Journal of Mid-life Health Journal of Mid-life Health
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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 12 | Issue 2
Page Nos. 85-184

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EDITORIAL  

Real World Evidence Need for Physician-Scientist/Clinician-Researcher Highly accessed article p. 85
Meeta Meeta, Vishal Tandon
DOI:10.4103/jmh.jmh_105_21  
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VIEW POINT Top

Research methodology course for postgraduate students by national medical commission: A welcome step that needs complimentary action p. 87
Ajay Gajanan Phatak
DOI:10.4103/jmh.jmh_103_21  
After decades of administrative hibernation, the Medical Council of India (MCI), now National Medical Commission (NMC), started deliberating on reforms in medical education a few years back. The MCI/NMC introduced vertical corrective actions, yet there is a need for horizontal integration, and these measures require adequate guidance on implementation strategies. All postgraduate medical students must conduct a research project as a “Thesis.” This crucial opportunity to instill scientific thinking is excellent, along with patient care and clinical training. This opportunity has a long-term impact on clinical practice and research and development in medicine if implemented well. To enforce this step, the Board of Governor introduced a compulsory course in basic research methods for all postgraduate medical students, but alas, without adequate deliberations on implementation and complementary mechanisms. This critical review provides a brief history of the evolution of medicine and medical education in India and reforms in medical education. Further, it presents a balanced critique of the process, intending to brainstorm in improving the process and achieving the expected outcome from this course. Albeit many relevant issues need attention, this article will focus mainly on ways to leverage infrastructure optimally to imbibe scientific thinking in medical students of India with cursory deliberation of the relevant issues.
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PERSPECTIVE Top

Enhanced recovery after surgery: Perspective in elder women p. 93
Sandhya Gupta, Ajay Rane
DOI:10.4103/jmh.jmh_89_21  
Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.
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REVIEW ARTICLE Top

Genitourinary syndrome of menopause assessment tools p. 99
Eduard Mension, Inmaculada Alonso, Marta Tortajada, Isabel Matas, Sílvia Gómez, Laura Ribera, Cristina Ros, Sònia Anglès-Acedo, Camil Castelo-Branco
DOI:10.4103/jmh.jmh_93_21  
New therapeutic options are being considered to treat genitourinary syndrome of menopause (GSM), such as vaginal laser, ospemifene, or prasterone, but there is no explicit agreement in the scientific community for its use. Some concerns have arisen on how to evaluate the improvement of GSM symptoms. In 2003, the FDA suggested possible end points for this purpose: change in severity of symptoms, change in vaginal pH, and change in vaginal maturation index (VMI). Contrarily, the most common assessment tools used to quantify severity and improvement of GSM nowadays are the visual analog scale of GSM symptoms, the vaginal health index, and the female sexual function index. In our opinion, subjective and objective variables to evaluate GSM can be differentiated, and not many of the considered objective outcomes are used in the recent literature assessing GSM. There is the possibility that some therapies present only subjective improvement, giving place to a possible placebo effect that is not being evaluated. To conclude, there is a demand to evaluate whether vaginal pH and VMI are enough to assess objectively GSM changes or new objective approaches should be audited.
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MINI REVIEW Top

Gender disparities in people living with obesity - An unchartered territory p. 103
Nitin Kapoor, Saurabh Arora, Sanjay Kalra
DOI:10.4103/jmh.jmh_48_21  
Gender is an important risk factor for the development of obesity. Female gender is associated with twice the risk of being overweight or having obesity. Women are also at higher risk for developing obesity-related physical and psychological comorbidities and have a twofold higher mortality risk than overweight men. Several risk factors have been described to explain the gender bias associated with an obese phenotype and these disparities have far-reaching implications on the medical, psychosocial, and the economical impact of an individual. Despite extensive awareness about gender differences related to obesity, this is still considered as an unchartered territory in obesity medicine. This is probably because of the complex multiple dimensions involved with the understanding of subject coupled with the lack of composite outcomes measures that could assist in the study of these factors. In this scoping review, we share the existing literature regarding the magnitude of gender disparities and gender discrimination in people living with obesity. We describe key factors leading to this gender bias and the impact of this discrimination on the psychological, social, and metabolic health of a given individual with obesity. We also discuss the possible implications of gender disparities on treatment of obesity which may help reduce the current mortality gap between overweight women and men.
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ORIGINAL ARTICLES Top

