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Patients may be responsible for copays and deductibles or out-of-pocket expenses based on the terms and conditions of their insurance plans. They often provide patients with new insight and valuable information about their own health. Patients also enjoy the additional time they spend with their physician and appreciate the support of other healthcare professionals. Follow Dr. If you're careening through midlife in crisis mode, this book will help you feel more confident about the changes that are occurring. The Cleveland Clinic Guide to Menopause is a compassionate, practical guide that gently reminds women that midlife is not only a time of change but also a time of great freedom.

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You'll learn about:. Thacker's new book is a compassionate, practical guide that gently reminds women that midlife is not only a time of change but also a time of great freedom. Appointments A Special Blend of Care for Women "While studying heart disease, I observed how women and men displayed different symptoms and responded differently to medications. Be Strong Be Healthy Holly Thacker says smear tests can boost chances of surviving cervical cancer. Watch the video. What We Treat Women are notorious for putting their healthcare needs behind those of everyone else.

Our Doctors. Filter by Close. Clear All Filters. Sort by Close. Speaking of Women's Health Be Strong Resources The Cleveland Clinic Guide to Menopause If you're careening through midlife in crisis mode, this book will help you feel more confident about the changes that are occurring. Vaginal lubricants can be recommended for subjective symptom improvement of dyspareunia Grade C. Vaginal moisturizers can be offered for vaginal dryness and dyspareunia Grade A.

Lifestyle modification, bladder drill, and pelvic floor exercises are recommended for urinary incontinence Grade B. Vaginal atrophy with ageing leads to dyspareunia. Acquired sexual desire disorder in some women responds to testosterone therapy. Formulations of testosterone for use in women are not available in India. Testosterone preparations meant for males should not be prescribed for women. Tibolone is a good option; since, it contains androgenic activity and can be used to treat libido problems. The incidence of CVD in Indian women has been noted to have significantly risen.

The prevalence rate of stroke is Use thiazide diuretics unless there is an absolute contraindication. Optimal lipid targets Grade A. The prevalence reported in the peri-menopause in India is Clinical conditions associated with IR include type 2 diabetes, CVD, polycystic ovary syndrome PCOS , non-alcoholic fatty liver, obstructive sleep apnoea, and certain cancers.

It is also a prominent feature of the metabolic syndrome. Effect of HT: A meta-analysis of pooled data from trials concluded that HT reduced IR, abdominal obesity, new-onset diabetes, lipids, BP, adhesion molecules, and procoagulant factors in women without diabetes and reduced fasting glucose and IR in women with diabetes. The effects were diminished by the addition of progestin Grade A. The basis of dietary recommendations is to reduce exposure to insulin both as a result of dietary stimulus and through decreased IR Grade B.

India has 63 million people with diabetes and is second largest in numbers, the first being China. The prevalence rates of diabetes in the last 30 years has increased from 2. Screening: Opportunistic screening for all women above the age of 30 years, every 3 years for younger women with risk factors Grade C. Diabetic women should be screened for hypertension, dyslipidemia, micro-albuminuria, and undergo yearly eye check. It may be indicated to evaluate the endometrium by transvaginal scan before starting HT. Hypothyroidism is much more common in older than younger individuals.

Symptoms and signs include lethargy, constipation, dry skin, alopecia, memory impairment, and depression. The individual is often obese and may have elevated cholesterol. Thyroid-stimulating hormone TSH is a good screening test. Anemia is common in the elderly people in India. Prevalence of iron-deficiency anemia, vitamin B12 deficiency, and folate deficiency is common, and should be an integral part of management of menopause.

In , there are 3. While the numbers are expected to double by , costs would increase 3 times. Prevalence of dementia is 0. The core mental functions are memory, communication and language, ability to focus and pay attention, reasoning and judgment, activities of daily living, and visual perception. Impairment of any two functions is suggestive of dementia B.

Many dementias are progressive, early diagnosis allows a person to get the maximum benefit from available treatments and provides an opportunity to plan for the future B. Factors that increase the risk of dementia are family history, genetic factor apolipoprotein E APOE , minimal cognitive impairment MCI , CVD risk factors, physical inactivity, diabetes, hypertension, dyslipidemia, smoking, obesity, autoimmune diseases, depression and stress, social engagement and diet, head trauma and traumatic brain injury, and age Grade B.

An objective marker is examination of CSF cerebrospinal fluid for amyloid beta or tau protein and phosphorylated tau protein concentration. ET is not currently recommended for reducing risk of dementia developing in post-menopausal women or retarding the progress of diagnosed AD A. For best preservation of memory and cognition, women should be advised about the importance of good overall health, good cardiac and vascular health, exercise, maintenance of active mind, avoidance of excessive alcohol consumption, and measures to reduce risk of diabetes and hypertension.

HT is not indicated for neuroprotection A. Introduction of accessible diagnostic and early stage dementia care services such as memory clinics is recommended Grade C. A detailed assessment of menopausal symptoms should always include questions about sleep pattern. Sleep questionnaires or sleep diaries can be useful to assess sleep in detail Grade C.

