Journal of Mid-life Health Journal of Mid-life Health
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   2020| October-December  | Volume 11 | Issue 4  
    Online since January 21, 2021

 
 
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NARRATIVE REVIEW
Postmenopausal hormone therapy and its association with breast cancer
Arshi Syal, Neelam Aggarwal
October-December 2020, 11(4):187-195
DOI:10.4103/jmh.jmh_284_20  
With the cessation of estrogen and progesterone at menopause, the hormone withdrawal affects various systems in the woman's body. In earlier days, menopausal hormone therapy (HT) was prescribed for primary prevention of coronary artery disease (CAD) and osteoporosis, which were thought to be because of estrogen deprivation and epidemiologic data supported a beneficial effect of estrogen on the heart and bone. Later on, robust data from the Women's Health Initiative study comparing two HT trials demonstrated adverse outcomes in terms of excess risk of CAD, stroke, venous thromboembolism, and breast cancer. Even with risk stratification based on family history, approximately only 15% of women diagnosed with breast cancer have such a risk factor. This implies that family history will not be elicited in more than 85% of women who develop breast cancer. Literature review suggests that the prior use of conjugated equine estrogen (CEE) alone has the potential to be effective as an intervention, leading to a reduction in mortality due to breast cancer. Therefore, it is time to reevaluate the risk reduction strategies for breast cancer that are currently in practice. In terms of absolute numbers, for every 10,000 person-years of prior use of CEE alone, there would be only two fewer deaths from breast cancer and two fewer deaths secondary to its sequelae. This translates into a significant number of women in our country with a population of 1.38 billion (of which 48%, nearly 650 million, are women).
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ORIGINAL ARTICLES
COVID-19 outcomes in postmenopausal and perimenopausal females: Is estrogen hormone attributing to gender differences?
Ruchika Garg, Prabhat Agrawal, Ashish Gautam, Nikhil Pursnani, Mohita Agarwal, Arti Agarwal, Avantika Parihar, Anjana Pandey
October-December 2020, 11(4):250-256
DOI:10.4103/jmh.jmh_287_20  
Background: Globally, case fatality rate is more in males compared to females. Some studies have suggested. It is hypothesized that estrogen hormone may decrease susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS CoV-2.) Objective: The objective of the study was to evaluate the gender differences in SARS CoV-2 outcomes and to analyze if there are any differences in outcomes in premenopausal females compared to postmenopausal females. Materials and Methods: Patients tested positive for SARS CoV-2 through real-time reverse transcription-polymerase chain reaction by Thermo Fischer Taqpath assay approved by the Indian Council of Medical Research were included in the study. The data obtained was analyzed for the epidemiological, clinical, and laboratory characteristics from their medical records. Results: The mortality rate in females was 12.6%, whereas mortality in males was 19.4%. In between-group analysis, 8.6% (16/185) of females died in premenopausal age group versus 12.8% (27/211) in postmenopausal group. The proportion of females who expired due to COVID significantly differ by age and postmenopausal status X2 (1, n = 293) = 7.2, the P value is 0.007. The difference is statistically significant at P < 0.05. Postmenopausal women were more likely to expire due to COVID-19 infection compared to premenopausal women. Conclusion: The mortality rate in postmenopausal age group was greater than mortality in premenopausal females emphasizing the protection provided by estrogens hormone in them. Postmenopausal women are also at higher risk of severe COVID-19 infection than premenopausal women. Mortality is greater in males compared to females, further strengthening the role of estrogens.
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COVID-19 and menstrual status: Is menopause an independent risk factor for SARS Cov-2?
Neha Mishra, Ritu Sharma, Pinky Mishra, Monika Singh, Shikha Seth, Trideep Deori, Payal Jain
October-December 2020, 11(4):240-249
DOI:10.4103/jmh.JMH_288_20  
Background: COVID-19 has shown a definite association with gender, a predilection for males in terms of morbidity and mortality. The indirect evidence of the protective effect of estrogen has been shown by Channappanavar, in the animal model and Ding T. in a multihospital study from China, suggesting menopause as independent risk factor and estrogen is negatively correlated with severity. Objective: Study the clinical profile and outcomes in premenopausal and menopausal. Covid-19-infected women and analyzed the effect of menstrual status on the outcome. Materials and Methods: A retrospective cohort study conducted on 147 mild and moderate category COVID-19 females admitted between May and August 2020 using hospital records and telephonic follow-up. Two groups formed based on menstrual status: group-1 (premenopausal/estrogenic) and Group-2 (menopausal/hypoestrogenic). Hospital stay duration was considered as primary, while the category of disease on admission, clinical course, the requirement of oxygen, and mortality and residual symptoms were taken as a secondary outcome to compare the groups. Results: Overall Group-1 had significantly more of mild disease, while Group-2 had moderate cases (39 [76.5%] vs. 14 [14.6%] P < 0.01). Menopausal group has significantly more requirement of oxygen (32 [62.7%] vs. 20 [20.8%]), ventilation (14 [27.5%] vs. 1 [1%]) progression-to-severe disease (23.5% vs. 7.3%) and prolonged hospital stay ([14.1 ± 8.9 vs. 8.6 ± 3.9 days] P < 0.01). However, multivariate logistic regression failed to show a significant association between hospital stay and progression with menopause. Ferritin and residual symptoms found significantly higher in menopausal. Conclusions: No definite association was found between menopause and COVID-19 outcome with hospital stay duration or disease progression in our study.
