Counseling in menopausal women: How to address the benefits and risks of menopause hormone therapy. A FIGO position paper.

Menopause marks the end of menstrual cyclicity and, depending on individual vulnerability, has several consequences related to gonadal steroid deprivation, especially if it is premature. Menopause may be more burdensome for some women than for others. Individual factors, such as personal history, socioeconomic status, ethnicity, and current health conditions, affect symptomatology and, thereby, the menopausal experience. In addition, some menopausal symptoms, such as severe hot flashes, sleep disorders, and depression, are markers of future health risks. Counseling is a fundamental part of health care in the peri- and postmenopause periods. It must include an assessment of the patient's symptoms, needs, desires, and risk profile to address the benefits and risks of menopausal hormone therapy (MHT) on an individual basis and promote a healthy lifestyle. Indeed, healthcare practitioners can and must protect the health and lives of mid-life women by increasing awareness of menopausal symptoms and ensuring healthcare options, especially MHT. The type and duration of MHT should be tailored based on the patient's history, menopausal age, physical characteristics, and current health status so that the benefits always outweigh the risks. This FIGO position paper focuses on the benefits and risks of MHT on health domains, target organs, and systems, and on systemic and vaginal MHT regimens, to provide indications that can be used in the clinical practice for menopausal counseling. Moreover, it offers insights into what FIGO considers the mainstay for the healthcare management of women in peri- and postmenopause, worldwide.

OOPHORECTOMY: When and Why? A Novel Risk Stratification Tool as an Aid to Decision Making at Gynecological Surgeries.

The decision regarding oophorectomy during gynecological surgeries, especially in perimenopausal and postmenopausal women, has historically posed a significant dilemma. Traditionally, it was widely believed that conserving the ovaries held no benefits, leading to a common practice of recommending bilateral salpingo-oophorectomy alongside hysterectomy for benign conditions in women aged 40-45 and above. Given our evolving comprehension of postmenopausal ovarian function and the genetic susceptibility to ovarian epithelial cancers, the decision regarding oophorectomy poses a dilemma. Oophorectomy is recommended for women with a higher risk of ovarian cancer and ovarian conservation is necessary with women with higher risk of co-morbidities. This paper reviews the available literature on these aspects of oophorectomy. Despite a wealth of literature narrating the advantages and disadvantages of oophorectomy, covering various aspects such as ovarian cancer risk, myocardial infarction incidence, and post-oophorectomy peritoneal cancer, there is a notable absence of a comprehensive evaluation system for risk stratification. The objective of the present paper is to address this gap by consolidating existing literature into a risk stratification system. This system will provide treating physicians a tool that facilitates more informed, case-specific decisions in collaboration with patients and their families. While recognizing that the ultimate decision must be tailored to the individual case and agreed upon mutually by the surgeon, patient, and family, the proposed system seeks to streamline risk stratification. This, in turn, should aid in determining the most suitable course of treatment that maximizes benefits for the patient.

Signing off As Editor in Chief.

I complete my tenure as editor in chief in January 2021, and here I bring to you the last editorial of my tenure. I have enjoyed every moment of this long association with the journal. I have done my best to improve the quality of this journal in terms of readership, citations, visibility, academic recognition, promoting good quality research and publications. Many new changes were brought in during my tenure including the publishing e-book of our journal which has furthered the go green initiative of FOGSI.

A Multicentre Observational Study on Risk Factors for Breast Cancer.

