Journal of Mid-life Health Journal of Mid-life Health
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   Table of Contents - Current issue
January-March 2021
Volume 12 | Issue 1
Page Nos. 1-84

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Medicine - Transition from art to science? Highly accessed article p. 1
Meeta Meeta, Vishal Tandon
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Polycystic ovarian syndrome and menopause in forty plus women p. 3
Sudhaa Sharma, Neha Mahajan
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age group, but it affects women's health and quality of life across the life course. During different stages of life, the PCOS phenotype can change, which requires a personalized diagnostic approach and treatment. With increasing age, the syndrome evolves from a reproductive disease to a more metabolic disorder. Along with various metabolic disturbances like insulin resistance and abnormalities of energy expenditure, PCOS is recognized as a major risk factor for the development of type 2 diabetes and cardiovascular disease (CVD) in later life. The aim of the current review was to conduct a nonsystematic review of published literature and research that has been presented so far regarding menopausal women with PCOS as well as the associated changes in hormone profile, their lipid profile, and various metabolic changes that occur. The current review may also contribute to raise awareness about the risk of hypertension and CVDs in postmenopausal women with PCOS.
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Gender bias in cardiovascular disease prevention, detection, and management, with specific reference to coronary artery disease p. 8
Shailesh Desai, Atul Munshi, Devangi Munshi
Even though cardiovascular disease (CVD) kills more women than men each year and remains a leading cause of death in women, it is a common misconception that women are less likely to develop CVD. Considerable sex difference exists between men and women with regard to prevention, investigations, and management of CVD. Coronary artery disease (CAD) is a major contributor to CVD morbidity and mortality and hence is specifically addressed in this article. With an explosive increase in the incidence of conventional risk factors for coronary artery disease in India, there has been an alarming increase in women's coronary events as much as men. A false sense of gender-based protection by estrogen leads to less aggressive and late prevention or management strategies that contribute to women's CAD. Metabolic syndrome (MetS) is an important contributor to future development of CAD and is also an indicator for earlier interventions for prevention. Due to physical inactivity and central obesity, MetS is more prevalent in women, especially postmenopausal. With estrogen loss, menopause marks a critical cardiovascular biological transition, with a significantly increased CVD risk in women aged >55 years. Certain female-specific risk factors, such as history of polycystic ovarian syndrome, pregnancy-induced hypertension, and gestational diabetes, also seem to play an essential role in the development of CVD in later life. Certain vascular and biological factors, such as smaller coronary vessel size, higher prevalence of small vessel disease, and lesser development of collateral flow, also play an important role. This review article is an attempt to provide important information on gender differences in CVD with specific emphasis on CAD.
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Gender differences in osteoarthritis of knee: An Indian perspective p. 16
Srinivas Thati
Introduction: The global burden of knee osteoarthritis (KOA) is on the rise with advancing age, as life expectancy is improving worldwide. The literature shows a higher prevalence and incidence of KOA in women. The gender differences are seen not only in the developing world but also in the developed world. KOA at advanced stage can be quite disabling affecting the individuals' functioning capacity. The available treatment modalities can improve the quality of life significantly. The aim of this review is to study the gender differences in epidemiological and clinical aspects of KOA in Indian population. Methods: The keywords “knee osteoarthritis, Gender, India,” “knee osteoarthritis, Sex, India,” and “knee osteoarthritis, Prevalence, India” are used for data search for retrieving data from Indian studies in MEDLINE and Google Scholar. The broad inclusion criteria were clinical and radiological diagnosis of KOA, inclusive of both men and women and excluded articles with rheumatoid arthritis, inflammatory arthritis, and secondary causes of arthritis. Results: A total of 18 articles were found to fulfill the broad inclusive criteria. Majority of the articles were cross-sectional prevalence studies either done in a community setup or in tertiary care hospitals. The overall prevalence of KOA in these studies ranges from 27.1% to 66.1%, depending on the lower age limit of the study population. Postmenopausal women are affected more than premenopausal women. High body mass index, hypertension, diabetes mellitus, and osteoporosis were the common comorbid conditions. Discussion & Conclusion: The gender difference in the incidence and prevalence is seen in several cross-sectional studies and case series in the Indian literature. However, there is a paucity of data on clinical presentation, progression of the diseases, disability scoring at various stages of the KOA, and management.
