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Disclaimer: Any answers provided are for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.




























































Hormonal Imbalance

Hormonal Imbalance

A DxD Session with Dr Marilyn Lee

Ended on Wed Jul 24 2019

Top Answers

Microgynon is a combined oral contraceptive pill and is a very effective form of contraception. The chances of getting pregnant is less than 1% whilst on the pill, so if you have been taking it regularly, you should be protected.

There are, however, other factors that may reduce the efficacy of the pill, such as missing a tablet or being on antibiotics.

Missing a tablet, especially if this is right before or right after the pill-free week, is a common cause of contraceptive failure.

Depending on when you wish to get pregnant, you may wish to consider a long acting contraceptive like the intrauterine device, especially if you're prone to missing tablets. You can discuss this with your gynecologist or your GP.

8 Feb 2018

Thank you for your question.

With regards to your PCOS. If you're having less than 6 periods a year, I would suggest seeing a doctor about it so that he/she will be able to give you some medicines to shed the womb lining and induce a period.

This is because if you're having very few periods a year, the womb lining becomes very thickened and if left untreated for many years confers a risk of cancer of the uterus. Further management of your PCOS will depend on whether or not you're currently pursuing fertility, and what your concerns are. For example management of acne or unwanted facial hair, management of infertility, management of weight gain etc, all of which are associated with PCOS.

Abnormal thyroid function test can also cause irregular periods. You mentioned having done a thyroid function test and having T4 and TSH within the reference range. If both T4 and TSH are within the reference range then your irregular periods are not thyroid related.

I would suggest seeing an endocrinologist/gynecologist/general practitioner who can evaluate your irregular periods and advise you accordingly.

10 Feb 2018

In PCOS, the most common reason for difficulty conceiving is the lack of ovulation.

Ovulation (when the egg is released) occurs 14 days before the next period. If you're having irregular periods, then it becomes difficult to predict ovulation.

There are certain medications available (for example Clomiphene) that may help to induce ovulation.
If you're having regular periods, that means that you're ovulating regularly, and PCOS is not likely the cause of the infertility. 

As there may be other reasons for the infertility, a check up of both partners would be beneficial.

I would suggest consulting an endocrinologist or gynecologist for an evaluation. You may also want to check out this article to find out more information about PCOS in Singapore.

14 Feb 2018

Thank you for your question.

Apart from hair loss and acne, other associations of PCOS include irregular periods, infertility, diabetes/abnormal glucose tolerance and obesity.

Management of PCOS would be to exclude causes of conditions that may mimic PCOS and treat whatever symptom you're experiencing by targeting the underlying cause. 

Both endocrinologists and gynecologists manage PCOS, and the management depends on what your priorities and concerns are, and finding a doctor that you're comfortable with.

17 Feb 2018

Thank you for your question. The normal menstrual cycle can vary between 21 and 35 days (most cycle length are between 25 to 30 days).

If the cycle length is more than 35 days, it is considered prolonged.

There are many reasons why your cycle length may be irregular, including:

But if you're having monthly periods, some variation in cycle length may not be much of a concern.

Once blood tests have excluded the common culprits (eg thyroid/prolactin disorders), the main concern would be getting pregnant.

Ovulation occurs 14 days before the next period, and if your cycle length is not consistent, it may be difficult for you to predict when you're going to ovulate, and hence make it difficult to time intercourse.

If you're having difficulty conceiving, you should discuss this with your doctor who will be able to advise you on how to use ovulation testing kits, how to time intercourse and consider whether you need to take any medications.

18 Feb 2018
It's not easy to admit that you went overboard with weight loss and being able to recognize it is a step in the right direction.
When your body weight drops below a certain threshold, your body "switches off" the periods. If the duration of weight loss is long, it may take a longer time for the periods to resume, even if target weight has been achieved.
In the meantime, while waiting for the periods to return, you may need some hormone replacement therapy, especially if you're experiencing symptoms of oestrogen deficiency (hot flushes, tiredness, mood changes).
Having a low body weight and low levels of oestrogen increases your risk of osteoporosis and it is worth doing a bone mineral density scan to check. If this is low, hormone replacement therapy can help improve the bones too.
Your calculated BMI is 16.6 kg/m2. Ideally, a BMI of 18.5kg/m2 and above is recommended to reduce the risk of osteoporosis and nutritional deficiencies. This may be difficult to achieve but a gradual weight gain would be ideal, to a level that is both healthy and one that is acceptable to you.
If you have any concerns, I would suggest consulting an endocrinologist of gynecologist for an evaluation.
10 Mar 2018

That does not necessarily mean that you have an eating disorder. There is concern of a possible eating disorder when you make yourself feel sick by being too full, or if you lose control over how much you eat, or if you think you're fat when people around you tell you that you're too thin. 

