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Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. 

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. 

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Latest Blogs

A Mother’s Guide to Miscarriage and Moving On

Miscarriages are relatively common in Singapore, with about 20% of pregnancies ending this way. This can be cold comfort when you are still coming to terms with a recent loss. But, one can gather strength from the knowledge of what just happened. Having that can help you grasp the situation, understand the underlying reasons with objectiveness, and move forward. 

We cannot tell you how to grieve over the loss, but we can help you make sense of it. We have gathered easily digestible information to understand the physical aspect behind pregnancy loss. Besides being of help to women who dealt with miscarriage, this information can also benefit those who are still planning to start a family.

What is a miscarriage? 

Miscarriage, also known as spontaneous abortion, refers to pregnancy loss before the 24th week of gestation. If a pregnancy ends after, it’s no longer called a miscarriage even though it’s a pregnancy loss but termed a stillbirth.

The American College of Obstetricians and Gynecologists (ACOG) estimates that about 15-20% of clinically recognised pregnancies end up in miscarriages. Some women may even miscarry even before they are aware that they’re pregnant, or before it was confirmed by their doctor. Compared to that in the first trimester, the risk decreases in the second trimester. That is why it’s a common practice for couples to make their baby announcement after the first three months. 

Types of Miscarriage - Infographic

Why do some women have a tendency to miscarry? 

There are indeed women who are more likely to miscarry than others. Sometimes, they may even blame themselves, but miscarriages usually happen for reasons that are beyond one’s control.

Causes like chromosomal abnormalities, abnormal placenta development, a weakened cervix, an abnormally shaped womb, and umbilical cord issues are causes that can be difficult to control, especially without professional help. A glitch in genetics accounts for more than 50% of miscarriages in the first trimester. Meanwhile, anatomical anomalies in the reproductive system also heighten the risk of recurrent miscarriages. Furthermore, complications involving the placental development or the umbilical cord can also compromise a pregnancy because it affects proper blood circulation between the mother and her baby. 

Fortunately, some of these potential causes are controllable, such as a poor diet  (e.g. high levels of caffeine and alcohol intake), medications, stress, and underlying health conditions (e.g. obesity, high blood pressure, severe uncontrolled diabetes, kidney disease, HIV, Malaria, Gonorrhea, Syphilis). Infections like german measles, listeriosis or chickenpox can also complicate and even terminate a pregnancy, especially if you contract it in the first trimester. 

All these causes strengthen the importance of getting preconception screening and regular prenatal check-ups

What are the factors that put me at risk of having a miscarriage?

Several risk factors can lead to miscarriage. If you’re planning to get pregnant or trying to make sense of a past miscarriage, you will benefit in knowing the contributing circumstances.

Here are the following risk factors that may lead to pregnancy loss:


Based on data by the World Health Organization (WHO), Singapore ranked second in overweight prevalence in the Association of Southeast Asian Nations (ASEAN) at 32.8 per cent in 2014. A study conducted by Singapore’s Health Promotion Board (HPB) also revealed that Singaporeans are 3 kilograms heavier than they were 15 years ago. 

Source: Food Industry Asia

Research also revealed that obesity is associated with increased risk of the first trimester and recurrent miscarriage. This lifestyle disease can also compound any risk factors that are associated with pregnancy loss. For instance, linked to high blood pressure, and it can also make diabetes difficult to manage.


On the other end of the scale, women who are underweight before they get pregnant have a higher chance to miscarry in the first trimester. 

Older maternal age

In terms of age, conceiving quite late may be successful for some, but it doesn’t mean that it comes without any risks. Women under 35 have a 20 per cent or less risk of miscarrying, while those over 40 have more than a 40 per cent chance. 

Previous history of miscarriage

A previous miscarriage can also increase your risk by up to 20 per cent. After two consecutive pregnancy losses, the risk increases by up to about 28 per cent, and 43 percent for three or more consecutive miscarriages.

Illicit drug use

Anything that is established to be harmful in regular individuals can have severe consequences to vulnerable populations like pregnant women and her unborn child. Illegal substances can cause miscarriage and preterm birth.

Alcohol intake

You don’t have to abuse alcohol to introduce risks to your pregnancy or the baby. One study showed that any amount increases the odds of a miscarriage by 19 per cent. In particular, binge drinking also comes with severe risks to the baby like fetal alcohol syndrome.


Cigarette smoke is also another habit that can put significant harm to your pregnancy. Research found that women who smoked heavily while pregnant (at least 20 sticks a day) have beyond twice as much risk as non-smokers to have a miscarriage. E-cigarettes are no safer option either because on top of nicotine it also contains a mix of other aerosolised chemicals.


Skipping coffee may not be an easy compromise, especially if your day jumpstarts with it. A 2016 study by the National Institutes of Health examined 344 pregnancies and found that the rate of miscarriage was higher if either one or both partners drank two or more caffeinated beverages a day in the weeks leading up to conception. The general advice is to keep to one cup of coffee a day in pregnancy. 