Adverse life-style factors, social factors, and risk factors should be considered and treated accordingly Grade C. If insomnia is identified, medical or psychiatric causes of insomnia should be ruled out and if present, treated accordingly. If specific neurological or breathing disorders are suspected, further investigations and referrals to specialists should be initiated Grade B.

Sleep hygiene measures and life-style modifications should be recommended as first line of treatment. If insomnia is resistant to life-style modifications, then hypnotics, benzodiazepines or melatonin agonists can be used in the short-term, but there is no definite or convincing evidence to suggest its efficacy. These should only be prescribed by supervision or after liaison with psychiatrists or sleep experts Grade C. No recommendations can be made about use of herbal remedies for insomnia as there is insufficient evidence. Mind body therapies such as yoga and tai chi have some evidence, but need further rigorous studies to prove its effectiveness Grade D.

The diagnosis of an osteoporotic fracture, the clinical end-point of osteoporosis is by the presence of fragility fracture clinical or by investigation and or by BMD [ Table 4 ]. Its value is expressed in SD units from the population mean in young adults T-score or from the mean in an age-matched population Z-score. The Z-score describes the number of SDs by which the BMD in an individual differs from the mean value expected for age and sex. It is mostly used in children adolescents and pre-menopausal women. Primary osteoporosis is seen in post-menopausal women in whom there is no specific pathogenetic mechanism other than age.

Bone is a dynamic tissue with a continuous remodeling leading to formation of new bone and absorption of old bone. A mismatch of this process forms the basis for osteoporosis while defective mineralization of the newly formed osteoid is called osteomalacia. Clinically, a fragility fracture can be defined as one that occurs as a result of minimal trauma, such as a fall from a standing height or less or no identifiable trauma. Osteoporosis is asymptomatic unless a fracture occurs. Early diagnosis in the asymptomatic period is and timely management of osteoporosis will prevent the associated morbidity and mortality.

In the absence of a validated population screening tool for post-menopausal osteoporosis in India, a case finding strategy utilizing clinical risk factors with the addition of DXA as needed is suggested Grade C. Opportunistic screening for women above 40 years is suggested. Risk assessment factors for fractures are derived by history and clinical examination.

It is important to distinguish between those risk factors, which lead to reduced bone mass from those which predispose to osteoporotic fractures with a BMD not in the osteoporotic range. Major risk factors defined by WHO are advancing age, prior fragility fracture, low BMI, family history of fracture, smoking, and more than three drinks of alcohol per day Grade A. Environmental factors include nutrition calcium intake using the quick dietary calculator, protein physical activity and sunlight exposure, which are important modifiable risk factors in India.

Relevance of risk of falling increases with ageing Grade B. Case finding for secondary osteoporosis is practiced in high-risk disease subgroups, such as chronic glucocorticoid users and patients with rheumatoid arthritis, collagen vascular disease, or inflammatory bowel disease, hypogonadism, thyroid dysfunction, type 2 diabetes Grade A. Women presenting with fracture complain of severe pain, which is sudden in onset with minimal trauma, or chronic pain localized to the mid back, may radiate to the abdomen.

Generalized bone pain indicates osteomalacia or metastasis. Physical examination should include the height and weight annually, check for balance and gait, get up, and go test by asking the women to get up from the chair without using their arms. Kyphosis and dowgers hump is seen in the late stage of osteoporosis Grade A. Laboratory studies [ Table 5 ]. For online use is available for India http: www.

FRAX is a validated and widely accepted tool used world-wide to identify patients in the osteopenia group most likely to benefit from treatment. It predicts the 10 year absolute risk for a fracture in an individual and the cost-effective analysis determines the interventional threshold above which treatment is cost effective.

All this is possible and valid when adequate data on the prevalence of osteoporotic fractures, mortality rates, and health economics data are available for the country. FRAX is country specific, and until more Indian data is available on the prevalence of osteoporotic fractures and mortality rates, the usage of FRAX in the Indian context for uniform guidance on intervention threshold is to be applied cautiously. Given the heterogenecity of Indian scenario, intervention thresholds and management may need to be individualized Grade C. Heterogeneity in different regions of the country and the prevalence of nutritional and other risk factors unique to the Indian population have not been considered in the calculation of FRAX R: Grade B.

It is suggested to conduct central DXA of spine and hip in all women 5 years beyond the natural age of menopause and in women than 5 years since menopause with 1 high clinical risk or more than 2 clinical risk factors. This suggestion is based on the following. Early age of natural menopause that is To monitor therapy - the interval to the next test should depend on the calculated individual risk and would mostly be scheduled between 1 years and 5 years later.

The diagnosis is based on central DXA of the spine, total hip, and neck of femur. Involves a population and a personalized-based approach. The target is primary prevention population-based , intervention, and rehabilitation individualized. Fracture risk is obtained by BMD both primary and secondary causes and the presence of clinical risk factors for osteoporotic fracture. For treatment purpose, combining BMD with clinical risk factors provides a better estimate of fracture risk. The term prevention and treatment in the context of osteoporosis has to be understood.