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A mini-review of office hysteroscopic techniques for endometrial tissue sampling in postmenopausal bleeding p. 21
Sergio Haimovich, Tanvir Tanvir
Postmenopausal bleeding (PMB) is a common cause for a gynecological visit. Endometrial cancer risk varies from 3% to 25% in women with PMB. There is a significant concern of malignancy of the endometrium and the endocervical canal by a physician in postmenopausal women, and hence, most prefer operating room hysteroscopies with dilation and curettage (D & C) compared to in-office procedures. With increased availablility of miniaturized instruments such as mini- resectoscope and tissue removal systems, there is high likelihood of blind D & C being replaced by hysteroscopic- guided targetted biopsy or visual D & C. The cost-effectiveness of office hysteroscopy is also well demonstrated. In December 2020, an electronic search was performed of PubMed, MEDLINE, and Cochrane Library to look for articles on office hysteroscopic biopsy techniques in postmenopausal women from 2010 to 2020. Relevant studies were included where various office hysteroscopic techniques are used for endometrial sampling in PMB. Studies with 5 Fr scissors, biopsy forceps, crocodile forceps, cup forceps, bipolar electrode, in-office tissue removal system (morcellator), flexible hysteroscope, and mini-resectoscope were included. Standard reference was used as an adequate endometrial sample for histology. The objective of this review is to explore the current evidence on different office hysteroscopic techniques available for endometrial tissue sampling in PMB. Research Question: What are the different available in - office hysteroscopy techniques for obtaining endometrial biopsy? Clinical Importance: Understanding the adequacy of an endometrial tissue sample obtained by different in - office hysteroscopy techniques and their accuracy by histology.
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Polycystic Ovary Syndrome (PCOS) transition at menopause p. 30
Duru Shah, Sabahat Rasool
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Perceived stress and its determinants among postmenopausal women in Urban Puducherry p. 33
Gokul Sarveswaran, Venkatachalam Jayaseelan, Yuvaraj Krishnamoorthy, Manikandanesan Sakthivel, Yashodha Arivarasan, Karthiga Vijayakumar, Yamini Marimuthu
Background: Menopause characterized by a gradual decline in ovarian hormones takes its toll on the women both physically and mentally. These health problems can negatively impact the mental status. Hence, the current study was done to determine the level of stress and its associated factors among postmenopausal women in urban Puducherry, India. Materials and Methods: A facility-based cross-sectional study was done among 219 postmenopausal women attending the outpatient department in urban primary health center during May 2017–June 2017. Information regarding sociodemographic profile was collected using pretested semi-structured questionnaire and Cohen's Perceived Stress Scale was used to assess the stress level. We calculated adjusted prevalence ratios (aPRs) to identify the determinants of stress. Results: Among 219 participants, 46.6% were in the age group of 60–74 years; 32.9% had primary to secondary level of education; 56.2% were unemployed; 42.5% belonged to lower socioeconomic class; and 32.9% had both diabetes mellitus and hypertension. The prevalence of stress among the postmenopausal women was 26.0% (95% confidence interval: 20.7–32.2). Postmenopausal woman with higher education (aPR – 2.18), belonging to nuclear family (aPR – 1.93), lesser parity (aPR – 1.18), and current alcohol/tobacco users (aPR-2.32) were found to have a significant association with stress among the study participants. Conclusion: The current study showed that more than one-fourth of the postmenopausal women had high to very high level of stress. Education, religion, parity, and substance abuse were the significant determinants of stress. However, further longitudinal research needs to be done to determine whether the factors informed in the current study are truly associated with stress and develop interventions accordingly.
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Mifepristone in fibroids: Comparative study of safety and efficacy of biweekly dosage vs daily dosage schedule p. 39
Neelofar Shaikh, Reeti Mehra, Poonam Goel, Ravinder Kaur
Background: Leiomyomas are the most prevalent benign tumors of the uterus and are seen more with increasing age. 50 mg biweekly dose was compared with 25 mg daily dose in terms of efficacy and safety in symptomatic women as the biweekly dose maybe an economically better alternative. Two different dosages of mifepristone for medical management of fibroids were compared in terms of efficacy and safety in symptomatic women. Materials and Methods: Ninety-two women were recruited who fulfilled the criteria after informed consent and were randomized in two groups. Sample size was calculated on the basis of earlier literature, for response in terms of reduction in fibroid volume, assuming 1% level of significance and 95 % power of study, the optimum sample size came out to be minimum 27 in each group. Assuming loss to follow up of few patients, we took 45 patients in group 1 and 47 patients in group 2. Group 1 was given mifepristone in a dose of 25 mg once a day and Group 2 was given mifepristone 50 mg biweekly for 3 months. Fibroid volume, uterine volume, endometrial thickness, pictorial blood loss assessment chart score, hemoglobin levels, and liver transaminases were recorded at the beginning and at the end of treatment. Side effects were noted at the end of the treatment. Results: Both the dosages lead to improvement in symptoms of the patients. Mifepristone significantly reduced fibroid volume in both the groups, but the difference between the groups was not significant (P = 0.99). Mifepristone treatment significantly reduced bleeding and increased hemoglobin levels in both the groups. The side effects were mild and tolerable. Conclusion: Mifepristone in both dosages is highly efficacious in causing amenorrhea, improving anemia, and enhancing the quality of life, and hence 50 mg biweekly dosage shows potential for being cost efficient.