Exposure to workplace hazards 

Long work hours, psychosocial stress, physical efforts, and environmental exposure (e.g. chemicals or radiation) are just some of the dangers that a pregnant woman can potentially encounter in the workplace. Fortunately, these are preventable factors. Expectant moms should be mindful of what she is exposed to because while some are harmful at high doses, other factors can already do damage at low doses. 

What are the symptoms of a miscarriage? 

As mentioned earlier, some miscarriages go unnoticed, but for those that do, some women may experience the following symptoms:

What are the diagnostic tests used to check if you had a miscarriage?

Besides red flags that signal a miscarriage, some measures can confirm if there was indeed a miscarriage. Diagnosis is essential because any treatment done before a confirmed diagnosis can have harmful consequences such as interruption of a pregnancy, pregnancy complications, and birth defects

Diagnosing early pregnancy loss is relatively straightforward, requiring limited testing or imaging. For other cases, the doctor may use a combination of these diagnostic exams to confirm a suspected miscarriage, and these procedures include:

1. Transvaginal ultrasound

If you’ve had an ultrasound during the early stages of pregnancy, you may be familiar with a transvaginal ultrasound since it’s the usual device used to assess the baby before you reach 8 weeks of pregnancy. It’s a wand-like probe inserted into the vagina, to check a suspected miscarriage. It can also help reveal any abnormalities in the structure of your womb, which may have led to pregnancy loss. It may not be as comfortable as a trans-abdominal scan, but a transvaginal ultrasound provides an accurate image and details problematic areas. 

2. Blood Test

A blood test can also be ordered by your doctor to check the levels of pregnancy hormones in the blood and compare it previous measurements. Abnormal levels may indicate a problem, especially if a decrease in other pregnancy symptoms accompanies it. However, a conclusive diagnosis of pregnancy loss may require an ultrasound to check your baby’s heartbeat, followed by a confirmatory process involving scans conducted on multiple days.

3. Pelvic exam

A pelvic exam, on the other hand, can check if your cervix is thinning or opening, since this is a strong indication that you could be miscarrying. If you experienced spotting or light vaginal bleeding, but the cervix has not opened, this may suggest a threatened miscarriage, which is a relatively common condition. However, it means that the pregnancy is still viable. 

Furthermore, an ectopic pregnancy, a condition where the fertilised egg implants outside the uterus, may be suggested on a pelvic exam usually manifested in unilateral lower abdominal pain. Sadly, this pregnancy is nonviable, and it may turn into a medical emergency if left untreated. 

4. Fetal heart rate monitors

These fetal heart rate monitors, also called fetal dopplers, are handheld ultrasound devices which solely detect the sound of your baby’s heart through your belly. This device is routinely used during prenatal visits although occasionally some women purchase one for use at home. 

In the early stage of pregnancy, the lack of a heartbeat doesn’t mean that you had a miscarriage. A baby’s heartbeat doesn’t develop until 6th week in the womb, and it becomes audible using fetal heart rate monitors somewhere between the tenth and twelfth week of pregnancy. However, the exact time may vary based on the position of your uterus, the position of the placenta, and other factors. 

A lack of heartbeat after 12 weeks of pregnancy is a strong indication of pregnancy loss. Your doctor may conduct a full ultrasound scan to check for any heartbeat. 

What can I do to reduce my risk of a miscarriage?

Almost 80-90% of miscarriages happen in the first trimester (before week 14). After that, your chance of miscarrying drops. While most cases of pregnancy loss can’t be prevented, some precautions can help increase your chances of a healthy pregnancy. But, here’s how to lower your risk:

Watch what you eat

To avoid a recurrent miscarriage, it’s also essential that you watch what you eat. Ensure a well-balanced diet that is rich in folic and calcium. You can also supplement this with prenatal vitamins which you must take daily to ensure that your baby gets the key nutrients for development. On the other hand, there are also food options that pregnant women must avoid because they pose serious risks to a pregnancy, such as raw meat, unpasteurised dairy or fishes with elevated concentrations of mercury.

Run ALL your medications by your doctor

On top of choosing your meals carefully, you must also be mindful of the medications you take. We are aware that as much as clinical drugs are therapeutic, they also come with side effects or adverse reactions that may be harmful to pregnant women and unborn babies.

Check with your doctor first before taking any medications, including over-the-counter drugs. For instance, what may seem as a regular headache medication can already pose serious risks to a pregnancy which could lead to complications or pregnancy loss.

Maintain a healthy weight before pregnancy

Controlling your intake not only provides you with essential nutritional requirements, but it’s consequential to your weight. The ACOG currently recommends that doctors offer nutritional counselling to obese women who plan to start a family, so you can always approach your doctor for weight management. Professional guidance is helpful when you struggle to shed the extra pounds when trying for a baby, and it’s also beneficial during pregnancy to check whether you’re putting in too much or too little.

Source: Health Hub

Limit caffeine intake

With most of us dependent on coffee to start our day, pregnancy doesn’t have to push you to go cold turkey on caffeine. Current guidelines from the ACOG and other experts say that it’s safe for pregnant women to consume up to 200 milligrams of caffeine a day, or around one 12-ounce cup of coffee daily.

