Journal of Mid-life Health Journal of Mid-life Health
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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 12 | Issue 3
Page Nos. 185-250

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EDITORIAL  

Implementing risk assessment tools for personalized management at menopause p. 185
Meeta Meeta, Vishal R Tandon
DOI:10.4103/jmh.jmh_167_21  
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NARRATIVE REVIEW Top

Weight, shape, and body composition changes at menopause p. 187
Anna Fenton
DOI:10.4103/jmh.jmh_123_21  
Obesity and overweight are associated with increased risks of cardiovascular and metabolic disease and overall poor health outcomes. Menopause is associated with significant changes in body composition and the accumulation of peri-abdominal or visceral fat. Changes in energy expenditure and spontaneous activity have been noted. These mid-life changes can add further to the burden of obesity and its associated risks. An understanding of the role of estrogen, gonadotrophins, gut hormones, sleep deprivation and the microbiome is still rudimentary, but research will ultimately provide further targets for more effective management. This narrative review will explore the pathogenesis of body composition changes at menopause, the impact on health outcomes and therapeutic and management options.
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ORIGINAL ARTICLES Top

Assessment of endothelial dysfunction by brachial artery flow-mediated dilatation in postmenopausal women at low risk for cardiovascular disease p. 193
Piyushi Sharad, Neha Agarwal, Seema Chopra, Vanita Jain, Pooja Sikka, Ajay Bahl, Nayana Gaba
DOI:10.4103/jmh.jmh_111_21  
Objective: The objective is to compare endothelial dysfunction measured by brachial artery flow-mediated dilation (BAFMD) in nonobese, nondiabetic post-menopausal women with their age-matched menstruating controls and to identify the correlation of BAFMD with Framingham risk score (FRS) and with the individual parameters of FRS in low-risk women. Methods: This study was done in the department of Obstetrics and Gynaecology, Chandigarh, India, for 1 year. Fifty postmenopausal and 50 menstruating females aged 45–55 years who were nondiabetic and nonobese and were low risk according to FRS were selected as cases and controls, respectively. All cases and controls were age-matched. The diameter of the brachial artery and the blood flow in it was measured at rest. Ischemia was produced and released after 5 min. The maximum blood flow velocity diameter of the brachial artery was measured. After 10 min of reactive hyperemia, 400 μg of sublingual nitrate was given, and vasodilatation mediated by nitroglycerine was subsequently measured. Results: Menopause did not have any significant effect on the endothelial dysfunction as measured by the brachial artery flow-mediated dilatation (P = 0.74) but did influence vascular smooth muscle as measured by nitroglycerine-mediated dilatation (P = 0.028). A significant correlation was found between flow-mediated dilatation with FRS helps us conclude that flow-mediated dilation is a reliable tool to estimate the cardiovascular risk (P < 0.001). A strong correlation was found between nitroglycerine-mediated dilatation and flow-mediated dilatation, demonstrating that both endothelial dysfunction and vascular smooth muscle are interrelated (P < 0.001). Conclusion: Menopause did not affect endothelial function, but it has a significant effect on vascular smooth muscle function. To know the effect of longer duration of menopause on vascular function in elderly women further studies with large number of postmenopausal women of different duration of menopause, may be needed.
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Experience and perceptions regarding menopause among rural women: A cross-sectional hospital-based study in South Karnataka p. 199
Deepika Nagaraj, Naveen Ramesh, Divya Devraj, Marciya Umman, Anila K John, Avita Rose Johnson
DOI:10.4103/jmh.JMH_196_20  
Background: There is a culture of silence around menopause in India, more so among rural women. This study was conducted to assess the prevalence of menopausal symptoms, factors associated with the severity of menopausal symptoms, and perceptions regarding menopause among rural perimenopausal women. Methodology: A cross-sectional study was conducted at a rural hospital, among women aged 40 years or more, having experienced at least one menstrual cycle in the past 1 year. Structured interview schedule was administered to capture perceptions of menopause. Symptoms of menopause and severity were assessed using the Menopause Rating Scale (MRS) and participants screened for depression using patient health questionnaire-9. Results: Among 200 women, the prevalence of symptoms of menopause was 70%. Commonly reported symptoms were somatic symptoms: Joint/muscular pain, hot