versus venous reading (blood taken from vein and sent to lab for analysis).

Diabetes diagnosis is established when we have 2 readings of fasting blood glucose of 7mmol/l or greater. If the fasting blood glucose level is between 5.5 and 7mmol/l, a special blood test that involves fasting and glucose drink consumption, known as oral glucose tolerance test will be recommended to differentiate prediabetes from diabetes. If the 2 hour post glucose drink reading is 11mmol/l or greater, diabetes diagnosis is confirmed.

Blood test for HbA1c (glycated haemoglobin) will aid us in giving a good indication of diabetes control in the past 2 to 3 months. This test measures the amount of red blood cells that is bonded with glucose in the blood stream. Red blood cells exist in body for about 3 months. Hence if a person’s blood glucose has been high, there will be many red blood cells that bond with glucose, and this will result in a high HbA1c level – meaning that the average blood glucose control in the past 3 months is poor. A good HbA1c level for a diabetic patient should be 7% or less.

Having a good reading using home glucose meter will not be establish good diabetic control for past 3 months, as it simply indicates the glucose control for past few hours. Hence it is vital to visit your family doctor regularly for HbA1c blood test so that your diabetes medications can be titrated for optimal control to prevent complications arising from diabetes. You can use your home glucose reading as a gauge to see if your diet portion quantities and choices are appropriate.



Complications of Diabetes

1) Stroke – People with diabetes are two to four times more likely to have a stroke compared to people who do not have diabetes. This is because over time, the high sugar can lead to increased fatty deposits in the blood vessels. If the blood vessels in the neck or brain are blocked, oxygen supply to the brain will be affected and this can result in a stroke. A carotid ultrasound can be performed to check for clogged carotid arteries (arteries in neck that supply nutrients to brain). MRI of the brain and blood vessels can also be used to ascertain the patency of all the blood vessels.

2) Heart Disease – Many diabetic patients have silent heart disease – asymptomatic. This is because diabetes can affect the nerves resulting in absence of chest pain. Early detection of heart disease can be achieved with the use of treadmill stress test.

3) Eye disease – Retinopathy, cataract, glaucoma. Diabetic retinopathy is a leading cause of blindness and visual disability. It is caused by small blood vessel damage to the retina. Yearly screening using retinal photograph is recommended for all diabetic patients.

4) Kidney Disease / Kidney Failure. Diabetes is a leading cause of kidney failure. High blood sugar damages the blood vessels in the kidneys and the damage occurs slowly over the years without any symptoms. Early detection of kidney disease can be done using urine test for blood and protein.

5) Nerve damage – Neuropathy. Diabetes can affect the blood flow to nerves resulting in loss of sensation, damage to limbs as well as impotence.

6) Foot damage – Diabetes can affect the blood vessels and nerves of feet, leading to ulceration and subsequently amputation. Foot screening is recommended yearly.

7) Skin condition – infection

8) Depression

9) Alzheimer’s disease

Asia Healthpartners offers health screening packages that include blood test for cholesterol, diabetes, kidney disease as well as eye tests (for cataract, glaucoma, retinopathy) and treadmill test for the heart

1 out of 3 Singaporeans die from heart disease or stroke. Cardiovascular disease (heart disease and stroke) is the leading cause of death worldwide, regardless of gender. Coronary heart disease is the most common type of heart disease.

What is a heart attack? Our heart muscles require oxygen. A heart attack occurs when the heart muscles are deprived of oxygen. This usually happens when the heart artery that supplies the heart muscle become narrower due to accumulation of cholesterol over a period of time. When the heart muscle is starved of oxygen and nutrient; the damage or death of the muscle results in a heart attack.

Warning signs / symptoms of a heart attack

1) Chest pain

2) Jaw, neck, arm pain

3) Shortness of breath

4) Light-headedness, nausea and vomiting

5) Cold sweats

The most common symptom is chest pain – usually described as tightness or squeezing sensation at the chest area, worsened by exertion. Women may be more likely to present with atypical features such as breathlessness, nausea, vomiting, dizziness, back or jaw pain.

Not all chest pain are equal

There are many different forms of chest pain – sharp, dull, burning, crushing. Chest pain has many possible causes; hence do consult a doctor for evaluation.

It can be divided into various organ systems.



Investigations for Heart Disease

1) Electrocardiogram - simple quick test that records the electrical activity of the heart. From the heart rate, rhythm and waveform, the doctor will be able to assess for any abnormality.

2) Blood test for cardiac enzymes and protein – increase in level of cardiac enzymes and protein indicates death of myocardial cells seen in heart attack.

3) Treadmill Stress Test – this is more useful compared to resting electrocardiogram in assessment of heart disease. Patient is required to brisk walk/ jog on the treadmill machine with electrodes pasted on the chest. The electrocardiogram waveform and blood pressure will be monitored continuously throughout the entire procedure. This will give information regarding heart’s response during exercise and whether blood supply to the arteries that supply the heart is reduced.

4) Stress Echocardiogram – an echocardiocardiogram (ultrasound) of the heart is done before and after the treadmill stress test to visualize the motion of the heart walls and pumping action when the heart is stressed. This will provide a better indication regarding heart disease.

5) Nuclear Stress Test – this involves injection of small amount of radioactive material to assess the parts of the heart that do not have adequate blood supply and do not function well.

6) CT Coronary Angiogram – this involves injection of contrast dye and CT scan to visualize the coronary arteries that supply the heart muscle for any cholesterol and calcium plaques and assess the severity of the stenosis by these plaques.

7) Coronary Angiogram – this is an invasive procedure which involves insertion of a small catheter into a blood vessel in the wrist or groin. With the injection of contrast, plaques in the coronary arteries will be visible. Depending on the severity of the disease, the cardiologist will decide if stent insertion is necessary.

How to prevent heart attack Take note of the following risk factors that you can do something about it!

1) Check your cholesterol!

Reduce your LDL (bad cholesterol) and triglycerides through diet modifications.

Increase your HDL (good cholesterol) through regular exercises.

There is a large scale study done globally over a 5 year period that showed cholesterol medicine lowered risk of cardiovascular events eg heart disease and stroke by about 25%.

2) Maintain a good blood pressure with low salt diet and regular exercise. The high blood pressure causes the coronary arteries that supply the heart muscle to slowly become narrow. This can result in heart attack if the blood flow to the heart muscle is interrupted.

3) Control diabetes well if you have diabetes. Diabetes seriously increases risk of heart disease. Low glycaemic index diet (low carbohydrate and sweets) is highly recommended.

4) Reduce your weight if your BMI exceeds 23kg/m2 . Waist Hip ratio is also important. Some studies have shown that high waist hip ratio is associated with increased risk of heart disease.

5) Men with erectile dysfunction should be screened for heart disease. Dysfunction of the inner lining of blood vessels smooth muscle can occur in the penis resulting in erection difficulties. The same problem can occur in the heart – hence the importance of early screening for heart disease to prevent heart attack.

6) Take up sports. To improve heart health, 30 minutes of moderate exercise 5 times a week is recommended. Some studies have shown that overdoing high intensity exercise may actually increase risk of heart attack in those with existing heart disease.

7) Avoid smoking. Smoking increases triglyceride(fat in blood), reduces HDL (good cholesterol), damages cells that line the blood vessels, increases build-up of plaque in blood vessels, causes narrowing of blood vessels and makes blood more likely to clot, which can block blood supply to heart. A recent large scale study showed that even smoking of 1 cigarette a day increases risk of heart disease. Men who smoke had 48% higher risk of heart disease, while women had 57% increased risk.

8) Eat a healthy diet. Health promotion board recommends use of My Healthy Plate as a guideline for healthy eating. Half the plate consists of fruits and vegetables, a quarter with fish and meat, and a quarter with carbohydrates such as whole grains.

9) Manage stress – practise stress reduction techniques eg deep slow breathing.

** Remember if you have major risk factors eg age, male, family history of hypertension, diabetes, cholesterol and heart disease, it will be even more crucial to manage the modifiable risk factors as your risk is already higher than a normal person! **

Treatment for Coronary Heart Disease

1) Lifestyle modifications – low fat, low salt diet

2) Regular exercises

3) Smoking cessation

4) Medications eg aspirin, cholesterol medications, blood pressure medications, medicine to lower heart rate

5) Medical procedures / surgery eg stent, cardiac bypass

Asia Healthpartners offers health screening packages that usually include electrocardiogram. Further evaluation for the heart using Treadmill stress test or CT Coronary Angiogram can also be done at our centre

Gastric pain is very common worldwide, regardless of age and gender. Most people experience gastric pain at some point in time of their lives. This is especially so in our fast paced competitive society, whereby life at work and at home can be stressful and people may not have regular meal times.

What is gastric pain? Gastric pain is a simple term to describe pain or discomfort at the upper region of the abdomen.

What causes gastric pain?