Ditch bad habits

Alcohol, recreational drugs, and cigarettes all bear adverse effects that can compromise a pregnancy. Remember that you pass much of what you eat, drink, and breathe into your baby. Besides the risk of pregnancy loss, the substances involved also pose certain risks to your baby’s development in the womb.

Attend all scheduled prenatal appointments

Prenatal care is an essential part of staying safe and healthy during pregnancy, and you must start it as early as possible. Doing so can help prevent problems for you and the baby. These visits are scheduled regularly for a reason, and you must come in for each one of them for the doctor to:

✔ track the progress of your pregnancy

✔ detect any problems along the way

✔ check your health and that of your baby’s

✔ clarify any concerns you might have about the pregnancy

✔ provide immunisation against infectious diseases

Beside prenatal appointments, pre-pregnancy care is just as important because it involves preconception health screening which can help detect any risk factor that may predispose you to have a miscarriage. 

Lighter regular exercise 

Physical activity doesn’t necessarily increase the risk of miscarriage, but it’s also an important point to discuss with your obstetrician during your prenatal appointments. If your doctor gives you the green light, you can consider which activities you can do safely. 

Benefits of Exercise During Pregnancy - Dr Pamela Tan

However, there are certain conditions or complications where this type of physical exertion may prove to be risky. These include the following: 

  • Certain types of heart and lung diseases  
  • Cervical insufficiency (the inability of the uterine cervix to retain a pregnancy in the second trimester) 
  • Being pregnant with twins or triplets (or more) with risk factors for preterm labour 
  • Placenta previa after 26 weeks of pregnancy (a problem where the placenta grows in the lowest part of the womb and covers all or a portion of the opening to the birth canal)
  • Preterm labour or ruptured membranes (your water has broken) 
  • Preeclampsia or pregnancy-induced high blood pressure 
  • Severe anaemia

Avoid environmental hazards

Besides what you introduce to your body, you must also be mindful of the hazards you are exposed to everyday, because a lot of these risks may just be right under your nose. For instance, cleaning products, cellphone radiation, and cosmetics may have compounding toxicity when used daily. Mom Junction provides easy tips on how to protect yourself, here.

What are the accepted management options for early miscarriage? 

Preferred treatment options for early pregnancy loss include expectant management, medical treatment, and surgical evacuation. The interventions may vary based on the unique presenting factors in a miscarriage. To know which among these is suitable for you means discussing it extensively with your OB.

Expectant Management

This approach involves watchful waiting for the miscarriage to happen by itself naturally without any treatment. With adequate time (up to 8 weeks), expectant management has been successful in achieving complete expulsion of pregnancy tissues in approximately 80% of women. Women with incomplete miscarriages ( already bleeding and passed out some pregnancy tissue) have a higher rate of complete expulsion then those with missed miscarriages or blighted ovums.

What to expect:

  • It may sometimes take a few weeks for the body to respond to a missed miscarriage. During a miscarriage, you may experience moderate to heavy bleeding and cramping. In general, the larger the gestation, the heavier or more painful symptoms are felt. Pain or bleeding should lessen or stop completely within 7-21 days.
  • You will be instructed on what to expect during this time and how to respond to it (e.g. tracking the severity of bleeding by counting soaked pads and reporting it to your OB).
  • You will learn when and who to call in case of excessive bleeding.
  • Prescription medications will be provided.
  • There may be a chance that miscarriage is incomplete, which means that there is a possibility that surgery might be needed.

Medical Management

This approach is suitable for women who have not encountered infection, haemorrhage, severe anaemia, or bleeding disorders and who want to shorten the time until complete expulsion but wish to avoid surgery. It increases the likelihood of complete expulsion compared to expectant management.  

What to expect: 

  • Medications will be prescribed to trigger expulsion of the pregnancy tissues. The most common side effects of the medicines are nausea, vomiting and diarrhea. 
  • You will be provided with pain medications.
  • Similar to expectant management, you may experience moderate to heavy bleeding and cramping during the miscarriage. Pain or bleeding should lessen or stop completely within 7-21 days.
  • Follow-up visits to document if there is a complete passage of tissue within 7-14 days using ultrasound.
  • If this approach fails, the treatment may shift to expectant management for a time agreed by you and your OB-GYN, repeated medication or consider surgery via a suction curettage.

Surgical Management

Surgical uterine evacuation has been the traditional approach for women who experience early pregnancy loss and retained tissue especially in women who need urgent care due to haemorrhage or signs of infection. It is also advised for those with medical conditions like cardiovascular disease, bleeding disorders, or severe anaemia. Many women opt for this type of treatment because it provides immediate completion of the process with fewer follow-up visits. Suction aspiration of the pregnancy tissue is performed under sedation as a day surgery procedure. 

Studies have demonstrated that either method used ,expectant, medical or surgical management of early pregnancy loss, all result in complete evacuation in most patients with rare serious complications. As a primary approach, surgical evacuation results in faster and more predictable complete evacuation. Intrauterine adhesions (scar tissue formation within the uterus) is a rare complication of surgical evacuation. Hemorrhage and infection can occur in all treatment approaches but rates are generally low. 

