Journal of Mid-life Health Journal of Mid-life Health
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   Table of Contents - Current issue
January-March 2022
Volume 13 | Issue 1
Page Nos. 1-90

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An enriching journey p. 1
Meeta Meeta, Vishal R Tandon
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Journal of Mid-life Health - A symphony p. 3
Meeta Meeta, Vishal R Tandon
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A convergent and multidisciplinary integration for research in menopause p. 5
B Vaidya Ashok, A Vaidya Rama
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How much calcium does an Indian postmenopausal woman need? p. 9
Meeta Meeta
Calcium is needed for many biological processes. The serum concentration is of calcium is regulated very finely. The absorption of calcium and excretion maintains the calcium balance. Net calcium excretion must be replaced, but the amount of calcium needed has been debated for decades. The debate is what is the adequate calcium in Indian postmenopausal women to maintain bone health and as an intervention to prevent and treat osteoporosis. In this article experts give their opinion on the increase in the Recommended Dietary Allowance (RDA) of the ICMR 2020 committee. Based on the present evidence, the Indian menopause Society guidelines 2020, retains the ICMR 2010 recommendation of 800 mg of calcium as RDA until new Indian data emerges. The positive impact of increasing calcium and vitamin D intake is most evident in calcium-deficient individuals.
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The cause of vasomotor symptoms: Resonance phenomena in the vascular bed p. 15
Keiko Uohashi
This paper describes the probable cause of vasomotor symptoms during climacterics and before menstruation/ovulation. We propose that sex hormones imbalance changes the elasticity, resonance frequencies, and resonance peaks of vascular beds primarily in the uterus/intestines. It is also explained that vasomotor symptoms occur in the locations which resonate blood flow from the uterus/intestines for the above reason.
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A neuro-vasculo-endocrine approach to menopause p. 18
Sanjay Kalra
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Gender difference in ocular diseases, risk factors and management with specific reference to role of sex steroid hormones p. 20
Nilay Reddy Korpole, Padma Kurada, Madhukar Reddy Korpole
Our eyes are windows to the world and to our soul. The approach to them offers an incredible space for conducting research to learn more about gender differences in ocular health and disease. There is inadequate data about gender differences to accurately plan and implement strategies to address the gender disparities. In this article, we discuss several conditions with ocular manifestations, focusing on those that disproportionately affect women more, with a specific emphasis on the role of sex hormones and the management of the conditions. Articles in the past two and a half decades were selected for this mini-review from the MEDLINE/PubMed database. The search terms used were: “Age Related Macular Degeneration,” “Blindness,” “Cataract,” “Diabetic Retinopathy,” “Dry Eye,” “Glaucoma,” “Ocular Diseases.” To restrict the articles found, we limited search results with the terms: “Estrogen,” “Gender difference,” “Hormone,” “Menopause,” “Sex Steroid Hormones.”
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Menopause and sleep disorders p. 26
Vishal R Tandon, Sudhaa Sharma, Annil Mahajan, Akhil Mahajan, Apurva Tandon
Women are likely to suffer from sleep disorders more in comparison to men during menopause and with advancing age. The incidence of sleep disorders ranges from 16% to 47% at peri-menopause and 35%–60% at postmenopause. Insomnia with or without associated anxiety or low lying depression and Mood disorder is most common associated manifestations. Sleep disorders and insomnia largely remain a clinical diagnosis based on the subjective complaints of patients. Benzodiazepines remain the mainstay of the treatment in majority of the sleep disorders including chronic or acute insomnia. Treatment of associated anxiety, depression, or psychosis is most important. Tricyclic antidepressant, Selective Serotonin Reuptake Inhibitors (SSRI), Melatonin, Duloxetine, Fluoxetine, Imipramine, Nortriptyline or Amitriptyline and other drugs such as Eszopiclone, Escitalopram, Gabapentin, Quiteiapine, Citalopram, Mirtazapine followed by long-acting Melatonin and Ramelteon, also are very useful for the management of various sleep disorders. Hormone replacement therapy presently lacks concrete evidence to be used in menopausal women for sleep disorder. Sleep hygiene practices, self-hypnosis, meditation, and exercise play a very important role.
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Executive summary of evidence and consensus-based clinical practice guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative p. 34
Piyush Ranjan, Naval Kishore Vikram, Ambuja Choranur, Yashodhara Pradeep, Maninder Ahuja, Meeta Meeta, Manju Puri, Anita Malhotra, Archana Kumari, Sakshi Chopra, Achla Batra, Geetha Balsalkar, Deepti Goswami, Kiran Guleria, Siddharth Sarkar, Garima Kachhawa, Aditi Verma, M Krishna Kumari, Jagmeet Madan, Anjali Dabral, Sandhya Kamath, Asmita Muthal Rathore, Raman Kumar, Srikumar Venkataraman, Gaurishankar Kaloiya, Neerja Bhatla, S Shantha Kumari, Upendra Baitha, Anupam Prakash, Mangesh Tiwaskar, Kamlesh Tewary, Anoop Misra, Randeep Guleria
Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. The key clinical questions specific to weight management in midlife women were finalized with the help of a multidisciplinary team of experts in the guideline development group. Phase I including a systematic and/or narrative review, grading of evidence, and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method, and GRADE approach. The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the health-care provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviors. Before initiating the management, a comprehensive assessment of clinical and lifestyle-related parameters should be completed. A personalized behavioral lifestyle modification program addressing the midlife-specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife-specific barriers for sustenance of healthy weight. These recommendations will be useful in opportunistic screening and management of obesity in midlife women across health-care settings.
