Category: For Her

Kuala Lumpur, November 5 – The Women’s Health Summit has always been one of the highlights of the year ever since its conception in 2013. Organised by Pantai Hospital Kuala Lumpur, the summit brings together over 300 participants from diverse backgrounds, and enjoys the participation and support from the Ministry of Women, Family and Community Development (LPPKN), Ministry of Health, NGOs, various medical associations and civil societies.

The high point of the day is the Consensus Roundtable, which sees various key opinion leaders, experts and advocates coming together to deliberate on important issues in women’s healthcare, as well as to recommend policy innovations that will enhance healthcare coverage for women in this country.

This year, the 3rd Women’s Health Summit Consensus Roundtable is chaired by YBhg Tan Sri Rafidah Aziz, Patron of the 3rd Women’s Health Summit. Dr Azlina Firzah, consultant breast surgeon, serves as co-chair while Dr Patricia Gomez, also a consultant breast surgeon, acts as moderator.

The issues

Breast reconstruction should be seen as a medical right for breast cancer patients.

Ms Ranjit Kaur, Chairman of Together against Cancer Malaysia and Non-Communicable Disease (NCD) Alliance Malaysia explains that treatment of breast cancer is holistic in nature. It is not solely about surgeries or chemotherapy; the patient needs to receive care for her psychological and emotional well-being too. Breast reconstruction plays a significant role in the healing process, as it allows her to regain her self-esteem and confidence, leading to better adherence to treatment and improved chances of survival.

However, breast reconstruction is currently considered a cosmetic procedure by nearly all Malaysian insurance companies and the Employee Providence Fund (EPF). As a result, breast cancer patients who undergo mastectomy do not have the ability to withdraw funds from their EPF account to cover the costs of breast reconstruction, and only three out of 60 insurance companies in Malaysia provide coverage for this medical procedure.

The Consensus Roundtable brings up the fact that there are already precedents such as in the United States, where the Women’s Health and Cancer Rights Act (also known as Janet’s Law) made it compulsory by law for all sponsored group health plans, insurance companies, individual policies and health maintenance organisations offering medical and surgical benefits with respect to a mastectomy to also offer coverage for reconstructive surgery (including costs of implants and treatment for physical complications at all stages of the mastectomy).

Breast cancer survivors or women carrying breast cancer genes are discriminated by insurance companies as well as employers.

Professor Dr Teo Soo Hwang, Chief Executive of the Cancer Research Malaysia, brings up the Genetic Information Nondiscrimination Act of 2008 (GINA), implemented in the United States to prohibit the use of genetic information by employers and insurance companies to deny a woman her right to employment and insurance coverage, respectively.

In Malaysia, however, there is no similar law, and consequently, she points out that there are many instances when breast cancer survivors find themselves denied further insurance coverage and employment. Those with breast cancer genes are either denied insurance or they have to pay very high insurance premiums.

The call for action

It is time for the government to act. Tan Sri Rafidah Aziz calls for the Malaysian government to make the right provisions for the women in this country. Dr Patricia adds that the government needs to look at Janet’s Law and GINA to see how countries such as the United States handle this matter.

The Consensus Roundtable also urges the Ministry of Health to consider abolishing the need for ex-government servants and pensioners to pay upfront for the prosthetics (implants) needed for breast reconstruction in government hospitals.

The insurance companies can play a role. Dr Myralini S Thesan (Chairman of the Joint Technical Medical Committee of LIAM and Medical Advisor and Head of Care Management of AHS, AIA Berhad) says that she will send a representative to talk to Prof Dr Teo and other parties on the types of changes that we need to see in local insurance policies, as well as to clear the air on any wrong perceptions or misunderstanding on how the local insurance companies operate.

EPF can step up. Mr Azrulzimar Aminuddin, the Deputy Manager of the Withdrawal Operations Department of EPF, states that he will propose allowing women to withdraw from their EPF accounts for breast reconstruction in an upcoming meeting, and Tan Sri states that she will personally write to the EPF to support Mr Azrulzimar.

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Professor Dr Jamiyah Hassan  Senior Consultant OBGYN, Feto-Maternal Specialist, University Malaya Medical Centre

Each year, millions of Muslims undertake the pilgrimage to Mecca during a 5-day period, from the 9th to the 13th of Dhu Al-Hijjah, the 12th month of the Muslim lunar calendar. This pilgrimage is both a religious goal and the high point of a Muslim’s life. For Muslim women preparing for the Hajj, however, there is always a question lurking at the back of their minds: what if they were to menstruate during those precious days?