Support group in Singapore after pregnancy loss

So you had a miscarriage, and your reproductive system is in the clear. However, moving on after pregnancy loss can be a long and difficult process – but it’s not without help. There are support groups and helplines available in Singapore to help you cope. You can check out any of these: 

If you want to get help to minimize chances of a miscarriage, improve your chances of having a healthy pregnancy, or plan your next one, it helps to have professional help close by. You may talk to Dr Pamela Tan to help you through this process. 

Managing Menopause: A Quick Guide on What To Expect When You’re Expecting

How much do you know about menopause or its symptoms? This is a question women should concern themselves with because it’s a stage they’re bound to enter sooner or later. It’s a reality that must be lived, even though it’s not always wrapped in a bow.

As some women have shared, the road to menopause can be a struggle. But, you can choose not to turn it into a dreadful experience. The changes that your body is expected to go through is manageable, but to gain the upper hand, the key is to understand these transformations and how it can be dealt with.


The process that leads to menopause doesn’t happen overnight, rather it involves gradual changes. So, before you reach that stage, your body goes through a transitional phase called the perimenopausal period.

This prelude takes an average of three years and even stretches up to a decade in some women. It may kick in your late 30s and 40s as a result of declining ovarian function causing your estrogen levels to fluctuate. 

This hormonal see-saw can last for years and may result in a more symptomatic period for women. During this time you may start to notice irregularities in your menstrual cycle, but it can also cause other symptoms such as: 

A guide to Perimenopausal Symptoms - Dr Pamela Tan

Now you’re thinking, “Hey, this sounds like menopause!” 

This is usually where the misconception is. 

Most people think that these unpleasant symptoms are that of menopause, when in fact, these are hallmarks of perimenopause. However, these can also be referred to as symptoms of menopause because they indicate what is coming imminently. 

Perimenopause is the period where the “real action” happens. Unfortunately, there’s no way to predict in advance for how long the perimenopausal stage would last. This experience can vary for each woman, with some not even displaying any symptoms of being perimenopausal at all. However, one can get an idea as to when they might get into menopause based on their family history.

When exactly is Menopause?

Officially reaching menopause means that it has been a full year that you have not menstruated. To put it simply, it’s just that one day to mark the anniversary of your last period. 

In Western societies, the average age of menopause is 51, but in Singapore, it’s 49. However, menopause has a wide starting range, but it is usually expected within the ages of 42-58 – sometimes earlier.

If there’s no test to determine for how long perimenopause will run its course, for menopause, you can get a ballpark figure on when it may happen based on how old your mother and grandmother reached theirs. 

Reproductively, this is a major milestone because it marks the end of your fertility. Although for most women, the journey leading to it is riddled with discomfort, menopause is not a health problem, rather a natural phase in your life

Premature Menopause

When your menses have officially ceased for 12 consecutive months, but this happens before you reach 40, this is known as premature menopause or premature ovarian insufficiency

This can run in families, but there are external influences that affect your ovaries such as, medical treatments (e.g. chemotherapy, radiotherapy, ovarian surgery, hysterectomy) and lifestyle choices (e.g. smoking).

It can be hard for women to come to terms with a diagnosis of premature menopause, especially if they still desire to have a baby in the future. Besides infertility, this condition also increases a woman’s risk for osteoporosis, cardiovascular disease, and diabetes

So, if your period becomes infrequent, or has stopped before you reach 40, you must schedule a visit to your OB-GYN. You may be offered blood tests to measure hormone levels that will help diagnose premature menopause. 

Managing Menopause Symptoms

Fortunately, it’s not like you don’t have a choice over those uncomfortable symptoms. There are various treatments such as lifestyle changes, non-prescribed therapies, and prescribed interventions to help allay some effects.

1. Lifestyle changes

Lifestyle Changes - Dr Pamela Tan

You can minimise the blow of these symptoms with some lifestyle tweaks. For instance, eating a healthy diet should be established or improved to accommodate your metabolism which is now running at a snail’s pace. Together with regular exercise, this can help you maintain a healthy weight and improve sleep. You may also have to cut back on caffeine and alcohol to reduce night sweats and hot flashes. 

2. Non-Prescribed Therapies

Non Prescribe Therapy - Dr Pamela Tan

Herbal Medicines

Mother nature’s treatments can also help you manage your symptoms. Black cohosh and evening primrose oil have received quite a bit of scientific attention when research revealed that it can reduce the severity and frequency of hot flashes. You might have even heard of other popular names thrown out there such as Dong Quai, Red Clover, Ginseng, or Kava – and some women swear by them. However, you must take this with a grain of salt because herbal remedies have no established safety standards. It may also run the risk of interacting with any prescribed medications. Therefore, consult your doctor first before you consider this type of treatment. 

Alternative Therapy

Acupressure, acupuncture, and aromatherapy massage are some non-traditional treatments that can also be effective for some women. These have been tagged to improve symptoms like hot flashes, night sweats, and even anxiety. Again, this should be considered with advice from your doctor. 