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Effect of menopause on arterial stiffness and central hemodynamics: A pulse wave analysis-based cross-sectional study from Gujarat, India p. 46
Jayesh Dalpatbhai Solanki, Devanshi Nishantbhai Bhatt, Ravi Kanubhai Patel, Hemant B Mehta, Chinmay J Shah
Background: Menopause, a cardiovascular risk in mid-life women, is studied in terms of blood pressure mostly. Arterial stiffness (AS) and central hemodynamics (CH) are direct surrogates measured by pulse wave analysis (PWA) with no study from our region. Objective: We studied AS, CH in relation to menopause using PWA. Materials and Methods: A cross-sectional study was performed in 134 middle-aged females divided into groups with or without menopause. Oscillometric PWA done by Mobil-o-Graph (IEM, Germany) gave – AS like augmentation pressure, augmentation index at heart rate (HR) 75, aortic pulse wave velocity (aPWV), and total AS pulse pressure amplification; CH like aortic blood pressure, cardiac output and related parameters, peripheral resistance, stroke work, prevalent brachial/central hypertension, and raised central pulse pressure. They were further compared between groups, in relation to body mass index (BMI) and by multiple regressions with P < 0.05 as statistical significance. Results: Postmenopausal women were significantly elder, physically inactive with comparable BMI and showed higher AS (only aPWV was significantly different) and CH. BMI was unrelated to AS or CH in postmenopausal group. Age (except for aPWV), BMI, and HR (except for [email protected]) were insignificant predictors, while systolic blood pressure (SBP) in premenopausal and diastolic blood pressure (DBP) in postmenopausal group was major AS predictors. Age, HR, and BMI were insignificant predictors, while SBP more than DBP was significant predictors of CH. Conclusions: In obese, predominantly sedentary midlife Gujarati women, menopause negatively affects AS and hemodynamics, central more than peripheral. Menopause accelerates cardiovascular aging, independent of BMI, and age that calls for further studies.
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Effect of Vitamin D3 supplementation on symptomatic uterine leiomyoma in women with Hypovitaminosis D p. 53
Amita Suneja, Fahmina Faridi, Shuchi Bhatt, Kiran Guleria, Mohit Mehndiratta, Richa Sharma
Objective: The objective of this study is to evaluate the effect of Vitamin D3 on symptoms, uterine and leiomyoma volume in women with symptomatic leiomyoma and hypovitaminosis D. Materials and Methods: In this pilot, interventional, prospective study, 30 premenopausal women with uterine leiomyoma and concomitant hypovitaminosis D (<30 ng/ml) received Vitamin D3 in doses of 60,000 IU weekly for 8 weeks followed by 60,000 IU every 2 weeks for another 8 weeks. Change in symptoms, uterine, and leiomyoma volume was evaluated at 8 weeks and 16 weeks. Serum Vitamin D3 levels were repeated at 16 weeks of therapy. Results: A significant negative correlation was observed between the baseline 25-hydroxy Vitamin D (25(OH) Vitamin D3) and leiomyoma volume (r = –0.434, P < 0.001). There was significant reduction of menstrual blood loss by 29.89% (P = 0.003) and severity of dysmenorrhea, pelvic pain, and backache by 44.12%, 35%, and 50% (P < 0.001, 0.019, and 0.002), respectively, at 16 weeks. At end of therapy, there was 6% reduction in mean uterine volume and 11% in leiomyoma volume which was not significant. Serum 25(OH) Vitamin D3 was significantly higher than baseline level (17.44 ± 5.82 vs. 39.38 ± 8.22, P < 0.001) at end of therapy. Conclusion: Vitamin D3 supplementation is effective in reducing leiomyoma-related symptoms and stabilizing uterine and leiomyoma volume.