“Muslim women are not allowed to perform religious activities such as fasting and praying when they have their menses,” explains Prof Dr Jamiyah Hassan. “This extends to performing the Hajj.”

Dr Jamiyah, speaking at the Women’s & Men’s Health Intertwined seminar conducted by the Obstetrical and Gynaecological Society of Malaysia (OGSM) recently, said that combined oral contraceptive pills (COC, sometimes better known as “the pill”) can be used to delay menses during pilgrimage.

Religious decisions

The use of COC involves manipulating the female hormones. Is such a method allowed?

There is no fatwa on delayed menses by the National Fatwa Council, according to Dr Jamiyah. She however points out to specific fatwa in the states. For example in 1985, the Penang Fatwa Council stated that Muslim women are allowed (harus) to delay their menses for the purpose of Hajj, due to the distance travelled for the pilgrimage as well as the difficulty of performing the Hajj ritual. She has also spoken to many religious figures who agreed with this fatwa.

Delaying the period

According to Dr Jamiyah, any COC would work for this purpose, but she recommends choosing the newer brands of COCs. This is because in newer COCs, the active ingredient progestogen is designed to have a longer half-life and therefore, these COCs are more effective.

She offers the following general tips:

• Start a month earlier, as your body needs time to acclimatise to the changes to your menstrual cycle.
• A traditional pill pack contains 28 pills, but only 21 are active. The other seven pills are inactive. Discard the nonactive pills, and continue taking the active pills until you have returned to Malaysia.
• If you bleed during the Hajj, you can still perform your religious duties, provided you clean up first. Dr Jamiyah explains that, according to the fatwa, such bleeding is not considered normal menses as it is the result of hormonal manipulation.

These are only general guidelines. Dr Jamiyah advises women hoping to delay their menses to first consult their doctor, for appropriate dosage and other important information.

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Dr Eeson Sinthamoney Consultant Obstetrician, Gynaecologist and Fertility Specialist

A sad fact of life is that biology is not feminist in nature. Women may have come a long way when it comes to attaining equal rights and becoming more independent, but human biology remains primordial. A woman’s peak fertility period is still in her late teens to her twenties – a time when she may not be ready to become a mother. By the time she is 35 (ironically the age when she may be ready to settle down), a woman’s chance of conceiving per month decreases by half. By age 45, natural fertility is reduced to only one percent.

Ah, but just imagine never having to worry about ‘baby panic’ or the biological clock counting down after hitting the big three-oh: being able to focus on establishing a career, working toward financial stability or emotional readiness. What’s more, if Mr Right is taking his time to show up, it’s no big deal – a lady can wait and not have to settle for less.

If that sounds great, well, these choices are now increasingly possible, thanks to advances in a procedure called egg freezing.

A woman may still have it all

Just like its name states, the procedure involves storing extracted eggs in a very cold environment. The very low temperature keeps the eggs in suspended animation, so that when they are thawed (even years down the road), they can be used to conceive a baby.

Fertility specialist Dr Eeson Sinthamoney explains that, traditionally, egg freezing is viewed as a method to preserve the fertility of women who are about to undergo chemotherapy or other forms of treatment that would affect their ability to produce healthy eggs in the future.

This is still true today, but egg freezing has evolved to become a solution for every woman who wishes to preserve her fertility.

The evolution is made possible because recent improvements made to egg-freezing technology have improved its chances of success.

Dr Eeson explains that, in the past, the freezing process could cause ice crystals to form in the eggs, damaging their structure and making them unusable when thawed.

This changed when a technique called vitrification was developed recently. The technique freezes the eggs very rapidly in order to prevent ice crystal formation. “The eggs can survive better because there is less damage,” Dr Eeson says. As a result, the success rate of egg freezing has improved tremendously. Dr Eeson describes this development as a ‘game-changer’ when it comes to preserving a woman’s fertility.

There’s still a catch

Unfortunately, there’s never a foolproof solution. Dr Eeson notes that there are many other factors determining the odds of success.

For example, the eggs that were harvested may already have some abnormalities in them that prevent a successful pregnancy. “The best time for egg freezing to take place is when the woman is in her late twenties to early thirties,” Dr Eeson says. Any later and it may be harder for the fertility specialist to extract enough healthy eggs for future use. This is because a woman is born with only a fixed number of eggs, which decreases as she grows older, and the eggs may also contain more abnormalities as time goes by.