Complementary Therapy 

Hypnosis, biofeedback and relaxation training are therapies that can be done alongside prescribed interventions to boost their results. 

Bioidentical Hormones

These are man-made hormones that are designed to be molecular copies of our natural hormones. However, concerns have been raised especially among custom-blended hormones for menopause because they tend to have unpredictable ingredient mixtures. This can pose reproductive risks which outweigh the relief of early menopause symptoms. 

3. Prescribed Interventions

Prescribed Interventions - Dr Pamela Tan

Hormonal Replacement Therapy (HRT)

HRT is a commonly prescribed treatment to relieve menopausal symptoms. It means being treated with the female hormones, estrogen and progestin since numbers decline as you approach menopause. 

HRTs offer the following benefits:

  • It can relieve hot flashes
  • Improve mood associated with menopause
  • It can improve sexual desire
  • Reduces vaginal dryness
  • Helps keep the bones strong, preventing osteoporosis

To know the different HRTs available for you, please check out the video below. 

However, this treatment is not for everyone, especially if you are pregnant, diagnosed with certain cancers, experiencing vaginal bleeding, have blood clots, have had a heart attack or stroke, or suffering from liver disease. 

Non-Hormonal Medications 

Medications can be prescribed to treat symptoms such as hot flashes. Some drugs can also be given to manage anxiety or depressive symptoms. 

Psychological Treatments

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that helps patients to modify dysfunctional thoughts, emotions, and behaviours. It can help with mood changes caused by hormonal fluctuations, and it may also help relieve associated symptoms like anxiety, depression, and even insomnia.


Stages of Menopause- Dr Pamela Tan

The post-menopause period starts the day after menopause – or pretty much the rest of your life. The transformation your reproductive system went through over the years can also have an effect during the post-menopausal period. For this, you must learn to adapt health-seeking behaviours that can help reduce the effects of menopause as you go into the next phase.

For the next couple of years, your body is exposed to the following changes and health risks: 

1. Bone changes

After the age of 35, it’s normal for men and women to experience a small amount of bone loss. But after menopause, you lose it at a rapid rate due to decreased estrogen levels. With excess bone loss, you increase your risk of osteoporosis which makes you vulnerable to fractures, particularly around the hips, spine, or wrist.

To keep bones strong in midlife, make sure that your fitness routine includes weight-bearing exercises. Do it regularly to slow down bone loss. Additionally, your diet must include foods high in calcium (dark leafy greens, dairy, and canned fish) and vitamin D (milk, orange juice, supplements, or 15 minutes of Singapore sunshine). You must also cut off any habit that compromises bone health, such as smoking. 

You may not notice your bones weakening just yet since it takes years before it shows any symptoms. A fracture is the first sign of the disease, which is why women above 65 are advised to get a bone mineral density test. 

2. Urinary incontinence

Almost half of post-menopausal women complain of urinary incontinence. Your low estrogen levels weaken the urethra, making you unable to control urine flow. You may have noticed this when you laugh, sneeze, cough, which is a common type called stress incontinence. To prevent this, you may empty your bladder as often as possible, control your weight, stay fit, or you can start doing regular Kegel’s exercise to strengthen your pelvic floor muscles. 

3. Sexual side effects

It is normal for changes to your sex life after menopause. Some say that they enjoy it more since they no longer have to worry about getting pregnant. However, others may no longer enjoy it as much. 

Decreased hormone levels can put a damper on your sex drive. It can even make sex less pleasurable as vaginal tissues become thinner and drier. A lot of women suffer in silence when they don’t need to because there are available treatments. If this is troubling you, don’t hesitate to seek professional advice from your gynaecologist. 

4. Heart attacks

The menopausal transition also breeds cardiovascular risk factors. This is even considered the biggest danger during the post-menopausal stage as rates of heart attacks spike roughly a decade in. 

Estrogen helps keep blood vessels flexible so they can easily contract and expand to accommodate blood flow. But, once it diminishes, this ability is lost giving way to problems like high blood pressure. This can thicken the walls of your artery which compromises blood flow making you vulnerable to heart attacks.

To protect yourself, you need to commit to a healthy lifestyle. There must be discipline in following diet modifications and regular exercise. If you have prescribed maintenance medications for high blood pressure, or any lifestyle disease, do take them regularly. 

5. Stroke

Premenopausal women are protected by the risk of cerebrovascular diseases such as stroke. As mentioned earlier, estrogen provides beneficial effects to blood vessels as it gives them more flexibility to expand to promote blood flow. However, for every decade after 55, the risk of stroke roughly doubles in women. The risk is further heightened in women with premature menopause. The low estrogen levels at this point triggers cholesterol build-up on artery walls including those that are in your brain. It results in this “brain attack” which is either caused by a blockage (ischaemic stroke) or rupture (Haemorrhagic stroke).

