|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 1 | Page : 49-50
Commentary on following of Menopausal Guidelines by practitioners in Indian setting
Sagar Borker1, Shruthi Bhat2
1 Department of Community Medicine, KVG Medical College, Sullia, Dakshina Kannada, Karnataka, India
2 Department of Anatomy, KVG Medical College, Sullia, Dakshina Kannada, Karnataka, India
|Date of Web Publication||24-Feb-2014|
Department of Community Medicine, KVG Medical College, Sullia, Dakshina Kannada, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Borker S, Bhat S. Commentary on following of Menopausal Guidelines by practitioners in Indian setting. J Mid-life Health 2014;5:49-50
I went through the April-June 2013 issue of Journal of Midlife Health. I congratulate the Indian Menopause Society for taking pains to complete this herculean task and for having come up with the guidelines, the absence of which was felt for a long time in Indian settings. In the course of this process we went through article titled "A study of quality of life among perimenopausal women in selected coastal areas of Karnataka, India". 
Regarding this article we thought that the period called premenopausal period needed to be specifically mentioned in the study as even a female of 20-40 years may also be considered to be premenopausal. The definitions of premenopausal, perimenopausal and postmenopausal lady needs to be made clear. The guidelines , refers to a premenopausal period as the entire reproductive period up to the final menstrual period. Perimenopausal period refers to the period immediately prior to and up to 1 year after the final menstrual period. It may last as long as 3-5 years. Since the article was published before the guidelines and no references of the guidelines have been mentioned, the authors should have explained these definitions precisely. This would have made things clearer to the readers. Now in the presence of the guidelines, the definitions are appropriately clarified. Title of the article states that selected coastal areas of Karnataka were chosen for conducting the study. Accordingly, a similar study should have been carried out in central Karnataka to know the difference between the symptom prevalence in central and coastal Karnataka. This could have been mentioned in the recommendations section otherwise the word coastal which is unimportant should have been omitted from the title. If kept in the title the readers might feel that the symptoms experienced by lady might be confounded by the location of the area. If such thing is possible suitable reference is necessary. Furthermore, in the study, women from local community, various women organizations, self-help group are included in the study. This description does not give a complete representative picture of the total women in that locality. The very basis behind setting guidelines in India was due to inaccessibility of treatment of menopausal symptoms by Indian ladies especially those who do not get themselves treated for the symptoms. Hence by omitting housewives and other unemployed women or women employed in unorganized sector correct representative sample has not been obtained. Thus according to my opinion we cannot call it a community-based survey but just a purposively sampled study carried out in an organizational setting. The second inclusion criteria as quoted by the author is that the study subjects were included in the study based on their menstrual history (to assess menopausal states) and their experience of menopausal symptoms by using the questionnaire. We interpreted that as those study subjects with bad menstrual history like menorrhagia or dysmenorrhea were only asked to tell about their experience of menopausal symptoms by using the questionnaire. The others who did not suffer from complaints were not included in the study. Since, this study assesses the prevalence of these symptoms then omitting those without symptoms, can only reveal the symptom profile and not the prevalence. Authors may kindly clear this point, enlighten us about the links between menstrual history and menopausal states through systematic reviews if available.
The result section mentions, out of 209, 200 were married and 8 were separated but what about the last study subject who has not been classified under any marital status. Again the marital status percentage does not add to 100%. In the discussion section last paragraph, the author mentions that in one women population, as a preliminary study 12 week yoga therapy protocol was implemented which included asanas , pranayama and meditation. The initial results were very encouraging with highly significant improvement in perimenopausal symptoms. No mention of this is done in methods section. To conclude another study needs to be carried out or a suitable reference needs to be quoted that yoga is beneficial. Unlimited references can be found on this topic. To quote one of these, in the article titled "Yoga and menopausal transition"  it is found that even short-term yoga can decrease both psychological and physiological risk factors for cardiovascular disease and may reduce signs, complications and improve the prognosis of these with clinical and underlying disease. Meditation increases plasma melatonin levels and it seems that melatonin effectively improves sleep quality. In discussion it is mentioned that for population with high incidence of vasomotor and sexual symptoms, hormonal treatment may be more beneficial while for predominant physical and psychosocial symptoms other alternative treatment may be better. No reference is quoted for such important statement and author may kindly evaluate the accuracy of this statement. According to the guidelines mentioned by Menopausal Society of India , the Grade(A) guidelines are enlisted as follows-
Most effective treatment for menopausal symptoms is hormone replacement therapy (HRT) or low grade Oral Contraceptive OC pills can be used in the menopause transition phase for relief of symptoms. Tibolone may be used for Indian women who complain of libido problems. Vaginal moisturizers can be offered for vaginal dryness and dyspareunia. Vaginal estrogen therapy is most effective in treatment of urogenital atrophy. Estrogens can be prescribed to elevate mood in women with depressive symptoms. The effect appears to be greater for perimenopausal symptomatic women than for postmenopausal women. A meta-analysis of pooled data from 107 trials concluded that HRT reduced insulin resistance, abdominal obesity, new onset diabetes (DM), blood pressure, adhesion molecules and pro-coagulant factors in women without DM and reduced fasting glucose and insulin resistance in women with DM. The effect was diminished by the addition of progestin. Long standing HRT is beneficial if prescribed for >5 year in osteoarthritis (OA). First two stages of OA can be addressed by life-style modification, pharmacotherapy and physical treatment. ,
In the methodology section the areas whether the study was carried out, i.e., the study setting has not been described appropriately by the authors. Was the study setting close to the health care facility or Medical College or far away? This needs a special mention since accessibility and availability of healthcare facility will determine the acceptance by women at least in the age group mentioned in the study in Indian settings.
To conclude, I feel strongly that The Indian Menopause Society guidelines should be used as a reference in future for the purpose of conducting scientific studies in Indian settings. These concepts need to reach each and every doctor treating patients with menopausal complaints in India so that no lady goes home untreated Thus, there is an urgent need for future authors to follow the guidelines meticulously and thoroughly to avoid ambiguity.
| References|| |
|1.||Nayak G, Kamath A, Kumar P, Rao A. A study of quality of life among perimenopausal women in selected coastal areas of Karnataka, India. J Midlife Health 2012;3:71-5. |
|2.||Meeta, Digumarti L, Agarwal N, Vaze N, Shah R, Malik S. Clinical practice guidelines on menopause: An executive summary and recommendations. J Midlife Health 2013;4:77-106. |
|3.||Meeta, Harinarayan CV, Marwah R, Sahay R, Kalra S, Babhulkar S. Clinical practice guidelines on postmenopausal osteoporosis: An executive summary and recommendations. J Midlife Health 2013;4:107-26. |
|4.||Vaze N, Joshi S. Yoga and menopausal transition. J Midlife Health 2010;1:56-8. |