Another thing that can cause you to feel hungry is low blood sugar. You'll usually have other symptoms such as tremors, feeling your heart beat very quickly, increased sweating, light headedness to name a few. And the symptoms are relieved when you take something sweet. If this is the case, you should see a doctor to investigate for low blood sugar (hypoglycemia). In the absence of medications taken to lower blood glucose, having hypoglycemia is rare but should be investigated if your symptoms are suggestive.

If you have a light or early dinner and you stay up late to work, you may feel hungry because you need to energy to focus on your work. If this is so, it may just be a normal response for you to feel hungry. 

Hope this helps. 

28 Mar 2018


It sounds like you had a bad experience previously and I can understand your concerns about stopping Diane-35. Apart from breast cancer, there are other concerns with the oral contraceptive pill including thrombosis (the risk increases with age and in women who are smokers and are obese).

In PCOS, there are medical therapies available for the acne, and this depends on whether you are planning to conceive in the near or distant future. Your symptoms may also be better now after 12 years, especially if there has been some weight reduction. Spironolactone can be considered and can be effective for the acne, but many women do complain of heavy menstrual periods whilst taking it. That in combination with medications to help your periods may be considered. If the acne is severe, this can be managed topically (creams, lasers etc) whilst waiting for the medications to take effect.

I would suggest having a review with an endocrinologist or gynecologist, to confirm the diagnosis of PCOS and discuss further management.

Hope this helps!

22 Mar 2018

Eating disorders can involve a restrictive pattern where there’s dieting and excessive exercise, or a binge eating pattern which involves binge eating and purging.

Most women with eating disorders have a low body weight and in extreme cases, the body mass index can be as low as 15kg/m2 or lower.

So how does this affect our hormones?

Your brain perceives this as starvation, and your body then adapts to divert the limited resources to the most essential organs, protecting your heart/brain etc and “switches off” your menstrual periods.

This usually happens after the weight loss but there have been women whose periods stop before the weight loss occurs.

Why is having a period important?

The periods stop because your body no longer produces enough oestrogen to maintain the lining of the womb, hence there is no lining to shed.

Low oestrogen can cause symptoms of:

  • tiredness
  • low mood
  • poor concentration
  • vaginal dryness and
  • a reduction in breast size

The most common symptom is probably hot flushes (similar to women who are in the menopausal period).

In the long term, it can also cause thinning of your bones and lead to osteoporosis. This can increase your risk of having a fracture.

The periods tend to return once you regain the weight. The general rule of thumb is to reach the weight you last were when you had regular periods.

If you’ve been at a low body weight for a long time, it may take months or even years for your period to return, even when you have reached your ideal weight.

In the meantime, if you have symptoms of oestrogen deficiency, or if the bones are significantly affected, hormone replacement therapy (HRT) is a treatment option.

This gives you a gentle replacement of your female hormones and improves your overall sense of well-being (and helps the bones too). Every woman is different, and there are different forms of HRT available so it is possible to find one that is most suitable to you.

29 Mar 2018

Thank you for your question.

We generally define clinically important weight loss as over 5% of body weight over 6 to 12 months. It is possible that the stress from your last semester at university may have contributed, but if you have been eating and exercising as per normal and still losing weight, I would suggest getting evaluated.

Conditions such as hyperthyroidism (associated with weight loss, increased bowel movement, tremors, irregular periods and palpitations), diabetes (associated with increased thirst and passing more urine) and some infections such as tuberculosis are major causes of unintentional weight loss. 

I would recommend speaking to your doctor who can take a full history of any associated symptoms and request for relevant laboratory tests to investigate the cause of your weight loss.

11 Apr 2018

Thank you for your question.

You mentioned having a low BMI ever since you were a child. It would be useful taking a look at your height and weight charts to see if you have been on the same centiles or crossing centiles. For example, if you are on the 10th centile and have always been on this centile over the years, it's less concerning than if you were on the 25th centile and now on the 10th centile.

Causes of poor weight gain are multiple, and can be explained by an imbalance in calorie intake vs calorie expenditure.