To prevent stroke, Singapore’s Health Promotion Board suggests the following: 

  • Eat healthily and in moderation
  • Keep blood pressure, cholesterol, and glucose under control
  • Exercise and maintain a healthy weight
  • Go for regular health screening and follow up
  • Avoid smoking

6. Gynaecological cancers

Cancers affecting your reproductive health are present even before menopause. However, you must still check for any warning signs such as bleeding after menopause. The risk increases as you age and in women who are undergoing hormone therapy to treat menopausal symptoms.

To maintain good gynaecological health during this reproductive milestone, you must seek regular cancer screening. You can read more about cancer screening in Singapore in our blog, here. If you have any bleeding after your menopause, you must seek attention immediately to rule out cancers of the womb and cervix. 

Some may look at menopause with a tinge of dread due to some horror stories shared by women who have gone through it or as played out in movies. While there’s truth to it, your journey doesn’t have to be that way. Now that you’re aware of what you could be going through in the coming years, you can prepare for it. With the right help, you can float your way through perimenopause with the least amount of issues, and even forge towards the post-menopausal period in good health.

We’re we able to tackle your concerns about menopause? For your questions and other concerns, you may book a consultation with Dr Pamela Tan today. 

5 Neurological Disorders in Pregnancy

We’re familiar with the threat of common diseases like gestational diabetes and pre-eclampsia in pregnancy. In addition to that, the nervous system can also be stricken with diseases that can turn into a health crisis in this delicate period of pregnancy and childbirth. These neurological disorders carry several symptoms that range from minor discomforts to medical emergencies. Therefore, being familiar with what these are will allow you to be more aware in identifying red flags. 

1. Pregnancy Headache

The surge of hormones and the increase in blood volume often result in frequent headaches in expectant moms. It’s a common discomfort during the first and third trimesters, which are usually challenging stages during pregnancy. 

Aggravating factors include: 

  • Stress
  • Lack of sleep
  • Nausea and vomiting
  • Dehydration
  • Sinus congestion or nasal stuffiness
  • Pregnancy-induced hypertension (PIH)
  • Low blood sugar levels
  • Poor nutrition

These trigger two of the most common types of headaches which are, tension headaches and migraines

Tension Headache

Due to the physical toll that pregnancy has on the body, tension headaches are likely to occur. This is why it’s also referred to as stress headaches

These are felt as mild to moderate pressing pain on both sides of the head, similar to having a tight band wrapped around it. This sensation is usually accompanied by a sore neck and shoulder. It resolves within a few minutes to a few hours, and in rare cases, it can last for several days. 


Migraines, on the other hand, aren’t your typical headaches. It’s characterised by severe, throbbing pain that comes with neurological symptoms like blurred vision, numbness, flashes of light or tingling on the face, arms, or leg. 

Women with regular migraine headaches may notice that they experience fewer episodes during pregnancy. Some may encounter it for the first time after getting pregnant, while others experience the same frequency. However, some may notice it getting worse especially during the first trimester. 

These episodes should not be taken lightly because expectant women who suffer from migraines have a greater risk of hypertensive diseases associated with pregnancy. 


A person can experience both tension headache and migraine, and their symptoms may overlap. Therefore, pregnant women should be quick to have a doctor check unexplainable and persistent headaches. Even more so if this is accompanied by symptoms like sudden dramatic weight gain or puffiness in the face or hands. 

A person can experience both tension headache and migraine, and their symptoms may overlap. Therefore, pregnant women should be quick to have a doctor check unexplainable and persistent headaches. Click To Tweet

Tests and scans may be needed to determine the cause behind these headaches. Blood pressure levels will be checked routinely. The OB-GYN may also order blood tests, blood sugar tests, a vision test or a scan of the head and neck if serious. 

Ways to cope with pregnancy headaches

Besides medical interventions, there are non-pharmacologic measures to treat headaches during pregnancy. You may try any of the following:

  • Stay hydrated.
  • Eat well-balanced meals.
  • Relieve tension headaches by applying a cold compress or ice pack at the base of your neck. 
  • Maintain blood sugar levels by eating small, frequent meals. 
  • Rest in a dark room and practice deep breathing exercises.
  • Take a warm bath or shower.
  • Get a neck or shoulder massage.
  • Relax and get plenty of rest.
  • Practice good posture.
  • Put your feet in a tub of warm water.

Medical treatments for pregnancy headaches vary depending on the different factors that surround it. While we often reach for over-the-counter pain medications to counter any bouts of headache, in this case, a doctor’s advice is necessary to ensure that any measures taken don’t compromise a pregnancy or the health of the baby. Common painkillers found in pharmacies that fall under the NSAID group (including the patches) are contraindicated while some paracetamol (panadol) can be taken in safe doses.

2. Epilepsy

Epilepsy is a neurological disorder that involves recurrent seizures. In every 1000 pregnancies, between 2-5 infants are born to mothers who have it. However, most of these women remain free of seizures during pregnancy and even move on to have uncomplicated pregnancies and healthy babies. 