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An audit of clinical studies involving elderly population registered in clinical trials registry of India p. 61
Avi Anil Sharma, Sonali Rajiv Karekar, Yashashri Chandrakant Shetty
Context: The elderly in India form a heterogeneous subset of the population with significant disease burden variations. However, there are no data available regarding the type of research studies conducted in an elderly population in India. Aims: The aim of this study was to analyze the research studies conducted in the elderly population in India based on data from the Clinical Trials Registry of India (CTRI). Settings and Design: This was an “audit” of available data on the CTRI website. Participants and Methods: Following exemption from the Institutional Ethics Committee, all studies in the elderly population registered in CTRI from its inception (July 2007 to August 2019) were reviewed. Data captured with respect to geographical distribution, study designs used, therapy area, trial registration, and funding. Statistical Analysis Used: The variables were analyzed using descriptive statistics using SPSS version 16.0. Results: Out of a total of 21,400 studies in CTRI, a total of 99 (0.46%) studies involved only elderly patients. Of these studies, 60 (60.6%) were interventional, whereas 39 (39.4%) were observational. Of all the interventional studies, 17 (28%) tested drugs, 26 (43%) tested a lifestyle intervention, and the rest were nutraceuticals, Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy, and physiotherapy. Postgraduate theses constituted 60 (60.6%) studies. Eighty-seven (87.9%) were academic projects, eight (8.1%) were government-funded studies, and only four (4%) were pharmaceutical-sponsored studies. The most commonly studied therapy area was the central nervous system, followed by community medicine and orthopedics. Conclusions: This study depicts the underrepresentation of the geriatric population in clinical studies.
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Understanding the endometrium at menopause: A sonologist's view p. 66
Mamata Deenadayal
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Robot-assisted laparoscopic approach in a patient of zinner syndrome with hematuria: A rare presentation p. 79
Harkirat Singh Talwar, Ankur Mittal, Sunil Kumar, Vikas Kumar Panwar, Tushar Aditya Narain, Rohit Ranjan, Satish Kumar Ranjan
Congenital malformations of the seminal vesicles (SVs) are rare and are often associated with abnormalities of the ipsilateral upper tracts as embryologically both the ureteral buds and SVs arise from the mesonephric ducts. The triad of SV cysts, ipsilateral renal agenesis, and ejaculatory duct obstruction is known as the Zinner syndrome. We herein present the case of Zinner syndrome with hematuria as the mode of presentation. A 52-year-old gentleman presented with complaints of gross and painless hematuria for 3 months. An initial ultrasound revealed absent right kidney with a cystic structure abutting the urinary bladder. Cystoscopic examination revealed a high bladder neck. Magnetic resonance imaging of the abdomen revealed an absent right kidney and a large tubular structure in the region of the right ureter extending up to right SV with blood content and stones within. It was distally seen communicating with one of the cysts of the right SV. The cystic structure was removed with a robot-assisted laparoscopic approach. The console time was 110 min with minimal blood loss. Postoperative course was uneventful. Histopathology of the cyst wall revealed chronic inflammation. The patient is doing well on 6 months follow-up. This case was unique in terms of it presenting with a large intra-abdominal cyst with sharp stones within, probably first of its kind to be ever reported. Surgery is mandated for such symptomatic cysts and the daVinci robot with its minimally invasive approach offers the perfect platform for treating such challenging cases.
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Steroid cell tumor of the ovary presenting with ascites: A rare neoplasm in a postmenopausal woman p. 82
Pavani Velamala, Parikshaa Gupta, Pooja Sikka, Divyesh Kumar, Arvind Rajwanshi
Steroid cell tumors of the ovary are rare sex-cord stromal tumors, accounting for approximately 0.1% of all ovarian neoplasms. Majority of these tumors are benign, occur in pre-menopausal women and are associated with hyperandrogenism. However, around one-third of cases are malignant and do not present with hormonal manifestations. A 48-year-old post-menopausal woman presented with complaints of gradually increasing progressive abdominal distension over the past 3 months. She had a history of weight gain but denied any symptoms of virilization. On examination, abdominal distension associated with ascites was noted. Serum CA125 level was raised. Contrast-enhanced computed tomography revealed a solid right adnexal mass. Based on the clinical impression of epithelial ovarian malignancy, the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy. Histopathological examination revealed steroid cell tumor of the not otherwise specified type in the right ovary with the capsular breach. However, all other organs, including the omentum were free of tumor. The index case is unique for its presentation in a post-menopausal woman, association with ascites, elevated CA125 levels and lack of any virilization manifestations. Establishing an early and accurate tissue diagnosis is essential so that appropriate surgical management can be done to prevent the development of metastases in potentially malignant cases.
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