Conditions that lead to reduced intake of food (unlikely if you're eating well), conditions associated with increased metabolic rate (for example hyperthyroidism), conditions associated with increased losses of nutrients (for example malabsorption, inflammatory bowel disease, coeliac disease etc) should all be considered.

If your BMI is below 18.5, you may be at risk of nutritional deficiencies and osteoporosis. 

If you have any concerns, I would suggest seeing your doctor to get an evaluation to exclude any underlying medical conditions. 

17 Apr 2018

Thank you for your question. 

With regards to height, we first have to know the height of both your parents and use that to calculate your mid-parental height and from there determine your genetic height potential.

Another useful thing to look at will be your health booklet, to see what your height has been over the years and if it plots steadily on the given percentile or if it crosses centiles.

For example, if you have been on the 25th percentile for height since young and have been consistently on the 25th percentile, it is less concerning than if you have been on the 25th percentile and now crossed to the 3rd percentile.

If your height is far off from your genetic height potential, or if you have been crossing centiles, this warrants evaluation to look for potential causes of short stature.

Hormonal causes include hypothyroidism, growth hormone deficiency and hypopituitarism etc. An Xray to assess bone age may be indicated, to see if there is potential for further growth. 

If there is no hormonal abnormality found, and the bone age is appropriate for your chronological age of 18 years then hormone treatment is not indicated. 

18 Apr 2018

Thank you for your question. There are a few associations of irregular periods and being overweight. 

1. Polycystic ovarian syndrome (PCOS).

Women with PCOS have irregular periods and this tends to worsen when the weight goes up. Many also experience irregular periods from the very first period. Women with PCOS may have symptoms of excess male hormones like acne, facial hair and scalp hair loss.

2. Hypothyroidism (where your thyroid gland is underactive).

This cause weight gain and irregular periods as well as constipation, cold intolerance and dryness of the hair/skin. 

3. Cushing's syndrome.

This is a state of excess steroid hormones. It is uncommon, but if the history and physical examination findings are suggestive, should be evaluated for.

It is usually recommended to have at least 4-6 periods a year to ensure the womb lining is shed regularly. For the above conditions, treatment of the underlying cause generally tends to result in more regular periods. 

I understand that it can be disheartening to see no improvement in weight despite a good diet and increased exercise. It would be worth seeing your doctor for an evaluation to look for any other causes of weight gain (and treat the underlying cause), look for complications of being overweight and depending on the severity discuss treatment options. 

Hope this helps!

6 May 2018


You mention having a high TSH and a Free T4 within the normal reference range. This is subclinical hypothyroidism. You don’t have to be worried about and I’ll explain more below. 

The commonest cause of subclinical hypothyroidism is Hashimoto’s thyroiditis. This is when there is presence of antithyroid peroxidase antibodies. The annual rate of progression from subclinical hypothyroidism to overt hypothyroidism (this is when Free T4 level is low and TSH is high) is around 2-4%, and is higher if antithyroid perixidase antibody is positive. If you develop overt hypothyroidism, treatment with levothyroxine (oral tablet) will help normalize your thyroid function. 

Most people with subclinical hypothyroidism do not experience any symptoms. If TSH level is less than 10 IU/L, treatment may not be indicated and follow up with annual blood test is recommended. If a woman of the reproductive age group is diagnosed with subclinical hypothyroidism, and she desires to get pregnant, she should be treated with Levothyroxine to optimise pregnancy outcomes. 

Hope this helps! 

28 May 2018

Please don’t worry or blame yourself for your baby’s hypothyroidism. It is very unlikely that your taking Panbesy in the first 2-3 weeks of pregnancy caused this. 

Studies looking at pregnancies exposed to Panbesy did not show any difference in outcomes in women taking it versus those who did not. Other appetite suppressants have been associated with the risk of cleft lips. 

I would advice regular follow up with your doctor, to ensure normal thyroid function is maintained, as thyroxine is required for optimal development and brain maturation.

30 Jun 2018

Panbesy will not cause an elevation in your thyroid antibodies, but it is not advisable to take Panbesy if you have an overactive thyroid gland. 

Panbesy works by increasing levels of catecholamines, and if you’re hyperthyroid, may increase the risk of cardiac complications. 

It is usually recommended as a short-term treatment of obesity (few weeks/months) together with exercise and a healthy diet.

If your weight has improved significantly, I would suggest stopping it. If your weight has not improved, I would suggest that you consider stopping it and getting evaluated to exclude other causes of obesity.