BACKGROUND: Breast cancer is the most common malignancy in Indian women. There is scant data from Indian hospital-based populations on the prevalence of risk factors of this disease. We performed this study to quantify and analyze various epidemiological risk factors in Indian breast cancer patients. METHODS: This was a multicenter collaborative study wherein breast cancer patients older than 18 years were served a structured questionnaire after informed consent. Patients or their relatives were required to fill out the questionnaire and those who were unable to read and write were excluded. Data were abstracted from case record forms and variables were descriptively analyzed. RESULTS: Between January 2015 and February 2016, 800 patients were screened, of whom 736 patients with a mean age of 50.13 years were enrolled in the study. The mean number of pregnancies was 2.75 (0-11), the number (percentage) of women who had breastfed for more than 6 months was 628 (85.3) and 406 (55.1%) patients were post-menopausal at the time of breast cancer diagnosis. Of the enrolled patients, 91 (12.8%) had history of exposure to passive smoke, 13 (1.8%) had partners who were heavy smokers, 27 (3.7%) had history of oral contraceptive use, 4 (0.5%) had history of hormone replacement therapy, and 103 (14%) had undergone hysterectomy with oophorectomy. CONCLUSION: Our study contributes to the descriptive prevalence of some known risk factors in Indian breast cancer patients.

Coping with COVID Crisis.

Emergence of the deadly corona virus infection took place in Wuhan in China in December last year. It soon spread to all countries and became a pandemic. India's first case of COVID 19 was confirmed in Kerala's Thrissur district on 30 January 2020. Ever since, our lives have changed and we are facing numerous difficulties. This editorial will take you through these difficulties faced by us at practice and in life in general. It presents a brief account of the impact of COVID 19 on functioning of this journal. We have compiled quality articles on COVID in a special section of this issue. This editorial also presents the highlights of these articles along with editorial comments. It contains lessons learned from original research on 141 covid positive pregnant women. It also covers issues faced by obstetricians like taking informed consent, lactation management, and safety of computed tomography imaging in pregnancy and newly introduced rapid testing strategies. It delves into the most sensitive issue of mental health of health care workers, economic crisis and takes a look at the way forward. We sincerely hope that this editorial is useful to our readers in their practice to cope up with this unforeseen crisis situation.

Does Saving Uterus Save Ovaries?

Ovarian function after hysterectomy is a subject of much controversy since many years. There is increasing awareness among gynecologists that the ovaries need to be spared at hysterectomy for benign conditions. However the awareness is limited, and many practitioners believe in removal of ovaries at hysterectomy. Removal of ovaries will save lives of patients at risk of developing ovarian cancer. But it will be unnecessary for low-risk women and will in fact endanger their lives by increasing cardiac risks. Recent data suggest that ovarian epithelial cancer arises from tubal epithelium, which adds new option of performing only salpingectomy and sparing ovaries, which will serve dual purpose of preventing ovarian cancer and continuing productive function of ovaries. Reproductive function is lost with hysterectomy. But it may be worth looking at impact of hysterectomy on productive function of ovaries. This editorial will focus on this issue and look at evidence on effects of other gynecological procedures on ovarian function.

Bias in Clinical Practice.

Role of bias in errors of decision making is receiving increasing attention. It is turning out to be one of the main sources of mistakes. Hence, it is important to be aware of biases and to design strategies toward an unbiased approach. Biases are of various types, and the potential sources of bias can be related to the consultant, patients and factors related to working conditions. Availability bias, base rate neglect, confirmation bias, conjunction rule, diagnostic momentum bias, framing effect and confirmation bias are the common types, and these have been discussed in this manuscript using a scenario-based format. Two types of human thinking, the rapid intuitive mode and the slow reflective mode, their pros and cons and their role in biases are discussed. Strategies to enhance awareness of biases, tips to improve reasoning, promote freethinking, enhance decision-making skills and resorting to checklists have been deliberated to achieve an unbiased approach.

Thyroid-Stimulating Hormone Values in Pregnancy: Cutoff Controversy Continues?