How pregnancy affects epilepsy

It’s difficult to predict how pregnancy affects epilepsy. However, some may experience frequent seizures while they’re pregnant. The reason for it is that the medications used to treat epilepsy may work differently during pregnancy, or it may not be absorbed well. It might be the case that expectant women are no longer taking it regularly or have stopped taking it entirely. Furthermore, the physical and emotional stress that comes with pregnancy are also considered as potent triggers. 

How epilepsy affects pregnancy

On the other hand, epilepsy poses certain risks to pregnancy. Besides general complications that come with the condition, the medications used to treat it can also have adverse effects on the mother, the unborn baby, and the pregnancy. 

Since women are at a more delicate state while pregnant, having a seizure disorder heightens the risk for injuries and complications. Maternal risks include trauma from falls, bumps, or accidentally biting the tongue. Meanwhile, the type of medications may have serious side effects to the baby, such as abnormalities to the heart, slightly smaller size, birth defects (e.g. cleft lip or cleft palate), or stillbirths. In addition, the risks to the pregnancy itself may result in the premature separation of the placenta from the uterus, premature labour, and miscarriages. 

So what can be done to ensure a safe pregnancy even in the presence of a seizure disorder? 

Pregnant women with epilepsy need close monitoring of the disease and fetal health, which means that there will be more frequent prenatal visits needed.  Click To Tweet

Pregnant women with epilepsy need close monitoring of the disease and fetal health, which means that there will be more frequent prenatal visits needed.  

Most women will be prescribed with anticonvulsant medications. Proper monitoring also follows to ensure that seizures are controlled and side effects are reduced. The goal of treatment is to use as few medications as possible at the lowest dose necessary to control these seizures

There is also a particular need to increase folic acid dosage in pregnant women with epilepsy. This prenatal vitamin is routinely prescribed to all pregnant women to reduce the risk of babies having defects to the spine, heart, and limbs. However, there is a need to prescribe a higher dose because epilepsy medications can interfere with folic acid absorption increasing the risk of the baby being born with spinal abnormalities. Conversely, special monitoring is needed to check if folic acid hasn’t lowered the blood levels of these seizure medications. Otherwise, it could increase the risk of seizures

While epilepsy medications come with risks, they should not be discontinued or changed without consulting a healthcare professional. Poorly controlled epilepsy may result in a very rare but serious complication called sudden unexplained death with epilepsy (SUDEP), which is highly likely to occur during the time of delivery and the postpartum period. 


3. Multiple Sclerosis

Multiple Sclerosis (MS) is an autoimmune disorder that affects the central nervous system, which is the brain and spinal cord. In this disabling disease, the body mistakenly attacks the myelin sheath, which is an outer coating that protects the nerve cells. When it gets damaged, the flow of information between your brain and the rest of the body gets disrupted. This leads to common neurological symptoms such as loss of coordination, muscle weakness, and trouble with sensation. 

Multiple sclerosis and pregnancy

Having MS doesn’t seem to affect getting pregnant, and neither does pregnancy speed up the course or worsen the effect of MS. In fact, the nine months of pregnancy are generally associated with fewer relapses, especially during the third trimester. Those with unrecognized MS prior to getting pregnant are more likely to start experiencing symptoms during pregnancy. However, within 3-6 months after delivery, the symptoms usually tend to flare up again. 

Challenges MS pose on pregnancy

Due to debilitating symptoms, it may be physically challenging for MS patients to carry a pregnancy. It increases the likelihood of injuries due to muscle weakness and coordination problems. Meanwhile, fatigue may also be felt more profoundly. 

With pelvic sensation compromised, a woman may not feel pain with contractions. While this may sound like a dream come true, the absence of any sensation can be hard for a woman to tell when labor starts and even its progression. Furthermore, delivery becomes difficult as the muscles and nerves needed for pushing are also affected. It is for this reason that these patients usually undergo a C-section, a vacuum delivery, or a forceps delivery

Currently, there is no available treatment for MS, but there are medications that can help control the symptoms. Since relapse is unlikely during pregnancy, there is usually no need for any medications. However, drug therapies may have to be resumed after pregnancy which means that breastfeeding may not be advised; but these can be arranged based on how the disease progresses. 

One can always consult a doctor or OB for any concerns – whether if it’s about getting pregnant, any advise on pregnancy, or close monitoring. Just like other neurological disorders, the presence of MS will require more frequent prenatal visits. 

You can read about a Singaporean mum’s struggle with MS, here

4. Myasthenia Gravis

Myasthenia gravis (MG) is another autoimmune disorder that causes weakness to the skeletal muscles of the face and extremities. It worsens after periods of activity, and improves after periods of rest. It usually affects women who are in their 20s and 30s, or during the childbearing years. 

MG tends to worsen during the first trimester and postpartum period. One study showed that 30% of patients do not experience any change in their MG status, 29% reported improvement, and 41% showed worsening of their MG symptoms during pregnancy. However, the course of the disease varies and pregnant women face the risk of it getting worse, respiratory failure, adverse drug reactions, a myasthenic crisis, and even death. 