The term prevention is used to denote the prevention of bone loss in post-menopausal women with osteopenia T-score between 1 and 2. Treatment is defined as a reduction in fracture risk in post-menopausal women with osteoporosis. Life-style management: Balanced diet, adequate physical activity, exposure to sunlight, avoidance of bone depleting agents such as tobacco, alcohol, etc. Assess the total calcium intake from dietary sources and if needed, supplements are used to correct the deficient balance.

The risk of cardiovascular events, calculi are not observed with the recommended doses of calcium. The following tool depicted in Table 7 can be used for a quick calculation of daily calcium intake. Quick dietary calcium assessment chart: A tool for a quick assessment of total dietary calcium intake. Calcium content of Indian foods [ Table 8 ]. Low sodium intake: Daily salt intake should not exceed 5 g 1 tsp.

A cup mL of brewed coffee contains mg of caffeine and instant coffee mg while tea contains mg of caffeine. Caffeine stimulates the central nervous system and induces physiological dependency. In general, low doses mg of caffeine produce mild positive effects such as a feeling of wellbeing, alertness, and energy.

Vitamin D: Dietary sources are limited, adequate sunlight exposure has limitations and presently, food fortified with adequate vitamin D is unavailable in India. Urgent and cost-effective measures need to be implemented. Hence, it is recommended to use vitamin D as supplements Grade A. Recommendations for management of vitamin D deficiency and maintenance are: Grade B. Cholecalciferol vitamin D3 is available in the form of oral tablets and oral spray of IU and 2, IU. Injections of cholecalciferol are cost-effective may be recommended in cases of malabsorption and to increase compliance. The disadvantage is being an oily injection, it is painful, and since it is administered intramuscularly and can produce an erratic blood levels.

Cholecalciferol is the preferred therapy for correction of deficiency and maintenance. One IM injection of , IU is given to correct the deficiency. Maintenance therapy from natural sources or supplements is advised after correction of the deficiency. Cholecalciferol tablet or powder 60, IU once a month in summer or twice a month in winter. Patients should receive a multifactorial risk assessment and intervention because it is the most consistently effective strategy to prevent falls Grade A. Home hazard assessment and modification, exercise, and physical therapy are recommended to prevent falls and injuries from falls.

Biomechanics of posture and safe movements are a vital component of counseling Grade A. Frailty: Fried et al. Frailty-related falls and fractures have been reported with OR of 1. The prevalence of osteoarthritis in India as reported from a community dwellers in a small study conducted in Delhi was Those contributing factors should be addressed on a priority basis. Epidemiological studies of a potential role for estrogens in osteoarthritis showed two very different findings. First, estrogen deprivation at the menopause seems to be associated with increases in the frequency of knee, hip, and finger osteoarthritis, and in the severity of hip osteoarthritis.

Second, HT for the menopause may decrease the incidence and progression of hip and knee osteoarthritis. The identification of the alfa and beta estrogen receptors in normal and osteoarthritic cartilage and the effects of 17 beta estradiol on cartilage in vivo in animals and In vitro confirm that the cartilage responds to estrogens. Finally, this response is dose-dependent: Physiological doses as with HT are protective and higher dosages are deleterious. Once osteoarthritis sets in, there is no protection from HT and osteoarthritis takes its own course.

In such cases, osteoarthritis should be treated on its own merits. Age, weight, female sex, quadriceps weakness, and overloading of knee joint climbing stairs, squatting posture, etc. Those contributing factors should be addressed on priority basis. First two stages of osteoarthritis can be addressed by life-style modification, pharmacotherapy, and physical therapy Grade A. Third and fourth stages need surgical intervention for which total knee replacement is the gold standard Grade B.

Blindness was more likely with increasing age and decreasing socio-economic status, and in female subjects and in rural areas. The causes of blindness were easily treatable in Glaucoma is the most common cause of irreversible, but preventable blindness world-wide. Established risk factors for glaucoma are age, family history, diabetes, shallow anterior chamber, refractive status, and race Grade A. Blindness due to primary angle-closure glaucoma is potentially avoidable if this condition is detected early and peripheral iridotomy or iridectomy is performed.

This requires detection of occludable angles, which lead to primary angle-closure glaucoma, using slit-lamp examination and gonioscopy. Blindness due to primary open-angle glaucoma is more difficult to prevent and medication in open angle glaucoma could prevent the progression of the disease Grade A. There is increased risk of dry eye in both genders with age due to decreased tear production.

The incidence is more in women than men. Menopause also contributes to the ocular surface impairment due to hormonal imbalance. Improvement in the quality of cataract surgery, and increase in the number of surgeries on persons blind in both eyes. Effective control of diabetes and yearly eye checkup to prevent diabetic retinopathy. A population-based study Million Death Study cancer mortality in India: A nationally representative survey revealed that 1 in 22 men or women aged 30 years alive today in rural India is likely to die of cancer before 70 years of age based on the rates of actual deaths and in the absence of other disorders.

In urban areas, the risks are 1 in 20 for men and 1 in 24 for women. In India, breast cancer is the second most common cancer with an estimated , new diagnoses and the second most common cause of cancer-related deaths with 53, breast cancer deaths in The data from atlas project suggest that breast cancer in urban areas of India is 3 times higher than in rural parts of the country.

