Journal of Mid-life Health Journal of Mid-life Health
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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 11 | Issue 3
Page Nos. 117-184

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EDITORIAL  

COVID-19 pandemic – Impact on elderly and is there a gender bias? Highly accessed article p. 117
Vishal R Tandon, Meeta Meeta
DOI:10.4103/jmh.JMH_175_20  
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ORIGINAL ARTICLES Top

Comparative efficacy and safety of clonazepam versus nortrptilline on menopausal symptom among forty plus women: a prospective, open-label randomized study p. 120
Roshi , Vishal R Tandon, Annil Mahajan, Sudhaa Sharma, Vijay Khajuria
DOI:10.4103/jmh.JMH_130_20  
Aims and Objectives: The aim of this study is to compare the effect of clonazepam and nortryptiline on menopausal symptoms in above 40 years women. Materials and Methods: A prospective, randomized, open-label comparative study was conducted in a tertiary care teaching hospital for 1 year. Patients were randomized into two groups. Both the groups had 60 patients, out of which Group A had 39 menopausal patients and Group B had 31 menopausal patients, respectively. Group 1 received tablet clonazepam 0.5 mg bed time orally daily. Group 2 received tablet nortryptiline 25 mg bed time orally daily. The primary efficacy end points were effect on menopausal symptoms evaluated by at 0, 4, and 8 weeks. Results: Mean age since menopause was 45 ± 4.06 years, and the mean number of years since menopause was 9.18 ± 7.59 years clonazepam and nortryptiline recorded statistically comparable effect with numerical superiority of nortryptiline both at 4 and 8 weeks on mean Menopausal Symptom Score, thereby indicating that both the drugs may have directly/indirectly improved the mean menopausal symptoms equally. Improvement in the clonazepam group was numerically and statistically more than nortryptiline group at 4 and 8 weeks on mean Vasomotor Symptom Score withP < 0.01 in clonazepam group andP < 0.05 in nortryptiline group both at 4 and 8 weeks. Both the drugs showed comparable results on psychosocial symptom score both at 4 and 8 weeks with numerical superiority in nortryptiline group. Clonazepam group showed more improvement on mean physical score than nortryptiline group numerically and statistically. Both the drugs showed comparable results on mean sexual symptom score at 4 weeks, but nortryptiline proved to be statistically better at 8 weeksP < 0.01 versusP < 0.05 in clonazepam group. Conclusion: Clonazepam and nortryptiline recorded statistically comparable effect at 4 and 8 weeks on mean menopausal symptom. Both the drugs were equally safe and did not recorded any serious Adverse Drug Reaction (ADRs).
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The relationship between anxiety and self-esteem in women suffering from breast cancer p. 126
Shahrzad Yektatalab, Elaheh Ghanbari
DOI:10.4103/jmh.JMH_140_18  
Background: Breast cancer is the most common cancer in women worldwide that has great impact on their lives. Women with breast cancer are at increased risk for anxiety and low self-esteem. Objective: The purpose of this study was to explore the relationship between anxiety and self-esteem in women suffering from breast cancer. Materials and Methods: In this descriptive correlational study, all 261 women diagnosed with nonmetastatic breast cancer referred to cancer care clinics in winter 2016 were assessed. Data were gathered using demographic information inventory, Spielberger's State–Trait Anxiety Inventory and Rosenberg's Self-Esteem Scale, and were analyzed using SPSS statistical software (version 22). Descriptive statistics, the t-test, ANOVA, the Pearson correlation and the Spearman's correlation were also used. Results: The mean ± standard deviation (SD) age of participants in the study was 48.33 ± 10.837 years. The mean score of state and trait anxiety was 46.29 ± 11.745 and 46.61 ± 10.936, respectively. The mean ± SD score of self-esteem was 18.38 ± 5.08. The study results show an indirect correlation between anxiety and self-esteem in women suffering from breast cancer (r = −0.690). Conclusions: According to the considerable influences of anxiety and self-esteem on other aspects of physical, psychological, and social health, it is suggested that health-care professionals pay more attention to the self-esteem and psychological state of women diagnosed with breast cancer besides other medical treatments. Screening strategies for detecting psychiatric disorders in breast cancer patients and planning of effective interventions to promote self-esteem and reduce anxiety and its consequences are recommended.