flushes, and psychological symptoms: Physical/mental exhaustion, anxiety. Median overall MRS score was low (4 [interquartile range = 1, 7]), pointing out to lesser severity. Significant association was found between MRS score and higher body mass index (P = 0.007), tobacco-chewing (P = 0.023), and depression (P < 0.001). Perception of menopause was generally positive, but we also documented some myths and misconceptions regarding menopause that indicate a need for health awareness in this population. Conclusion: This study found high prevalence but low severity of menopausal symptoms. Our findings point to a need for mitigating symptoms of menopause through diet, physical activity, tobacco cessation, and counseling for depression. Targeted interventions using community women's groups and village-level health workers are recommended to provide not only awareness regarding menopause but also an opportunity to screen for comorbidities with appropriate referrals.
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Diagnostic accuracy of hysteroscopic scoring system in predicting endometrial malignancy and atypical endometrial hyperplasia p. 206
Bhukya Harika, Murali Subbaiah, Dilip Kumar Maurya
DOI:10.4103/jmh.jmh_246_20  
Aims and Objectives: The aim of this study was to determine the diagnostic accuracy of a hysteroscopic scoring system in predicting endometrial cancer and endometrial hyperplasia with atypia. Materials and Methods: This is a prospective study involving 95 peri and postmenopausal women with abnormal uterine bleeding who underwent hysteroscopic-guided endometrial biopsy. After the calculation of hysteroscopic score, biopsy was obtained and sent for histopathological examination. Hysteroscopic diagnosis of carcinoma endometrium was made when the total score was ≥16 and a score ≥7 supported a diagnosis of endometrial hyperplasia with atypia. Results: Out of the 95 women, 46 (48.4%) women had postmenopausal bleeding. The mean age of women was 50.4 ± 10.3 years. Eight women were diagnosed to have endometrial cancer and eight had endometrial hyperplasia with atypia on histopathological examination. Using a hysteroscopy score ≥16, the sensitivity and specificity were found to be 62.5% and 90.8%, respectively, for diagnosing endometrial cancer. Hysteroscopy score ≥9 was found to be a better cutoff for diagnosing endometrial cancer using Youden index. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing endometrial cancer with score ≥9 was 100%, 67.8%, 22.2%, and 100%, respectively. The sensitivity, specificity, PPV, and NPV for diagnosing endometrial hyperplasia with atypia with score ≥7 was found to be 75%, 58.6%, 14.3%, and 96.2%, respectively. Conclusion: The hysteroscopic scoring system has a good diagnostic performance when a cutoff score ≥9 is used in predicting endometrial cancer. However, the scoring system has lower diagnostic accuracy in predicting endometrial hyperplasia with atypia.
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Role of short-term estradiol supplementation in symptomatic postmenopausal COVID-19 females: A randomized controlled trial p. 211
Shikha Seth, Ritu Sharma, Pinky Mishra, Hariom Kumar Solanki, Monika Singh, Manisha Singh
DOI:10.4103/jmh.JMH_57_21  
Background: Protective role of estrogen in COVID-19 was speculated once the epidemiological studies reported increased susceptibility of estrogen-deficient population – males and postmenopausal females to severe disease category and involvement of angiotensin-converting enzyme 2 receptors and renin–angiotensin–aldosterone system in pathophysiology. Materials & Methods: An open-label randomized controlled trial was planned to assess the efficacy of short-course oral estradiol in preventing the clinical progression to severe disease and reduce case-fatality rate and the hospital stay duration in estrogen-deficient postmenopausal women. The intervention group (n = 40) received 2 mg per day of estradiol valerate per orally for 7 days along with the standard care, while the control group (n = 40) received only the standard care. Results: A significant difference was observed in the rate of reverse transcriptase–polymerase chain reaction negativization in the intervention versus control group at day 5 and day 7 of admission (42.5% vs. 15%, P = 0.007; 72.5% versus 50%, P = −0.026). No significant difference was noted in the duration of hospitalization (P = 0.213). A significant decrease was noted in the mean values of inflammatory biomarkers – D-dimer, lactate dehydrogenase, and C-reactive protein on day 5 in the intervention group. Interleukin-6 also showed a declining trend on day 5 in the intervention group, while a rising trend was noted in the control arm. Only one case (2.5%) in the intervention group while seven in the control group (17.5%) progressed to the moderate category; however, the difference was not statistically significant (P = 0.057). Conclusion: Oral estradiol in postmenopausal females can be a novel and efficient option for managing nonsevere COVID-19 infection.
