Women's Health & Antenatal

The first visit, often called booking, should ideally happen in the first trimester and before twelve weeks where possible. It covers your medical, surgical, obstetric and family history, your medications, your last menstrual period, and a full examination including blood pressure and weight. Folic acid should already have been started — ideally before conception, since it reduces neural tube defects in the earliest weeks, often before a woman knows she is pregnant. An early ultrasound confirms the pregnancy is inside the uterus, establishes dates far more accurately than the last period does, checks for a heartbeat and identifies twins.

The booking blood panel is substantial and every element of it earns its place. Full blood count identifies anaemia, which is common and treatable. Blood group and rhesus status matters because a rhesus-negative mother may need anti-D to protect future pregnancies. Antibody screening follows from that. Hepatitis B status matters enormously, because a baby born to a hepatitis B positive mother can be protected at birth if this is known in advance and cannot be if it is not. Syphilis screening with VDRL matters because untreated syphilis harms the baby and is curable with antibiotics. HIV screening matters because treatment in pregnancy dramatically reduces transmission to the baby. Rubella immunity is checked so that vaccination can be offered after delivery if you are not immune. A fasting or random glucose establishes a baseline, and urine testing checks for protein and infection — asymptomatic urinary infection in pregnancy needs treating because it can progress to kidney infection and preterm labour.

The visit schedule for an uncomplicated pregnancy follows a familiar shape: roughly monthly until around twenty-eight weeks, then fortnightly until around thirty-six weeks, then weekly until delivery. The intervals tighten as the risks that matter — pre-eclampsia, growth restriction, malposition — become more likely. Higher-risk pregnancies are seen more often, and that schedule is set with the specialist.

Every visit checks the same handful of things, and the repetition is the point. Blood pressure, because rising blood pressure is the earliest sign of pre-eclampsia. Urine for protein, for the same reason, and for glucose and infection. Weight. From the second trimester, fundal height to track growth, then fetal heart, and later the position of the baby. Each of these is simple, and together they detect most of what goes seriously wrong.

Screening for gestational diabetes is offered, typically in the middle of the pregnancy, and earlier or repeated where there are risk factors — a high BMI, a family history of diabetes, a previous large baby, previous gestational diabetes, or PCOS. This matters particularly in Malaysia, where the underlying prevalence of diabetes is high. Gestational diabetes usually causes no symptoms whatsoever and is found only by testing, and controlling it changes outcomes for both mother and baby.

Between visits, the things to report immediately rather than waiting are bleeding, fluid leaking, severe or persistent headache, visual disturbance, upper abdominal pain, sudden swelling of the face and hands, fever, burning on passing urine, and reduced fetal movements once you have established a pattern. Never wait until the next scheduled appointment for any of those.

We are glad to see your partner at antenatal visits, and postnatal care matters too — the check after delivery covers your recovery, mood, breastfeeding, contraception and any condition such as gestational diabetes that needs re-testing afterwards.

Almost all cervical cancer is caused by persistent infection with high-risk types of human papillomavirus, a very common virus transmitted sexually that the immune system clears on its own in the great majority of people. In a minority it persists, and over many years it can drive changes in the cells of the cervix from mild abnormality through to pre-cancer and eventually cancer. That progression typically takes a decade or more, which is the gift screening exploits: there is a long window in which a treatable pre-cancerous change can be found and removed before any cancer exists at all.

A Pap smear samples cells from the surface of the cervix and examines them for abnormal changes. HPV testing looks instead for the virus itself, using a sample taken the same way. HPV testing is more sensitive at identifying who is at risk, which is why many national programmes have moved towards it as the primary test, sometimes with cytology used to triage a positive result. Which approach applies to you depends on your age and the current programme guidance, and our doctors will advise.

Who should be screened: women who are or have been sexually active, starting in the age band recommended by current guidance and continuing at the recommended interval — which is measured in years, not months, because the disease develops slowly and screening too often produces harm without benefit. Screening continues past menopause; the idea that it stops once periods do is a common and dangerous misunderstanding. Women who have had a hysterectomy should ask, since the answer depends on why it was done and whether the cervix was removed.

Having had the HPV vaccine does not remove the need for screening. The vaccine protects against the most important high-risk types but not against every type, so vaccinated women continue with the programme. The vaccine is most effective before any exposure to the virus, which is why it is given to adolescents, and it is available here.