Thyroid disorders in pregnancy are important causes of adverse pregnancy outcome. So it is very pertinent that thyroid function is maintained in normal range during pregnancy. Serum thyroid-stimulating hormone (TSH) value is the best indicator for assessing and monitoring thyroid function. The increasing metabolic demands of pregnancy alter the thyroid physiology in early pregnancy; hence, it becomes necessary to define trimester-specific reference range. Several reports and guidelines have been published recommending varied TSH cutoffs in different studies. The most significant guidelines which created controversy about TSH cutoffs was that of American Thyroid Association (ATA) (Stagnaro-Green et al. in Thyroid 21:1081-1125, 2011) followed by Endocrine Society clinical practice guideline (De Groot et al. in J Clin Endocrinol 97:2543-2565, 2012). Both these gave stricter TSH cutoffs as .1 to 2.5 mIU/L in first trimester, .2 to 3.0 mIU/L in second trimester and .3 to 3 mIU/L in third trimester. Subsequently many reports, meta-analysis and systematic reviews were published which recommended higher cutoffs. With due consideration, ATA revised the guidelines in 2017, recommending the upper cutoff limit .5 mIU/L less than the preconception TSH value or as 4.0 mIU/L when local population-specific reference range is not available (Alexander et al. Thyroid 27(3):315-389, 2017). The controversy is not yet completely resolved specially regarding management of subclinical hypothyroidism. This editorial addresses this ongoing controversy.

Can Polycystic Ovarian Syndrome be cured? Unfolding the Concept of Secondary Polycystic Ovarian Syndrome!

Classic polycystic ovarian syndrome (PCOS) is one of the commonest endocrine metabolic disorders in women of reproductive years. It is very disappointing that we have still not been able to know the exact cause, and hence, we cannot completely cure this syndrome. With availability of effective drugs and lifestyle modification, it can only be controlled and symptoms can be reduced. There are some well-defined factors which lead to PCOS phenotype. A concept of secondary PCOS is being described recently. This condition, even though rare, is completely curable, as majority of these factors are treatable. Hence, it is advisable to actively look for these conditions and offer treatment in time. This editorial gives an account of various causes of secondary PCOS, gives broader view of PCOS phenotypes and aims for an insight into pathophysiological aspects of PCOS. The clinical categorization by HA-PODS nomenclature of both primary and secondary PCOS can minimize diagnostic and therapeutic pitfalls and will serve as a checklist to ensure the appropriate investigation is ordered and specific treatment is initiated as per diagnostic code. This will achieve uniformity in therapies offered and also enable better comparison of data and a smooth conduct of research which is much needed in this field.

Obesity in Pregnancy: Obstetrician' s Obstacle.

Obesity in pregnancy is associated with several complications which today's obstetricians have to face often. Overcoming these obstacles is truly challenging. There is a steady rise in incidence of overweight or obese women at reproductive age group in India and as well as other countries. Recent advances in bariatric medicine as well bariatric surgery have led to increasing number of pregnancies in obese women. Since obesity is associated with adverse maternal and fetal outcome, it is considered as a high-risk pregnancy and such pregnancies need to be managed in maternity units which are well equipped with necessary infrastructure and availability of expert multidisciplinary faculty. This editorial will look into various challenges and difficulties faced by obstetricians and provide practical tips for managing obese pregnant women. We are introducing a new type of article "Invited Debate," with this issue. It deals with pros and cons of bariatric surgery. I sincerely hope that readers are benefitted from views and reviews presented in the invited debate as well as the editorial.

Musculoskeletal Disorders and Menopause.

Menopause has an adverse impact on overall musculoskeletal health. It is associated with osteoporosis, osteoarthritis and Sarcopenia. Sarcopenia includes age-related muscle wasting as well as loss of muscle function. It is a relatively newly recognized condition and is known to be accelerated by estrogen deficiency. Osteoarthritis is also linked with estrogen deficiency more recently. Locomotor disability leads to a compromised quality of life. Sarcopenia and obesity (sarcobesity) have adverse outcome as it leads to morbidity due to increased incidence of lifestyle diseases like diabetes mellitus, hypertension. Poor musculoskeletal health may progress to frailty and higher incidence of falls and fractures which further increase associated morbidity and mortality. The healthcare providers and policy makers need to focus on this group of disorders and include its prevention in national program to reduce the health resources utilization.

Post-reproductive Health: Window of Opportunity for Preventing Comorbidities.