Modifiable risk factors are age at first child, breast-feeding, parity, obesity, physical activity, and menopausal HT. The debate about value of screening continues. There is no organized, systematic, government funded screening program for breast cancer in India. Clinical breast exams CBE every 3 years starting in the 20 s till 39, and annually thereafter mammographic screening annually starting at the age of 40 years.

BSE is performed by the woman herself and involves examination of the breast, skin, and axillae based on palpations by her hands. The woman should examine the look and feel of her breasts as well as any signs, symptoms or changes to the breasts. BSE is recommended so that women understand their breasts for detecting any suspicious changes over time.

Initially, BSE should be performed very frequently and regularly so that a woman understands the physiological changes that occur during the different phases of menstrual cycle and then continue monthly around 7 th or 8 th day of cycle. They are encouraged to report any recent or persistent changes. Nodular and lumpy feel of the breasts and increased pain and tenderness, which is a physiological finding prior to menstruation, needs to be explained to the patient.

Women can be taught to examine the breasts in any of the following ways in both supine as well as standing positions. CBE and increasing awareness of breast cancer are viable alternative in view of limited health-care resources and advanced stage of disease distribution for Indian women in age group less than 50 years of age.

For women between 50 years and 70 years of age, annual CBE and selective use of mammography, once in 3 years, in high-risk groups, determined by the above mentioned criteria has been found to be equally effective JNCI CBE is performed by the clinician or other health professional and involves a systematic examination of the breast skin and tissue.

The health professional is looking for signs and symptoms or if any changes occur, including development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction turning inward , redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. CBE should include all the 4 quadrants of the breast and the central nipple areola complex followed by examination of axilla and supraclavicular fossae. These findings are generalized and all lumps may not classically fit into these descriptions.

Normal breasts may feel lumpy and tender prior to menstruation, especially if felt with the tips of the fingers; hence, use of a flat hand is recommended. In India, breast cancer incidence peaks before the age of 50 years, and a recent review of the evidence in younger women aged years based on 8 trials conducted between and , suggests that mammographic screening is also beneficial in this younger age group.

Limitations of mammography in developing countries are economic constraints and quality assurance. Cost affectivity and false positives are the other limitations in the use of mammography in India. The decision to perform mammography should be determined with shared decision making about risks and benefits and by individual patient values. Role of PET Positron Emission Tomography imaging: PET has currently a limited role in breast can cer, due to its low sensitivity and is not recommended in most of the cases, especially in early disease.

The risk of breast cancer may be lowered to some extent by lifestyle changes, working on modifiable risk factors, and diligent use of HRT. Indications of risk reducing surgery, mastectomy, salpingo oophorectomy, and chemoprevention can be discussed with experts. The decision is individualized. Cervical cancer is the leading cause of cancer death in women in both rural and urban areas. By contrast, the risk of dying during the pregnancy for Indian women aged years is about 0. About 1, 34, new case are being diagnosed every year. Risk factors: HPV-Human Papiloma Virus, sexual intercourse at an early age, multiple sexual partners, sexual partners who have had multiple partners, HIV positive status, and smoking.

In India, currently only 4. Geneva: WHO; and 2. The first three are useful at community and low resource setting whereas, the last three are still in the experimental phase. Cytology-based screening has made little impact in developing countries due to relatively high false negative rate and lack of organized screening program and referral pattern. This unique approach is based on the principle that the screening test should provide rapid and accurate results and the treatment modality should be appropriate, adequate, and effective.

VIA and cryotherapy satisfied these criteria and yielded satisfying results. A randomized trial in South India done by Sankaranarayanan et al. This can be carried out both by physicians and trained nurses and mid wives. HPV testing also has been tried in a screen and treat approach. However, it has two limitations - time and infrastructure required for current HPV testing and a lack of consensus about appropriate follow-up for test positives and also treatment strategy.

Some studies suggest that cryotherapy is protective against the future development of cervical disease among women with current HPV infection. Because of this, and due to the low morbidity of cryotherapy, the occasional treatment of screen-positive women without confirmed cervical disease is acceptable. Applicability of screening techniques at different settings both in rural and urban [ Table 11 ]. HPV co-testing is to be performed only if the woman crosses 30 years of age as most of the HPV infection clears by then with natural immunity.

Colposcopy: For screen-positive women, post any primary screening method adopted, for diagnostic confirmation with guided biopsies. Because of hormonal changes, many post-menopausal women will have an unsatisfactory colposcopy. Estrogen treatment estrogen cream application intra-vaginally each evening for 4 weeks and stopped 1 week before repeat cytology will cause enough ectropion of the endocervical cells to result in a satisfactory examination. Screening recommendations from different organizations [ Table 12 ]. All these screening methods may be sometimes inconclusive in menopausal women whose transformation zone is inside the cervical canal or due to atrophic changes.