1) Heart – heart disease eg heart attack

2) Stomach – non ulcer dyspepsia, gastroenteritis (viral infection of stomach/colon), gastritis (gastric inflammation), gastric reflux, stomach ulcer, stomach cancer

3) Pancreas – pancreatitis (pancreas inflammation), pancreas cancer

4) Gallbladder – gallstones, cholecystitis (gallbladder inflammation)

5) Liver – hepatitis (liver inflammation), liver abscess (pus in liver), liver cancer

6) Kidneys – kidney stones

As you can see from the above list of possible causes, it can be daunting even to medical personnel to pinpoint the exact etiology.

Heart disease typically presents with chest pain/tightness, breathlessness on exertion. However in some cases, especially in women, the presentation can be atypical – gastric pain and nausea. Hence it is vital to pay attention to the heart for those with risk factors for heart disease – age, hypertension, diabetes, high cholesterol, smoker and family history of heart disease.

Pancreatic disorders include pancreatitis whereby digestive enzymes are activated in the pancreas resulting in the inflammation of pancreas. Predisposing factors include high cholesterol (triglyceride), smoking, alcohol and gallstones

Gallstones can cause pain at the upper right or centre abdomen and shoulder blade pain, as well as nausea and vomiting. It may also lead to complications of fever and jaundice (yellow skin and eyes).

Liver conditions that can cause gastric pain include acute Hepatitis. Acute Hepatitis, commonly caused by virus eg Hepatitis A, can present with gastric pain, nausea, vomiting, yellow skin, pale stools, dark urine, fever and poor appetite.

Kidney stones can cause pain at the abdomen and back – typically pain that comes in waves and vary in intensity. Other symptoms include painful or frequent urination, red/brown/cloudy urine and fever.

Most cases of stomach disorders are due to non ulcer dyspepsia and gastroenteritis. Non ulcer dyspepsia may occur due to stomach motility problem, Helicobacter pylori bacteria infection, medications, alcohol as well as psychosocial factors eg stress, depression, anxiety. Helicobacter pylori bacteria is transmitted from person to person through saliva contact, contaminated food/drinks. This bacteria can cause complications of gastritis, stomach ulcer and stomach cancer. Some medications eg painkillers, steroids, certain antibiotics and osteoporosis medicines and alcohol can predispose to gastric pain. Gastroenteritis, commonly known as stomach flu is usually due to viral infection transmitted through physical contact or contaminated food / drinks.

Gastroesophageal reflux (GERD) occurs when gastric acid flows backwards into the food tube (oesophagus). Besides gastric pain, one may also experience burning sensation at chest area, sensation of lump in throat or difficulty swallowing, regurgitation of sour fluid and chronic cough. Risk factors for GERD include obesity, pregnancy, smoking, large meals, late meals close to bedtime, fried greasy food, coffee and alcohol.

Stomach ulcer (Peptic ulcer) refers to sores at the stomach or small intestine lining. Symptoms include gastric pain, bloatedness, and nausea. It can also cause vomiting of blood, black stools and giddiness. Causes of stomach ulcer include Helicobacter pylori bacteria, painkiller medicines, stress, smoking and alcohol.

When do we suspect stomach cancer? Stomach cancer is 7th most common cancer in men and 9th most common cancer in women in Singapore. The cancer can form a mass or ulcer within the stomach or it can spread diffusely throughout the entire wall of the stomach.

Although most gastric pain cases are not due to stomach cancer, we need to make sure that we do not miss the window of opportunity to diagnose stomach cancer at an early stage. Hence we should always be vigilant in the following scenarios –
What test should I go for if I have gastric pain?

A lot of people dismiss gastric pain as something insignificant and simply want medications to ease the pain. If your gastric pain is frequent, recurrent or does not improve with medications or there are red flags as listed above, please do visit your doctor for a check-up.

Health screening inclusive of doctor consultation, physical examination and appropriate tests can be done.

Appropriate investigations

1) Blood test for Full blood count, Liver function, Hepatitis A, B, Amylase, AFP liver cancer marker, CEA colon cancer marker, CA 19-9 pancreas cancer marker.

2) Stool occult blood test

3) Urea Breath Test – check for Helicobacter pylori

4) Ultrasound Abdomen – check the liver, gallbladder, pancreas, kidneys

5) ECG – check the Heart

6) Gastroscopy – day surgery procedure which requires fasting. Patient is sedated during the procedure, hence it will be painless. A thin flexible tube is inserted via the mouth into the oesophagus and stomach. With the use of a camera, the oesophagus, stomach and duodenum can be clearly visualized, and biopsy can be done for any suspicious lesions.

Treatment and Prevention Tips for gastric pain 1) Diet modification – a) Eat smaller but more frequent meals
b) Eat on time, avoid skipping meals
c) Reduce consumption of fried, greasy, spicy, acidic foods
d) Eat less smoked, salty foods & eat more fruits and vegetables
e) Reduce coffee, tea and carbonated drinks
f) Do not eat heavy meals just before bedtime
g) Keep a food diary to check for foods that trigger gastric pain

2) Limit Alcohol intake

3) Quit smoking

4) Stress reduction and regular exercises

5) Maintain a healthy weight 6) Avoid certain painkillers

7) Supplements eg probiotics

8) Medications – You can visit your family doctor for gastric medications eg antacid, H2 blockers and proton pump inhibitors.

Treatment of Stomach Cancer

Treatment option is dependent on the type and stage of the stomach cancer as well as patient preferences and health status.

Options include surgery, radiation therapy, chemotherapy and targeted therapy. The cancer care will usually involve a multidisciplinary team inclusive of gastroenterologist, surgeon, oncologist, pathologist, radiologist and nurses.

Asia Healthpartners offers health screening packages, imaging scans, gastroscopy and colonoscopy services. Our clinic is medisave accredited for scope procedures.

If you could prevent cancer, would you?

What is gastric pain? Many people are concerned about using supplements to improve their health, some even believe certain supplements can prevent or cure cancer. But unfortunately, only some believe in the truth that vaccines can prevent cancer. Currently only some cancers can be prevented with vaccine – HPV vaccine to prevent cervical cancer, vulvar cancer, vaginal cancer, anal cancer, penile cancer and oral cancer, while Hepatitis B vaccine to prevent liver cancer.

Cervical cancer can affect any woman regardless of background. I am sure people remember that Anita Mui passed away at her prime time at 40 years old due to cervical cancer. This is really unfortunate, considering that cervical cancer if undetected early has good survival rate.

There are myths and facts about cervical cancer that we will discuss in this article.

Myths

1) HPV is rare, especially if I only have 1 partner.

HPV is the most common sexually transmitted disease in the world; in fact it is so common that nearly all men and women who have had sexual intercourse before get the virus at some point in time in their lives

HPV (Human Papillomavirus) is spread by sexual intercourse and through skin contact with the genitalia

There are more than 100 strains of HPV, some cause cancer, and some cause genital warts. There are no symptoms of HPV infection. In most cases, HPV is cleared by the body’s immune system. But if it persists in the body, it can lead to health problems eg cervical cancer, vaginal cancer, penile cancer, anal cancer, oral cancer and genital warts.

Having HPV does not necessarily mean that the partner has cheated as the virus can remain dormant in the body for weeks, months or lifetime without signs and symptoms.

HPV can be tested in women by doing a vaginal swab test for HPV DNA (FDA approved test). But there is currently no HPV test for men.

Please note that HPV is not the same as HIV or herpes.

2) My Abnormal PAP smear has been treated, hence I do not need any further action.

Abnormal PAP smear can occur due to a variety of reasons eg infection due to any bacteria or inflammation due to vaginal discharge, HPV infection, dysplasia due to precancer or cervical cancer and atrophy due to menopause.

If the PAP smear result is abnormal, the doctor will explain to you regarding the abnormality as well as need for treatment and follow-up plan. It is important to follow up abnormal PAP smear as the cells in the cervix can change to become cancerous.

HPV (culprit of cervical cancer) can cause normal cells to change into precancer cells (CIN) which can then progress into cervical cancer. There are 3 stages of CIN (cervical intraepithelial neoplasia). In CIN 1 - up to 1/3 of cervix lining has abnormal cells, in CIN2 - the abnormal cells have affected up to 2/3 of the cervix lining, in CIN 3 - the full thickness of the cervix lining has been affected.


If abnormal cells still persist in the PAP smear, further evaluation by the gynaecologist using colposcopy will be necessary. Colposcopy is a safe and short procedure whereby a magnifying instrument is used to examine the cervix, a solution will be applied to the cervix to highlight abnormal areas and biopsy can also be done for suspicious areas.

Precancer of cervix, CIN will require treatment eg LEEP (Loop electrosurgical excision), cone biopsy as well as close follow-up for early detection of progression to cervical cancer.

3) PAP smear is embarrassing and painful.

PAP smear is a simple, non-invasive test done in the office setting by your family doctor or gynaecologist. It is the best screening tool for early detection of cervical cancer, recommended for all ladies who have had sexual intercourse before, regardless of age or frequency of sexual activity. It is best done a few days away from menses. During the procedure, the doctor will insert a small speculum into the vagina and use a soft brush to scrape the cells of the cervix to check for any cancerous or precancerous cells in the cervix. The sample will then be analysed in the lab. The whole process of the PAP smear lasts less than 5 minutes and it is virtually painless.