Also, some eggs may be more susceptible to damage compared to others. Fertility specialists do not have a reliable way to ensure that all harvested and frozen eggs are normal or will be able to withstand the freezing process. Hence, there is no guarantee of a healthy pregnancy. 

What is the procedure like?

1. The first step is always a consultation, during which the fertility specialist will review the procedure thoroughly with the client. The specialist will also discuss the risks and address any concerns the client may have.
2. The fertility specialist will then conduct a pre-screening test, called the ovarian reserve testing. This is a simple blood test, usually taken on day three of the menstrual cycle, in which the blood sample is used to measure the levels of anti-Müllerian hormone present. The results will give the fertility specialist a good idea of the woman’s ovarian reserve, which is the number of eggs remaining in her ovaries.
3. Once all is in order, the client will receive fertility injections to stimulate the production of a large number of eggs.
4. When the time is right, the fertility specialist would retrieve the eggs while the woman is under deep sedation. This is done using a needle under the guidance of an ultrasound.
5. The eggs will then be frozen. Special chemicals called cryoprotectants may be used to prevent ice crystal formation.

The entire procedure would take about 10 to 14 days, and would not disrupt the woman’s normal routine much, says Dr Eeson.

For a reasonable annual fee, the fertility centre will store the eggs until they are needed.

Frequently asked questions

• How long can the eggs keep?
  They can keep for a long time, Dr Eeson says. In fact, the actual limiting issue is the age of the woman when she wants to be a mother. Most fertility specialists would prefer that the woman uses her frozen eggs before she turns 50, as pregnancy at age 50 and above has its share of potential complications.
   
• What happens if the frozen specimens end up missing or damaged?
  Consent forms will have to be signed before any procedure takes place to define what the fertility centre will and will not be held accountable for. Generally, the fertility centre will not be held accountable for any damages that are caused by what’s known as ‘acts of God’: natural disasters and other events that cannot be avoided by any amount of foresight or precautionary measures. If you suspect that the fertility centre has been negligent, you should consult a lawyer for further action.

What happens if the fertility centre goes out of business? What will happen to the frozen eggs?
To the best of Dr Eeson’s knowledge, there are currently no laws or regulations in Malaysia that set out the course of action required when a fertility centre closes shop. To date, no one in Malaysia has had to face such a situation.

Normally, an ethical fertility centre will make arrangements for another fertility centre to take custody of its frozen specimens. Perhaps the best course of action is to ask the fertility centre about this beforehand, as each centre may have its own contingency plan for such a situation.

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WORDS PANK JIT SIN

A multinational effort by stakeholders from University of Malaya (UM) and VCS Foundation Australia has resulted in an innovative approach to reduce and eliminate cervical cancer in Malaysia. Known as Removing Obstacles to cervical ScrEening (ROSE), the pilot programme integrates self-sampling, human papillomavirus (HPV) testing and e-health technology to improve cervical cancer screening uptake among Malaysian women.

According to Professor Woo Yin Ling, consultant obstetrician and gynaecologist at UM, who helmed the pilot programme, ROSE integrates “self-sampling, HPV testing and e-health technology to enhance every woman’s personal journey of maintaining good cervical health.”

“At its heart, ROSE is driven by empathy for the screening experience of women. ROSE embodies safety, privacy and dignity through self-sampling, encouraging more women to willingly participate in screening in a timely manner,” says Prof Woo. 

The HPV test accompanying ROSE is evidence-based and highly accurate, thus providing greater reassurance to the women tested. The diagnostic accuracy also allows for less frequent testing over a woman’s lifetime. Prof Woo reveals that it was the e-health component of ROSE that makes it unique and powerful. The programme utilizes mobile technology and VCS Foundation’s canSCREEN^®, a population health management platform that enables healthcare professionals to track the progress of every woman screened through their lifetime regardless of whether they did it in a government or private setting.

The programme provides a welcome safety net to ensure women are screened at recommended intervals and followed up accordingly.

“It also allows optimization of health resources by preventing duplication of services while establishing a powerful resource to monitor our progress towards eliminating cervical cancer as a nation,” says Prof Woo.