Hence, choosing the appropriate test is important. High-risk oncogenic HPV DNA testing could be adopted for appropriate triage management of post-menopausal women with unequivocal cytology results. In the event of availability of low-cost and rapid HPV testing as primary screening test every 5 years up to the age of 65 is recommended. Above recommendation holds true for women seeking opportunistic services in apex and secondary care levels in public and private sector health facilities where good quality PAP cytology services and molecular testing for HPV DNA are available. In the absence of organized cervix cancer screening for the vast women population in rural and urban areas, once in a life time screening by contesting by combined use of cervical cytology and high-risk HPV DNA testing would be appropriate.

Women should be educated early on to think of cervical cancer as an extension of a sexually transmitted disease. Behavioral changes to reduce the risk of cervical cancer include limiting the number of sexual partners, delaying initial age of sexual intercourse, and avoiding sexually transmitted disease. The association of cigarette smoking with cervical cancer should also be emphasized. An HPV vaccine needs to be promoted especially in the age group of 9 years to the age of first sexual debut. Indian incidence of EC: 4. Overall morbidity and mortality of EC is low because most patients present at an early stage because of abnormal bleeding or PMB.

A strong influence of modifiable risk factors such as increasing obesity, life expectancy, and adjuvant tamoxifen use for breast cancer has been attributed. Adenomatous and atypical hyperplasia are the common precursors of endometrial carcinoma. Factors that increase the risk of EC are those associated with increase in endogenous estrogens or HT with estrogens.

Unopposed ET in women with an intact uterus increases the risk of EC 2- to fold, and risk increases with duration of use. Relative risk of EC with obesity is 3. Women taking tamoxifen for more than 2 years have a 2. There is no evidence that screening by ultrasonography e. There is no indication that screening for EC is warranted for women who have no identified risk factors.

It is recommended that, at the time of menopause, women at average risk should be informed about risks and symptoms of EC, and strongly encouraged to report any unexpected bleeding or spotting. For those with increased risk and special situations such as on HT, genetic risk, and on tamoxifen therapy should have a complete diagnostic evaluation for abnormal bleeding.

Regular screening for high-risk group for endometrial carcinoma has not been fully evaluated. The most common sign of ovarian cancer is enlargement of the abdomen caused by accumulation of fluid or a large ovarian mass. However, many women have bloating or weight gain in the abdominal area, making this sign non-specific. In women over 40, digestive disturbances that persist and cannot be explained by any other cause indicate the need for a thorough evaluation for ovarian cancer, including a carefully performed pelvic examination and ultrasound. Screening: No screening guidelines are available for mass screening for ovarian cancer.

Recommendation for screening is dependent on the risk status of women. A heightened awareness of the symptoms of early ovarian cancers on the parts of the patients and practitioners may help to reduce the delay in diagnosis and hopefully result in an improvement in outcome of some progress.

For general population - annual pelvic examination, PAP smear, and transvaginal sonography are recom-mended as a part of post-menopausal surveillance.

Primary prevention: Limited data are available on the efficacy of prophylactic oophorectomy in decreasing the risk of ovarian cancer in mutation carriers. Still, it is recommended that prophylactic surgery be considered in BRCA mutation carriers who have completed childbearing. The median age of onset is approximately years for invasive cancer and approximately years for carcinoma in situ. Risk factors for vulvar cancer include the following: HPV, previous genital warts, greater number of sexual partners, current smoking, abnormal PAP smear, diabetes, obesity, chronic vulvar pruritis, and poor personal hygiene have also been suggested as contributing to risk.

Protected intercourse, monogamy, and adequate hygiene of the external genitalia protect against vulvar cancer. Prevention and detection: The prevention of vulvar cancer rests in the avoidance of risk factors and application of protective factors as summarized above. Annual examinations should be performed to check for vulvar cancer. High-risk patients should be examined every 6 months. White lesions and chronic ulcerative lesions should be biopsied for evaluation.

In women aged years, the second most common fatal cancers were stomach Stomach cancer rates were higher in rural than in urban areas of India due to increased prevalence of chronic Helicobacter pylori infection. Million death study cancer mortality in India: A nationally representative survey This may include stomach and primary liver cancer. This underscores the importance of vaccination, control of infection. Use of tobacco in pan and beedi should be strongly discouraged. This is probably an overestimate for the study did not differentiate between natural, surgical or secondary causes.

Menopause occurring at an age less than 2 SD below the mean estimated age for the reference population is called as premature menopause. Diagnosis is established by hormone analysis repeated 1 month apart. Appropriate counseling, life-style modification and HRT form the mainstay of treatment. HRT should be started as early as possible in women with POF and continued till age of natural menopause. Androgen replacement should be considered for women with persistent fatigue, loss of libido in spite of estrogen replacement.

No evidence that HT increases risk of breast cancer, CVD or dementia, over and above that found in menstruating women with a normally timed menopause. The exact prevalence of surgical menopause is not known, but varies in the rural to urban areas and across states. A significant number of hysterectomies along with bilateral oophorectomies are performed at a young age. This trend of unwarranted hysterectomies and surgical castration for fear of cancer by the professional and the women should be discouraged. There is wide diversity in awareness, about public health problems and QOL among both physicians and population.