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Atypical manifestations of women presenting with myocardial infarction at Tertiary Health Care Center: An analytical study p. 219
Neethu Maria Joseph, Lakshmi Ramamoorthy, Santhosh Satheesh
DOI:10.4103/jmh.JMH_20_20  
Introduction: Typical chest pain symptoms are the cause that requires individuals to seek out medical care in Acute coronary syndrome(ACS). Evidence suggests, symptoms labelled as 'atypical 'is more common in women with ACS. The present study focuses on the need for the implementation of a gender specific approach in the current scenario by identifying gender based differences that exist in clinical presentations of the patients with ACS. Early identification of women's prodromal and acute symptoms of Myocardial Infarction is an important step in provision of appropriate treatment modality. Present study focus on need for implementation of gender-specific approach in current scenario by identifying gender based differences that exist in risk factors, clinical manifestations in patients presenting with MI. Methodology: Cross- sectional analytical study was conducted among 240 Participants (120 males and 120 females). Both men and women diagnosed with MI, who survived, stabilized after admission was included in the study. Consecutive sampling technique was used to select the participants. Data was collected on risk factors profile, clinical manifestations by administering structured questionnaire. Results: Risk factors such as history of diabetes, history of dyslipidemia was found to be homogenous among both men and women. 60% of men were ever smokers. Hypertension and known IHD was noted to be significant in women (p<0.002, p <0.001) but men presented with higher BMI (p<0.030). Females increasingly presented with atypical presentations when compared to males (p<0.005). Women commonly had squeezing and tightness type of pain and men reported tightness, burning, pricking type of pain (p<0.003). The majority of the women reported the onset of pain occurrence between 6am to 12 pm(p<0.004), whereas men significantly reported the onset of pain between 12 am -6 am(p<0.001). Conclusion: Gender based differences in risk factors and clinical presentation in men and women with myocardial infarction had been a focus in researches that emphasized need for focused assessment for women as they increasingly presents with atypical symptoms. The current study also supports the need of a gender specific approach to avoid delay in diagnosis and care of them.
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Cardiovascular disease risk factors and 10 year risk of cardiovascular events among women over the age of 40 years in an urban underprivileged area of Bangalore City p. 225
Avita Rose Johnson, Sakthi Arasu, Nancy Angeline Gnanaselvam
DOI:10.4103/jmh.jmh_219_20  
Background: Cardiovascular disease (CVD) is one of the leading causes of death among Indian women but not a focus of current strategies to improve women's health. Objectives: To assess 10-year CVD risk and estimate the prevalence of CVD risk factors among underprivileged women. Methods: A cross-sectional study among women aged 40–79 years in an urban underprivileged area of Bangalore city, using nonlaboratory-based World Health Organization and the International Society of Hypertension risk prediction chart and INTERHEART list of CVD risk factors. Blood pressure, random blood sugar, height, weight, and waist circumference were measured. The Chi-square test was done for the association between CVD risk status and risk factors. Multiple logistic regression performed to calculate adjusted odds ratios (ORs). Results: Of 1027 women, 11% women had high risk of CVD (≥20% risk of fatal/nonfatal cardiovascular event within next 10 years). The prevalence of CVD risk factors was high with 20.2% diabetes, 53.7% hypertension, 77% overweight/obesity, and 92% central obesity. Majority were physically inactive with unhealthy diet, lacking daily fruits and vegetables, excess consumption of salty food, junk food, red meat, and excess oil. Significantly higher CVD risk found among women who were sedentary during leisure time (P = 0.028), single/separated/widowed women (OR = 1.84 [1.26–4.29] P = 0.002), and women who did not walk or cycle as a regular means of transport (OR = 1.47 [1.98–2.19] P = 0.041). Conclusion: High risk of CVD among underprivileged women reveals an urgent need for community-based interventions for prevention of CVD. Screening and management of diabetes and hypertension must include weight reduction and health education strategies. Policy-makers need to initiate efforts toward improving affordability of healthy diets for the urban underprivileged.
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PICTORIAL REVIEW Top