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Vaginal pH as a diagnostic tool for menopause: A preliminary analysis p. 133
Nitin Makwana, Maitri Shah, Megha Chaudhary
DOI:10.4103/jmh.JMH_1_20  
Introduction: Menopause is defined as the permanent cessation of menstruation, as a result of decrease in ovarian follicles and the loss of ovarian activity. There is decrease in inhibin B level which causes decrease in negative feedback on the serum follicle-stimulating hormone (FSH), which in turn increases the level of serum FSH. Serum FSH is routinely used as a marker of menopause. Decline in the estrogen level causes thinning of vaginal epithelium, resulting in less exfoliation of the vaginal epithelial cells, lesser available glycogen, and decreased substrate for acid production, leading to increase in vaginal pH. Aims: The aim of this study is to compare the sensitivity of vaginal pH versus serum FSH level to diagnose menopause. Settings and Design: This is a cross-sectional study, performed in obstetrics and gynecology outpatient department of a teaching hospital of central Gujarat. Subjects and Methods: A total of 120 women who had their last menstrual period >1 year back (menopause) were included in the study. Vaginal pH was measured and serum sample was taken to measure FSH level. Sensitivity of both vaginal pH and serum FSH to diagnose menopause was compared. McNemar test was used to analyze the convergence of the two methods for the diagnosis of menopause. Results: In the absence of vaginal infection, sensitivity of vaginal pH to diagnose menopause was 90%, while sensitivity of the serum FSH was 85%. Conclusions: Sensitivity of the vaginal pH is similar to the serum FSH for diagnosis of menopause.
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Association of menopausal symptoms with overweight and obesity among rural middle aged women in North India: A population based study p. 137
Komal Singhania, Meenakshi Kalhan, Priyanka Choudhary, Tarun Kumar
DOI:10.4103/jmh.JMH_123_19  
Background: Overweight and obesity are important determinant of increasing morbidity among all age groups, including menopausal women. The symptoms of menopause have a negative impact on the quality of life. Objectives: The aim of this study is to assess the prevalence of overweight and obesity in menopausal women and also to find its association with menopausal symptoms and sociodemographic variables. Materials and Methods: The study was conducted among middle-aged women (40–60 years) from April 2018 to March 2019. The Menopausal Rating Scale was used to assess the severity of menopausal symptoms in 400 women, and data were collected for sociodemographic factors, menstrual history in the past month, and personal history. Results: About 35.5% of menopausal women were overweight/obese (26% overweight and 9.5% obese) with average body mass index of 23.9 ± 4.84 and mean age of 53.65 ± 5.11 years Joint and muscular discomfort (P = 0.001), hypertension (P = 0.014), literacy level (P = 0.009), and socioeconomic status (P = 0.01) were significantly associated with overweight/obesity. With reference to women with no/little somatic and urogenital complaints, the odds of developing obesity was more (adjusted odds) in patients with mild (odds ratio [OR] - 2.8), moderate (OR - 2.1), and severe (2.19) somatic complaints and also higher risk in patients with mild (OR-3.2), moderate (OR - 1.1), and severe (OR - 1.74) urogenital symptoms. The age of menopause was significantly more among overweight than normal-weight women (P = 0.033). Conclusion: Overweight and obesity associated with menopause require increased attention and a multidisciplinary approach to women's health to prevent morbidity in this population group.