Evaluation of the efficacy and safety of rheum rhaponticum root extract (err 731) for menopausal symptoms in perimenopausal indian women: An interim analysis p. 108
Jignesh Shah, Sonia Chandanani, Jayanthi Reddy, Hepzibah Kirubamani, Arun Madhab Boruah, Anju Jain, Sheela Mane, Parag Biniwale, Poonam Mathur, Anuradha Ridhorkar, Suma Natarajan, Brajbala Tiwari
DOI:10.4103/jmh.jmh_86_21  
Background: Hormonal therapy for menopause has been found to be the most efficacious treatment, but it may be associated with adverse effects in some of the women. Rheum rhaponticum root extract (”ERr 731”), which is available worldwide, is a natural, reliable, effective, and well-tolerated remedy for women in perimenopausal women with menopausal symptoms (MSs), but there is no Indian study demonstrating its efficacy, safety, and tolerability till date. Objective: This study aimed to evaluate the efficacy and safety of ERr 731 in alleviating MSs in perimenopausal Indian women. Patients and Methods: In this open-labeled prospective study, 129 perimenopausal women were treated with tablet containing 4 mg of Rr dried root extract once daily for 12 weeks. The Menopause Rating Scale (MRS) II score, endometrial thickness (ET), blood pressure, glycemic status, lipid profile, and high-sensitivity C-reactive protein (hs-CRP) level were periodically assessed and compared. Results: A significant reduction (67% by 12th week) in the mean MRS II score was observed from baseline till the end of 12 weeks (18.1; 95% confidence interval [CI]: 17.0–19.2; P < 0.001). A monotonic reduction in the mean total MRS II score over time was found (1.51 units/week; 95% CI: 1.42–1.60 units/week; P < 0.001) noticeable. There was a reduction in the mean ET from baseline till the end of 12 weeks, although the change was not significant. There were significant reductions in the mean fasting (6.3 mg/dl; 95% CI: 1.7–11.0 mg/dl; P = 0.008) and postprandial (6.3 mg/dl; 95% CI: 1.0–11.7; P = 0.021) blood glucose levels and glycated hemoglobin level (0.30%; 95% CI: 0.085–0.520; P = 0.007) at 12 weeks. No significant changes were noted in terms of blood pressure, lipid profile, and hs-CRP level. The drug was found to be safe. Conclusion: ERr 731 was well tolerated and was found to be efficacious and safe in alleviating MSs in Indian perimenopausal women.
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The Effect of mindfulness on quality of life among women with premature ovarian insufficiency: A randomized clinical trial p. 116
Fatemeh Pyri, Parvin Abedi, Elham Maraghi, Maryam Gholamzadeh Jefreh
DOI:10.4103/jmh.JMH_66_20  
Background: Premature ovarian insufficiency may impair the quality of life and expose women to disorders such as cardiovascular disease, osteoporosis, and depression. This study aimed to evaluate the effect of mindfulness on the quality of life in women with premature ovarian insufficiency. Methods: This study involved 62 women who were randomly allocated into two groups of mindfulness and control. The mindfulness group received eight sessions of training. A demographic questionnaire, menopause-specific quality of life and a checklist (for assessing hot flashes) were used to collect the data. The quality of life, frequency, and intensity of hot flashes were measured before the intervention, immediately, and 3 months after it. Independent t-test, the Chi-square test, and the repeated measure test were used for data analysis. Results: The scores of quality of life dropped from 95.6 ± 9.77 at baseline to 77.32 ± 7.93 after intervention and 48.32 ± 4.96 at 3-months follow-up in the mindfulness group but rose from 99.5 ± 16.1 at baseline to 100.2 ± 15.33 after intervention, and 102.6 ± 14.9 3-months after it in the control group, P < 0.001. The scores of vasomotor, psychological, physical, and sexual domains also improved significantly in the mindfulness group compared to the control group. The mean of hot flashes in the mindfulness group was 1.30 ± 0.69 and decreased to 1.1 ± 0.56 and 0.66 ± 0.58 immediately and in 3 months after intervention, respectively. The frequency of hot flashes was 14.74 ± 10.4 per week before intervention in the mindfulness group which reduced to 12.38 ± 8.66 and 6.74 ± 6.34 per week, immediately and 3 months after the intervention, while in the control group, there was an increase in the frequency of hot flashes (P < 0.0001). Conclusion: According to the results of this study, mindfulness could improve quality of life and reduce hot flashes, so mindfulness training for women with premature ovarian insufficiency is strongly recommended.
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Role of preoperative and postoperative pelvic floor distress inventory-20 in evaluation of posthysterectomy vault prolapse p. 122
Jai Bhagwan Sharma, Mukesh Kumar, KK Roy, Rajesh Kumari, Kavita Pandey
DOI:10.4103/jmh.JMH_102_20  
Background: Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse. Materials and Methods: Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy. Results: Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m2 respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88–152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80–126 with mean being 106.40 ± 16.45 after surgery (P < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different (P = 0.18). Conclusion: PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.
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Pelvic floor disorders among gynecological cancer survivors in sub-urban regions of Kanchipuram District–India p. 128
M Anbupriya Sureshbabu, PS Abirami
DOI:10.4103/jmh.JMH_186_20  