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EDITORIAL
Webinar: A virtual reality in medical communication
Meeta Meeta, Vishal Tandon
October-December 2020, 11(4):185-186
DOI:10.4103/jmh.jmh_289_20  
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ORIGINAL ARTICLES
A study of anxiety and depression in benign breast disease
Vivek Srivastava, Rakesh Kumar Meena, Mumtaz A Ansari, Dheeraj Kumar, Anand Kumar
October-December 2020, 11(4):200-209
DOI:10.4103/jmh.JMH_85_20  
Background: To compare the prevalence of anxiety and depression levels in patients with benign breast disease (BBD) and healthy individuals using Hospital Anxiety and Depression Scale (HADS) and Brief Patient Health Questionnaire (BPHQ). Methods: This study includes 100 patients who were clinically suspected of having BBDs and were matched against 100 healthy age-matched controls from June 2016 and July 2018. The diagnosis of BBD was established on the basis of ultrasonography, fine needle aspiration cytology, and/or histopathology. For the diagnosis of anxiety and depression, BPHQ was used and the level of anxiety and depression was measured using the HADS. The questionnaire at both prediagnosis and at follow-up assessment after 3 months was done. Results: On comparing anxiety and depression using BPHQ score among cases and controls, both were significantly associated with cases than controls (P < 0.001 and P = 0.0016, respectively). On comparing anxiety and depression using HADS score, there was a significant difference (median) in both anxiety and depression level between cases and controls (P < 0.001 and P < 0.001, respectively). After 3 months of follow-up, there was a significant improvement in anxiety and depression scores by both BPHQ (P = 0.007 and P = 0.0016) and HADS (P < 0.001 and P < 0.001). The 3-month follow-up data showed a significant improvement in BPHQ (depression) score in patients with breast lump and mastalgia (P = 0.001 and P = 0.008). The HADS (anxiety score) showed significant improvement in patients presenting with diseases/aberrations other than fibroadenoma while the HADS (depression) score showed a significant improvement in all except fibroadenosis present either alone or along with fibroadenoma. The HADS (depression) score showed a significant improvement in fibroadenoma, others group, breast lump, and mastalgia (P = 0.040, P = 0.005, P < 0.001, and P = 0.025, respectively). Conclusion: Indian female patients who present with BBDs are also affected by anxiety and depression.
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COMMENTARY
Menopause hormone therapy in the changing trends of breast cancer in India
Meeta Meeta, Tanvir Tanvir
October-December 2020, 11(4):196-198
DOI:10.4103/jmh.jmh_291_20  
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ORIGINAL ARTICLES
A comparative analysis of body mass index with estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 status in pre- and postmenopausal breast cancer patients
Richa Chauhan, Vinita Trivedi, Rita Rani, Usha Singh
October-December 2020, 11(4):210-216
DOI:10.4103/jmh.JMH_97_20  
Background: Breast cancer is now the most common cancer among Indian women. Recent studies have suggested a possible link between risk factors like high BMI and molecular subtypes of breast cancer. Studies from Western and Asian population have shown varying relationship between post- menopausal obesity and expression of ER, PR, Her2-neu receptors in breast cancer patients. Aim: This study was done with an aim to explore if overweight or obesity as defined by BMI and status of ER, PR and Her2-neu receptors differ in Indian pre-menopausal and post-menopausal breast cancer patients. Methods and Material: This is a retrospective analysis of 446 breast cancer patients treated at Mahavir Cancer Sansthan, Patna from July to December 2019. Their case records were evaluated and data regarding age, menopausal status, height, weight and ER, PR & HER2-neu receptor status were extracted for analyses. Statistical Analysis: Chi-square test was used to compare categorical variables between the pre-menopausal and post-menopausal group. Results: The prevalence of obesity in the post-menopausal group was 2.3% more than the pre-menopausal group (P-value = 0.24). As compared to the pre-menopausal group, there was an increase in the ER/PR positivity in the post-menopausal group by 3.41% (P-value = 0.47) and in the Her2-neu positivity by 6.38% (P-value = 0.15). As compared to the pre-menopausal group, there was further increase in the ER/PR positivity in the post-menopausal group by 6.85% (P-value = 0.40) in sub-group of patients with BMI ≥ 25kg/m2. Conclusions: Our study showed slightly increased incidence of obesity in post-menopausal breast cancer patients. Overweight post-menopausal patients also had a higher percentage of ER/PR receptor positivity and lower percentage of Triple negative breast cancer. The percentage of Her2-neu receptor positivity was more in post-menopausal patients. A high BMI was found to be associated with a lower Her2neu positivity.