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Correlates of functional limitations in midlife: A cross-sectional study in middle-aged men (45–59 years) from Pune p. 144
Aarti Nagarkar, Rashmi Gadkari, Snehal Kulkarni
DOI:10.4103/jmh.JMH_79_19  
Background and Objective: The present article aims to determine the correlates of functional limitation in middle-aged men (45–59 years age) in the slums of Pune, India. Materials and Methods: A total of 553 community-dwelling middle-aged men were randomly selected from the study area. Data on demographic characteristics, health-related conditions, and social and psychological determinants of health were collected using a pretested, structured questionnaire. Functional ability was assessed using the Pune-Functional Ability Assessment Tool. Univariate analyses and bivariate logistic regression analyses were carried out to examine the associations between various correlates and functional limitations. Results: A total of 55.2% of the respondents displayed functional limitations. Univariate analysis identified significant correlates of functional limitations, which were increasing age, nature of the occupation, presence of chronic diseases, self-reported aches and pains, vision problems, previous hospital admission, and stress. Binary logistic regression displayed the higher odds of having functional decline in men with age above 55 years (odds ratio [OR] = 2.592; 95% confidence interval [CI] = 1.597–4.207), unskilled occupation (OR = 1.681; 95% CI = 1.050–2.692), chronic disease (OR = 2.608; 95% CI = 1.553–4.378), and reporting aches and pains (OR = 6.605; 95% CI = 3.732–11.689) as compared to their counterparts. Conclusion: This study has identified the magnitude of functional decline and its risk factors for midlife men. These study findings suggest that men having several risk factors should be monitored to protect against accelerated functional loss. These findings are important because functional decline has implications on older adult's health and disease conditions. A better understanding of these factors will help to develop health promotion interventions for men in midlife.
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Impaired quality of life and its determinants among postmenopausal women of slum communities in Bhubaneswar, India p. 149
Amrita Kumari, Ansuman Panigrahi, Adrija Roy, Jyochnamayi Panda
DOI:10.4103/jmh.JMH_111_19  
Background: The severity of menopausal symptoms negatively impacts a woman's quality of life (QoL). Objective: The aim of the study was to assess the prevalence of menopause-related impaired QoL and determine its associated factors among postmenopausal women living in slum areas of Bhubaneswar, India. Materials and Methods: This cross-sectional study was conducted among 198 postmenopausal women aged 45–65 years during the year 2016–2017. The Menopause Rating Scale (MRS) was used to assess the prevalence and severity of menopausal symptoms. Results: Joint and muscular discomfort was the most prevalent moderate-to-severe symptom (90.4%), followed by hot flushes (72.8%), irritability (67.2%), and physical and mental exhaustion (64.2%). More than two-third (133, 67.2%) of women had impaired QoL (severe total MRS score ≥17). Multivariate logistic regression analysis revealed that impaired QoL was associated younger age (adjusted odds ratio [AOR]: 4.6, 95% confidence interval [CI]: 2.12–9.98), tobacco consumption (AOR: 2.0, 95% CI: 1.05–3.82), not being satisfied in relation with husband (AOR: 3.33, 95% CI: 1.84–6.06), not having autonomy in health-care decision-making in the family (AOR: 2.30, 95% CI: 1.12–4.73), history of reproductive tract infection (AOR: 4.57, 95% CI: 1.71–12.19), and earlier onset of menopause (AOR: 3.26, 95% CI: 1.18–8.96). Conclusion: The point prevalence of menopause-related impaired QOL in postmenopausal women living in slums of Bhubaneswar was high. Incorporating these determinants in the existing strategies can be useful to improve the QoL of these women.