Background: Pelvic floor muscle is the group of muscles: layering down the pelvic region; Controlling the bowel movements, urination, and sexual intercourse; working in a balanced and coordinated contraction and relaxation. The inability to control the pelvic floor muscles leads to pelvic floor disorders like urinary incontinence, faecal incontinence, dyspareunia, and pelvic pain. Objective: The aim of this study is to find the prevalence of pelvic floor disorders among gynaecological cancer survivors in sub-urban regions of Kanchipuram district, India. Materials and Methods: This study employs a nonexperimental study design. The procedure is well explained and informed consent is obtained from the gynaecological cancer survivors based on the inclusion and exclusion criteria. Gynecological cancer survivors who are not under any treatments for the last 1 year has been considered for this study. There were two sets of questionnaires in which one depicts vulvar pain function (Vulvar Pain Functional Questionnaire) and the other relates to pelvic floor symptom botheration (Pelvic Floor Bother Questionnaire). The individual has given enough time to fill the questionnaire. Patients seem necessary are further referred to the outpatient physiotherapy department. Results: A moderate amount of Pelvic pain was reported to be felt by at least 64.6% of survivors. Added to it, a moderate level of bothersome was found to be reported by at least 56.2 % of survivors. Conclusion: Findings conclude that there is a higher prevalence of pelvic floor dysfunction among gynecological cancer survivors.
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A Cross-sectional Case–control Study of Depression in Incontinent Women p. 132
Tanudeep Kaur, Rajesh Kumari, JB Sharma, Kavita Pandey, Bharti Uppal, Koushik Sinha Deb1
DOI:10.4103/jmh.JMH_98_20  
Background: Urinary incontinence (UI) presents in over 50% menopausal women affecting their quality of life leading to depression and hence needs addressal and treatment as very few of them seek medical help. Aims: Our aim was to determine the prevalence of depression, and the correlation of severity of UI with depression in incontinent women versus continent controls. Methodology: A cross-sectional case–control study of previously diagnosed 100 incontinent women (Stress/Urgency/Mixed) was done over a period of 3 months. The severity of UI was assessed on Patient Incontinence Severity Assessment (a form of Likert scale) and depression was assessed on a validated Patient Health Questionnaire-9 scale. Statistical Analysis: The statistical analysis was performed using SPSS version 19.0. Results: Most of our cases were 51–60 years, with Urge UI being the most predominant (88%). Hundred percent of our incontinent patients were depressed, with 48% and 45% being severely and moderately severely depressed, respectively. A highly significant correlation was found between the severity of incontinence, amount of leakage, leaking pattern, and depression. Conclusion: All of our incontinent patients were depressed, with the severity of depression increasing with the severity of incontinence.
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A study on prevalence and factors associated with depression among elderly residing in tenements under resettlement scheme, Kancheepuram District, Tamil Nadu p. 137
Buvnesh M Kumar, TK Raja, Fasna Liaquathali, Jasmine Maruthupandian, Pragadeesh V Raja
DOI:10.4103/jmh.JMH_45_20  
Background: Mental disorders have got high prevalence and low priority among the elderly in most of the countries worldwide, of which depression being the most common treatable condition. The causes for elderly depression are multifactorial and preventable. Objective: The aim of this study is to estimate the prevalence of depression and to assess the factors associated with depression among the elderly age. Materials and Methods: A cross-sectional study was conducted among participants more than 60 years of age residing in tenements under resettlement scheme in Semmenchery, Kancheepuram district, Tamil Nadu with a sample size of 184. Systematic sampling method was adopted to collect data at participants door step. A predesigned, pretested questionnaire was used to assess the factors associated with depression, and the Geriatric depression scale-30 was used to assess depression. The data were analyzed using SPSS and Chi-square <0.05 was considered significant. Results: The overall prevalence of depression was 35.3%. The factors such as female gender, educational status, occupation, type of family, financial dependency, history of depression, smoking and medical factors such as hypertension, cardiac disease, and chronic kidney disease and life events like conflict in family, unemployment, and financial problem were statistically significant (P < 0.05). Conclusion: Loss of spouse, financial dependency, neglected care, lack of awareness about the disease were found to be barriers in reaching basic mental health care for the elderly. Depression remains one of the main causes of DALY, especially among elders. National Program for Health care of elderly provides doorstep services, so incorporation of depression screening into that can impart the effects of depression on quality of life and DALY.
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Effects of Menopause on Sexual Function in Indian Women: A McCoy's Questionnaire-Based Assessment p. 144
Meeta Meeta, Sharmila Majumdar, Tanvir Tanvir, Seema Sharma, Jyoti Shah, Neelam Aggarwal, Roya Olayi, Maninder Ahuja, SA Joshi
DOI:10.4103/jmh.jmh_95_21  