PAP smear is not 100% accurate hence it is vital to do the test at least once in 3 years. If the PAP smear result is abnormal or if there are gynaecological symptoms eg abnormal menses or vaginal discharge, it will warrant earlier follow-up.

To improve the accuracy of the PAP smear, we can consider doing Liquid based PAP smear test – the process of doing the test is similar, but at the lab level, the machine will filter out the mucus and blood from the cervical cells allowing for more accurate reading of the sample. We can also add on HPV DNA test - this checks for the virus that can lead to cervical cancer , thereby giving us extra information about the risk of cervical cancer. Bear in mind that the HPV DNA test does not replace the PAP smear as PAP smear checks for abnormal cells which cannot be seen by the HPV DNA test.

Cervical cancer often does not cause symptoms unless the disease is advanced. So it is of utmost importance to get screened even if you feel healthy.

4) I do not have any sex, hence I do not need HPV vaccine./ I already have children, hence it is too late for HPV vaccination.

For ladies who have not had sexual intercourse before, the risk of cervical cancer may be lower, but it is not impossible as the cervical cancer can occur due to family history, mutation of genes or HPV transmitted though skin contact. PAP smear is the only screening tool for cervical cancer. It is also highly recommended to consider prevention using HPV vaccine especially if PAP smear is not done for surveillance.

Even after sexual intercourse or childbirth, prevention of cervical cancer using HPV vaccine is still useful, especially since you may not be infected with certain strains of HPV yet.

HPV vaccine is recommended for both males and females above 9 years of age. Medisave usage is applicable for Singaporean / Singapore PR ladies under 27 years of age. For ladies above 27 years of age, the HPV vaccine is still useful for prevention of cervical cancer according to studies that monitor the antibody titres.

HPV vaccine is the only proven method to prevent at least 80% o fall cervical cancer cases. There are 3 brands available internationally – Cervarix, Gardasil and Gardasil 9. All 3 vaccines contain synthetically manufactured virus like particles to induce the body’s antibody response. Cervarix prevents HPV 16 and 18 strains, with enhanced antibody coverage due to the adjuvant ASO4. Gardasil prevents HPV 6,11,16 and 18 strains, hence preventing genital warts as well as cervical cancer. Gardasil 9 prevents HPV 6,11,16,18,31,33,45,52,58 – broader spectrum of action against cervical cancer and genital warts. Research shows that the vaccine protection is long lasting with no weakened protection over time yet.

Dosage regime for children under 14 years of age = 2 doses in 6 months. Dosage regime for those above 14 years of age = 3 doses in 6 months. In clinical trials and real world use, the vaccines appear to be very safe with no major side effects proven. The vaccine is not recommended for pregnant women, although studies show that HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant. If a woman realises that she is pregnant after having 1 or 2 shots of vaccine, she should wait till after delivery to complete the remaining doses.

5) Condoms prevent HPV.

Condoms, if used correctly, are very effective against sexually transmitted diseases eg gonorrhoea and HIV that are spread by body fluids. But they are likely to be less protective against sexually transmitted diseases that are spread through skin contact eg HPV and herpes. The reason is because condoms do not cover the entire genitalia area of either party. It can still reduce the risk of HPV infection, but because of lesser protection, HPV vaccine should still be considered.

6) Cervical cancer is hereditary.

It is true that some female cancers eg breast cancer and ovary cancer are hereditary. But most cases of cervical cancer are related to HPV rather than genetic causes.

7) I feel well, hence I do not need to do checkup or vaccination.

Most women with precancer of cervix (CIN) or early cervical cancer have no symptoms.Possible symptoms occur in the later stage of the disease. Symptoms include abnormal menstruation, bleeding after sexual intercourse, bleeding after menopause, abnormal vaginal discharge, increased pain during sexual intercourse, persistent lower abdominal pain. If you have any of these symptoms, do consult a doctor for further evaluation on the appropriate action plan. Ignoring the symptoms may allow the cancer to grow to more advanced stage and lower chance for effective treatment.

Do not wait for symptoms to appear. Do go for regular PAP smear. Consider HPV DNA Test to screen risk of cervical cancer. Consider HPV Vaccine to prevent cervical cancer.

Asia Healthpartners offers health screening packages that usually include PAP smear. You can also see our female doctors for PAP smear and HPV DNA test. We also offer all 3 types of HPV vaccines within our clinic. Our doctors will be able to discuss the choice of vaccine with you. Our clinic is medisave accredited for HPV vaccines





The colon/large intestine is about 1.5m in length and 7cm in diameter. The main function of the colon is to absorb water from the indigestible food matter, create stools and transmit the stools out of the body. The colon also helps in absorption of vitamins made by the bacteria that resides in the intestine

Symptoms of Colon Cancer

As with all diseases, there are signs and symptoms that may suggest colon cancer. Do listen to what your body is trying to tell you. What you see in the toilet may give an indication about your health. For example - Light coloured/ white stools may indicate bile duct obstruction. Black stools may indicate bleeding from the stomach, while Red stools may indicate bleeding from colon, rectum or haemorrhoids.

Sometimes the symptoms may be glaring, yet many people choose to ignore them due to denial or fear of knowing the truth – the Ostrich effect. Remember – Earlier detection = Better chance of cure.

Bear in mind that the symptoms can also be caused by other medical conditions. A common disorder of the colon -irritable bowel syndrome – which can be triggered by stress or certain foods, can cause constipation, diarrhoea, abdominal discomfort. Food intolerance or lactose intolerance can result in abdominal discomfort and diarrhoea. Thyroid conditions can also affect the bowel movements. There is a multitude of medical conditions with similar presentations; therefore it is of vital importance to consult a doctor for further evaluation before jumping to conclusion.

For those aged 50 years and above, get screened even if you do not have any symptoms. Early stage colon cancer often do not present with any symptoms.

Red Flags=

1) Change in bowel movements

2) Change in consistency of stools

3) Blood in stools

4) Mucus in stools

5) Feeling of incomplete defecation

6) Persistent abdominal discomfort / Bloatedness

7) Weight loss

8) Fatigue

9) Anaemia (low blood count)

Risk Factors For Colon Cancer

RISKS THAT YOU CANNOT CONTROL

1) Age – Above 50 years old

2) Personal medical history of colon polyps, colon cancer, rectal cancer, breast cancer, ovary cancer, womb cancer

3) Personal medical history of inflammatory bowel disease eg Ulcerative colitis, Crohn’s disease

4) Family history of Colon cancer

For those with family history of colon cancer, it is important to get screened with colonoscopy at least 10 years before the family member’s colon cancer diagnosis age.

RISKS THAT YOU CAN CONTROL

1) Sedentary lifestyle

2) Smoking

3) Alcohol

4) Diet rich in red meats and fats

5) Obesity

According to many studies, red meat and processed meat consumption increases risk of colon cancer by 20-30%. Hence guidelines advise the recommended amount of red meat intake for healthy people to be 500g/ week.

Prevention of COlon Cancer

1) Maintain a healthy body weight

2) High fibre diet – take more fruits and vegetables and whole grains

3) Reduce consumption of red meat and fats in your diet

4) Exercise regularly – 3 times per week, half hour per session

5) Limit alcohol intake

6) Stop smoking

SCREENING is the PREVENTION OF COLON CANCER

1) Stool Test for occult blood – recommended yearly. This test checks for blood in stools that cannot be visualized using the naked eye.

2) Health Screening with doctor consultation, physical examination and blood test for full blood count, liver function and CEA (colon cancer marker)

3) Genetic Test for colon cancer – This can be done for those with strong family history of colon cancer eg more than 2 family members with colon cancer.

4) Colonoscopy- This is a half day procedure. Bowel preparation to clear the colon is required the day prior to the procedure. Fasting is required on the day of the procedure. Patient will be sedated for the test. During the colonoscopy, the specialist will insert a thin, long flexible scope with camera through the anus, rectum then into the colon. If there are polyps / abnormal growth noted, the specialist will remove the polyp/ growth and the sample will then be sent to the lab for analysis.

Regular colorectal screening is a powerful weapon against colon cancer. It can take years for a colon polyp to develop into colon cancer. During the colonoscopy, the colon polyp can be detected and removed before it has the chance to become cancer.

Every day 5 people in Singapore are diagnosed with colon cancer and 2 die from it. Screening is important to catch the cancer in early stage and to prevent the colon polyp from turning into cancer. Colon cancer develops from polyps that grow on the inside walls of the large intestine and rectum. If the polyps are discovered early and removed, cancer is prevented.

For people at average risk, the stool occult blood test can be done yearly and colonoscopy every 10 years.

For people at increased risk, surveillance should be more stringent.

For those with colon polyps whereby histology show tubular adenoma with dysplasia, the repeat colonoscopy should be done in 3 to 5 years.

For those with inflammatory bowel disease eg ulcerative colitis or Crohn’s, colonoscopy should be done every 1 to 2 years.

For those with family history of colon cancer, colonoscopy should be started at age 40 years of age or 10 years before the family member’s diagnosis age, whichever is earlier.