The procedure takes a few minutes. You lie back, a speculum is inserted to visualise the cervix, and a small brush collects cells. It is uncomfortable rather than painful for most women, and telling the doctor or nurse if you are tense, in pain or have had a difficult experience before genuinely changes how it is done — a smaller speculum, more lubricant, more time, a different position. Do not book it during a period, since blood obscures the sample. Avoid vaginal creams, pessaries and intercourse for a day or two beforehand.

An abnormal result is common and is usually not cancer. Most abnormalities are low-grade changes that resolve by themselves and are managed by repeating the test. Higher-grade changes are referred for colposcopy, where the cervix is examined under magnification and a biopsy or treatment is done if needed. We will explain exactly what your result means and arrange the referral. What we ask in return is that you do not ignore a recall letter — an abnormal result that is never followed up is the commonest route to a cervical cancer that screening should have prevented.

Separately from screening: any bleeding between periods, bleeding after intercourse, or bleeding after menopause should be assessed regardless of when your last screening was and regardless of it being normal. Those are symptoms, and symptoms are investigated rather than screened.

The first thing to understand is the gap between perfect use and typical use. Methods that depend on you remembering something every single day, or on doing something correctly in the moment, have a real-world failure rate considerably higher than their theoretical one. Methods that work without you having to do anything — the implant, the intrauterine device — have real-world failure rates that are extremely low precisely because human memory is removed from the equation. If you have had a contraceptive failure before, or you know you are inconsistent, that is not a character flaw. It is information that should steer the choice.

Combined hormonal contraception, most often the pill, contains oestrogen and progestogen. It is effective when taken consistently, and it has genuine non-contraceptive benefits: lighter and more predictable periods, less period pain, improvement in acne for many women, and a reduction in the long-term risk of ovarian and endometrial cancer. It is not suitable for everyone. Migraine with aura, a history of blood clots, uncontrolled high blood pressure, certain heart conditions, smoking over the age of thirty-five, and the early postpartum period particularly while breastfeeding are all reasons to choose something else. This is precisely why a consultation matters — these contraindications are not obscure and missing them causes real harm.

Progestogen-only methods avoid oestrogen and therefore suit many women who cannot use the combined pill, including those who are breastfeeding. They include the progestogen-only pill, the injection given every few months, and the implant placed under the skin of the upper arm and lasting several years. Their main drawback is unpredictable bleeding, which is not harmful but is the commonest reason women stop. Being warned about it in advance makes a large difference to whether it is tolerated.

Intrauterine devices come in copper and hormonal forms. Both are among the most effective methods available and both last for years. The copper device contains no hormones at all, which some women prefer, but it tends to make periods heavier and more painful. The hormonal device usually makes periods much lighter and is often used specifically to treat heavy bleeding. Insertion is uncomfortable and takes a few minutes; there is a small risk of infection in the weeks afterwards and a very small risk at insertion.

Barrier methods, principally condoms, are the only method that also reduces transmission of sexually transmitted infections. This matters, because no hormonal method or device offers any protection at all against infection. A woman on the pill or with an implant who has a new or non-monogamous partner still needs condoms for that reason.

Emergency contraception is available and is more effective the sooner it is taken after unprotected intercourse. If it is needed, come promptly rather than waiting to see whether a period arrives. It is not a substitute for regular contraception, and the consultation is a good moment to sort out a method that means you do not need it again.

Permanent methods exist for people who are certain their family is complete, and we can discuss and refer. The word to weigh is permanent — reversal is not reliably achievable, and the decision deserves proper thought rather than being made in the exhausted weeks after a birth.

Whatever you choose, come back if it is not working for you. Side effects that are tolerable in month one and intolerable in month six are worth acting on, and switching is easy. The worst outcome is quietly stopping a method and using nothing.

Menopause is the point at which periods have stopped for twelve consecutive months. The years leading up to it, the perimenopause, are when most symptoms occur and when cycles become erratic — this phase can last several years and is frequently the more difficult part. It is a normal life stage rather than a disease, which does not mean the symptoms should be endured in silence.

The symptoms extend well beyond hot flushes. Night sweats and disrupted sleep, which then drive fatigue and irritability. Mood changes, anxiety and a low mood that can be mistaken for depression, and sometimes is depression. Difficulty concentrating and word-finding problems that many women find frightening because they interpret them as early dementia. Joint aches. Vaginal dryness and discomfort during intercourse. Urinary frequency and recurrent urinary infections. Reduced libido. Changes to skin and hair. Weight redistributing towards the abdomen.