Labour and delivery for women with MG

Pregnancy does not appear to worsen the long-term effects of MG on women. Vaginal delivery is safe, and it should be encouraged. A c-section is carried out only when there is a need to because surgery is associated with worsening of MG, and it might even result in a myasthenic crisis. 

Since the uterine muscles are composed of smooth muscles, its ability to contract is not compromised with MG. Therefore, the first stage of labour is not affected. But as the woman progresses to the second stage of labour, she will need the striated muscles to work. This can be exhausting and it often requires the need for forceps or vacuum extraction.

Another complication of labour with a higher incidence in mothers with MG is premature rupture of membranes holding the amniotic fluid, although the reason for it is unclear. 

Effects of MG on the baby

Infants who are born to women with MG are thought to develop neonatal MG through the passage of MG antibodies between mother and fetus. The symptoms are usually mild to moderate, which is observed through poor sucking and muscle tone. Generally, this is temporary, and the baby’s symptoms disappear within two to three months after birth. 

Treatment of MG during pregnancy

Treatment must be individualised based on the severity of MG as well as the effectiveness of various treatment options and their possible harmful effects on pregnancy. Optimal management during this delicate period calls for a multidisciplinary team approach comprising an obstetrician, neonatologist/pediatrician, and neurologist. 

For those planning to get pregnant, but are also struggling with MG, doctors would often advise to delay pregnancy for at least 2 years following diagnosis. The severity of symptoms and risk of maternal death is highest within this period. Most myasthenic women can have an uneventful pregnancy with good outcome as long as there is careful planning and close monitoring.

5. Peripheral Neurological Disorder

The disorders mentioned above are issues that affect the central nervous system. But there are also conditions that target the nerves outside the brain and and spinal cord, and these are called peripheral neurologic disorders. 

There are over 100 types of these neuropathies, but the ones common to pregnancy are carpal tunnel syndrome and Bell’s palsy. These conditions are usually due to compression during pregnancy and childbirth. 

Carpal Tunnel Syndrome (CTS)

Carpal Tunnel Syndrome affects 4% of the general population, but it is more common during pregnancy where it is 31%-62% of pregnant women. Click To Tweet

Carpal Tunnel Syndrome affects 4% of the general population, but it is more common during pregnancy where it is 31%-62% of pregnant women. Experts could not pinpoint the root cause behind it, but they suspect that it could be hormone-related swelling. Increased fluid and relaxation of the ligaments puts pressure on the nerve on the wrist, called the median nerve, as it passes through the carpal tunnel in the wrist. 


There are certain factors that increase a woman’s risk of developing CTS during pregnancy. Aggravating factors include obesity, gestational diabetes, pregnancy-related hypertension, and having previous pregnancies.

Read: Gestational Diabetes: Why It Is No Sweet Talk 

Most doctors recommend treating CTS conservatively during pregnancy because patients experience relief weeks or months after giving birth.

Treatments that can safely be applied during pregnancy include the use of splints to keep the wrist in a neutral position. This also controls the motion to the wrist, like when one types on the keyboard. Proper rest, especially when the affected hand feels painful or fatigued. Elevating the wrists and applying a cold compress can help relieve the symptoms. On top of that, doctors may also prescribe physical therapy and pain relievers


Bell’s Palsy


Bell’s palsy is a temporary weakness of facial nerve. It can strike at any age and it occurs without warning. It’s more common during pregnancy, with most cases occurring during the third trimester and postpartum period. The symptoms are often confused with that of a stroke, which is why it must be evaluated immediately. 

Bell’s palsy is a temporary weakness of facial nerve. It can strike at any age and it occurs without warning. It’s more common during pregnancy, with most cases occurring during the third trimester and postpartum period. Click To Tweet

There are several theories as to why pregnant women are more likely to experience Bell’s palsy than non-pregnant women. Below are the following reasons: 

  • Increased total body water which causes swelling and/or compression of the facial nerve
  • Increased blood clotting factors
  • Weakened immune system
  • Elevated levels of the female hormones, estrogen and progesterone

In general, those who experience Bell’s palsy will experience a full recovery within 6 months. Unfortunately for Bell’s palsy during pregnancy, the prognosis for complete recovery isn’t as great as the general population, 52% vs. 80%, respectively. It should be noted that the poorer outcomes reported are likely related to the past reluctance of physicians to prescribe steroids and antivirals in treatment. Today, management of Bell’s palsy in pregnancy should mirror that of nonpregnant individuals and include steroids combined with antivirals, with the exception of first trimester cases. Steroids help to reduce swelling and compression of the nerve and anti virals may aid in Bell’s palsy secondary to a viral infection. 

Neurologic disorders may come with symptoms that can make pregnancy more challenging, even to a point of being risky. However, it doesn’t mean that having these conditions can rob a woman of bearing a child.  With preparation, precaution, and close monitoring, it’s possible to have a safe pregnancy. 

Whether you are still planning for a baby or drafting your birth plan, it’s important that you have the right professional help to guide you along. In Singapore, Dr. Pamela Tan provides warm, caring, and personalised obstetric and gynaecological services for every woman’s unique concerns.  Make an appointment today!