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Management of genitourinary fistulas following benign gynecological and obstetric procedures: A single surgeon experience p. 156
Rahul Gupta, Arti Mahajan, Manik Mahajan, Ajay Anand, Suhail Masood
DOI:10.4103/jmh.JMH_70_20  
Background: Genitourinary fistula results in lot of anxiety in the suffering females. Scant literature regarding the comprehensive management of genitourinary fistula i.e. VVF and UVF is available. Objective: The aim of the study was to review a single surgeon experience in dealing with these complex situations. Material and Methods: We conducted a retrospective, institutional review board approved chart review of patients who underwent genitourinary fistula repair from Jan 2014 till Dec 2019. Of all the fistulas VVF accounted for 18 and UVF for 12 cases. Pre-operative diagnosis in these patients was based predominantly on the history, local examination and cystoscopy. Of the 18 VVF 12 were managed laparoscopically and 6 by open O'Connor's repair. Of the 12 UVF, 8 were managed laparoscopically and 4 by open ureteric reimplants. All were followed up for three months post operatively. Results: A total of 30 patients were treated since 2014 till December 2019. Average age for the VVF was 54.72 ≤ 10.9 years and that for UVF repair was 59.9 ≤ 7.6 years. Hysterectomies for benign diseases accounted for 66.66% of VVF and 91.6% of UVF. Of the VVF patients one required a ureteric reimplantation, remaining were managed with O'Connors' repair. We had one failure which was successfully repaired after 6 weeks. None of our patients with UVF repairs had a failure at three months follow-up. Conclusion: Genitourinary fistulas are a debilitating problem in females but a comprehensive approach regarding diagnosis and treatment can cure these patients.
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A Cross-Sectional Study to Assess the Quality of Life of Perimenopausal and Post menopausal Women in Rural Etawah, Uttar Pradesh, India p. 161
Debora J Mathew, Sandip Kumar, Pankaj Kumar Jain, Sushil Kumar Shukla, Nawazish Ali, Deepali Raj Singh
DOI:10.4103/jmh.JMH_88_19  
Background: Perimenopause is the period in a woman's life during which she passes from the reproductive to the nonreproductive stage. According to the 2008 estimates, the number of menopausal women in India was 43 million. Projected values in 2026 depict the menopausal population at 103 million. Due to the increasing life expectancy, improved quality of life is imperative to decrease the disability and frailty of a society. Objectives: To study the quality of life of perimenopausal women in rural areas of Etawah district, Uttar Pradesh, and the various factors associated with it. Materials and Methods: This is a community-based cross-sectional study conducted in 4 villages in the Saifai block of Etawah district, Uttar Pradesh, India. One hundred and ninety-nine healthy, perimenopausal women of the age group 45–55 years were included in the study. Data were collected on sociodemographic variables, and Menopause Specific Quality of Life Questionnaire - Intervention version questionnaire was used to assess the quality of life. Results: The mean age of attainment of menopause was 45.38 ± 3.58 years. Majority of the women experienced physical (100%) and psychosocial (94.5%) symptoms; the most common symptom being “decrease in physical strength” (86.4%) and being able to “accomplish less than previously” (80.4%). Women who handled stress poorly showed severe vasomotor (P = 0.047) and psychosocial (P = 0.014) symptoms. Postmenopausal women who regularly exercised were 52.6% less likely to have vasomotor symptoms (odd's ratio OR 0.474 (0.235–0.960), P = 0.038). Conclusion: The quality of life among the study population was affected by the physical and psychosocial problems they experienced. By taking appropriate preventive measures, these can be ameliorated, and further deterioration can be checked.
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Sociodemographic pattern of postmenopausal women and health issues: A study in rural Bathinda, Punjab p. 168
Ratika Samtani, Deepali Garg, Noopur Sharma, Roumi Deb
DOI:10.4103/jmh.JMH_139_19  
Background: The diminishing hormonal concentrations in women after menopause may trap them into a number of reproductive health deficits. Their lifestyle, occupation, dietary constituents, etc., affect the overall health. Unfortunately, women belonging to rural areas lack basic amenities and cultural aspects give them a backseat to pay heed to personal health. Therefore, it is important to take into consideration the demographic profile of rural women. Objective: The objective of the study is to evaluate postmenopausal women of rural Punjab for sociodemographic, reproductive parameters and health issues. Results: This study analyzed 425 women showing a high rate of illiteracy (74.6%), agricultural occupancy (85.2%), and consumption of vegetarian food (94.4%). The mean age at menarche and menopause was observed as 14.04 ± 1.12 and 47.97 ± 3.4 years, respectively. The most frequent complaints were fatigue (70.4%), backache (69.4), breathing problems (52.2%), and abdominal discomfort (43.1%). Conclusion: Later age at menopause in women was found concurrent with involvement in agriculture and exposure to pesticides. Delayed menopause may indicate a risk of reproductive cancers while protection in cardiovascular diseases. Therefore, age at menopause and dependent sociodemographic parameters should be considered important tools in determining the reproductive health of aging women. Large-scale studies dealing with this health aspect are warranted at village level.