Post-reproductive health is a challenging issue as it is surrounded by many controversies. Menopausal hormone therapy (MHT) has witnessed a rise and fall over last several years. We do understand that comorbidities incidence rises beyond menopause and we need to prevent them. When MHT was used universally, the risk-benefit ratio became unfavorable. Hence, the use of MHT dropped drastically. But newer studies have introduced the concept of window of opportunity, wherein MHT does not have harmful effects, but in fact it will prevent comorbidities associated with menopause. This editorial focuses on the prevention of menopause- and MHT-related comorbidities.

The Plague of Plagiarism: Prevention and Cure!!!

Plagiarism is a serious form of scientific misconduct. Literal meaning of the Latin word "to Plagiare" is "to steal or to kidnap". The act of taking the writings of another person and passing them off as one's own is plagiarism. It implies intellectual theft in the world of medical writing. The "copy and paste" culture is becoming rampant all over the world after the advent of electronic publications, and Indian medical literature is no exception. This editorial will enlighten aspiring authors and readers about various forms of plagiarism and reasons for engaging in plagiarism. More so, it will also elaborate on how to prevent and cure this plague. Possible consequences that authors may face on detection of the plagiarism are also discussed. I am concluding my editorial series on medical writing with this last editorial of the year. I sincerely hope that these editorials helped authors and readers and this journal continues to receive high-quality papers written with the greatest honesty and integrity.

Scientific Misconduct: A Global Concern.

In today's world, evil appears to be all pervading. Medical publication is no exception. Scientific misconduct in medical writing is slowly becoming a global concern, especially over the last few decades. While the occurrence of such events is certainly rare, every researcher and reader should be aware of this entity. The researcher should ensure that no inadvertent error is construed as misconduct, and should take every effort to guard against it, and the reader should have a critical eye for the same. This article looks into various aspects of scientific misconduct and encourages awareness regarding the same.

Rejection Blues: Why Do Research Papers Get Rejected?

It is really disheartening when your paper gets rejected by a journal. Authors work very hard to conduct research. They present their work in the form of platform presentation in a conference and/or as a research article for publication. When their platform presentations get applauded by the audience, researchers feel encouraged to publish it. However, it may not be appreciated by editors and reviewers when the research is submitted to a journal for publication. One should not get disappointed by rejections. Most top journals have almost 80% rejection rates. This editorial will take a brief review of reasons for rejection and advise how to deal with rejections.

The Art and Craft of Making a Draft: Writing a Good-Quality Scientific Paper!

Writing a good-quality scientific paper is an art. The art and craft of making a draft of a good scientific paper are not simple! The research conducted must be original and should help clinicians to improvise the way they practice. Work should have relevance to women's health and should be significant enough to create an impact on health care. Will, skill, and drill are the three components of art of quality scientific writing. These are built on the sound foundations of science and integrity of the researcher. The key to master this art is to keep on doing good work and writing consistently good quality articles. This editorial will give some insights into how to write a good quality scientific paper.

Quantification of Peri-partum Blood Loss: Training Module and Clot Conversion Factor.

OBJECTIVES: To design an objective and accurate method to assess the peri-partum blood loss and to document the benefits of using this method on estimation of blood loss by healthcare professionals. MATERIALS AND METHODS: This prospective study was conducted over 6 months at Cama Albless Hospital, Mumbai. To quantify the loss of liquid blood and clots, we made use of plastic drapes, measuring jars, gravimetric method and a training module along with novel clot conversion factor which was designed to validate the visual assessment of blood loss by healthcare professionals. RESULTS AND CONCLUSION: The visual assessment of blood loss is unreliable. Training module should be on display in labor room and periodic training sessions on visual assessment by and for healthcare professionals are recommended, as we documented that training has definitely a beneficial impact on visual assessment. Clot conversion factor calculated in this study can prove to be a useful tool for objective assessment. Routine use of quantitative measurement rather than visual assessment of blood loss will go a long way to prevent hemorrhage-related maternal deaths.