30 Jun 2018


I can understand that it must be quite distressing for you.

There are a number of conditions that are associated with weight gain. These include:

1. Hypothyroidism. This is when your thyroid hormone level is low. Apart from weight gain, other symptoms associated with this are generalized tiredness, constipation, feeling cold, slowing of your heart rate and abnormal menstrual cycles.

2. Hypercortisolism. This is when your steroid hormone level is elevated. Associated symptoms include weight gain (mainly central weight gain), menstrual irregularities, thin skin, easy bruising, stretch marks/striations and can be associated with increase in blood pressure and blood sugar levels. The most common cause of excess steroid hormone is from external source eg steroid creams, steroid tablets, steroid inhalers etc.

3. PCOS. This is associated with weight gain, irregular periods and symptoms of acne/facial hair/scalp hair loss. The symptoms usually worsen when the weight increases.

I would suggest seeing an Endocrinologist for a review of your symptoms and blood tests can be done depending on the indication. If any hormonal cause for weight gain is found, it is usually amenable to treatment.

I hope this helps.

31 Jul 2018

Hypothyroidism can manifest at any age. Symptoms include feeling tired and lethargic, feeling cold, weight gain, constipation, dry skin and menstrual irregularities. Some people may not notice any symptoms but get diagnosed during blood test done as part of a health screen.

Blood test include free thyroxine level (Free T4) and thyroid stimulating hormone (TSH). The pituitary gland secretes TSH which in turn stimulates the thyroid gland to produce thyroxine. If the thyroid gland is unable to produce enough thyroxine (resulting in low Free T4 levels), it will send a signal to the pituitary gland which in turn produces more TSH to try and stimulate the thyroid gland further. Hence, Free T4 level is low but TSH level is high. This is primary hypothyroidism where the cause of the hypothyroidism comes from the thyroid gland.

If the thyroid gland is working fine but the problem is at the level of the pituitary gland, then when Free T4 level is low, the pituitary gland is unable to respond to it and TSH level is low. This is secondary (central) hypothyroidism. 

The implications of central hypothyroidism is that because the pituitary gland is also responsible for all the other hormones in our body, there may be other associated hormone deficiencies which you will be screened for. 

Causes of central hypothyroidism include medications (certain medications can affect the thyroid function, giving a picture of central hypothyroidism), masses in the pituitary, previous brain/pituitary surgery/radiation etc. An MRI scan will be able to pick up any mass lesions.

I hope this helps.

31 Jul 2018


PCOS is a condition that is associated with weight gain and obesity, and women with PCOS find it easy to put on weight and difficult to lose weight. Most women with PCOS gain weight over a period of months and years.

Such a rapid weight gain of 10% body weight in 2 months is not typical of PCOS, though if other causes have been excluded, may well be the case.

It is important to exclude other causes, for example hypothyroidism (low thyroid hormones) and hypercortisolism (high steroid hormones) as they're also associated with weight gain and irregular menstrual periods.

I would suggest seeing an endocrinologist who can help investigate for the underlying cause of your weight gain and manage accordingly.

5 Aug 2018

Obese adults (BMI over 30 kg/m2 ) are at high risk for vitamin D deficiency because vitamin D is a fat soluble vitamin and the the body fat sequesters it, hence they require higher doses of Vitamin D than their non-obese counterparts.

However, there is no good evidence that replacing Vitamin D will boost weight loss. The main non-calcium related benefit of vitamin D is fall prevention.

If you are deficient in Vitamin D (blood test show a low Vitamin D level), then treatment is indicated.

8 Aug 2018

Regular menstrual periods are associated with regular ovulatory cycles. You have a period 14 days after you ovulate. For example, if your period comes every 28 days, you ovulate on day 14. If your period comes every 30 days, you ovulate on day 16. Many women with PCOS don't ovulate regularly, hence they have irregular periods. 