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CASE REPORTS Top

Secretory endometrial adenocarcinoma: A rare sequelae in a postmenopausal woman following tamoxifen therapy for breast cancer p. 171
Sonam Sharma
DOI:10.4103/jmh.JMH_104_19  
The double-edged sword effect of tamoxifen therapy on the female reproductive system including the breast is quite well established. However, it is still poorly understood at the molecular level which significantly affects the management of such patients receiving it in terms of therapeutics and prognosis. An experience of an extremely rare case of secretory endometrial adenocarcinoma developing due to the adverse effect of tamoxifen used for the treatment of breast cancer in a 60-year-old woman is being described herewith so as to create awareness among the dealing clinicians about the occurrence of rare histological types of endometrial cancer after long-term tamoxifen therapy. The approach to such a case, pathogenesis, differential diagnosis, and a brief literature review is also presented.
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Symptomatic primary ovarian leiomyoma in a postmenopausal woman: A rare entity p. 175
Mukta Meel, Deepika Hemrajani, Mukesh Kumar, Bhawna Agnani
DOI:10.4103/jmh.JMH_105_19  
Leiomyomas are benign mesenchymal neoplasms mostly seen in the uterus and are one of the most common pelvic masses seen in women, but primary ovarian leiomyomas are rare among all the benign ovarian tumors, which account only for 0.5%–1%. The definitive diagnosis of such lesions is difficult prior to surgical excision, as there are no pathognomonic symptoms or characteristic imaging findings. Here, we report a case of primary ovarian leiomyoma with brief review of literature, highlighting the differential diagnosis of ovarian spindle cell lesions. The correct diagnosis of an ovarian leiomyoma requires identification of the nature of tumor as smooth muscle. An immunohistochemistry marker analysis is recommended for definitive diagnosis.
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Cystic uterine endosalpingiosis in a patient with carcinoma endometrium p. 178
Murali Subbaiah, Pampa Ch Toi, Gowri Dorairajan, S Norton Stephen
DOI:10.4103/jmh.JMH_162_19  
Endosalpingiosis is a benign condition characterized by the presence of tubal-type epithelial cells outside the Fallopian tube. It may rarely involve the uterus and present as a cystic or tumor-like mass. We report an unusual case of cystic uterine endosalpingiosis in a postmenopausal female with carcinoma endometrium. Preoperative and intraoperative diagnosis of this condition is challenging. Awareness about this condition in clinicians may help in preventing misdiagnosis and overtreatment.
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Lantern on dome of st. paul's cathedral – An apt metaphor for a challenging leiomyoma p. 181
Neema Acharya, Sonakshi Singhal, Mohit Agrawal, Nidhi Singh, Neha Verma
DOI:10.4103/jmh.JMH_143_19  
Fibroids are ubiquitous in women of the reproductive age group more so in midlife. The cervical fibroids are challenging to operating surgeons because it distorts the surgical anatomy of the pelvis and urogenital system. The metaphor given historically to this condition is apt as the uterus appears like a lantern sitting on the dome of cervical fibroid similar to the dome of the cathedral. Here, we report two cases of cervical fibroid in perimenopausal age group of different sizes managed by following specific steps.
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