Understanding the endometrium at menopause: A hysteroscopist's view p. 232
Milind Telang, Tanvir Tanvir
DOI:10.4103/jmh.jmh_152_21  
The risk of premalignant and malignant endometrial pathologies increases in the postmenopausal period. Dilatation and curettage fail to diagnose one in ten endometrial pathologies. Hysteroscopy is the gold standard to evaluate the endometrial cavity. Hysteroscopy can identify malignant or benign pathology with approximately 20% false-positive results. Hysteroscopy combined with biopsy increases the accuracy of diagnosis up to 100%. This pictorial review takes you through the hysteroscopic view of normal-looking postmenopausal atrophic uterus, cystic atrophy, benign endometrial pathologies, endometrial hyperplasia, endometrial cancer, tamoxifen-induced endometrial hyperplasia and histiocytic endometritis. The purpose of this pictorial review is to guide the operator in systematic evaluation of the endometrial cavity with special attention to the thickness of the endometrium, vascular architecture, location of the lesion and surface aberrations, which adds value to the diagnosis and management of endometrial pathologies.
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CASE REPORTS Top

Malakoplakia of endometrium with osseous metaplasia on evaluation of postmenopausal leukorrhea: A rare case report p. 237
Yavana Suriya Venkatesh, S Norton Stephen, Murali Subbaiah, Bhawana A Badhe, Gowri Dorairajan
DOI:10.4103/jmh.jmh_213_20  
Malakoplakia is a chronic xanthogranulomatous condition that affects the genitourinary tract reported earlier as urinary granulomas and pelvic masses. We report a different clinical manifestation of malakoplakia presenting as postmenopausal pyometra. A 64-year-old postmenopausal female presented with foul-smelling vaginal discharge with a past history of induced abortion, followed by dilatation and evacuation. On examination, abdomen was soft, vaginal examination revealed pus discharge, parous size uterus with free fornices, and pap smear ruled out malignancy. Ultrasonography revealed linear, echogenic structures in the endometrial cavity suspicious of bony spicules with fluid around. Hysteroscopy revealed congested endometrium with multiple pieces of shredded bone-like structures that were removed followed by curettage. Histopathological examination was suggestive of malakoplakia with osseous metaplasia. Retained bony spicules can cause chronic granulomatous inflammation that may become symptomatic postmenopause due to absent cyclical shedding. This is the first reported case of malakoplakia of uterus following retained bony spicules.
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Choristomatous endocervical polyp with heterologous adipose tissue p. 241
Brij Mohan Kumar Singh, Varun Kumar Singh, Parvati Vinod Bhat
DOI:10.4103/jmh.JMH_96_20  
Endocervical polyps are a common occurrence in the postmenopausal age group and many reports have described the presence of heterologous elements in the stroma of such polyps. The presence of mature adipose tissue in the stroma has been hypothesized to be arising from the perivascular fat or metaplastic transformation of the smooth muscle cells posttrauma. A 75-year-old female presented with spotting per vagina. Colposcopic examination revealed an endocervical polyp which was excised. Microscopic examination showed an ulcerated epithelium with metaplastic changes along with sheets of mature adipose tissue with focal S100 positivity conferring a diagnosis of choristomatous endocervical polyp with heterologous adipose tissue. The primary clinical concern of a malignant cause in this age group is alleviated by the diagnosis of this rare benign entity. Only three such cases have been reported in the English literature so far, and the present case accounts for the fourth such case.
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Acute presentation of port site hernia following robot-assisted hysterectomy: A case report and review of the literature p. 244
Rooma Sinha, Rupa Bana, Girija Shankar Mohanty
DOI:10.4103/jmh.jmh_23_21  
Port site hernia (PSH) has been reported following both laparoscopic and robotic surgery. Subsequent surgical intervention increases postoperative morbidity. We report the case of a PSH through the 8-mm trocar following robot-assisted hysterectomy in a 49-year-old female patient, along with a review of the literature. The case was performed with the standard protocol; however, increased intraoperative bleeding was encountered from right uterine artery and vein. Discharged at 48 h, she presented in emergency on the fourth postoperative day with acute intestinal obstruction. Computed tomography scan showed herniation of the jejunal loop through the 8-mm left-sided port. She underwent resection and anastomosis of the necrosed jejunal loop. We review the literature for PSH following robotic gynecological surgeries. Although rare, PSH requires surgical intervention, increasing the postoperative morbidity. Need for fascial closure of 8 mm ports should be considered. High index of suspicion and early recognition can avoid resection of the bowel loop.
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A sinister gut feeling p. 247
Maureen P Tigga, Ganesh G Gowda
DOI:10.4103/jmh.JMH_10_19  
Women are generally spared from abdominal aortic aneurysm (AAA) formation by the immunomodulating effects of estrogen. However, once they develop it, especially in the postmenopausal group, its behavior is more sinister with rapid expansion, a higher tendency to rupture, and higher mortality as compared to the male counterparts. Reported here is a case of AAA in a postmenopausal woman who came to the outpatient department with low backache, vague abdominal pain, and dysuria which initially gave a picture of pelvic inflammation with urinary tract infection but was later found out to be aortic aneurysm.
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ERRATUM Top

Erratum: The effect of mindfulness on quality of life among women with premature ovarian insufficiency: A randomized clinical trial p. 250

DOI:10.4103/0976-7800.328372  
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