Background: Menopause is associated with physical, physiological, psychological changes and may lead to sexual dysfunction (SD) effecting woman's health and well-being. Scientific research in the area of female sexuality in India is scant. Therefore, this study aimed to investigate female sexual function at perimenopause and menopause and determine the association between sociodemographic and physiological factors with sexual function. Materials and Methods: This was a cross-sectional hospital-based study carried out in perimenopausal and menopausal women. Study participant's details were collected by gynecologists and clinical research professionals following the participant's informed consent. The case report and McCoy female sexuality questionnaire were used. The association between sociodemographic status and sexual function was determined. Data were summarized using descriptive statistics for portraying profile of the participants and t-test for comparison. Results: A total of 129 women in the menopausal (SD − 3.26) and 112 in the premenopausal group (SD − 6.01) were enrolled. The sociodemographic parameters did not significantly affect the sexual function scores in both groups. In terms of vaginal atrophy, a significant increase in urgency was noted in the postmenopause group. The general domain of sexual function was significantly lower in menopausal than and perimenopausal with a P < 0.001. Looking at individual domains of sexual function, for sexual interest, satisfaction, vaginal lubrication, and orgasm, the mean value of perimenopausal participants was significantly higher when compared to menopausal women; for a primary partner domain, no significant differences between the two groups were noted. Conclusion: Overall, the sociodemographic profile did not impact sexual function in this study. Compared with menopausal women, perimenopausal women showed better, more complete sexual function based on McCoy's score except partner-related domain that is constant from perimenopause to menopause in a monogamous relationship.
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Sex hormone-binding globulins and testosterone levels as a risk marker for type 2 diabetes mellitus among postmenopausal women p. 155
Uma K Saikia, PK Jabbar, Darvin V Das
DOI:10.4103/jmh.JMH_142_20  
Background: Endogenous sex hormones and sex hormone-binding globulins (SHBG) determine the risk of occurrence of Type 2 diabetes mellitus (T2DM) in postmenopausal (PM) women. Aims: To investigate the association between sex hormones (estradiol and testosterone) and SHBG with plasma glucose, fasting insulin levels, HbA1c, and homeostasis model assessment insulin resistance (HOMA-IR) and also to investigate independent role of sex hormones in the occurrence of T2DM among PM. Settings and Design: Cross-sectional case–control study. Subjects and Methods: The present study was conducted in Endocrinology department Guwahati, Medical College, Assam, India. The participants included cases – PM women with T2DM (n = 100) and controls – Healthy PM women (n = 86). The medical history, clinical examination, and investigations including total testosterone, serum estradiol, SHBG, free testosterone index, high sensitivity C-reactive protein (hs-CRP), lipid profile, fasting insulin, fasting plasma glucose (FPG), and postprandial plasma glucose (PPPG) were done and analyzed. HOMA-IR was calculated. Statistical Analysis: Pearson correlation between sex hormone level and SHBG with plasma glucose, HbA1c, fasting insulin, hs-CRP, and HOMA-IR was seen. Multivariance logistic analysis was done to find the independent association between sex hormones/SHBG and the occurrence of T2 DM. P < 0.05 was considered statistically significant. Results: Among the cases, a significant positive correlation was found between total testosterone/free testosterone index with waist circumference, FPG PPPG, HbA1c, fasting insulin, and HOMA-IR, and a significant negative correlation was found between SHBG and FPG, PPPG, HbA1c, fasting insulin, and HOMA-IR (P < 0.01). The logistic analysis showed total testosterone levels and SHBG are independently associated with the occurrence of T2 DM among PM (P < 0.01). Conclusion: SHBG and testosterone levels in PM can be a risk marker for the development of T2DM.
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Menopause-related quality of life among urban women of Hyderabad, India p. 161
Aruna Kumari Yerra, Sudha Bala, Ranjith Kumar Yalamanchili, Rajiv Kumar Bandaru, Archana Mavoori
DOI:10.4103/jmh.jmh_272_20  
Background: Menopause is regarded as the marker for various symptoms such as physical, psychological, vasomotor, and sexual impairing the quality of life (QOL). Objectives: To assess the menopause-related QOL and determine associated factors among postmenopausal women. Materials and Methods: A cross-sectional study was conducted among 378 postmenopausal women attending the obstetrics and gynecology department of a tertiary care hospital using a standardized menopause-specific QOL (MENQOL) questionnaire consisting of physical, vasomotor, psychosocial, and sexual domains. Results: The study included 378 women aged above 40 years, with majority belonging to the age group of 46–50 years. The total MENQOL mean score was found to be 19.35 ± 16.20, with physical domain score the highest 14.89 ± 11.85, followed by vasomotor 1.98 ± 3.83, psychosocial 1.82 ± 3.29, and the least as sexual domain with score of 0.624 ± 2.21. Post menopausal women with age less than 50 years, No formal education, High socio-economic status, Home makers and duration of menopause less than 5 years was found to have statistical significant association with higher vasomotor domain score; No formal education, higher socio economic status and duration of menopause with greater than 5 years was found to be significant with higher sexual domain scores. Conclusions: Menopause may be associated with a decrease in QOL. Certain sociodemographic variables showed a statistically significant association with the vasomotor and sexual domains. Awareness and interventions that affect the modifiable factors may help in increasing the QOL at menopause.
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PICTORIAL ESSAY Top