Ovarian hyperandrogenism (excess male hormone coming from the ovary) is often seen in PCOS and leads to irregular periods. This is driven by obesity and insulin resistance. Hence, weight loss and medications to improve insulin sensitivity (Metformin) can help improve cycling of the periods.
Women with PCOS are oestrogen replete. When exposed to oestrogen, the womb lining builds up and if you don't have a period for a long while, it can build up excessively, increasing the risk of womb cancer. Hence, it is recommended to have at least 6 periods a year so you ensure regular "shedding" of the womb lining.
Abnormal bleeding, especially in women with PCOS who have fewer periods, may signify abnormal lining of the womb and an ultrasound scan would be warranted. Other causes of intermenstrual bleeding include the use of the oral contraceptive pill, fibroids, polyps etc. 
If you have abnormal or intermenstrual bleeding, I would suggest that you see your gynecologist for a review. If you're having symptoms of PCOS or concerns about it, I would suggest seeing an endocrinologist or a gynecologist for a review. 
14 Aug 2018

Yes, there are some individuals with normal BMIs who are at increased risk of high blood pressure, diabetes and heart disease. This may be something genetic, where there is a family history of these conditions.

If you have increased visceral fat (this is the fat that is stored in your tummy), you are at increased risk of these medical conditions, even if your BMI is normal. Visceral fat is associated with increased waistlines, and is also related to the amount of fat consumed.

So if the belly size is large, it is likely that there is significant visceral fat and this is associated with an increased risk of metabolic complications like diabetes.

13 Sep 2018

Obesity, particularly abdominal obesity, is associated with insulin resistance (where your body is resistant to the effect of insulin and requires higher levels of insulin to maintain the same level of glucose) and this often leads to the development of diabetes.

The definition takes into account a few parameters, namely your glucose levels, triglyceride levels, good cholesterol levels , blood pressure and waist circumference.

Smoking, high carbohydrate diet and lack of exercise are a few of the factors that increase your risk of having metabolic syndrome. You can prevent this by improving your lifestyle and reducing your weight.

Reducing weight by improving your diet and increasing physical activity are all important aspects of treatment. Choosing foods with low glycemic index (brown rice as opposed to white rice, wholemeal bread as opposed to white bread) and having a diet rich in vegetables and fruit.

Generally, we recommend having at least 30 minutes of moderate intensity exercise (eg brisk walking) 5 times a week, but all forms of exercise is useful.

Aerobic exercise helps you burn calories and increases your metabolism. Weight training can build muscle and this in turn improves your metabolism too, as muscle is metabolically active. If you're able to maintain this healthy lifestyle and maintain a healthy weight, you'll reduce your risk of becoming obese.

13 Sep 2018

There is no hard and fast rule for this. It is generally prescribed as an adjunct to diet and exercise in suitable individuals. If the BMI is very high (>30 kg/m2 or >27 kg/m2 with other risk factors like diabetes, high cholesterol, high blood pressure) then the benefits of treatment may outweigh the risks.

This is generally a short term measure. If an individual's BMI is not that high but has other complications of weight gain (physical/psychological), and treatable causes of weight gain have been excluded, then a short course of this may be considered.

Although rare, the effect on the heart (can cause palpitations or increased heart rate, acquired problems with the heart valve or pulmonary hypertension) is a significant potential adverse effect, hence this is not prescribed on a long term basis.

13 Sep 2018

Hormone imbalance implies that the levels of certain hormones are too high or too low. This can involve any of the different hormones (e.g. thyroid hormone, female/male hormones, steroid hormones, growth hormones, and insulin).

I will discuss the conditions that are more frequently encountered below. In women, a good sign of normal hormonal balance is regular menstrual periods.

hormonal imbalance singapore

Thyroid hormones

Hyperthyroidism occurs when the body produces too much thyroid hormones. The symptoms are akin to everything “speeding up”. 

Your metabolism speeds up and you lose weight, feel hot and perspire a lot, you heart rate speeds up, your bowels move more frequently, you tend to be fidgety and some people have difficulty sleeping because your mind is constantly active.

The commonest cause is Grave’s disease (caused by antibodies, tends to run in the family). Other causes include a functioning nodule (when there is a thyroid nodule producing too much thyroid hormones. There may be more than 1 nodule present) and thyroiditis (inflammation of the thyroid gland).

Hypothyroidism occurs when the body does not produce enough thyroid hormones. The symptoms are opposite to that mentioned above. Everything tends to slow down. Y

our metabolism slows down so you gain weight and tend to feel cold, heart rate slows down, bowels move more slowly so there is a tendency to constipation, as well as feel more forgetful and tired.

The commonest cause is Hashimoto’s thyroiditis (caused by antibodies and tends to run in the family).

Female/Male hormones

In women, low female hormones will result in irregular or lack of periods and cause symptoms of hot flushes, tiredness and mood changes, and is a cause of infertility. This may be due to early menopause, when the ovary stops producing oestrogen.

