Mazhar SB. Healthy Heart Matters for Women. J South Asian Federation Menopause Societies 2017;xx(xx):xx-xx.

Cervical carcinoma, the commonest carcinoma affecting Indian females, is caused by human papilloma virus (HPV) infection. Primordial prevention and primary prevention with HPV vaccine and cancer screening respectively, can go a long way in preventing this carcinoma. The health system project in Tamil Nadu has done a commendable job in reducing the disease burden by introducing screening programs for cervical carcinoma at the grassroots level, way back in 2005. This study was done to evaluate the cervical biopsy specimens received as a part of this program to compute its incidence, compare the incidence among various districts, and suggest future directions based on our observations.

From visual inspection with acetic acid/visual inspection with Lugol’s iodine positive cervical biopsy specimens, 506 were chosen randomly from various districts. Based on histopathological examination, incidence of individual lesions and district-wise incidence were calculated. Predictive factors that determine the progression of these lesions were analyzed based on the literature.

Out of the 506 cervical biopsy specimens, 34 were unsatisfactory. The incidence of high-grade dysplasia peaked around 31 to 40 years, and squamous cell carcinoma peaked among 51 to 60 years. Madurai ranked high in the incidence of both high-grade dysplasia and carcinoma.

Incidence of dysplasia and carcinoma in our study was comparable to those seen in the literature. Integration of HPV deoxyribonucleic acid studies into the program can increase the detection rate, detect the progressors, help to identify the HPV species prevalent in an area, and aid in formulating cost-effective HPV vaccine cocktail.

Ibrahim SS, Kesavaraj K, Arun M, Ameen SAM, Sankar R. Review of Cervical Carcinoma Screening Program in Tamil Nadu – Current Trend and Recommendations from a Histopathologist’s Viewpoint. J South Asian Feder Menopause Soc 2017;5(1):1-7.

Vaginal route of hysterectomy is a safe procedure with less morbidity and hospital stay. So, there is a need to expand the indication for vaginal hysterectomy beyond uterovaginal prolapse.

To determine the feasibility and outcome of nondescent vaginal hysterectomy (NDVH) and to assess the pre- and postoperative complications, duration of surgery, and hospital stay.

A prospective observational study was conducted between 2012 and 2014 at a tertiary care center. A total of 256 patients satisfying the selection criteria of hysterectomy for benign gynecological conditions, uterus size <16 weeks, and excluding stage IV endometriosis, genital tract malignancy, and uterine prolapse were included. The NDVH was performed by the standard technique, and the following parameters of age, parity, indication for surgery, duration of surgery, intraoperative and postoperative complications, and hospital stay were recorded. The data were analyzed using Statistical Package for the Social Sciences version 16.0 by frequency and percentage analysis and Chi-square test.

All 256 patients were analyzed. The mean age was 44.4 ± 6.1 years; fibroid uterus was the commonest indication. About 89.4% had a uterine size ≤12 weeks and 59% had uterine volume <200 cm³. The mean duration of surgery was 83.5 ± 11.0 minutes; salpingo-oophorectomy was performed in 25.8% of the patients. Intraoperatively, 1.2% had bladder injury and 0.4% required conversion to laparotomy for pelvic hematoma. The mean duration of hospital stay was 4.9 ± 2.2 days, and the mean pain score in numerical rating scale pain scale was 3.0 ± 0.3. Intraoperative blood transfusion was required in 1.9% of the patients only.

The NDVH is a safe and feasible procedure for benign gynecological disorders.

The NDVH is a boon in this techno-savvy era by reducing the morbidity and promising early return to work.

Vembu R, Dharmalingam S. Hysterectomy by Vaginal Route: Not a Pressure. J South Asian Feder Menopause Soc 2017;5(1):8-10.

To compare the effects of continuous combined conjugated equine estrogens (CEE) with those of tibolone on symptom control, lipid profile, and tolerability in women with surgical menopause.