Evidence for ROSE comes from a multi-sectoral collaborative effort, which was established to conduct the screening study. The pilot project took place in five MOH clinics in 2018 and involved 4,188 women. It was supported by academia, government, corporate, non-profit organizations, as well as private sponsors.

The pilot project found that 99% of the participants preferred the self-sampling method of ROSE, suggesting that Malaysian women would generally find this new approach to screening more acceptable.  Abnormal test results were detected in 5% of the women screened, and three cases of cancer were diagnosed and had the appropriate follow up. The mobile technology and e-health facilitated comprehensive follow through of the ‘screening to treatment’ pathway in the women.

 “The studies also found a high level of engagement with the ROSE model among participating healthcare professionals. They were very encouraged by its potential to increase the uptake of cervical cancer screening by women attending the clinics while not burdening the healthcare staff with additional administrative workload,” says Prof Woo.

Thus, the findings suggest that ROSE is the right way ahead in strengthening the national cervical cancer screening programme.

ROSE’s potential to change the landscape of cervical cancer has been recognized by WHO, Union for International Cancer Control, International Papillomavirus Society, U.S. National Cancer Institute and International Federation of Gynecology and Obstetrics. Dr Tedros Adhanom, Director-General of WHO, wrote in to endorse the women-centred approach of ROSE and said Malaysia is well on its way of meeting WHO’s target of screening and managing 80% of women aged between 35 and 45 by 2030.

Malaysia is the first country in the world to implement a programme such as ROSE, which incorporates self-sampling, HPV DNA-testing, and a digital platform that securely monitors the entire screening journey of women through an integrated platform.

The launch of ROSE and signing of Memorandum of Understanding between UM and VCS Foundation was also attended by Professor Dato’ Dr Adeeba Kamarulzaman, Dean of the Faculty of Medicine, UM, Dato’ Seri Dr Wan Azizah Wan Ismail, Deputy Prime Minister of Malaysia, Datuk Seri Dr Dzulkefly Ahmad, Minister of Health and Hannah Yeoh, Deputy Minister of Women, Family and Community Development. HT

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WORDS LIM TECK CHOON

Imagine being able to focus on building our career and achieving financial stability without having to worry that time may be running out when it comes to having a family. Perhaps life can be like a romantic movie or novel, and maybe we can wait until we can find that special someone without hearing the biological clock ticking away in our head.

Thanks to advances in fertility methods and technology, we now have options to gain some semblance of control over our fertility (within realistic limits, of course). This month, fertility specialist Dr Agilan Arjunan invites us to take a closer look at these options.

How Long Can A Woman Wait To Have A Baby?

WOMAN’S HEALTH AND FERTILITY WITH

When it comes to fertility, the biological clock is quite real. Dr Agilan shares that:

• A woman’s most fertile period is usually between the ages of 20-25.
• Her fertility begins to decline after the age of 25 (more steeply after the age of 35), often when she is finally ready to settle down and start a family.

Why Is There Even A Biological Clock In The First Place?

While a man’s testicles continuously produce sperm over time, a woman is born with all her eggs already produced, to be released over time during each menstrual cycle.

This means that she has a limited number of eggs that can be used to conceive a child throughout her reproductive years. As we can see from Figure A, a woman has 100% of her eggs at birth,but the number decreases over time. By the time she is 30, she has approximately 10% of her eggs remaining, and the number continues to decline until she experiences menopause, after which she is no longer able to conceive a child.

It’s Not Just The Number That Counts, It’s Also The Quality.

Dr Agilan explains that age doesn’t just affect the number of eggs available for a successful conception. The quality of the eggs is affected too.

“The good quality eggs are often released during a woman’s most fertile age,” he elaborates. As the years pass, there is a higher risk for an egg to contain abnormal genetic material or develop into an abnormal embryo. This is why the risk of having a child with genetic disorders such as Down’s syndrome increases when a woman has a child at a later age (especially after 40).

There Are Other Factors That Also Affect A Woman’s Fertility.

Some of these include:

Hey, how come only women need to plan their fertility? How about the men?

Don’t shoot the messenger, but biology isn’t big on equality of the sexes. Unlike women, men continue to produce sperm cells throughout their reproductive period, and hence there is usually no need to freeze their sperm. Dr Agilan says that sperm freezing is often an option to consider if the man is about to go for cancer treatment. Other than that, he believes that there isn’t any need for a man to freeze his sperm.