  1,103 159 -
Predictors of unsatisfactory conventional pap smears
Reetika Sharma, Marie Moses Ambroise, Anita Ramdas, Kandasamy Ravichandran
October-December 2020, 11(4):231-235
DOI:10.4103/jmh.JMH_110_20  
Objective: The objective of this study is to determine the clinical predictors of unsatisfactory Pap smears. Methodology: This was a case–control study done in a tertiary care institute. All unsatisfactory conventional pap (CP) smears between January 2015 and June 2017 were retrieved, and the slides were viewed. Clinical details were recorded from request forms and case files. Simple and multiple logistic regression analyses were used to identify the predictors of unsatisfactory CP smears. Results: In this study, we have included 314 unsatisfactory Pap smears and 541 controls with satisfactory Pap smears. Clinical parameters such as older age and cervical erosion proved to be important predictors of unsatisfactory pap smears. The most common reason for unsatisfactory pap smears was due to a paucity of epithelial elements (66.6%), followed by obscuration of smear details by blood/inflammatory cells/mucus (9.9%) and air drying artifacts (4.4%). There were multiple reasons in 19.1% of cases with unsatisfactory pap smears. Conclusion: Our study shows that older age groups and cervical erosion are predictors of unsatisfactory pap smears. Incidence of unsatisfactory pap smears can be reduced by education and retraining of health-care workers and doctors.
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Comparison of quality of life and bone mass density among postmenopausal women: A cross-sectional study
Neetu Singh, Dileep Kumar, Ganesh Yadav, Mohit Kishore Srivastava, Sudhir Ramkishore Mishra, Anil Kumar Gupta, Sugandha Jauhari, Madhumita Singha Roy
October-December 2020, 11(4):224-230
DOI:10.4103/jmh.JMH_107_20  
Background: Postmenopausal women are at highest risk of developing osteoporosis, since their bone mineral density is reduced due to decrease in estrogen level. Various other physiological, emotional, and psychological changes jeopardize the health of these vulnerable females in total and reduce their quality of life (QoL). Aims and Objectives: To compare the QoL and bone mass density (BMD) among normal BMD, osteopenic, and osteoporotic postmenopausal women. Setting and Design: A cross-sectional observational study was conducted in the outpatient department of physical medicine and rehabilitation at a tertiary care center of northern India from August 2019 to February 2020. Materials and Methods: Baseline sociodemographic characteristics of all postmenopausal women were collected using a quantitative tool. Assessment of QoL was done by pretested and validated QUALEFFO-41 scale. For all the women, a bone mineral densitometry test was performed on the L1–L4 lumbar spine, femoral neck, and forearm by the dual-energy X-ray absorptiometry method. Statistical Analysis: One-way ANOVA test was used to compare the mean BMD values across the three groups. Determination of predictive factors for QoL was performed using stepwise logistic regression analysis. Results: Significant differences were noted for the mean values of the three domains, i.e., pain, physical, and social function (P < 0.01). Women with osteoporosis had significantly higher pain scores as compared to others. Among those with osteoporosis, the pain scores have significantly increased gradually as age increases. Conclusion: Postmenopausal women with osteopenia and osteoporosis have poor QoL as compared to those with normal BMD.
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OPINION
COVID-19: The vital sign
Sai Praveen Haranath, Meeta Meeta
October-December 2020, 11(4):199-199
DOI:10.4103/jmh.jmh_286_20  
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ORIGINAL ARTICLES
Predicting malignancy in adnexal masses by the international ovarian tumor analysis-simple rules
Vrushti Solanki, Pratibha Singh, Charu Sharma, Navdeep Ghuman, Binit Sureka, Shashank Shekhar, Meenakshi Gothwal, Garima Yadav
October-December 2020, 11(4):217-223
DOI:10.4103/jmh.JMH_103_20  
Background: Accurate prediction of adnexal tumors preoperatively is critical for optimal management of ovarian cancers. The International Ovarian Tumor Analysis Algorithms (IOTA) is a newer tool to characterize adnexal masses as benign or malignant. Objective: This study is aimed to predict malignancy in adnexal masses and differentiates benign from malignant, applying the sonography features of simple rules given by IOTA. Methodology: A prospective study was carried out at AIIMS Jodhpur for 1½ years. Women presenting with adnexal masses planned for surgery were recruited. Ultrasonography-transabdominal combined with transvaginal was done, and pelvic masses were characterized using IOTA simple rules. Patients underwent their planned surgery. Histopathology is considered the gold standard and was compared with the IOTA simple rules. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: One hundred and seventy-four women were included in the study, of which the majority (82.75%) were benign, the rest being frankly malignant or borderline cancer. The sensitivity of IOTA is 96.6%, specificity of 92.3%, PPV of 72.5%, NPV of 99.2%, where indeterminate cases were considered malignant. Conclusion: IOTA simple rule is an effective tool for identifying malignant adnexal masses. It also suggests that IOTA-simple rules can be used as a diagnostic criterion for differentiating adnexal masses into benign and malignant on an out-patient department basis.