This was a randomized controlled trial study conducted in the Department of Obstetrics and Gynaecology of Global Rainbow Hospital Pvt. Ltd., Agra (2014–2016) comprising 150 women. Generally, healthy postmenopausal women having undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy irrespective of age and indication of surgery and no absolute contraindications to hormone replacement therapy (HRT) or tibolone were enrolled. Fifty subjects did not receive any HRT, 50 were treated with CEE 0.625 mg, and 50 were given tibolone 2.5 mg for 13 treatment cycles, each of 28 days. Results were statistically analyzed regarding drug efficacy in amelioration of menopausal symptoms and side effects at follow-up periods of 1, 6, and 12 months.

A total of 150 subjects were enrolled and received at least one dose of the study medication, of which 134 (89.4%) subjects completed the study (n = 40 in CEE and n = 44 in tibolone). The incidence of postmenopausal symptoms decreased significantly over time in the treatment groups, compared with baseline, including significant decreases in the incidence of urogenital and sexual health symptoms, with p-values 0.001 and 0.004 in cases that received CEE and tibolone respectively.

Significant differences in symptom control (other than hot flashes) were observed between treatment groups in a few different cycles for different symptoms, but no consistent or clinically significant trends were observed.

Significant decreases in total cholesterol (5.6%) and low-density lipoprotein cholesterol (7.5%) were observed at cycle 13, compared with baseline, in the CEE group, and significant decreases in high-density lipoprotein cholesterol (8.5%) and triglycerides (13.7%) were observed at cycle 13, compared with baseline, in the tibolone group.

Significant weight gain was observed at cycle 13 in the tibolone group (3.05 kg), compared with the CEE group (0.96 kg). The incidences of adverse events were similar in both treatment groups.

Women treated with CEE and tibolone showed significant improvement of climacteric symptoms, including urogenital and sexual health symptoms. Treatment with either preparation significantly improved subjective wellbeing, vasomotor symptoms, and vaginal dryness.

The CEE and tibolone each induced a different mix of beneficial changes in the lipid profile.

It is seen that tibolone seems to be effective on estrogen withdrawal symptoms and with its acceptable androgenic side effects can be an appropriate selection for HRT in postmenopausal women with decreased sexual desire.

Gupta N. Hormone Replacement Therapy for Surgical Menopause: Is there an Ideal Drug? A Comparative Study of Conjugated Equine Estrogens and Tibolone. J South Asian Feder Menopause Soc 2017;5(1):11-15.

Sex hormones play an important role in women’s health. There is a close relationship between female sex hormones and lung function in postmenopausal women. Deterioration of lung function is observed more after menopause. Estrogen deficiency after menopause accelerates adverse effects of biological aging on lung mechanics in postmenopausal women. Our study uses spirometer to analyze and evaluate these effects of menopausal aging.

To study the effects of menopause on pulmonary function tests in women of perimenopausal age group.

This study was carried out in the Department of Obstetrics and Gynecology in Indira Gandhi Government Medical College & Hospital, Nagpur, India. A total of 50 women each in premenopausal and menopausal age group were included in our study. Venous blood was collected under aseptic precaution on 10 to 14 days and 18 to 23 days corresponding to follicular and luteal phase of menstrual cycle in premenopausal women and in postmenopausal women, and serum estrogen and progesterone levels were estimated by microparticle enzyme immunoassay. Pulmonary function of all subjects was measured with digital micro spirometer and data collected. Peak expiratory flow rate (PEFR), forced expiratory flow (FEF)_25-75, forced expiratory volume in 1 second, and forced vital capacity were studied and correlated with symptoms. Data analysis was done using Student’s unpaired t-test and chi-square test.

The mean percentage of predicted values of FEF_25-75 and PEFR were lower in postmenopausal women compared with premenopausal women. Mean serum estrogen levels were significantly lower in postmenopausal women as compared with premenopausal women. Progesterone levels were lower in postmenopausal women and in proliferative phase of premenopausal women as compared with luteal phase of menstrual cycle.

As menopause sets in decreased hormonal levels leads to decreased lung capacity as evident by pulmonary function test. Decreased pulmonary function test can be attributed to lower levels of sex hormones estrogen and progesterone in postmenopausal women.

Karia AK, Kedar KV, Munje RP. Effect of Menopause on Pulmonary Functions: An Analysis. J South Asian Feder Menopause Soc 2017;5(1):16-18.

The study tried to analyze the efficacy of levonorgestrel intrauterine system (LNGIUS) for the treatment of heavy menstrual bleeding in the urban and suburban Indian women.