However, do note that male fertility has been decreasing on a global scale, although we have yet to fgure out the exact reasons for this phenomenon. Dr Agilan believes that some men may have fertility issues after the age of thirty, and as such, they should consider visiting a fertility specialist if they had been trying to have a child through regular sexual intercourse for a year or so, but have yet to be successful.

WORDS ABRAHAM MATHEW SAJI

Sarah—the writer’s late mother—frequented visits to her doctor when she was in her mid-60s due to occasional vaginal discharge with bleeding and fever. Initial examination revealed urinary tract infection and she was treated accordingly. She reduced her visits to her doctor due to shyness and inability to afford the costs of treatment. Within a period of about 9 to 12 months, her condition started getting worse with discharge and blood stains visible on her clothes and bed sheets. Pathological, radiological and biopsy tests revealed that she had stage 4 cervical cancer. The cancerous cells were so active and malignant that they had spread to her bladder and colon. The treatment options available then could hardly sustain her for another 3 months and she passed away.

To avoid the trauma that Sarah and her loved ones had, and in conjunction with World Immunization Week (April 24 to 30, 2019), let’s take the opportunity to learn and spread the awareness of cervical cancer. 

INTRODUCTION TO CERVICAL CANCER

The cervix is the lowest part of the uterus. It is also commonly known as the neck of the womb. Cancer of the cervix, also known as cervical cancer, begins with abnormal changes in its tissues.

The human papillomavirus (HPV) is responsible for the majority of cervical cancer cases. The cancerous cells can grow abnormally and invade the other adjoining tissues and organs like vagina, bladder, rectum, liver or lungs. In 2018, more than 300,000 women died due to cervical cancer and more than 85% of them were from low- and middle- income countries. In Malaysia, cervical cancer is the third most common cancer among women, with an average of about 2,000 women being diagnosed every year. Due to its slow progression rate, cervical cancer can be detected early and treated. It can also be prevented by HPV vaccine.

Some of the common symptoms of cervical cancer are:

1. Abnormal vaginal discharge
2. Abnormal vaginal bleeding (different to menstrual bleeding eg, bleeding after sexual intercourse)
3. Vaginal bleeding post- menopause
4. Pain in the pelvic region (eg, pain during sexual intercourse)

It is recommended for women to consult their doctor if they have any of the above symptoms.

CAUSES OF CERVICAL CANCER

The most common causes or associated risk factors for cervical cancer are:

• HPV infection: A sexually transmitted disease, HPV infection manifests itself in different forms and is the number one cause of cervical cancer.
• Weakened immune system: The risk of contracting an infection which can thereby progress to be cancerous is higher in those with HIV/AIDS and those who have undergone an organ transplant.
• Birth control medications: Long term use of certain birth control medications can increase the risk of developing cervical cancer.
• Sexually transmitted diseases (STDs): Other sexually transmitted diseases like chlamydia, gonorrhea and syphilis infections can also increase the risk of developing cervical cancer.
• Smoking: The chemicals in cigarette smoke interact with the cells of the cervix to cause certain precancerous changes that could lead to cervical cancer over a period of time. The risk  of cervical cancer is about two to five times higher in smokers compared with non-smokers.
• Socioeconomic background: The rates of STDs and cervical cancer appear to be higher in lower income groups.

“LADIES, CONSULT YOUR DOCTOR QUICKLY IF YOU HAVE UNUSUAL VAGINAL DISCHARGE OR BLEEDING TO RULE OUT CERVICAL CANCER.”

STAGES OF CERVICAL CANCER

Timely detection of the cancer and determining its stage is one of the main steps in the treatment of cervical cancer. It helps to identify the most appropriate treatment to prevent the cancer from spreading and affecting other organs. Treatment options are based on age, severity of condition, other underlying diseases in addition to the rate and extent of the cancer. The stages of cervical cancer are:

 Stage 0: Precancerous cells are present in the cervix.

 Stage 1: The cancerous cells have grown, divided and spread from the surface of the cervix to other deeper tissues near or maybe even into the uterus.

 Stage 2: The cancerous cells have spread beyond the cervix, past the uterus into the lower parts of the vagina, affecting the adjoining lymph nodes.

 Stage 3: The cancerous cells have spread beyond the lower parts of the vagina to the walls of the pelvis, blocking the passage of the ureters and affecting the surrounding lymph nodes.