Understanding the endometrium at menopause: magnetic resonance imaging: A radiologist's view p. 168
Madhavi Nori
DOI:10.4103/jmh.jmh_94_21  
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CASE REPORTS Top

Hematuria – look beyond the urinary tract – a rare case Report p. 176
Rohit Bansal, Priya Bansal
DOI:10.4103/jmh.JMH_164_20  
The major causes of hematuria in a middle-aged female include infections, renal calculi, or structural abnormalities of the urinary tract. Most patients are investigated and treated on an outpatient basis. While a possibility of malignancy of the bladder or kidneys may also be considered, hematological malignancy is an uncommon cause of hematuria. Detailed evaluation is important to rule out malignancy in new-onset hematuria. We report a case of a 49-year-old female who presented with gross hematuria, later diagnosed to have multiple myeloma (MM), despite the absence of its classical symptoms. This unusual presentation reaffirms its status as “The Great Masquerader.” The case is worth highlighting because gross hematuria as the first presentation of MM is uncommon. The author wishes to stress that the clinician should also suspect blood dyscrasias with associated coagulation abnormalities in the workup of gross hematuria.
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Angioleiomyoma of uterus and cervix: A rare report of two cases p. 179
Ankit Seth, Anjali Mathur
DOI:10.4103/jmh.JMH_102_19  
We report two rare cases of genital angioleiomyomas (ALs), one each of uterus and cervix. The uterine AL showed a very rare presentation of endometrial polyp, while the cervical AL presented as an intramural cervical growth. We have also reviewed the literature and enlisted all uterine and cervical ALs reported till now.
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