Sonia Malik

Clinical practice guidelines on menopause: *An executive summary and recommendations

Guidelines are a method of translating the best available evidence into clinical, communicable, organizational, and policy making statements in the hope of improving health‐care and/or policies. Unlike protocols, guidelines are meant to aid the clinician in decision making. Do we need country‐specific guidelines? Yes, we do, given the fact that the model of health‐care delivery system and the prevailing environment of one country may not be extrapolated to that of another.

Levonorgestrel intrauterine system: Current role in management of heavy menstrual bleeding.

A review of literature was conducted to report on the effectiveness of levonorgestrel intrauterine system (LNG-IUS) in women with heavy menstrual bleeding (HMB). The relevant data were obtained by computerized searches of PubMed up to December 2012 and other references available with the authors. Information was obtained from references listed. Studies and case reports were excluded if they did not specifically provide information about LNG-IUS usage in women with HMB. After perusal, each relevant publication was summarized and appraised in terms of whether it contained information relevant to the stated objective. Available data shows that LNG-IUS therapy is effective and safe, providing significant reduction of menstrual bleeding in patients with HMB. LNG-IUS is a good strategy to reduce the number of hysterectomies in women with HMB.

Are women satisfied when using levonorgestrel-releasing intrauterine system for treatment of abnormal uterine bleeding?

Aim: To determine the efficacy of levonorgestrel intrauterine system (LNG IUS) in treatment of abnormal uterine bleeding (AUB) in women over 35 years and to determine satisfaction of users of LNG IUS in case of AUB. Materials and Methods: This was a multicentric, retrospective, and observational study. Case records of patients with AUB from the hospitals in Pune, Delhi, and Gurgaon for the last 6 years were examined. Records of 80 women who had an LNG IUS inserted were included. The chief complaints and their duration were recorded. Investigation results, histopathology reports, and date of LNG IUS insertion were noted. The incidence of spotting, heavy menstrual bleeding, pain, expulsion, and amenorrhea were recorded at 3, 6, 12, and 18 months following treatment. Following this a telephonic interview was conducted to determine the efficacy of LNG IUS in treating the symptoms. Patients’ satisfaction in percentage was also noted and they were asked if they would recommend the LNG IUS to other women. Results: The mean age of women was 42.3 years. 77.5% of the women had menorrhagia as the chief complaint, and the mean duration was 12 months. Fibroids and adenomyosis were the most common pathology, present in 21.3% and 20% of the patients respectively. At 3 months, spotting seemed to be the predominant symptom (59.4%) and only 15% women had heavy bleeding. 49.3% of women were asymptomatic at 6 months. 27.5% had amenorrhea by the end of 18 months. 14 women in whom the device was expelled or removed due to persistent symptoms, underwent hysterectomy at various stages during the study period. Overall patient satisfaction was high at about 80%. Furthermore, 73.8% patients agreed to recommend it to other women. Conclusion: LNG IUS seems to be a viable and effective treatment option for AUB in women after 35 years. There is a high rate of patient satisfaction in appropriately selected patients.

Management of Polycystic Ovary Syndrome in India

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrinopathy affecting women.[1] It has an unknown etiology and is recognized as a heterogeneous disorder that results in overproduction of androgens, primarily from the ovary, and is associated with insulin resistance (IR).[1] The Rotterdam 2003 criteria defines PCOS as incidence of any two of the three key criteria, namely, oligoovulation and/or anovulation, excess androgen activity and polycystic ovaries(PCO).[1,2] However, the terminology used in the context of PCOS needs to be revisited to reflect the actual clinical nature of PCOS.

Clomiphene citrate usage pattern in India: A knowledge, attitude, and practice survey among gynecologists

Introduction: Clomiphene citrate (CC) has an important place in therapy for management of ovulatory dysfunction. The objective of the present survey was to understand the knowledge, attitude, and practice (KAP) of Indian gynecologists toward the use of CC. Materials and Methods: A prospective, cross-sectional, observational, questionnaire-based KAP survey conducted among Indian gynecologists. Out of 22 multiple-choice questions (MCQs), 9 questions were related to efficacy, 5 to safety, and 8 to perception about CC usage in routine clinical practice. Data were summarized by percentages in frequency tables and graphs. Results: Seven hundred seventy-one gynecologists in total across India participated in this survey. The majority of the participants preferred CC in treatment of ovulatory dysfunction associated with polycystic ovary syndrome (PCOS). The ovulation rate was reported to vary 21-60% and the pregnancy rate was noticed to be 11-30% by the majority of the participants. CC was reported to have very good to excellent efficacy and tolerability. Resistance to CC was encountered sometimes. Commonly encountered adverse effects included abdominal/pelvic discomfort or pain, ovarian enlargement, and nausea and vomiting. Frequent complications included multiple gestation, ovarian hyperstimulation syndrome (OHSS), and spontaneous abortion. Quite a few doctors reported congenital malformations with CC therapy. A majority of participants preferred CC in a dose of 50-100 mg/day for 5 days starting on the second or third day of the cycle. Most participants advised natural conception to patients receiving CC therapy. Metformin and gonadotropins were the preferred drugs coadministered with CC treatment. Conclusion: The present KAP survey highlighted CC as a commonly used agent for ovulatory dysfunction, with very good to excellent efficacy and tolerability.

Good clinical practice recommendations on management of infertility in patients from India with polycystic ovary syndrome

Sonia Malik, Sohani Verma, Kuldeep Jain, Pankaj Talwar, Bharati Dhorepatil, Gouri Devi, Umesh Jindal, Sudha Prasad, Kanad Dev Nayar, Neena Malhotra, Neeta Singh, Geeta Radhakrishnan, Rashmi Sharma, Leena Wadhwa, Nomita Chandhiok, Gita Khanna, Sushma Sinha, Pondicherry Marudachalam Gopinath Past president, Indian Fertility Society, FS Secretariat, Department of Obstetrics & Gynecology, MAMC, Lok Nayak Hospital, Jawahar Lal Nehru Marg, New Delhi-110002 PCOS Working GroupIndian Fertility Society, Jawahar Lal Nehru Marg, New Delhi-110002, India

The many hues of mid life health

The populations of the last and present centuries continue to have turbulent lives as far as health and healthcare are concerned. World Health Organization (WHO) statistics talk of an aging world population (WHO 2013)[1] and the inadequate preparedness across nations to face this “epidemic” if it may be so called! India too lacks majorly in according help to the elderly. However, individuals and small Non-Government Organizations (NGO) groups are trying hard to meet the challenge. Providing good surgical (Batla Verghese et al)[2] help to women in remote areas of the country needs to be applauded. Operating large prolapse uteri with bare minimal facilities at hand is indeed commendable.

True Mirena failure: Twin pregnancy with Mirena in situ.

Mirena levonorgestrel intrauterine system (LNG-IUS) is a very reliable method of contraception with the failure rate comparable to sterilization. We present a case of failure of the Mirena intrauterine device in situ in a woman with twin gestational sac with positive Beta Human Chorionic Gonadotropin (β HCG) within 2 years of insertion. Although LNG-IUS is one of the most effective methods of contraception, the risks of failure should always be kept in mind and the women be appropriately counseled before its use.