Treatment of Colon Cancer

Treatment for colon cancer is based on the stage of the disease.

Stage 0 cancer – The cancer is limited to the inner lining of the colon – Operation by removal of the colon polyp or part of colon

Stage 1 cancer – The cancer has spread to layers of colon wall but not outside colon/ lymph nodes – Operation by removal of the colon polyp or part of colon and nearby lymph nodes

Stage 2 cancer - The cancer has spread to layers of colon wall and nearby tissue but not lymph nodes - Operation by removal of part of colon and nearby lymph nodes & may require Chemotherapy

Stage 3 cancer - The cancer has spread to nearby lymph nodes but not other parts of body - Operation by removal of part of colon and nearby lymph nodes & Chemotherapy

Stage 4 cancer - The cancer has spread to distant organs eg lungs, liver – Chemotherapy, radiation therapy

Survival Rates for Colon Cancer

Survival rate is dependent on the stage of the disease. The 5 year survival rate for Stage 1 colon cancer is about 92%. For stage 2 to 3, the survival rate is about 50% to 80%. The 5 year survival rate drops drastically to about 10% in stage 4 colon cancer. Bear in mind, the survival rates are estimates and can differ from person to person.

1) Colon Cancer – Colon cancer is the most common cancer affecting men and women in Singapore. It is usually more common after 45 years of age.

Risk factors include personal medical history of inflammatory bowel disease eg Ulcerative colitis, Crohn’s disease, colon polyp, colon cancer as well as family history of colon cancer, familial adenomatous polyposis, and hereditary non polyposis colorectal cancer. Other risk factors include diabetes, obesity, sedentary lifestyle, high fat low fibre diet, alcohol and smoking.

Symptoms include blood in stools, change in bowel habits, feeling of incomplete defecation, persistent abdominal discomfort, loss of appetite and weight.

Screening tests include Stool Occult blood test (checks for blood in stools that cannot be seen using naked eyes), Blood test for CEA (colon cancer marker). CT Colonoscopy also known as virtual colonoscopy, is a non-invasive procedure that uses low dose radiation CT scan to image the intestines to look for any colon polyps or colon cancer. Colonoscopy is a day surgery procedure whereby a long flexible fibre optic tube is inserted from anus into the entire colon. If there are any polyps or suspicious areas, biopsy will be done at the same setting.

Prevention – lifestyle modification with healthy diet, regular exercise, avoidance of smoking and alcohol and weight reduction (if obese).

2) Lung Cancer – Lung cancer is usually more common after 40 years old.

Risk factors include smoking. Smoking causes lung cancer and the risk is dose dependent and increases with the number of cigarettes smoked per day and number of years of smoking. On average, the risk of lung cancer in smokers is about 20 times that of non-smokers. This includes exposure to second hand smoke. Other risk factors include exposure to workplace chemicals eg arsenic, asbestos, cadmium, chromium, coal gas, nickel, vinyl chloride as well as family history of lung cancer.

Symptoms include persistent cough, chest pain, breathlessness, blood in sputum, hoarseness of voice, weight loss.

Screening tests include Chest XR, Low dose radiation CT scan of Lungs (to reveal small lesions in lungs that cannot be visualized with chest xray).

Prevention – avoid smoking, second hand smoke and toxic chemicals. Eat a diet full of fruits and vegetables.

3) Prostate Cancer – Prostate cancer usually occurs after 50 years of age, but is more common after 70 years old.

Risk factors include age, obesity and family history of prostate and breast cancer.

Symptoms include urination problems eg slow urination, weak stream of urination, blood in semen, erectile dysfunction, and bone pain in advanced stages. Early stages are typically asymptomatic.

Screening tests include digital rectal examination, Blood test for PSA (prostate cancer marker), Ultrasound prostate.

Prevention – Maintain healthy weight and adopt healthy lifestyle.

4) Liver Cancer – Liver cancer is more commonly seen in Asians. It usually affects those above 40 years of age. But it can occur earlier in people with Hepatitis B or C.

Risk factors include Hepatitis B, Hepatitis C, Liver cirrhosis, Alcoholic liver disease and aflatoxin (poison arising from fungus growing in badly preserved foods). The risk of liver cancer in a Hepatitis B or C carrier is about 100 times higher compared to a non-infected person.

Symptoms include abdominal discomfort, abdominal swelling, nausea, vomiting, jaundice, loss of weight and appetite.

Screening tests include Blood test for AFP (liver cancer marker), Ultrasound Liver (checks for liver lesions and fatty liver), Fibroscan (checks for liver hardening), CT or MRI scan Liver.

Prevention – Hepatitis B vaccination, lifestyle modifications including avoidance of alcohol consumption and maintenance of healthy weight, avoidance of unprotected sexual intercourse, multiple sexual partners and intravenous drug abuse.

5) Lymphoma – Lymphoma is a cancer of lymphatic system. It can be seen in children, young adults as well as those above 50 years of age.

Risk factors include infection with viruses that lower immune system eg HIV, medications that suppress immune system, Helicobacter pylori and EBV.

Symptoms include painless swollen lymph nodes of neck, arm pit, groin, persistent fever, night sweats, and weight loss.

Screening tests include biopsy of lymph node.

Prevention – healthy lifestyle.

6) Skin Cancer – Skin cancer is divided into melanoma and non-melanoma skin cancer eg basal cell carcinoma and squamous cell carcinoma. In Singapore, basal cell carcinoma is the most common, followed by squamous cell carcinoma. But melanoma is the most dangerous due to its ability to spread early.

Risk factors include fair skin, prolonged sun exposure, personal medical history of moles, precancerous skin lesions or skin cancer, exposure to radiation eg radiation treatment for eczema, weakened immune system and family history of skin cancer.

Symptoms include skin lesions – Asymmetry, Border (irregular, uneven), Color (haphazard, color changes), Diameter (>6mm), Evolving (enlargement).

Screening tests include Skin biopsy.

Prevention – avoid sun and ultraviolet radiation exposure, use of sun protection devices.

7) Stomach Cancer – Stomach cancer is more common in men and people above 50 years of age.

Risk factors include personal medical history of Helicobacter pylori infection, stomach polyps, long term stomach inflammation (chronic atrophic gastritis and intestinal metaplasia), smoking, diet rich in salty and smoked foods, low consumption of fruits and vegetables, and family history of stomach cancer.

Symptoms include abdominal discomfort, bloatedness, indigestion, heartburn, nausea, vomiting, loss of appetite and weight, fatigue due to anaemia resulting from blood loss.

Screening tests include blood test for full blood count (checks for anaemia) and Helicobacter pylori, Urea breath test (checks for current Helicobacter pylori infection), Barium meal (XR with ingestion of barium) and Gastroscopy (day surgery procedure whereby a thin fibre optic tube is inserted from throat into the stomach – biopsy can be done if there are suspicious areas).

Prevention – eat more fruits and vegetables and less salty and smoked foods, avoid smoking and eradicate Helicobacter pylori infection with medications.

8) Nose Cancer – Nose cancer affects men more than women and is more common in age group 35 – 55 years of age. It is more frequently seen among Chinese.

Risk factors include male gender, race (Chinese), EBV infection, diet rich in salt cured foods and family history of nose cancer.

Symptoms include painless neck lump, nose blockage, nose bleed, decreased hearing, ringing in ears, unusual facial pain or numbness, double vision, headache.

Screening tests include blood test for EBV and Nasoendoscopy (office procedure whereby a thin, flexible tube is inserted via the nostril to the back of nose to check for lumps) and Biopsy of cervical lymph node.

Prevention – eat more fruits and vegetables and less salty and smoked foods, avoid smoking.

9) Kidney Cancer – Kidney cancer is slightly more common in men than women.

Risk factors include obesity, personal medical history of hypertension and certain inherited syndromes, smoking and family history of kidney cancer.

Symptoms include blood in urine, persistent abdominal or back pain, persistent fever, weight loss.

Screening tests include urine test for blood and Ultrasound/ CT kidneys.

Prevention – maintain a healthy weight, control high blood pressure and avoid smoking.

10) Pancreas Cancer – Pancreatic cancer is more common above 50 years of age.

Risk factors include smoking, obesity, genetic syndrome eg neurofibromatosis type 1, Multiple endocrine neoplasia type 1 and family history of pancreatic cancer.

Symptoms include abdominal discomfort, bloatedness, jaundice and weight loss.

Screening tests include blood test for CA 19-9 (pancreas cancer marker) and Ultrasound Abdomen/ CT or MRI Pancreas and ERCP( a fibre optic scope is inserted down the throat into the stomach and small intestine where the ducts of the pancreas drain into, dye is then injected into the ducts, xr taken and biopsy can be done).

Prevention – eat more fruits and vegetables, maintain a healthy weight and avoid smoking.

With age, our body changes and our immune system begins to lose some of its function and cannot respond as quickly and efficiently to stimuli. This puts us at higher risk of diseases as we age. The severity of the diseases is also greater.