The present study was conducted in the Department of Gynecology and Obstetrics, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratishthan, Kolkata, over a period of 1 year. A total of 20 patients suffering from abnormal uterine bleeding in the age group of 20 to 45 years were recruited in this study. The LNGIUS was inserted in all the women and they were followed up at the end of 3, 6, and 12 months. All subjects completed 1 year duration of follow-up. We used the Student’s paired t-test to evaluate the reduction in the menstrual blood loss, passage of clots, and increase in hemoglobin concentration at each point from the baseline.

At the end of 6 months, most (90%) of the women had an acceptable bleeding, with 10% having amenorrhea (pictorial blood-loss assessment chart score 0). Statistically significant improvement in the hemoglobin level was observed at the end of 3, 6, and 12 months postinsertion. The level of satisfaction increased steadily with time.

Levonorgestrel intrauterine system is an effective reversible treatment for menorrhagia. Levonorgestrel intrauterine system can be used as an effective alternative to hysterectomy in the future in the urban and suburban affluent Indian women.

Gupta A, Roychoudhury B, Sanyal P, Chowdhury B, Zoha MMS. A Study to Analyze the Efficacy of Levonorgestrel Intrauterine System in the Management of Abnormal Uterine Bleeding among Urban Indian Women. J South Asian Feder Menopause Soc 2017;5(1):19-22.

Surgical site infections (SSIs) are among the most common complications in surgical patients and have serious consequences for outcomes and costs. There is a dearth of information on risk factors for developing SSI in patients undergoing gynecologic cancer surgery, and this has not been studied using national data.

The objectives of this study were to estimate the prevalence, preoperative and operative risk factors associated with the higher risk of SSIs in gynecologic cancer patients undergoing surgery in a tertiary care facility in a developing country.

Department of Obstetrics and Gynaecology, Aga Khan University Hospitals, Karachi, Sindh, Pakistan.

Retrospective record review of gynecologic oncology patients admitted for surgery from January 2015 to December 2015 was performed.

A total of 100 patients met the inclusion criteria. Of these, 15 were identified with SSIs, which were all found to be of the superficial type. Approximately, 44, 40, and 7% were diagnosed with endometrial, ovarian, and cervical cancers respectively. The mean time from surgery to developing SSI was 12.9 days. Among endometrial cancer, 22.7% (10/44) had SSI compared with 7.5% (3/40) for ovarian cancer and 14.2% (1/7) for cervical cancer. The significant predictors of SSI were body mass index ≥35 (p-value <0.004), endometrial cancer diagnosis, the American Society of Anesthesiologists class more than 3, modified surgical complexity scoring system 3 to 4, and blood sugar levels more than 180 mg/dL within 48 hours after surgery in known diabetics.

About 15% of patients undergoing laparotomy for gynecologic malignancy developed SSIs. In this study, we identified several risk factors for developing SSI among gynecologic cancer patients. These findings may contribute toward identification of patients at risk for SSIs, and the development of strategies to reduce SSI rate and potentially reduce the cost of care in gynecologic cancer surgery.

Khan ES, Irfan S, Khalid N. Rate and Risk Factors for Surgical Site Infection in Gynecologic Oncology Surgeries at a Tertiary Care Facility in a Developing Country. J South Asian Feder Menopause Soc 2017;5(1):23-27.

To evaluate vitamin D, serum calcium, and serum phosphorus levels in postmenopausal women attending gynecology outpatient department in Lady Goschen and Kasturba Medical College Attavar hospitals.

To study the prevalence of vitamin D deficiency among the studied group. To correlate vitamin D levels with diet and environmental factors.

The study was conducted in 100 postmenopausal women attending Lady Goschen hospital and Kasturba Medical College Attavar hospital, Mangaluru. It was a hospital-based, prospective cross-sectional study conducted over the period between August 2014 and June 2016. Levels of vitamin D and serum calcium and phosphorus were assessed in them.