This can also be due to eating disorders, stress or disorders of the pituitary gland. If this is present for a long time, the bones can get affected, increasing the risk of osteoporosis and fracture.

In most cases, women seek help when they notice that their periods have stopped or become irregular, and only notice their subtle symptoms of tiredness, mood swings, etc on hindsight when they get treated and feel significantly better.

Some women have excess male hormones and this may cause symptoms such as lack of or irregular periods, acne, increased facial hair, and in severe situations, deepening of the voice and shrinking of the breasts.

Polycystic ovarian syndrome (PCOS) is a common cause of acne and increased facial hair, but will not cause the latter 2 symptoms where a search for a testosterone-producing tumour is indicated.

In men, low male hormones can cause symptoms of tiredness, low sex drive, erectile dysfunction and reduced shaving frequency. Some men may notice increased breast size.

Locally, some young men get picked up during the NS pre-enlistment check up and are brought to medical attention when they are noticed to not complete pubertal development.

In the older age group, difficulty conceiving, erectile dysfunction and reduced sex drive usually leads one to seek medical attention.

Steroid hormones

The symptoms of excess hormones include weight gain (especially around the tummy area), thin skin, easy bruising, thick and dark stretch marks as well as an increase in blood pressure and blood sugar levels.

The most common cause for this would be if you’re taking steroid tablets/creams/sprays. Otherwise, other causes are rare. If there are any concerns, simple blood/urine tests can be done to exclude this as a cause of weight gain.


Insulin resistance or deficiency leads to diabetes. Symptoms of diabetes include feeling thirsty, passing a lot of urine and blur vision, as the sugar causes the lens of the eyes to swell. Many people with diabetes have no symptoms and are only detected on routine health screens.

The vast majority of people with diabetes have type 2 diabetes, and many people with type 2 diabetes (insulin resistance) have a genetic susceptibility, and it’s quite common to have a family member with diabetes. Being overweight/obese will increase your risk of developing diabetes. 

4 Sep 2018

This will depend on what symptom you’re suffering from and generally, blood (and possibly urine) tests will be done to look at the levels of the appropriate hormones.

4 Sep 2018

Hi Yi Xin,

Thanks for the D2D. Menstrual periods are a very good indicator of general health. If your periods are regular, it is unlikely that you have an underlying hormonal problem. Irregular periods and sudden weight loss may be due to hyperthyroidism, where your body produces too much thyroid hormones.

Other symptoms include increased heart rate (you may be aware of your heart beating quickly), increased bowel frequency, increased sweating and feeling hot all the time, and difficulty sleeping.

Another potential explanation is the weight loss being the underlying cause of your irregular periods. We need a certain amount of body fat to have regular periods and if you’ve lost a significant amount of weight, your body will “switch off” the periods.

This can happen if you have been exercising a lot recently, or reducing your food intake.

4 Sep 2018

With regards to male hormones, symptoms of male hormone deficiency can be non-specific, so you feel tired all the time, lack the energy to do things and perhaps feel more moody. They can be more specific like shaving less (for example, you previously used to shave daily and now only need to shave weekly because of less growth), reduced sex drive and erectile dysfunction, reduced morning erections and reduced fertility.

You may also notice an increase in breast size as this can occur if the ratio of male to female hormones is altered. Most men tend to seek medical help when they get the more specific symptoms of low male hormones. If the level of male hormones is low for a significant amount of time, you will be at risk of having a low bone density and osteoporosis.

4 Sep 2018

No, it isn’t. Treatment of PCOS depends on what your current concerns are. As you have been given the pill, I assume you’re not planning to get pregnant anytime soon. The next thing to determine is what type of symptoms you’re experiencing.

If you have symptoms of excess male hormones (acne, facial hair, scalp hair loss), medications can be given to treat these symptoms. This can include medications to block the effect of testosterone (eg spironolactone), medications to improve insulin sensitivity (metformin) and the oral contraceptive pill.

If the concern is the lack of periods, metformin can help to improve the regularity of periods (I find that a dose of 1500mg daily is pretty effective). Whilst waiting for it to regulate, progesterone tablets can be given to help you shed the lining of the womb periodically to reduce the risk of overexuberant growth of the womb lining which may in turn increase the risk of womb cancer. If you are overweight, losing weight will help all of your symptoms.

4 Sep 2018

The birth control pills do not actually make your hormones go back to normal. They will suppress your hormones (eg reduce male hormones from the ovary) and hence improve symptoms of acne and facial hair. I find that acne tends to improve within a few weeks.