Vaccines can help to boost the immune system to lower the chance of one getting a vaccine-preventable disease.

Highly recommended vaccines

1) Pneumococcal Vaccine – Prevnar Pneumococcal 13-valent conjugate vaccine (PCV13), Pneumovax 23-valent polysaccharide vaccine (PPSV23).

Pneumococcal disease is caused by the bacteria Streptococcus pneumonia which is transmitted though physical contact or droplet. It causes sudden onset of fever, cough, chest pain, breathlessness. It can cause pneumonia and invasive pneumococcal disease – bacteremia and meningitis (brain infection). The disease is most common in young children; the elderly as well as those with chronic diseases eg heart disease, diabetes and poor immune system.

Adults more than 50 years of age can consider doing PCV13 first followed by PPSV23 about 2 months later. PPSV23 can be covered by medisave for adults above 65 years of age as well as those under 65 years of age with certain medical conditions.

2) Diphtheria, Pertussis (Whooping cough), Tetanus (Lockjaw) Vaccine – Boostrix

Diphtheria is an infection caused by Corynebacterium diphtheria bacteria which is transmitted through physical contact and droplet. It causes fever, sore throat, swollen glands and pseudomembrane at the nasal passage and throat with difficulty breathing. It can lead to severe heart muscle inflammation and nerve damage.

Pertussis, a respiratory illness commonly known as whooping cough, is a very contagious disease caused by a type of bacteria called Bordetella pertussis. It is transmitted through contact and droplet. The disease usually starts with cold like symptoms, followed by violent, rapid coughs for up to 10 weeks. It can also lead to ear infection and pneumonia.

Tetanus is an infection caused by bacteria called Clostridium tetani. The bacteria is present everywhere in the environment, including soil, dust and manure. It can get into the body through broken skin, usually through injuries from contaminated objects. Symptoms include fever, headache, jaw cramp, muscle stiffness and spasm, seizures and complications include breathing difficulty, pneumonia, pulmonary embolism.

The vaccine (Boostrix) is recommended once in 10 years.

3) Influenza Vaccine

Influenza (flu) is a contagious respiratory illness caused by influenza viruses – transmitted through physical contact and droplet. It can cause mild symptoms such as fever, cough, running nose, sore throat, fatigue. It can also lead to severe illness such as pneumonia, bronchitis, sinus and ear infection. Serious outcomes of flu infection can result in hospitalization or death. Some people, such as young children, elderly and those with chronic medical problems are at high risk for serious flu complications.

The vaccine is recommended yearly because flu viruses are constantly changing and the flu vaccine is updated annually to keep up with the change in the flu viruses.

4) Zoster Vaccine – Zostavax

According to the CDC, 1 in 3 people will experience zoster (shingles) in their lifetime. 70% occurs in people above 50 years of age. This occurs due to reactivation of the varicella virus (chicken pox). It can lead to painful blister like rashes, post-herpetic neuralgia, brain infection (encephalitis), blindness, hearing problem and pneumonia.

1 dose of zostavax is able to reduce the incidence of zoster by 70%.

Sexually transmitted diseases (STD) refer to infections that are transmitted through sexual intercourse. It can strike anyone, regardless of age, gender, race, sexual tendency, marital status and type of sex (oral, anal or vaginal sex) and the consequences may last a lifetime. Although condom is highly effective in reducing risk of contracting a sexually transmitted disease, it may not be 100% foolproof. Many STDs are silent – they cause no symptoms in the initial stage, especially in women. Even if a person is asymptomatic, the disease can still be transmitted to the sex partner.

Long term consequences for women include pelvic inflammatory disease, infertility, ectopic pregnancy and cervical cancer. It may also lead to irreversible damage to babies infected by their mothers during gestation or birth, including blindness and mental retardation. For men, the long term consequences include sterility and cancer of penis and anus.

HPV
Human Papilloma Virus (HPV) is the most common sexually transmitted disease. There are many subtypes of HPV that can infect the genital areas of both men and women. Even the mouth and throat can also be infected. Most people who are infected do not know that they have it as they do not have any symptoms. It is transmitted through genital and skin contact.

Complications
1) Cervical Cancer – High risk oncogenic strains of HPV such as HPV 16 & 18 are responsible for at least 80% of cervical cancer cases.

2) Other types of cancer – Vulvar cancer, Vaginal cancer, Penile cancer, Anal cancer, mouth and throat cancer.

3) Genital warts – this presents as bumps in the genital area, within weeks or months after sexual contact. This is usually caused by HPV strains 6 & 11.

Investigation – HPV DNA test together with PAP smear for females

Treatment – There is no treatment for the virus itself. Treatment is available for warts and cancer. For warts, podofilox, imiquimod, cryotherapy using liquid nitrogen, surgical removal can be considered.

Prevention – HPV vaccines – Cervarix and Gardasil are highly recommended from age of 9 years old.

Chlamydia
This is caused by the bacteria Chlamydia trachomatis which can damage the female reproductive organs. It can be transmitted through oral, vaginal and anal sex and from mother to baby during childbirth.

Majority of patients have no symptoms. Symptoms may occur within 1 to 3 weeks. Women – abnormal vaginal discharge, burning sensation during urination, pain during intercourse, lower abdominal pain, bleeding between menstrual periods, fever. Men – penile discharge, pain during urination, itch of penis.

Complications – chronic pelvic pain, pelvic inflammatory disease, fallopian tube infection, ectopic pregnancy, infertility, epididymitis, Reiter’s syndrome

Investigation – urine, cells from penis / cervix for Chlamydia DNA PCR test

Treatment – Antibiotics eg doxycycline, azithromycin

Gonorrhea
Gonorrhea is caused by Neisseria gonorrhoeae bacterium. It can infect the mucous membranes of the female reproductive tract, the urethra and the mouth, throat, eyes and anus. It can be transmitted through sexual contact (no ejaculation required) with mouth, vagina, penis, and anus and from mother to child during childbirth.

Many do not have symptoms. Symptoms may occur within 1 to 14 days.
Women – painful urination, foul smelling vaginal discharge, abnormal vaginal bleeding, lower abdominal pain.
Men – painful urination, white/yellow/green urethral discharge, scrotal pain

Complications – pelvic inflammatory disease, ectopic pregnancy, epididymitis, infertility, disseminated gonococcal infection.

Investigation – urine, urethral, endocervical, vaginal specimen for Gonorrhea DNA PCR test

Treatment – Antibiotics – combination therapy using intramuscular ceftriaxone and oral azithromycin or doxycycline

Genital Herpes
This is caused by Herpes Simplex Virus – Type 1 or Type 2. HSV Type 1 usually causes cold sores, but sometimes may cause genital herpes. HSV Type 2 is the usual cause of genital herpes. The virus is spread by direct physical contact.

Incubation period ranges from 2 days to 2 weeks. Some people do not have symptoms. Others get blisters on or around the genitals, anus or mouth. The blisters break and leave painful sores that may take up to 1 month to heal. Once infected, the virus hides in neurons in the body indefinitely and gets reactivated in times of triggers such as stress and hormonal changes.

Complications – bacterial and fungal superinfections such as balanitis, eye infections, corneal ulcers, blindness, skin infections, brain infections (encephalitis and meningitis), disseminated herpes, neonatal herpes (baby).

Investigation – blood test for HSV Type 1 and 2 antibodies, HSV culture and PCR test for viral DNA or RNA.

Treatment – There is no cure for herpes. Antiviral medications can prevent or shorten outbreaks.

Syphilis
This is caused by the bacterium Treponema Pallidum. It is transmitted through direct contact with syphilitic sore, chancre. Chancres can occur at the external genitalia, vagina, anus and mouth. Pregnant women can transmit the disease to the unborn child.

Symptoms may appear as early as 10 days or as late as 3 months after exposure. In the primary stage, there may be a single chancre (sore) or multiple sores. The sore is usually firm, round and painless. It usually lasts 3 to 6 weeks and heals regardless of treatment. If the person is not treated, it progresses to secondary stage, whereby there are rough, red, non itchy skin rashes on hands and feet and sores in mouth, vagina, and anus. There are non specific symptoms of fever, sore throat, headache, swollen lymph nodes, fatigue and weight loss. Without treatment, it will progress to latent stage with no signs or symptoms. Late stage of syphilis can occur after 10 to 20 years, with damage to multiple organs – brain, nerves, eyes, heart, blood vessels, liver, bones and joints.

Genital sores caused by syphilis make it easier to transmit and acquire HIV sexually.

Investigation – Blood test for VDRL and TPHA

Treatment – Intramuscular injection of penicillin

Chancroid
This is caused by a bacteria – Haemophilus ducreyi. It is transmitted through sexual contact. Symptoms appear within 1 day to 2 weeks. It starts with a small bump at the genitals. The bump transforms into a soft, painful, well defined ulcer with grey base that bleeds easily. Inguinal lymph nodes may be swollen.