A total of 11% were found to have vitamin D deficiency, 38 and 48% had insufficient levels and sufficient levels of vitamin D respectively, 53% had normal levels of serum calcium, and 47% had inadequate levels. About 70% were found to have normal levels of serum phosphorus and 24% had inadequate levels. Dietary intake was found to be inadequate in 61% of the studied population. Serum calcium and phosphorus deficiency had significant corelation with vitamin D deficiency. Also significant corelation was noted with sun exposure and dietary intake in relation to vitamin D. No corelation was established between hypertension, diabetes and vitamin D.

This study helped us to assess basal levels of vitamin D, serum calcium, and serum phosphorus among postmenopausal women, giving us an idea regarding prevalence of vitamin D deficiency among South Indian postmenopausal women. We should consider counseling all postmenopausal patients regarding the benefit of vitamin D supplementation, adequate dietary intake, and sun exposure.

Jayakumar NP, Rao B, Shetty N. Study of Vitamin D Status among Postmenopausal Women. J South Asian Feder Menopause Soc 2017;5(1):28-34.

To discuss the incidence of various hysteroscopic findings in patients of infertility, abnormal uterine bleeding (AUB), and postmenopausal bleeding and to compare the prevalence of various uterine pathologies in patients of primary and secondary infertility.

This is a retrospective observational study, which evaluated 296 patients who underwent diagnostic hysteroscopy for evaluation of primary or secondary infertility, AUB, and postmenopausal bleeding over a period of 18 months in a Gynae-endoscopy Unit. Detailed hysteroscopic evaluation of the endocervical canal and uterine cavity in all recruited cases was done by the same surgeon and the data were collected by reviewing the case records.

Among the 296 cases analyzed, 157 cases were of primary infertility, 81 cases were of secondary infertility, 45 cases were of AUB, and 13 cases presented with postmenopausal bleeding. Among the primary infertility patients, 58.6% had abnormal findings on hysteroscopy, while among the secondary infertility patients, hysteroscopy revealed abnormalities in as high as 72.5% cases. In the present study, uterine synechiae was the most common abnormality detected among the infertile patients. Endometrial polyps were the most common pathology detected among patients with AUB and postmenopausal bleeding.

Hysteroscopy is a minimally invasive and highly safe technique to directly visualize the endocervical canal, uterine cavity, and tubal ostia. It has an added advantage of treating the pathology in the same sitting, thus improving the clinical outcomes. Based on our findings, we conclude that uterine pathologies are a major contributor in causing infertility and menstrual irregularities, which are missed on blind modalities like hysterosalpingography and dilatation and curettage.

This article stresses on the use of hysteroscopy as a primary diagnostic modality in evaluating patients of infertility, AUB, and postmenopausal bleeding in order to increase the detection rates of uterine pathologies.

Yadav G, Manchanda R, Pathak C. Hysteroscopic Management of Intrauterine Pathologies: A Case Series of 296 Patients. J South Asian Feder Menopause Soc 2017;5(1):35-40.

Cervical cancer is still one of the most common cancers affecting females in India, leading to a lot of mortality and morbidity. Since it is a preventable cancer, the study is aimed to assess the knowledge and awareness of cervical cancer and human papilloma virus (HPV) vaccine among medical students.

This is a cross-sectional study conducted among the medical students in a tertiary care center in Mahatma Gandhi Medical College & Research Institute, Puducherry, India. Three hundred students were administered a validated 53-point questionnaire regarding knowledge of cervical cancer, its risk factors, preventive measures, HPV vaccine, and screening tests. Data were kept confidential and the results were analyzed by Statistical Package for the Social Sciences software version 16.

The results show 93.3% of students were aware that cervical cancer is caused by HPV, but only 61.4% knew that HPV vaccine was available. Majority of the students were uncertain about age group, number of doses, and side effects of vaccine. Only 11.74% felt the need to get vaccinated in future; 96.64% of students knew that pap smear was used to screen for cervical cancer, but only 57.72% opted to screen themselves or family members in future as they believed that they were not at risk. The common obstacle against vaccination was worry about complications, inadequate information, and efficacy of vaccine.

The study showed that there were misconceptions among medical students regarding cervical cancer, vaccine, and screening, which have to be cleared. Creating awareness among health care workers on risk factors, vaccination, and current methods for cervical cancer screening is a necessary step toward implementing effective prevention programs in the society.