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Cardiovascular and osteoporosis protection at menopause with lycopene: A placebo-controlled double-blind randomized clinical trial p. 50
Meeta Meeta, Sudhaa Sharma, Jyothi Unni, Sunila Khandelwal, Ambuja Choranur, Sonia Malik
Objective: The effect of lycopene (LycoRed) supplementation was evaluated in healthy postmenopausal women by biochemical markers for cardiovascular protection and osteoporosis protection. Study Settings and Design: This was a multi-centric placebo-controlled double-blind randomized clinical trial that screened 198 postmenopausal women at 21 centers across 12 cities in India. Levels of lycopene, lipid profile, high-risk C-reactive protein, and bone turnover markers: amino-terminal propeptide of Type I collagen (P1NP) and C-terminal telopeptide of Type I collagen (β-CTx) were measured at baseline and 6 months postsupplementation with LycoRed or placebo. Interventions: The study was completed with 57 of the 100 women on LycoRed 8 mg (antioxidant potency is equivalent to 24 mg of lycopene) and 43 placebos for 6 months by randomization. Main Outcome Measures: Rise in serum lycopene and effect of serum lycopene on surrogate markers of cardiovascular health and bone health. Results: LycoRed supplementation increases lycopene levels and P1NP and nonsignificant fall in β-CTx levels in healthy postmenopausal women. Conclusions: Lycopene supplementation in Indian menopausal women may confer protection from osteoporosis as shown by the directional change in the surrogate biochemical markers. This study can form a basis for larger studies with different doses to understand the effect of lycopene to prevent and act as adjuvant treatment on clinical endpoints for cardiovascular disease (CVD) and bone health.
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Development and validation of comprehensive evaluation tool for weight management at menopausal transition and early menopause stage p. 57
Archana Kumari, Sakshi Chopra, Piyush Ranjan, Aditi Verma, Anita Malhotra, Ashish Datt Upadhyay, K Aparna Sharma, Naval K Vikram
Objective: To develop and validate a comprehensive questionnaire to evaluate risk factors, perceptions, and practices for weight management in women at menopausal transition and early menopause stage. Methodology: A mixed-method study was conducted in two phases. In the first phase, the questionnaire was developed by literature review and focused group discussions with the target population and experts. In the second phase, content and face validity were established by expert evaluation and cognitive interviews with the target population. The developed questionnaire was crosssectionally administered in 215 women and responses were used to determine the construct validity by factor analysis and reliability by evaluating internal consistency. Results: The finalized questionnaire consisted of two sections; section A included sociodemographic characteristics, anthropometric measures, and menopausal status with symptom severity, while section B contained 32-items focusing on readiness to initiate weight loss, perceptions and practices related to lifestyle behaviors, built environment, and social support. The Cronbach's α value of the questionnaire is 0.79 with good internal consistency. Conclusion: The developed questionnaire is a valid and reliable tool to assess weight-related risk factors, perceptions, and practices in middle-aged women, which can potentially be used by doctors and other healthcare practitioners to customize weight management advice in women at menopausal transition and early menopause.
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A randomized comparative study to compare Karman's cannula and pipelle biopsy for evaluation of abnormal uterine bleeding p. 67
Meeta Gupta, Puneeta Gupta, Poonam Yadav
Objectives: This study aimed to compare the diagnostic accuracy, inadequate sampling, pain during the procedure (Visual Analog Scale [VAS] score), and ease of insertion of the Karman's cannula and Pipelle biopsy for patients with abnormal uterine bleeding (AUB). Methods: This prospective observational randomized comparative study included women of age more than 40 years with complaints of AUB. Two hundred and fifty women were randomly divided into two groups: (1) Group A (n = 125) who underwent endometrial aspiration using Karman's cannula and (2) Group B (n = 125) who underwent Pipelle endometrial sampling. Both the groups were followed by conventional dilation and curettage (D and C) which was considered the gold standard. Sensitivity, specificity, positive predictive value, and negative predictive value for differentiating benign and malignant conditions of endometrium were calculated. Results: Group B had a sensitivity of 89.29% followed by Group A (86.36%); on the other hand, Group A had a specificity of 96.08% followed by Group B (95.74%) (P > 0.05). Inadequacy was comparable among the two groups with 1 inadequate in Group A and 3 inadequate in Group B. Mean VAS score was significantly lesser in Group A than Group B (4.5 ± 2 vs. 5.8 ± 2.1, P < 0.0001). Ease of insertion was similar in Groups A and B (P = 0.345). Conclusion: Both procedures were equivalent in diagnostic accuracy, inadequacy, and ease of insertion. However, the use of Karman cannula resulted in less pain and is a much cheaper option in comparison to Pipelle. Overall, either procedure can be performed on an outpatient basis without cervical dilation and anesthesia and thus may be routinely used for women presenting with AUB.