Complications – urethral fistulas and scars

Investigation – diagnosis is clinical

Treatment – Antibiotics eg azithromycin, erythromycin, ciprofloxacin, ceftriazone

Bacterial Vaginosis
This is a common type of infection of the vagina caused by bacteria. It occurs when the normal balance of bacteria in the vagina is disrupted and replaced by overgrowth of bad bacteria. The cause is not fully understood, but it may be related to douching, smoking and having multiple sexual partners.

Symptoms include abnormal white/gray/yellow foul smelling vaginal discharge, itch around genitalia, and burning sensation during urination

Complications – increase in risk of other STDS, increase risk of miscarriage and preterm delivery during pregnancy.

Investigation – vaginal discharge for bacteria and DNA, PAP smear

Treatment – antibiotics – oral or vaginal eg metronidazole, probiotics for prevention

Trichomoniasis
This is caused by a parasite- Trichomonas vaginalis. It is transmitted through sexual contact. Only about 30% of people infected develop symptoms. Infection is more common in women. Symptoms occur within 5 days to 1 month.

Symptoms in men include itch, irritation inside penis, burning sensation after urination or ejaculation, penile discharge. For ladies, there is itch, burning sensation, redness of the genitals and vaginal discharge.

Complications – premature delivery (for pregnant women with the infection).

Investigation – urine, vaginal swab for Trichomonas PCR DNA test

Treatment – antibiotics – metronidazole for patient and partner

HIV
The Human Immunodeficiency Virus is a virus that kills the body’s CD4 cells. CD4 cells help the body fight infection and disease. AIDS (Acquired ImmunoDeficiency Syndrome ) is a disease whereby HIV destroys the immune system. HIV is transmitted by blood and body fluids. It is not transmitted though sharing of food and drinks. Babies born to mothers with HIV can get infected during pregnancy, birth and breastfeeding.

HIV remains asymptomatic for years. Stages of HIV – acute retroviral syndrome (fever, fatigue), HIV without symptoms, HIV with symptoms (e.g. weight loss, pneumonia, cancer), AIDS

Complications – AIDS (late stage of HIV infections) – this usually develops within 10 to 12 years after infection. The CD4 count is very low and person succumbs to multiple infections caused by viruses, bacteria, fungi and parasites and cancers such as Kaposi sarcoma, lymphoma and cervical cancer.

Investigation – HIV antibody test (window period up to 6 months), Confirmation blood test using Western Blot

Treatment – Anti HIV drugs

Viral Hepatitis
The most common forms of viral hepatitis are A, B and C. These are viruses that affect liver.

Hepatitis A is spread through ingestion of contaminated food or drinks. Symptoms of fever, vomiting, abdominal pain, yellowing of skin, dark urine and pale stools occur within 2 to 6 weeks of exposure. It may lead to liver failure.

Hepatitis B & C are transmitted by childbirth, blood and body fluids. They are not spread through food and water. They may cause acute hepatitis (symptoms similar to hepatitis A) with 6 weeks to 3 months. Chronic infection can occur whereby the virus resides within the body – Hepatitis B / C carrier state.

Complications – Liver damage, Liver hardening, Liver cancer, Liver failure.

Investigation – Blood test for Hepatitis A, B, C

Treatment – No treatment is available for acute Hepatitis A, B, C. Chronic Hepatitis B, C carriers require lifetime surveillance with blood test, ultrasound liver & fibroscan. Medications may be considered if clinically warranted.

Prevention – Hepatitis A vaccine is advised from age 1 onwards. Hepatitis B vaccine is advised at birth / any age. Combined Hepatitis A & B vaccine is available. There is no vaccine for Hepatitis C.


Common questions on HPV vaccination (cervical cancer)

What is the HPV vaccination for? HPV vaccination is a preventive measure to protect one from HPV, a virus that can affect many parts of the body. HPV is a family of many subtypes of virus, with some that lead to certain types of cancer, including Cervical Cancer, one of the top cancers that affect women worldwide. For example, HPV types 16 & 18 cause about 80% of cervical cancers, while HPV types 6 and 11 cause about 90% of genital warts.

Our clinic carries both vaccines that have been approved for use in Singapore- Cervarix & Gardasil.

Is HPV vaccination medisave-claimable?

As with MOH’s regulations, for HPV vaccination, ladies (Singaporeans and Singapore PRs) between the ages of 9-26 years old are eligible to claim under Medisave (from own account or family members’ account), for up to $400 per year.

Why is HPV vaccination important?

Without vaccination, it is estimated that the majority of sexually active people will catch HPV during their lifetime. Non-sexually active people can also get infected with HPV through contact- e.g. towels, underwear, skin etc. Many people who have HPV may not show any signs or symptoms. This means that they can transmit (pass on) the virus to others without knowing it.

How long will the HPV vaccine last?

From research and modeling predictions, the HPV vaccine should last about 10 to 20 years. However, it varies with individual. No booster is required at the moment.

How is the HPV vaccine given?

The HPV vaccine is given as an injection usually in the arm muscle by our certified nurse. The full course comprises of 3 doses to be administered in 6 months.

The dosage schedule depends on the vaccine brand. (pls refer above). The schedule is flexible.

How do I know if I’m suitable for the HPV vaccine? All ladies above 9 years of age and men 9-26 years of age are suitable. The vaccine works best when given before exposure to HPV and when the person has not become sexually active. Studies have shown benefits of the vaccine in age groups up to 45 years of age. You can consult our doctor to find out the appropriate vaccine for you and your child.

You are not suitable for the HPV vaccine if:

You are allergic to any of the ingredients in the vaccine (including any of the ingredients listed under inactive ingredients) or if you have an allergic reaction after receiving a dose of the vaccine. The vaccine is not recommended during pregnancy.

If I’m already sexually active, will I still benefit from the HPV vaccine?
What if I already have HPV? Will the HPV vaccine still work on me?
Can I do the vaccination if my PAP smear test is abnormal?


YES! You can still benefit from the vaccine, because even if you have been exposed to HPV, you may not have been exposed to the types of the virus covered by the vaccine. Moreover the body may not be able to mount sufficient antibodies to prevent future infections.

By doing the HPV vaccine, your body will be able to produce sufficient antibodies to prevent future HPV infections. Clinical studies have shown that women, who have been previously exposed to HPV type 16 or 18 but had cleared the infection, were subsequently protected after vaccination.

HPV vaccine does not cure HPV infection.

Are there any possible side effects of the HPV vaccine?

The vaccine is generally well tolerated with minimal side effects. The reported side effects include pain, redness, and swelling at the injection site and generalized reactions.

For any unusual or severe symptoms after receiving the vaccine, patient should contact the doctor immediately.

Is the HPV vaccine suitable for young children?

The HPV vaccine can be used in children as young as 9 years old.

Is there anything I should do or take note of before the HPV vaccination?

You should tell the doctor if you or your child:
• has had an allergic reaction to the vaccine
• has a bleeding disorder and cannot receive injections in the arm
• has any illness with a fever higher than 100°F (37.8°C) is pregnant or is planning to get pregnant
• takes or plans to take any medicines, including over- the-counter medicines
• has a weakened immune system, for example due to a genetic defect or Human Immunodeficiency Virus (HIV) infection, or if you take medicines that affect your immune system.

Can I go for other vaccines and medications after I have received the HPV vaccine?

Yes, you can do so with common vaccines such as Hepatitis A, B, DPT, polio, Flu vaccines.

What should I do if my child or I miss a dose?

The doctor will decide when to give the missed dose.

It is important that you follow the instructions of the doctor regarding return visits for the follow up doses. Usually, our nurse will give a reminder call to the patient one day before the designated date.

What other important information about the HPV vaccination should I know?

There are more than 100 HPV types: the HPV vaccine will not protect against every type.

Regular PAP smear test is still advisable for all ladies who have had sexual intercourse.

Womb Cancer
Womb cancer usually affects ladies in age group 60 – 70 years.

Risk factors include early onset of menses, late onset of menopause, never being pregnant, obesity, tamoxifen, long duration of estrogen therapy, medical conditions such as diabetes, polycystic ovary syndrome, endometrial polyps and colon cancer as well as high fat diet.

Symptoms/span> include abnormal menses, bleeding after menopause, abnormal vaginal discharge and persistent abdominal pain.

Screening tests include PAP smear (abnormal cells eg endometrial cells), Ultrasound Pelvis (non invasive scan of womb and ovaries with no radiation). Ultrasound pelvis can visualize the womb for the womb lining, growths of the womb eg uterine fibroids and ovary lesions such as ovary cysts and ovary cancer. Other tests include endometrial sampling (office procedure) and hysteroscopy, dilation and curettage.

Prevention – lifestyle modification with low fat diet, oral contraceptive pills.

Ovary Cancer
Ovary cancer can affect ladies of any age group.

Risk factors include personal medical history of breast, womb, colon and stomach cancer, never being pregnant, high fat diet and family history of ovary, womb, breast and colon cancer.

Symptoms include abnormal menses, abdominal pain, bloatedness, loss of weight and appetite, change in bowel and urination habits and backache.

Screening tests include pelvic exam, blood test for CA125 and Ultrasound pelvis.

Prevention – lifestyle modification with low fat diet, oral contraceptive pills.