Rathod S, Samal SK, Samal S, Ghose S. Knowledge and Awareness of Cervical Cancer and Human Papilloma Virus Vaccine among Medical Students: A Cross-sectional Study. J South Asian Feder Menopause Soc 2017;5(1):41-44.

Yadav P, Gupta M, Agarwal M, Garg R, Verma U, Gupta S. Role of Imaging in Dilemma of Adnexal Masses in Postmenopausal Women. J South Asian Feder Menopause Soc 2017;5(1):45-50.

As there is dilemma for treatment of postmenopausal vaginal atrophy, effort has been made to review the literature for the same.

About half of all postmenopausal women will experience symptoms related to urogenital atrophy. Vaginal atrophy becomes clinically apparent 4 to 5 years after menopause, and subjective complaints as well as objective changes are present in 25 to 50% of all postmenopausal women.

Measures could be taken for not only treatment but also prevention of atrophy before symptoms become troublesome, but establishment of this prevention principle globally would require a formal cost-effective analysis and further research.

Treatment with local estrogen is simple, safe, and can transform a woman’s quality of life.

Women experiencing sexual and urinary symptoms as a consequence of vaginal atrophy should be diagnosed and treated without delay in order to avoid a cascade of events which do not resolve spontaneously.

Yadav P, Dayal M. Management of Postmenopausal Vaginal Atrophy: Review of Literature. J South Asian Feder Menopause Soc 2017;5(1):51-57.

Primary fallopian tube carcinoma is the least common gynecological malignancy encountered in practice. It accounts for about 1% of all cancers of a woman’s reproductive system, and it is more commonly seen in postmenopausal women. Transitional cell carcinoma (TCC) of the fallopian tube is a rare histological variant; only around 20 cases have been reported worldwide so far. The rate of preoperative diagnosis is in the range of 0 to 10%.

A 55-year-old P3L3 previous three normal vaginal delivery, postmenopausal for 6 years, type II diabetes mellitus patient presented with complaints of bleeding per vagina and excessive watery discharge per vagina for 6 months. Complete investigations and evaluation were done. Papanicolaou smear and endometrial aspiration were normal, and showed no evidence of malignancy. Taking age into consideration with duration of symptoms for 6 months, we went ahead with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Intraoperatively, right hydrosalpinx was noted. Postoperatively, histopathology revealed right TCC of fallopian tube stage Ta1 Nx M0. Patient had wound infection postoperatively and was treated with IV antibiotics. Once infection settled, patient was taken up for diagnostic laparoscopy with omental biopsy and cystoscopy with bladder wall biopsy, which showed no evidence of malignancy.

It is more common for other cancers to spread to the fallopian tubes rather than for cancer to begin there. This diagnosis is rarely considered preoperatively and is usually first appreciated at the time of operation or by a pathologist. If detected early, fallopian tube cancer can often be successfully treated.

Indumathi KPK, Bhuvana S, Vijayaraghavan J. Primary Transitional Cell Carcinoma of Fallopian Tube in Postmenopausal Women: A Case Report and Review of Literature. J South Asian Feder Menopause Soc 2017;5(1):58-61.

Leiomyoma arising from the vagina is a rare entity with varied presentations.

A woman 44 years of age presented with complaints of something coming out vaginally, polymenorrhea, and pain in abdomen. A mass arising from the right posterolateral wall of vagina was seen. Ultrasound reported it to be cervical fibroid. The mass was enucleated through vaginal route. Histopathology confirmed it to be a leiomyoma. Review of literature revealed that it has a varied presentation. Diagnosis is often missed.

The condition should always be kept in mind whenever coming across any mass in vagina.

Gupta M, Saini V, Jindal R, Kumari S, Nargotra N. Vaginal Leiomyoma: Case Report and Literature Review. J South Asian Feder Menopause Soc 2017;5(1):62-65.

Jarathi A, Ramamoorthy S, Mohan J. Krukenberg Tumor from Gastric Carcinoma presented as Acute Abdomen: A Unique Presentation. J South Asian Feder Menopause Soc 2017;5(1):66-68.

Bannur HB, Suranagi VV, Davanagere R, Pilli GS. Bilateral Ovarian Transitional Cell Carcinoma. J South Asian Feder Menopause Soc 2017;5(1):69-70.