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Comparison of effectiveness of home-based verses supervised pelvic floor muscle exercise in women with urinary incontinence p. 74
Daxa G Mishra, Smruti Bhalendu Vaishnav, Ajay Gajanan Phatak
Background: Urinary incontinence (UI) is a significant health problem with serious physical, psychological, and social consequences. Pelvic floor muscle exercise (PFME) is proven efficacious in the prevention and management of UI. A lack of trained physiotherapist in rural areas mars the uptake of physiotherapy and therefore innovative mechanisms are required. The present study was undertaken to evaluate the usefulness of home-based physiotherapy in the management of UI. Materials and Methods: A total of 49 women, who screened positive for UI from a larger study conducted in 4 randomly selected villages of Charutar region, were included in the study. They were assigned home-based or supervised regimens randomly. All participants received education about UI and its management. A structured PFME schedule was developed. Participants in the supervised group received PFME by a trained physiotherapist, while those in the home-based group received training on exercise. Details of each session were documented through a daily diary in both groups. Revised urinary incontinence scale (RUIS) and incontinence impact questionnaire (IIQ-7) were administered at baseline and after 6 months to assess and compare the impact across groups. Results: Analysis of variance (with post hoc comparisons) was employed to compare the effect of physiotherapy across groups. Only 18 (10 supervised and 8 home-based group) out of 49 women participated. Another 10 provided the required data, albeit had not done any exercises. The mean standard deviation of RUIS (P = 0.84) and IIQ-7 (P = 0.55) scores was similar at baseline across the groups. The RUIS (P = 0.01) and IIQ-7 (P = 0.006) improved significantly; however, post hoc analysis revealed that both RUIS and IIQ-7 improved significantly only in the supervised group. Conclusion: Supervised exercise worked better, whereas home-based exercise failed to achieve the desired impact. Identifying barriers in home-based exercise and finding feasible solutions would prove a breakthrough in the management of UI in resource-limited settings.
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Improvement in quality of life of postmenopausal women with depression with commonly used antidepressants (Escitalopram vs. Desvenlafaxine): A randomized controlled trial in a tertiary care teaching hospital of North India p. 80
Sonia Shinde Mahajan, Manu Arora, Vishal R Tandon, Annil Mahajan, Suman Kotwal
Introduction: The postmenopausal symptoms affect the quality of life (QoL) of women. Depression and anxiety too have been associated with diminished QoL. It is known that antidepressants escitalopram and desvenlafaxine are effective in the treatment of depression and anxiety. However, to the best of our knowledge, their comparative effect on the QoL of postmenopausal women with depression and anxiety has not been studied in the Indian setup. Materials and Methods: The present study was a randomized, intention to treat, open-label trial undertaken in North India's a tertiary care teaching hospital. Postmenopausal women attending the psychiatry outpatient department and newly diagnosed with depression and anxiety were randomized in two groups to receive Tab. Escitalopram 10–20 mg and Tab. Desvenlafaxine 50–100 mg. Their QoL was assessed using the WHOQOL BREF scale at baseline, 3 weeks and 6 weeks. Results: Escitalopram was observed to be statistically better than desvenlafaxine in improving the overall QoL score of the WHOQOL-BREF scale. Individually, escitalopram significantly improved the scores of the physical health domain, psychological and environmental domains except for the social relationship domain. Desvenlafaxine significantly improved scores of all four domains. Conclusion: Escitalopram was observed to be significantly better than desvenlafaxine in improving the overall QoL scores. Both the drugs were well tolerated.
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Intramyometrial pregnancy presenting as abnormal uterine bleeding in perimenopausal female p. 85
Amrita Razdan Kaul, Usha Priyambada Gupta, Divya Kant, Anita Kant
Abnormal uterine bleeding (AUB) is frequently encountered in the gynecological complaint of perimenopausal female visiting the outpatient department. Beginning in mid-40s, perimenopause is often marked with menstrual irregularities. Intramyometrial pregnancy (IMP) is a rare type of ectopic pregnancy with an incidence of <1% of all ectopic gestation may present as AUB in perimenopausal female. It remains a diagnostic challenge, especially in background of negative pregnancy test with the lesion ultrasonographically mimicking a fibroid with or without degeneration or an adenomyoma. We report the case of a 41-year-old perimenopausal female presenting with AUB not responding to medical management and ultrasound suggestive of degenerative fibroid. Hence, total laparoscopic hysterectomy was done and histopathology revealed the lesion to be IMP. The aim of this case report is to consider this rare entity as a possible cause of AUB in perimenopausal female even in the pretext of negative pregnancy test.
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Intraluminal endometriosis: A rare entity p. 88
Harshi Dhingra, Asif Baliyan, Ruchi Nagpal, Suchita Pant
The case presents an incidental finding of a rare variety of endometrioses in both the fallopian tubes termed intraluminal endometriosis in a 52-year-old female.
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