Cervical Cancer
Cervical cancer can affect ladies of any age group ranging from as young as 18 years old til as old as 80 years old.

The main cause of cervical cancer is the Human Papilloma Virus (HPV). There are more than 100 subtypes of HPV – some non cancer causing, some cancer causing, some can cause genital warts. HPV strains 16, 18, 31 and 48 account for more than 80% of all the cervical cancer cases. This is the most common sexually transmitted disease - up to 50% of all ladies have this virus at some point in time of their lives.

This virus is transmitted by sexual intercourse, skin contact, fomites eg towels, undergarments and mother to newborn. Condoms reduce the risk of transmission but it is not 100% effective. There is no treatment available for the virus. The virus may be cleared by the body’s immune system, but the body does not develop sufficient antibodies to prevent future infections.

Risk factors include multiple sexual partners, sexual intercourse from young age, having sex with partner whose sexual history is unknown, personal history of other sexually transmitted diseases, those with weakened immune system such as diabetes and HIV, smokers, those on long term steroids and oral contraceptive pills and family history of cervical cancer.

Symptoms include abnormal menses, intermenstrual bleeding, abnormal vaginal discharge, pain during sexual intercourse, lower abdominal pain, loss of weight and appetite.

Screening tests include PAP smear, Thin Prep and HPV test. PAP smear is a painless, non invasive test whereby cells are collected from the cervix via a soft brush. It should be done at least once in 3 years. The accuracy is not 100%, hence if done yearly, the accuracy is enhanced.
Thin Prep is the most comprehensive FDA approved PAP smear test available. The cells are placed in a solution instead of being spread on a slide. The solution with the cells will be sent to the lab. The thin prep imager system increases disease detection.
HPV test is a FDA approved molecular test which screens the cervix for 14 high risk HPV types. The high risk HPV types will cause transformation of normal cells in cervix into abnormal cells. The abnormal cells will become pre-cancer cells (CIN) which will subsequently change into cervical cancer if not treated. It is highly recommended for ladies above 30 years of age and those with abnormal PAP smears. HPV test is only available for ladies.
Colposcopy is recommended if PAP smear test shows precancerous changes.

Prevention – keep to 1 sexual partner, delay age of sexual intercourse, and avoid unprotected sexual intercourse. Consider HPV vaccination for yourself and your family members for prevention of pre-cancer and cervical cancer. The vaccination is highly recommended for all men and ladies above 9 years of age. It is safe and 99% effective with no significant side effects. It is incorporated in childhood immunisation programmes world-wide. The vaccine is also recommended for ladies who are already married. Older women can also benefit from the vaccine. Protection should last at least 10 to 20 years.

Singaporeans and Singapore PRs under 27 years of age can make use of their own or family members’ Medisave for full payment of the HPV vaccine at Medisave accredited clinics.
Asia Healthpartners is a Medisave accredited clinic.

Breast Cancer
Breast cancer is the top cancer for ladies. It is more common in ladies after 40 years of age.

Risk factors include early age of menses, late age of menopause, never being pregnant, family history of breast, womb, ovary and colon cancer, defective genes (BRCA1 and BRCA2), radiation exposure to chest during childhood days, obesity, high fat diet, excessive alcohol consumption, long term conventional hormone replacement therapy with estrogen.

Symptoms include breast lump, breast pain, nipple discharge and skin changes over the breast.

Screening tests include mammogram and ultrasound breasts. Mammogram is a low dose x-ray of the breasts that can pick up very small breast cancers, breast calcifications (benign and malignant). It is recommended yearly for ladies between 40 – 50 years of age and once in 2 years for ladies above 50 years of age. Asia Healthpartners Mammogram is fitted with Mammopad Breast Cushion which makes the mammogram experience softer and more comfortable. Ultrasound breasts is a painless, non invasive, no radiation type of scan for breast lumps. It can determine if the breast lump is solid or liquid and if it looks suspicious in nature. It is recommended for any age group, especially those with lumpy breasts. MRI Breasts is recommended if mammogram and ultrasound breasts are abnormal, to give more information about the nature of the growth. Other tests will include Breast Biopsy done by needle aspiration, ultrasound guided, mammotome or open.

Prevention – lifestyle modifications including low fat diet, regular exercises reduction in alcohol intake and maintenance of healthy weight.

Men and women are not alike. Most of us are aware of this fact. When a woman goes through menopause, she experiences a variety of physical and emotional changes. The truth is that, men also go through a change very much like women in the middle years. Hence the term – 'mid life crisis' is derived.

Of course, every one of us is different. Not everyone will experience turbulence in the middle years. Sometimes it may be difficult to differentiate the symptoms of such changes from symptoms due to other diseases.

Male menopause, also known as andropause, generally occurs from around 40 years of age. This happens as a result of decline in hormones such as male sex hormone – testosterone. Compared to women, the decline is more gradual, hence the changes may be more subtle. As a result, a lot of men attribute the changes to normal ageing.

Testosterone is the most important male sex hormone. It is essential for maintaining health as well as quality of life. It is produced mainly in the testes. Testosterone declines with age due to death of testes cells and decreased stimulation by thebrain.

As a result of reduced levels of testosterone, a multitude of symptoms can occur in the male body.

1. Feel tired

2. Tend to fall asleep after meals

3. Anxious, irritable, depressed

4. Poor sense of well being, decreased enjoyment of life

5. Increased sweating

6. Problem with sleep

7. Decrease in muscular strength, endurance, sports ability

8. Decrease in work performance

9. Bodyache

10. Increase in weight, especially around the waist

11. Decrease in sexual desire/ libido

12. Decrease in morning erections

13. Erection is less strong

If a man in such a situation ignores the problem, he may be at reater risk of heart disease as well as osteoporosis.

How does one confirm the condition?
If you do have some of the symptoms listed above, a blood test for testosterone, sex hormone binding globulin (protein that binds to testosterone), ther hormones such as DHEA(S) and growth hormone is advised.

Tips to cope with the change -
1. Healthy diet

2. Regular exercise

3. Adequate sleep

4. Stress reduction techniques

5. Sufficient fluids

6. Less alcohol and caffeine

7. Good social support

Treatment
Testosterone replacement therapy must always be administered by trained physicians. Regular follow-up including blood test for testosterone, prostate cancer marker and blood counts is required.

Testosterone is available in different forms – oral tablet, topical cream and injection. Oral tablet does not provide steady blood levels – hence not generally recommended. The cream form makes use of bio-identical testosterone and the preparation is custom made in doses suitable to patient’s needs and condition. The cream is applied daily in the morning to the inner arms / thighs. As for the injection form, it provides convenience to the patient as it requires only 4 injections per year. The testosterone level with the injection method is more consistent.

DHEA therapy is administered orally. This is an adrenal gland hormone. Low levels may lead to fatigue and low sex drive.

Growth hormone therapy is administered by own self via injection – fine needle or needleless method on daily basis. This is a brain hormone. Decline may contribute to memory and sleep problems, increase in weight, decrease in muscle bulk, poorer hair and skin.

In my clinic practice, I encounter many men in mid 40s with the problem of andropause. A lot of them were not aware of such a condition previously due to lack of publicity. For those who are on the treatment programme, they are happy with the outcome as the treatment has ‘renewed’ their life. As one patient has said – I feel like a different person altogether! I have become stronger in sports and I have lost weight too.

In conclusion, early diagnosis and treatment is the way to go to improve your health and vitality!

The mind speaks a thousand words. Our state of mind can relate to the status of our health. In the current economic situation, we are bombarded with bad news from multiple sources. Financial issues, work stress, family problems will lead to a cumulative impact on our mind. The stress and frustration that one faces, if poorly managed, can lead to a cascade of health issues. The classic scenario is that of a tired, nervous person with pain at different parts of the body and suffers from indigestion, poor appetite and sleepless nights.

It is therefore essential to manage stress well to maintain good physical and mental fitness in order to fight the challenges of life. Stress can have a negative impact on health as it may weaken the immune system, making us more susceptible to diseases.

Stress management involves recognizing and acknowledging that one is under stress, Looking for the sources of stress and learning healthy ways to overcome stress. Time management, prioritization and positive thinking are important techniques. Living a healthy lifestyle and having a strong social support network are equally as crucial.

It is never too late to make the first step to overcome stress and reverse the damage.

Here are some great tips:

For The Mind -

1. Practice slow deep breathing in between work – this will allow your mind to relax and recharge

2. Listen to soft smoothing music

3. Talk to a friend/colleague – vent out your frustrations

4. Pen down your thoughts and things that bother you

5. Indulge in something enjoyable, take up a new hobby

6. Laughter is the best medicine. Look for humor in life

For The Body -

1. Start a regular exercise regime - 3 times a week, 30 minutes for each session. Walk whenever there are opportunities

2. Increase your intake of vegetables and fruits

3. Consider supplements such as anti-oxidants

4. Pamper yourself with a massage to release muscle tension and relax the mind

Kick-starting the routine may seem hard at first but as it develops into a habit, it would be a breeze. Remember to assess the overall progress. Seek professional input and guidance. Health screening is also useful as a guide to assess for any medical problems and complications as a result of stress.