Women who need oophorectomy before menopause should be counseled about the risk of surgical menopause. Routine HT is not recommended for surgical menopause in post-menopausal women as primary prevention for chronic conditions. HT should be considered in women less than 50 who have undergone surgical menopause. Clinical examination includes a holistic approach to health, rather than simply looking for features of menopause in isolation and this leads to diagnose the latent and overt NICD.

Non communicable disease. Examination can be broadly divided into three main categories:. General physical examination: Examination of respiratory, cardiovascular system, and bones may detect common age related problems. Breast examination: This should be carried out regularly due to an increased risk of breast cancer as women get older. Pelvic examination: This is performed to assess for complications of menopause, such as urogenital atrophy and must include PAP smear.

Relevance of risk of falling increases with ageing. R Grade A. Risk factors for coronary heart disease: Pre- maturemenopause, hypertension, dyslipidemia, homocystenemia, lipoprotein a , high-risk CRP, DM, obesity, sedentary life-style, smoking, and metabolic syndrome. Risk factors for DM: Advancing age, obesity, family history, hypertension, dyslipidemia, personal history of gestational DM or impaired glucose tolerance, PCOS, and physical inactivity. Risk factor for deep vein thrombosis: Personal or family history of clot, if so, when and why?

Prolonged immobilization-surgery or while pregnant or on the contraceptive pills. Any tests to confirm the clot history of the treatment with anticoagulants. Risk factors for stroke: Hypertension, diabetes, smoking, obesity, atrial fibrillation, asymptomatic carotid stenosis, and hyperlipidemia.

Polypharmacy and thyroid disease are two examples of reversible causes of memory loss in older adults. These are necessary to establish the diagnosis, determine etiology, and screen for complication. Some investigations may be necessary to perform for diagnosis or to help in formulating a treatment plan. Today, the art of medical counseling and translating the statistics in simple language is an important part of the consultation.

If a therapy is chosen, the patient and clinician should agree on the goals, risks, and benefits, whether they are short-term menopause symptom relief , long-term primary or secondary prevention of diseases associated with aging , or both. The clinician should review the decisions about menopause management with the patient at subsequent visits.

The National Institute of Nutrition plan for an adult sedentary woman is a good strategy for healthy living [ Table 14 ]. Physical exercise helps to maintain a healthy weight, improves bone density, coordination and balance, muscle strength and joint mobility, lipid profiles, genitourinary problems, relieves depression, and induces sleep.

Combination of exercises, diet, and yoga helps the post-menopausal women to increase her metabolic rate and maintain a healthy weight. Social interactions either in an exercise program or otherwise, help the post-menopausal women to improve mood, relieve depression, and anxieties. Hepatitis B vaccination is indicated for all unvaccinated adults at risk for HBV infection and all adults seeking protection from HBV infection including post-exposure prophylaxis.

Pre-vaccination screening in general population has not been found to be cost-effective in India Level B. The expert group of Association of Physicians of India recommends vaccination of the entire community at risk during an outbreak situation Grade B. Two doses of varicella vaccine are strongly recommended in adults at increased risk for exposure of varicella Grade B. Non-hormonal prescription agents may relieve VMS, but have their own side effects. These can be considered when HRT is contraindicated or not desired. Complementary and alternative treatments should be advised with caution as the data is still insufficient, especially in moderate to severe VMS Grade A.

Awareness should be created regarding the phytoestrogens and lycopene rich foods in the Indian diet. It is recommended to validate the effects of locally used herbs in the Indian context, according to modern medicine and prescribe them rationally using clinical research tools and well-designed and documented RCTs.

Whilst prescribing or recommending herbs, it would be essential to fully inform the women that very little human data is available on the usefulness of these formulations and side-effects of the herbs have not been studied. It is important to read labels to determine isoflavone content and to warn them that in India, there are no regulations to ensure the content or quality of such products Grade C.

HT covers therapies including estrogens, progestogens, combined therapies, androgens, and tibolone. Three indications for post-menopausal HT, which have constantly withstood the test of time, derived from the results of various clinical trials are the beneficial effect of estrogens on symptom relief, urogenital atrophy, and bone. Surgical menopause continued VMS despite estrogen replacement, decreased wellbeing despite estrogen replacement, and acquired sexual desire dysfunction.

Progesterones or Low dose oral contraceptive pills can be used in the menopause transition phase for relief of symptoms Grade A. Vaginal ET is most effective in the treatment of urogenital atrophy. Low dose vaginal preparations are as effective as systemic therapy. Some women on oral ET may require additional local therapy Grade A. Recurrent attacks of atrophic vaginitis require the use of the smallest effective dose over a period of time.

After control of acute symptoms, the dose of local estrogen can be tapered for long-term maintenance therapy. Treatment may be continued indefinitely, although safety data from studies do not go beyond 1 year Grade C. Recurrent urinary tract in this age after ruling out other causes may benefit from the local application of ET Grade A.

Obstetrics and Gynecology – Menopause: By Fiona Mattatall M.D.

Progesterone supplement for endometrial protection is not needed along with the use of vaginal estrogen Grade C. Endometrial surveillance is not necessary in low risk asymptomatic woman. Unscheduled bleeding should be investigated by an ultrasound and endometrial biopsy Grade A. HT should not be started solely for bone protection after 10 years of menopause. Extended use of HT in women with reduced bone mass is an option after considering the risk benefit analysis compared to the other available therapies for osteoporosis.