Diagnosis in a woman over the usual age is clinical — the pattern of symptoms and the change in periods. Hormone blood tests are unreliable during perimenopause because levels fluctuate enormously from week to week, and a normal FSH does not exclude perimenopause. Testing is more useful in younger women, where premature ovarian insufficiency needs to be identified because it has different implications and generally requires treatment.

Hormone therapy remains the most effective treatment for hot flushes and night sweats, and it also protects bone. The reputational damage it suffered from early reporting of large trials led to a generation of women being denied it unnecessarily, and the current understanding is considerably more nuanced: for most healthy women starting near the time of menopause and within a defined window, the benefits outweigh the risks. That said, it is not right for everyone — a personal history of breast cancer, certain clotting disorders and some other conditions rule it out or require specialist input. The route matters too, since transdermal preparations differ from oral ones in their clotting risk. Women with a uterus need progestogen alongside oestrogen to protect the lining. This is a decision to make individually with a doctor who knows your history, and we are happy to have that conversation properly rather than dismissing it.

Vaginal symptoms deserve a separate mention because they respond extremely well to local vaginal oestrogen, which acts largely where it is applied. Many women suffer for years with dryness, discomfort and recurrent urinary infections without ever raising it, often because they assume it is untreatable or are too embarrassed. It is treatable, and unlike the flushes, vaginal symptoms tend to worsen with time rather than settle on their own.

Non-hormonal approaches help too, and are the route for women who cannot or prefer not to use hormones: certain non-hormonal prescription medications for flushes, cognitive behavioural approaches for sleep and mood, weight management, reducing alcohol and caffeine triggers, and lubricants and moisturisers for vaginal symptoms.

Menopause is also a natural point to look at long-term health, and this is arguably the most valuable part of the consultation. Cardiovascular risk rises after menopause, so blood pressure, lipids and glucose should be checked. Bone loss accelerates, so risk factors for osteoporosis should be reviewed and calcium, vitamin D and weight-bearing exercise discussed. Cervical and breast screening continue. And any bleeding after menopause has been established must be investigated — never assume it is a period returning.

Pre-marital screening is offered to couples and is straightforward. It typically covers infectious conditions that could be transmitted between partners or to a future child — hepatitis B, HIV and syphilis among them — along with blood group and rhesus status, a full blood count with attention to thalassaemia trait, and a discussion of family history and immunisation. Rubella immunity is relevant for the woman because rubella in early pregnancy causes serious harm and vaccination beforehand prevents it entirely.

Thalassaemia deserves particular attention in Malaysia because carrier rates are meaningful here. A carrier is generally healthy and may never know. When both partners carry the trait, there is a significant chance in each pregnancy of a child with the severe form, which requires lifelong transfusion. Knowing this before starting a family allows genuine informed choice, and that is the single strongest argument for pre-marital screening. Results are given to each person individually and confidentially — a screening programme does not mean your partner is told your results without your consent.

On fertility: the working definition is a failure to conceive after a year of regular unprotected intercourse, and assessment is reasonable at that point — or after six months if the woman is over thirty-five, because time matters more then. Fertility declines with age and the decline steepens noticeably from the late thirties, which is biology rather than a judgement about anybody's choices.

Both partners are assessed, always. A substantial proportion of infertility involves a male factor either alone or in combination, and the male assessment is simpler and less invasive than the female one — which makes it illogical to investigate the woman thoroughly while never testing the man. A semen analysis is the starting point, and we can arrange it.

For the woman, the initial assessment covers cycle regularity as an indicator of ovulation, hormone testing timed appropriately in the cycle, thyroid function and prolactin, rubella immunity, and pelvic ultrasound to look at the uterus and ovaries. History matters enormously: previous pelvic infection, previous surgery, endometriosis symptoms, and PCOS all point in particular directions. General health is part of it too — weight at either extreme, smoking, alcohol and poor diabetes control all reduce fertility in both partners, and these are the modifiable factors people are least often told about.

Folic acid should be started before conception rather than after a positive test, since the neural tube closes very early. Anyone with a chronic condition or on regular medication should have a pre-conception review, because some medications need changing before pregnancy rather than during it.

Where the assessment points to something we cannot manage — tubal blockage, significant male factor, a need for ovulation induction or assisted conception — we refer. Referral should not be delayed for the sake of trying a little longer, particularly when the woman is in her late thirties or older. We will be honest with you about when that point has arrived.