Economical comprehensive health screening packages which include anti-stress massages are now available at Asia HealthPartners.

People who exercise may lower their risk of diseases but only those who are aware of the possible risks of strenuous sports and be prudent about it will reap the full benefits of physical activities.

In Singapore, there is an increasing trend of mortality- marathon related sudden death cases over the past few years, with the latest headlines of a 17 year old death in a triathlon and a 25 year old death in a 21km run. Even so, the number of participants for the competitions did not seem to decrease but continue to soar with popularity.

Do the participants fully understand the risk they have put themselves through?

A recent study in Orlando cited that the risk of sudden death in participants of triathlons is at least twice that of marathons. Statistics showed that there are 15 deaths per million participants of triathlons compared to 4-8 deaths per million participants of marathons. It was concluded that the main risk is due to heart failure during the swimming part. Autopsies revealed that 60% of the death was due to underlying problems.

"When we exercise, the heart is made to pump harder to ensure sufficient oxygen and nutrients reach the heart muscles. Contacting an external lower temperature such as cold water will constrict vessels resulting in the heart having to pump even harder to push the blood through," explained Dr. Chong Yeang Chern, Wellness Physician at Asia HealthPartners. “In whichever case, over-stressing the heart may aggravate pre-existing problems and increase mortality risk. Hence a pre-race checkup is important to screen for pre-existing medical conditions and should not be overlooked."

This is supported by the Triathlon Association of Singapore which encourages participants to have a thorough medical check up before any race.

When carefully manipulated, physical exercises can lower the risk of heart diseases, hypertension, diabetes, high cholesterol, and osteoporosis; reduce stress and keep the body looking fit!

• Have regular health screening. Ensure that your medical screening includes Treadmill Stress Test to

• check that the heart is fit for the physical stress of exercise and does not have underlying problems such as heart artery diseases.

• Self-check assessment: Measure your own heart rate during peak exercise and look out for any chest

• discomfort or difficulty breathing. Maximum heart rate should not exceed (220 – age)/ minute. Recommended heart rate to achieve is 60-80% of the maximum heart rate.

• Be well-trained and conditioned for any types of physical competition. Check with your trainer or

• professional pertaining to the risk of activities if unsure, especially for any physical challenges.

• Eat right. Seek a professional or a dietician’s advice at least months before any competition.

Remember – Staying fit is a challenge. So be sure to take good care of your health!
Prevention pays in the long run!
Live Well. Live Happy.

- A repercussion of hormone deficiency
If you have been experiencing weight gain despite cutting down on daily food intake portion, choosing food wisely and exercising regularly, you may have medical conditions that contribute to the weight gain such as hormone deficiencies and food intolerance.

Hormone deficiencies will have an impact on the quality of life. Symptoms such as sleepless nights, body ache, dry skin, thin hair, fatigue, poor concentration, poor physical stamina, low sex drive as well as weight gain may creep in. Unfortunately any people attribute it to part and parcel of the ageing process and live with it without realizing that medical options are available for treatment as well as prevention. In the long run, the hormone deficiencies can lead to serious health onsequences such as heart diseases and osteoporosis.

Determine your Health Status
Before concluding that the above symptoms are due to hormone deficiencies, one should have a thorough check done.

Health Screening can detect silent pre-existing medical conditions and prevent deterioration of the existing problems, thereby reducing healthcare costs incurred due to serious conditions. An affordable yet comprehensive screening can be done with a simple blood test checking on hormones such as male hormone (testosterone), female hormones (estrogen and progesterone), brain hormone (growth hormone), thyroid hormones and adrenal hormone (DHEAs). It is always advisable to consult the doctor prior to the screening so that appropriate tests can be done as each and every one of us is different in our genetic makeup and lifestyle habits.

Know the options & keep an open mind
Based on in-depth consultation as well as medical analysis, a holistic multi-pronged approach by a medical practitioner will be used. This will involve advice with regards to nutrition, exercise, supplements as well as use of bio-identical (natural) hormone therapy. The therapy can be administered via oral, topical or needleless (pain-free) injection. These treatments will be customized based on individual needs and requirements. With a good treatment programme and monitoring, the hormonal imbalance can be reversed and the harmony of good health and beauty can be achieved.

Finally scientific revolution has proved its worth in both treatment and prevention.

Live Well. Live Happy.



As a female family physician with about 20 years of clinical practice, I have encountered patients from all walks of life ranging from locals to expats, men and women of different age groups, ethnicities and socioeconomic classes.

There are myths and misconceptions about breast cancer that circulate among the masses regardless of the background of the person.

Myths 1) Breast Cancer will not affect me as there is no one in my family with breast cancer.

Only 10% of cancers are hereditary. Most cancers are sporadic due to mutations. If you have multiple family members with breast cancer, you may consider doing genetic test for BRCA1 and BRCA2.

If you do not have family history of breast cancer, you should consider yearly mammogram between 40-50 years of age and 2-yearly mammogram after 50 years of age. Monthly Breast self-exam is important, but a normal breast physical examination will not be sufficient for early breast cancer detection in ladies above 40 years old.

2) Breast Cancer will not affect me as I have breastfed my children.

Breast feeding can lower the risk of breast cancer, especially if you breastfeed for more than 1 year. But it does not mean zero risk.

3) Breast Cancer will not affect me as I have small breasts.

Size of the breasts is not a risk factor in breast cancer. Large breasts do not increase the chance of breast cancer and small breasts do not decrease the risk.

4) Breast Cancer will not affect me since I lead a healthy lifestyle.

Risk factors for breast cancer include obesity, high fat diet, alcohol and sedentary lifestyle. Healthy lifestyle may lower the risk but with age, there is a higher chance of mutations occurring leading to breast cancer. No food or diet can prevent breast cancer, but healthy foods with more fruits and vegetables can help to boost the immune system. Maintain a healthy weight, do regular exercises with some sunshine for vitamin D, control stress, reduce alcohol consumption and avoid smoking.

5) Mammogram is harmful due to the radiation and it can cause cancer.

Radiation dose from an 8 hr airplane flight = 0.04mSv
Radiation dose from mammogram = 0.4mSv
Radiation dose from chest XR = 0.1mSv
Accumulated dosage to cause fatal cancer years later in 5% of people = 1000mSv
Based on this, a lady will have to undergo at least 2000 mammograms to accumulate a cancer-causing radiation dose.

6) Mammogram is very painful.

The discomfort from a mammogram is similar to squeezing into a tight pair of shoes. Deep breathing as well as scheduling the mammogram the week after menses can be helpful in minimizing the discomfort.4 things that may hurt more than a mammogram – Botox, eyebrow threading, high heels and tattoo.

7) Mammogram is not accurate. My friend had done her mammogram and yet the breast cancer was not detected till mid stage.

As with all tests, there are false positives and false negatives with mammogram. Mammogram may not detect all cancers, especially in women with dense breasts. With dense breast tissues, the white appearance of the breast tissue can look similar to breast lumps, making it difficult to interpret. Hence ultrasound breasts will be highly recommended to complement the mammogram. In addition, patients with symptoms of breast lump, breast pain, nipple discharge should consult a doctor for physical examination to check if any other tests are necessary besides the screening mammogram.

8) Bras, antiperspirants, deodorants can cause breast cancer.

There is no scientific evidence to prove that these can cause breast cancer.

9) I have removed a non-cancerous breast lump; hence I will not get breast cancer.

Benign breast conditions eg breast nodules/fibroadenomas, breast cysts, are very common. Most of the time, they are not life threatening. But some are linked to future increased risk of breast cancer.

Even after operation to remove a non-cancerous breast lump, one should still undergo regular mammogram and ultrasound breasts for follow-up to check for recurrences.

For women with multiple benign breast nodules or cysts, the approach is to monitor them closely to check for any changes so that action can be taken if there are any suspicious changes. Operation to remove multiple stable breast lumps is not routinely done as removing all would involve removing some surrounding normal breast tissue, resulting in scarring that would make future interpretation of mammograms more challenging. In addition, with any types of operation, there are surgical and anaesthetic risks.

10) Ultrasound breasts is better than mammogram.

Mammogram and ultrasound breasts are different imaging modalities that complement each other, since they serve different functions. Ultrasound does not replace mammogram and vice versa.

Mammogram is a non-invasive screening tool that utilizes low-dose x-ray to examine the breasts. The machine works by compression of the breasts for a few seconds to flatten the breast tissue so that abnormalities can be clearly visualized. From the mammogram, we are able to detect cancerous as well as benign calcifications.

We do not usually do mammogram for women under 40 years of age since their breast tissue tends to be denser and this can affect the accuracy of the mammogram. Hence for women under 40 years of age with breast symptoms, it is advisable to consult a doctor for further advice and investigation.

Ultrasound breasts is a non-invasive test that uses high frequency sound waves through the breasts to convert into images. There is no radiation involved. It is a good test for breast lumps- to ascertain the nature of the breast lumps. Breast calcifications cannot be seen via ultrasound.