 Stage 4: The cancerous cells have grown and spread affecting the bladder or rectum and begins to grow out of the pelvis to affect other organs like liver, lungs, bones and lymph nodes.

“EARLY DETECTION AND TREATMENT OF CERVICAL CANCER HELPS TO PREVENT IT FROM SPREADING TO OTHER PARTS OF THE BODY.”

DETECTION OF CERVICAL CANCER

Early detection of cervical cancer significantly improves the success rate of treatment.

• Cervical smear test: A Pap smear test can identify early signs of cervical cancer. This test helps to identify abnormal changes in the cervical cells, which when left untreated could develop into cancerous cells. The test is recommended for every woman aged 30 and above.
• HPV DNA test: This test can help to determine if the patient has any HPV infection. Cervical cells are collected for testing for any abnormality and HPV infection especially the high-risk HPV strains. (Read Cervical Cancer Elimination Receives a Boost with ROSE, page 30-31, HealthToday March 2019)
• Colposcopy: In this test, the cells of the cervix and vagina are examined visually using a speculum and colposcope. The colposcope is a lighted magnifying laboratory instrument that can aid in the visual examination of abnormalities in the cells. In cases where a more thorough examination or incision is required, the examination may be done under anaesthesia.
• Biopsy: A small section of the cervical or affected tissue is taken out for further laboratory analysis and investigation.
• Cone biopsy: It is an extended form of the normal cervical biopsy where a small cone-shaped wedge of the cervical tissue is removed for further laboratory analysis and investigations.
• Large loop excision of the transformation zone (LLETZ): A fine wire loop charged with electricity is used to shave off the cervical tissue which contains abnormal cells and seals the blood vessels in the adjoining area. This procedure is normally performed under anesthesia.
• Blood tests: Additional pathological tests and blood counts can identify liver or kidney dysfunctions related to spread of cancer.
• Ultrasound of the pelvis: An ultrasound uses high frequency sound waves to create an image of the target area which is examined on a monitor for any abnormalities.
• Scans: A computerised tomography (CT) is widely used to improve clinical staging of cervical carcinoma. CT is useful in evaluating tumour size, lymph node status and distant metastasis which are all critical prognostic factors in cervical carcinoma. A magnetic resonance imaging (MRI) scan can also help in local staging of cervical carcinoma.

TREATMENT OF CERVICAL CANCER

Cervical cancer cases can be treated by surgery, radiotherapy, chemotherapy or a combination of these methods. The type, dosage and regimen of treatment will depend on various factors like age of the individual, stage of the cancer, other underlying conditions and overall state of the individual’s health. The success rates of treatment in early stages of the cancer are high; with reducing trends due to treatment delays and extent of spread. During early stages of the cancer, surgery combined with radiotherapy can help to a large extent. Advanced stages of cervical cancer may require a combination of surgery, radiotherapy and chemotherapy to kill the cancer cells and prevent further spread.

PREVENTION OF CERVICAL CANCER

Some of the preventive measures that every woman can take are:

• Get vaccinated for HPV: There is a clear and established link between the HPV infection and development of cervical cancer. Two HPV types (type 16 and type 18) are responsible for 70% of the cervical cancer cases.
• Practice safe and protected sex: The HPV vaccine can only protect from two strains of the virus. Other strains of the virus may also lead to cervical cancer.
• Cervical screening: Regular cervical screening and smear tests can help to detect and identify any abnormal cells.
• Stop smoking: As there is a clear line of incidence of cervical cancer among smokers, it is best to avoid smoking.

THE ROAD AHEAD

A comprehensive cervical cancer control begins with primary prevention (HPV vaccination), followed by secondary prevention (early detection and treatment), tertiary prevention (timely diagnosis and appropriate treatment depending on the stage of cancer) and palliative care (inter-disciplinary approach of specialized medical and paramedical care). Cervical cancer is both preventable and treatable. HT

“CERVICAL CANCER IS BOTH PREVENTABLE AND TREATABLE. A COMPREHENSIVE CERVICAL CANCER CONTROL BEGINS WITH HPV VACCINATION.”

References: 1. World Health Organization. Human papillomavirus (HPV) and cervical cancer. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/ human-papillomavirus-(hpv)-and-cervical-cancer. 2. Immunise4Life. 7 Vital Facts About Cervical Cancer. Retrieved from: https://immunise4life.my/diseases/7-vital- facts-about-cervical-cancer/.

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