With regards to facial hair, because of the length of the growth cycle of hair, I would expect improvements to be seen at around 6 months. Once you’re on the birth control pill, your periods will come every month. This is a withdrawal bleed, where the period will come during the pill-free week. You can improve your hormone levels by reducing weight if you’re overweight.

4 Sep 2018

Increase stress can cause increase in cortisol (stress hormone) levels. But this is usually still within the normal range and does not tend to increase to pathological levels. You should not experience symptoms of high cortisol (weight gain, thin skin, easy bruising etc) from just work stress.

Severe stress may affect your menstrual periods by suppressing your female hormones at the level of the hypothalamus/pituitary gland. Most of the time, treatment is not needed in this situation as your hormones will normalize when the stress is over. If this is persistent and prolonged, you may require some female hormones.

There are some conditions that can cause stress and anxiety, namely hyperthyroidism, and treating this with medications can help improve your symptoms.

4 Sep 2018

This depends on what type of hormonal imbalance is present. Generally, if there is a hormone deficiency, replacement of the hormone is usually required. If there is hormone excess, detection of the source of excess and management according to what the problem is. In women who experience menopausal symptoms, there are certain supplements that contain phytoestrogens that may help to relieve these symptoms.

4 Sep 2018

Similar to adults, children have symptoms depending on the type of hormonal imbalance that is present. Weight and height are usually measured at each clinic visit and are important parameters to take note of. Short stature, especially if the height is under the 3rd percentile or if its crossing centiles on the growth chart (for example, previously 50th percentile and now 10th percentile) would be a significant symptom.

Obesity can sometimes be due to hormonal causes so this would warrant evaluation. Early puberty before the age of 8 in girls (breast development, pubic hair development) and before the age of 9 in boys (increase in the size of their testes) would warrant further evaluation. These are just a few suggestive symptoms. If you have any concerns about your daughter having a hormonal imbalance, I would suggest seeing a paediatrician for an evaluation.


*disclaimer: I don’t deal with children in my practice

4 Sep 2018

Certain psychiatric medications can increase the prolactin levels, and this can affect the female hormones. This is a picture of the hypothalamic-pituitary-gonadal axis in women (left) and men (right). Essentially, the hypothalamus secretes gonadotropin releasing hormone (GnRH) which stimulates the anterior pituitary to secrete luteinising hormone (LH) and follicle stimulating hormone (FSH) and these in turn will stimulate the ovaries in women and the testes in men to produce oestrogen and testosterone respectively. High prolactin levels that have come about as a result of the anti-depressants can affect production of the hormones at anywhere along this axis.


Some antidepressants are associated with weight gain and in some women with polycystic ovarian syndrome (PCOS), this is usually associated with manifestations of symptoms of PCOS. For example, when weight gain occurs, these women would notice increase length of the menstrual cycle and may notice increase in symptoms of excess male hormones (acne, facial hair, scalp hair loss).

4 Sep 2018

This again depends on what type of hormonal imbalance you are referring to. For example, in the case of hyperthyroidism (excess thyroid hormone), the commonest cause is Grave’s disease and medical therapy for about 18 months is a common treatment modality. If it is hypothyroidism (thyroid hormone deficiency, where the commonest cause is Hashimoto’s thyroiditis), then lifelong thyroxine replacement is required.

In the case of PCOS, the hormonal imbalance tends to improve with weight loss because insulin resistance (usually comes on with increased weight) is an important factor in this condition. Weight loss is associated with improvements in insulin resistance and many women notice that their periods becoming more regular and that their symptoms of male hormone excess improve.

4 Sep 2018

Certain conditions can be prevented, whilst others can’t. For example, if you have thyroid autoimmunity (antibody against the thyroid gland), you cannot prevent yourself from developing abnormal thyroid function. If you have PCOS, a healthy lifestyle and maintaining a healthy body weight can reduce your chance of developing symptoms of PCOS.

4 Sep 2018

I probably wouldn’t call it “best treatment”. The term “most suitable treatment” would probably be a better term to use. The treatment plan would be tailored to what your priorities are. For example, if you’re having difficulty conceiving, Clomiphene is a medication used to help induce ovulation, so you can predict when you’re ovulating and time intercourse accordingly.

If you’re overweight, weight loss (either by lifestyle modification or with medical therapy) is an important aspect of treatment. I find Metformin useful in this aspect, and it also helps to improve regularity of the menstrual periods and is generally very well tolerated.