The bone protective effect is lost after stopping HT Grade B. HT should be offered to women with POF or early menopause and it can be recommended until the age of natural menopause Grade C. Estrogen can be prescribed to enhance mood in women with depressive symptoms. The effect appears to be greater for perimenopausal symptomatic women than for post-menopausal women Grade A.

Estrogen benefits verbal memory over the short period when initiated soon after surgical menopause Grade B. HT in the early menopausal period improves QOL by its effects on vasomotor and urogenital symptoms, improvement on sleep, and mood Grade B. All preparations including low dose, non-oral routes of estrogen are effective in symptom control and in preserving bone mass.

In women with hypertriglyceridemia, obesity, glucose intolerance, history of deep vein thrombosis, and tobacco users, non-oral route should be the preferred Grade B. Women who have general risk of breast cancer can be prescribed HT according to their need after a detailed history, examination, and counseling. They should be provided information about breast cancer risk with HT as per evidence. Women who are at high-risk of breast cancer also can be prescribed HT after risk benefit analysis. HT does not appear to influence the clinical pattern of benign breast disease in a post-menopausal woman Grade C.

Center for Specialized Women's Health

Use of HT in breast cancer survivors is debatable. It is recommended to use non-hormonal therapies. HT Hormone Therapy given to women below the age of 60 or within 10 years of menopause, the risks are rare. The tables below two elaborate the benefits and risks in terms that can be easily communicated during counseling. Based on WHI: number of less events on estrogen vs. Progesterone in adequate dose should be supplemented along with oral estrogens in women with uterus Grade A. Pre-HT work-up and an annual follow-up are essential when prescribing HT. The dose and duration of use of HT should be individualized and a risk-benefit assessment carried out annually.

A full gynecological assessment is mandatory prior to starting HT and at regular intervals thereafter. Self-breast examination is advised monthly and CBE at least annually. Premature menopause-HT can be prescribed up to the natural age of menopause; further continuation of therapy is a shared decision between the woman and the physician according to the indication and the need Grade C. Role of extended use of HT is a shared decision between the woman and the physician and may be considered in cases of recurrence of symptoms after stopping therapy, in cases of management of osteoporosis when other therapies are contraindicated Grade A.

Minimum effective dose is the principle to be followed while prescribing HT. The potency needed by the woman may change over time. After starting standard dose therapy, dose can be lowered and maintained accordingly. Low dose and ultralow dose therapy are effective in relieving symptoms and increasing bone mass.

Transdermal estrogen has a neutral effect on triglycerides, CRP, and sex hormone binding globulin and is preferable for use in women with hypertriglyceridemia, obesity, glucose intolerance, high-risk of deep vein thrombosis, and tobacco users. HT should not be prescribed for primary or secondary prevention of CVD. However, healthy women within 10 years of menopause tend to have a lower risk. Standard dose oral HT increased stroke risk by about one third in generally healthy post-menopausal women Grade B. Low dose ET may not increase the risk of stroke Grade C. Estrogen alone increases percentage mammographic density, not as much as estrogen and progesterone together Level A.

Estrogen increases the risk of breast cancer after more than 5 years of use, particularly in recently post-menopausal women Level B. It falls under the rare category. Use of estrogen for less than 5 years may reduce the risk especially in women who start HT many years after menopause Level B. The risk returns to approximately that of non-users within 3 years of cessation Level B. Available data is of low quality and conflicting regarding the risk of breast cancer relating to use of androgens Level D. Prospective randomized double-blind trials are needed Level D.

It reduces the risk of breast cancer in post-menopausal women Grade B. Route of administration: Transdermal administration has reduced risk of blood clotting VTE risk compared to oral administration. Progestin: Side-effect profile of various progestins may play a clinical role in selecting the optimum treatment regimen. Natural progesterone is a choice. Tissue selective estrogen complex TSEC : Newer formulations of combination therapy of estrogen and selective estrogen receptor modulators are soon to be available.

Tibolone is a selective tissue estrogenic activity regulator. It is a synthetic steroid compound, which has estrogenic, progestogenic, and androgenic properties. It has an estrogenic effect on bone, inhibiting bone resorption by reducing osteoclastic activity. Tibolone is approved in 90 countries to treat menopausal symptoms and in 45 countries to prevent osteoporosis.

Tibolone is prescribed in a single daily dose of 2. A lower dose of 1. It should be prescribed 1 year after amenorrhea Grade A. Tibolone reduces the risk of vertebral and non-vertebral fracture in older osteoporotic women. Tibolone prevents bone loss and is as effective as standard doses of conventional post-menopausal HT. Tibolone increases lumbar spine and total hip BMD to a statistically significantly greater extent than raloxifene Grade A. It does not induce endometrial hyperplasia or carcinoma in post-menopausal women Grade A. Tibolone may be preferable to HRT in symptomatic menopausal women with mammographically dense breast tissue Grade A.