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CASE REPORTS
Severe idiopathic osteoporosis in a premenopausal woman: A case for dual therapy
Sudarsanababu Lalitha Soumya, Kripa Elizabeth Cherian, Nitin Kapoor, Thomas Vizhalil Paul
October-December 2020, 11(4):260-263
DOI:10.4103/jmh.JMH_168_20  
Currently available agents improve bone mineral density (BMD) values on their own in monotherapy but may not completely restore microarchitecture and the patient may continue to sustain fragility fractures. Current monotherapies can only address either increased bone resorption or decreased bone formation. In this setting, combination therapy with antiresorptive and anabolic agents appears to be a promising option. A 49-year-old premenopausal woman presented with severe low backache associated with significant height loss. Evaluation elsewhere revealed severe osteoporosis, which prompted treatment with three doses of parenteral zoledronate 4 mg annually, followed by oral alendronate 70 mg once weekly for 7 years. However, her symptoms persisted despite treatment, and investigations done at our center confirmed severe osteoporosis, with multiple vertebral compression fractures. She was initiated on teriparatide therapy but despite 1 year of treatment, there was persistent height loss. In addition, there was a marked elevation of bone resorption, which prompted us to add denosumab which was administered subcutaneously every 6 months. On follow-up, there was marked relief from pain, no further decrease in height, and progressive improvement in BMD, and bone turnover markers were noted. A dual therapy with anabolic agent teriparatide and antiresorptive agent denosumab for osteoporosis may be a viable option in individuals with severe osteoporosis who do not respond well to a single agent.
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ORIGINAL ARTICLES
A study of matrix metalloproteinase-2 and interleukin-18 in preinvasive and invasive lesions of cancer cervix
Shuchi Shukla, Sabuhi Qureshi, Uma Singh, Sanjay Khattri
October-December 2020, 11(4):236-239
DOI:10.4103/jmh.JMH_87_19  
Introduction: Human Papilloma-Virus infection is the major event for cervical carcinogenesis, whereas host physiological changes may confer individual susceptibility and prognosis. So here, we aimed to compare serum levels of matrix metalloproteinase-2 (MMP-2) and interleukin-18 (IL-18) between cervical cancer patients and healthy controls. Materials and Methods: In the present study, we enrolled 168 subjects (10 CIN I, 10 CIN II, 10 CIN III, and 54 invasive cervical cancers with 84 age-matched healthy controls). Serum levels were estimated by enzyme-linked immunosorbent assay. Results and Discussion: The levels of serum MMP-2 showed a characteristic pattern of increasing trend with statistically significant P value on comparing pre-invasive lesions and cervical cancer versus healthy controls. However, IL-18 levels showed a decreasing trend in serum levels of controls versus cases with a statistically significant P value (P < 0.05). Conclusion: MMP-2 accentuates tissue damage and controls many interleukins secretion, which leads invasion and malignancy. Increased levels of MMP-2 and decreased circulating levels of IL-18 were found in cases. Hence, we raise an issue to study MMP-2 and IL-18 further for their diagnostic and prognostic marker role.
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CASE REPORTS
Complete labial fusion causing pseudo-urinary incontinence: A long-term sequelae of genitourinary syndrome
Tanvir Tanvir, Meeta Meeta, Akanshi Singh
October-December 2020, 11(4):257-259
DOI:10.4103/jmh.JMH_34_20  
Genitourinary syndrome (GSM) of menopause is due to hypoestrogenism affecting the vagina and lower urinary tract. Atrophic changes manifesting as complete labial fusion (CLF) are rare. They may present with urinary incontinence and cannot be classified as stress or urge urinary incontinence. We report a case of 68-year-old postmenopausal women who presented with symptoms of urinary incontinence secondary to CLF. Surgical correction and restoration of the labial anatomy with topical estrogen lead to successful management.
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NOTICE OF RETRACTION
Retraction: Office cervicoscopy versus stationary colposcopy in suspicious cervix: A randomized controlled trial

October-December 2020, 11(4):264-264
DOI:10.4103/0976-7800.307580  
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