If you’re suffering from symptoms or signs of excess male hormones (acne/facial hair), spironolactone (a medication that blocks the male hormones) +/- the oral contraceptive pill can be used. In severe cases, I find that both of these, taken together with Metformin, to be effective. The oral contraceptive pill should be used cautiously in obese women, as the risk of having thrombosis (clot formation) is higher.

In women who have very irregular periods, progesterone tablets taken every 2 months can help induce a period and shed the lining of the womb. This ensures womb health and reduces the risk of womb cancer. Metformin can help regulate the periods, and whilst on metformin and waiting for periods to become more regular, a 1-week course of progesterone can be taken if you haven’t had a period for 2 months.

4 Sep 2018
Grave's disease is the commonest cause of hyperthyroidism (excess thyroid hormones) and its effects on your body is akin to everything "speeding up". Your metabolism speeds up so you lose weight and feel hot and sweaty, your bowels move faster so you get loose stool/diarrhoea, your heart speeds up so you may notice that your heart is beating very quickly, your mind is very active and may have difficulty sleeping and you may notice some tremors in your hands.
These are some of the signs and symptoms of hyperthyroidism. Our main concern is the heart, because if you heart keeps beating too quickly for too long, you may develop heart failure. In severe cases, thyroid storm may develop. This is a life threatening condition where there may be manifestations such as heart failure and you may become drowsy/confused/have a change in mental state.
Treatment is essential and involves medications to block the thyroid gland from making more thyroid hormone. This group of medication is called Thionamides and Carbimazole is one of them. Another medication is given whilst the thyroid hormone is still high to bring down your heart rate. You will need to be evaulated by your doctor who will determine whether or not it is safe to start it. 
I'm afraid alternative therapy and nutrition treatment cannot replace medical therapy for Grave's disease. Carbimazole should only be stopped at the advice of your doctor as he/she will be able to determine whether or not it's safe to stop. If you suddenly stopped taking Carbimazole and switched to alternative therapy, the diarrhoea and weakness that you're experiencing is possibly the result of high thyroid hormone levels.
I would suggest seeing your doctor as soon as possible for an evaluation. If you stopped Carbimazole because of some side effects that you're experiencing, please discuss this with your doctor as there are other medications available. 
2 Oct 2018

I'm sorry to hear that you've been having trouble with your skin. 

Before determining the best treatment for your acne, it may be worth considering if there is any underlying cause for the acne that should be addressed first. There are a number of hormonal causes of acne, for example polycystic ovarian syndrome (PCOS). This is one of the more common causes of acne in young women.

Women with PCOS may experience increased facial hair growth and scalp hair loss, as well as irregular periods (usually longer cycles). This is usually caused by increased male hormones (testosterone) and insulin resistance.

Treatment can be in the form of medications to block the effect of testosterone, improving insulin sensitivity or suppressing the hormones responsible. Other rarer conditions include having excess male hormones, high steroids hormones (cushing's syndrome) and high growth hormone levels. Certain medications can also cause acne.

An evaluation by your doctor would include a thorough history and physical examination, to see if there are features of any of the above mentioned conditions. Once the underlying cause of the acne has been ascertained, effective treatment targeting that can be initiated. 

1 Nov 2018


In PCOS, periods tend to be irregular and less frequent.

Progesterone is given periodically to induce a period so that your womb lining doesn't grow over-exuberantly and remains healthy.

Generally, if you do not have a period for 2 months, you will be given a 1-week (duration may vary slightly) course of progesterone and a period will come a few days after.

This is not a form of contraception and will not prevent a pregnancy.

When you want to conceive but are having difficulty, medications such as Clomid can be given to induce ovulation and increase the chances of pregnancy.

I hope this helps.

25 Jan 2019

I'm sorry to hear that you have been troubled with fertility issues. Yes, PCOS can result in difficulty conceiving, and this is usually because you don't ovulate regularly, hence unable to predict when the next ovulation will occur. There are medications available that can help with this. If you are able to ovulate with medication but still unable to get pregnant, then the cause for the infertility may not be PCOS related. I would suggest speaking to your fertility doctor about this and he/she will be able to suggest other tests (if clinically relevant) to do. PCOS is also associated with insulin resistance and diabetes and I would recommend getting screened for diabetes before you try to conceive.

I hope this helps.

25 Jan 2019