Tibolone should not be used in breast cancer survivors as it increases the recurrence risk Grade A. Tibolone should be used with caution in women over 60 years and should not be used in those who have strong risk factors for stroke Grade A. Selective estrogen receptor modulators, e. Raloxifene can be used as therapy for the prevention and treatment of osteoporosis especially for women with an increased risk of breast cancer Grade A.

Other side-effects include hot flushes, which are more likely in the perimenopausal period, and leg cramps. Indian health-care system is one of the most privatized systems where government spends much less and individual has to pay for health insurance. Insurance may be described as a social device to reduce or eliminate the risk of life and property. Under the plan of insurance, many people associate themselves by sharing risk, attached to individual insurance plan that covers only health-care costs and is called health insurance. It is indeed very important to enroll in any of the good health insurance schemes for a secure future.

Health-care insurance provides a cushion against medical emergencies. Most companies stop enrolment after years of age. Indirect costs include laboratory testing, management of adverse events, loss of productivity at home and at work, and treatment of associated medical disorders.

Rates prevailing in different regions of India are compared and the preliminary cost without medication is found to a range between Rs. Various oral estrogen and tibolone preparations are available in Indian market, cost of which ranges from Rs. Local and transdermal estrogen preparations are scarce in Indian market, cost of which ranges from Rs. Various oral and non-oral progesterone preparations are available in Indian market, cost of which ranges from Rs. Various groups of molecules are available for prevention and treatment of osteopenia and osteoporosis.

Cost of therapy varies according to the indication whether they are prescribed for prevention or treatment of osteopenia or osteoporosis. Alternative and complimentary medications are usually not considered to be part of mainstream medicine, but are popularly available in Indian market, cost of which ranges from Rs. Menopause is a time of significant changes, which often have a negative impact on QOL.

Comprehensive Management of Menopause | Paul Lorrain | Springer

However, it is possible to live well with menopause. Adopting a healthy life-style is cost-effective. National Center for Biotechnology Information , U. Journal List J Midlife Health v. J Midlife Health. Author information Copyright and License information Disclaimer. Indian Menopause Society, Hyderabad, India. Address for correspondence: Dr. E-mail: moc. The text of the unpublished references can be procured from Dr.

Meeta at moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. To stimulate interest in research on all aspects of menopausal medicine. System for grading: Evidence used in the document The quality of evidence and the level of recommendation were done using the Grades of Recommendation, Assessment, Development, and Evaluation system. Grades of evidence High quality Grade A: Further research is very unlikely to change our confidence in the estimate of effect.

Very low quality Grade D: We are very uncertain about the estimate. Revision of the guideline It is recommended that the Guidelines are upgraded every 5 years. Editorial independence The views expressed are independent of any extraneous influences. Open in a separate window. Flowchart 1. Flowchart 2. Contraception Table 2 Risk of deaths with contraception compared to no contraceptive method.

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Perimenopausal bleeding PMB Common cause of PMB is due to atrophic changes in the vagina and the endometrium. Quality of life QOL VMS Urogenital symptoms Sexual problems Sexual dysfunction is multifactorial and needs to be addressed accordingly. Non-communicable diseases CVD Prevention and management Life-style interventions Grade A. HT is not indicated solely for primary or secondary cardio protection Grade B. The metabolic syndrome: Insulin resistance IR Table 3 BMI category.

DM Risk factors: Ref Section IV - Thyroid disease Anemia Screening and diagnosis Management Universal recommendations Table 7 Quick dietary calcium assessment chart: A tool for a quick assessment of total dietary calcium intake. Table 8 Calcium content of Indian foods. Maintenance therapy Cholecalciferol tablet or powder 60, IU once a month in summer or twice a month in winter. Vitamin D derivatives: Calcitriol, the active form of vitamin D is reserved only for patients with chronic renal and hepatic disease Alfacalcidol is a synthetic analog of the active vitamin D metabolite calcitriol 1,dihydroxyvitamin D3 , and it is metabolized to calcitriol by its hydroxylation in the liver.

It is less potent than calcitriol. The use of vitamin D derivatives necessitates monitoring of serum and possibly urine calcium. There is the risk of hypercalcaemia and hypercalciuria. Adverse effects of prolonged hypercalcemia include impairment of renal function and nephrocalcinosis. The sunlight between 11 am to 2 pm is preferably the best. In post-menopausal women, the intake of vitamin D should be in addition to sunlight exposure.

Interestingly, exposure to complex nutrients and food constituents interact to affect bone mass, it is, however, left to individual clinician to decide on supplementing vitamin A, vitamin B12, and phytoestrogens Grade B. Prevention of falls xv. Flowchart 3. Treatment algorithm for postmenopausal women asymptomatic woman. Flowchart 4. Treatment algorithm for postmenopausal women with fragility fracture. Frailty Osteoarthritis Eye Table 10 The causes of blindness. Glaucoma Dry eye Prevention of blindness: Improvement in the quality of cataract surgery, and increase in the number of surgeries on persons blind in both eyes Effective screening to detect refractive error blindness and provision of spectacles Initiation of long-term strategies to prevent corneal and glaucoma blindness Effective control of diabetes and yearly eye checkup to prevent diabetic retinopathy.