The document discusses a conference on South Asia Day that focused on improving quality of care in obstetrics and gynecology through sessions on topics like patient safety, violence against women, menopause, and cancer. It also provides details on a session about the rising rate of cesarean sections and its consequences, including increased rates of morbidly adherent placenta. Current approaches to the conservative management of morbidly adherent placenta are discussed.

1. South Asia Day
July 6, 2018
South Asian Federation of Obstetrics and Gynaecology
Royal College of Obstetricians and Gynaecologists

2. SOUTH ASIA DAY
Friday, 6th July 2018
Joining Hands to Achieve SDG 3 & 5

4. Using Patient Safety as a Tool to Improve
Quality of Care
Session-I
09.30-10.30am

9. Violence against women in South Asia-Role of Medical
Professionals
Session-II
10.30-11.30am

14. Menopause – In context of South Asia
Session-III
12.00-01.00pm

19. Demon of Gynaecological Cancer
Session-IV
01.00-02.00pm

24. Rising Rate of CS & its consequences – Highly morbid
placenta – Way Forward
Session-V
03.00-04.00pm

29. Rising Rate of CS & its
consequences – morbid
placenta – Way Forward
Moderated by
Prof. Lubna Hassan .FRCOG
Prof. Fawzia Hossein

30. Rising Rate of CS & its consequences – morbid
placenta – Way Forward

32. Introduction
• Over the last 40 years, cesarean delivery rates around the world have
risen from less than 10% to over 30%,
• almost simultaneously a 10‐fold increase in the incidence of placenta
accreta spectrum (PAS) disorders has been reported in most medium‐
and high‐income countries.

33. • The latest available data show that almost 1 in 5 women in the world
now give birth by CS
• The absolute and yearly increases are more remarkable in less
developed countries.
• Asia witnessed the second largest absolute increase ,although it is still
currently the region with the second lowest CS rate in the world
(19.2%), after Africa .
Regional Level

34. • 65.84% is in private sector, it is 33.99 % for public sectors.
A systematic review by Soto-Vega E et al. in 2015
In India
• The overall rate showed an increase from 21.8 per cent in 1993-94 to 25.4 per cent in 1998-99.
• What was alarming was that 42.4 per cent were primigravidas and 31 per cent had come from rural
areas.
The escalating rates of Caesarean sections in teaching hospitals in India had been compared between 1993-94 and 1998-99, with data from
30 medical colleges/teaching hospitals [12].
C-section rates were found to have increased in Pakistan , with an especially significant rise from 2.7%
in 1990–1991 to 15.8% in 2012–2013
A greater likelihood of having a cesarean section was observed in the richest, highly educated, and
urban-living women
Evidence from Pakistan Demographic and Health Surveys, 1990-2013

35. cesarean delivery: placenta previa
In two systematic reviews,
• the risk for placenta previa us cesarean delivery was found to increase by
47 percent and 60 percent .
• The risk increases with an increasing number of cesarean deliveries .
• Prelabor cesarean delivery may increase previa risk in a subsequent
delivery more than previous intrapartum cesarean or vaginal delivery .
M Kamara, JJ Henderson, DA Doherty, JE Dickinson, CE Pennell
School of Women’s and Infants’ Health, The University of Western Australia,Crawley, WA, Australia
Published Online 28 February 2013
he risk of placenta accreta following primary elective caesarean delivery: a case–control study

36. Rising trend in C-section
Q.1. what are some of the factors that have contributed to the
continued rising trend in C-sections ? Globally, Regionally and
in your particular practice

37. • Rates of cesarean section have risen around the world in recent years.
• Accordingly, much effort is being made worldwide to understand this
trend and to counteract it effectively.
• A number of factors have been found to make it more likely that a
cesarean section will be chosen, but the risks cannot yet be clearly
defined.

38. • changed risk profiles both for expectant mothers and for their yet unborn children, lower tolerance to any complications or outcomes other than the
perfect baby .
• an increase in cesarean section by maternal request.
• scheduling issues, , increase the convenience for health professionals and also for the mother and family
• economic pressures,
• provider- and patient-driven medicalization of birth;
• fear of medical litigation
• labor induction rates,
• a broader perception of cesareans as safe have all been raised as possibilities
• The strongest predictor of caesarean delivery for the first birth of “low risk” women appears to be maternal age; a factor that continues to increase.
• Most women whose first baby is born by caesarean delivery will have all subsequent children by caesarean delivery.
While cesarean delivery rates that are too low are associated with increased adverse events, cesarean delivery rates above the risk-adjusted expected rate
for an institution have not been shown to improve maternal or neonatal outcomes, but do add cost and unnecessary intervention..
Srinivas E, Fager C, Lorch SA. Evaluating the risk-adjusted cesarean elivery rate as a measure of obstetric quality. Obstet Gynecol. 2010;115:1007–13. [PMC free article] [PubMed]
Some possible reasons for increasing CS rates are repeatedly reported in studies from
many countries such as:

39. The consensus around the indications for cesarean section has changed in many
countries ,nevertheless, the reasons for increasingly liberal attitudes toward cesarean
section are diverse and not always easily discernable.
Q2. What are some of the subjective indications for C-sections in your
country ?

40. Absolute indications
• Absolute disproportion/:Maternal pelvic deformity
• Chorioamnionitis (amniotic infection syndrome):
• Eclampsia and HELLP syndrome:
• Fetal asphyxia or fetal acidosis:
• Umbilical cord prolapse:
• Placenta previa:
• Abnormal lie and presentation:
• Uterine rupture:
( Association of Scientific Medical Societies in Germany [AWMF] guideline “Absolute and
relative indications for cesarean section with discussion of cesarean delivery on maternal
request”

41. Relative indications/subjective
• Pathological cardiotocography (CTG):
• Failure to progress in labor (prolonged labor, secondary arrest):
• Previous cesarean section:
• cord around the neck or nuchal cord
• post dates
• failed induction
• C-section on demand
• Large baby
• Precious baby
• Patient risk profile : BMI, age ,Maternal request

42. C-section on maternal request
Q.3 “Doctor, I want a C-section.” How
should you respond?
Is she motivated by a fear of childbirth or a true wish for C-section?

43. In general, when a patient inquires about elective primary C-section, it is best to
consider the “6 C’s of elective cesarean” in a careful discussion with her. That
approach entails consideration of the following:
• Clarification of her request
• Comorbidities in maternal health or surgical history
• number of Children planned overall
• Clear Consent for the procedure
• Correct determination of gestational age at the time of planned
delivery
• Confirmation of coverage by her insurance carrier.

44. •
WHO 2014 statement: Caesarean sections should ideally only be undertaken when
medically necessary.
• FIGO: C-section for nonmedical reasons is not justified
• Nice 2018 : For women requesting a CS, if after discussion and offer of support
(including perinatal mental health support for women with anxiety about
childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.
• ACOG: Individualize the decision consistent with ethical principles
Different world views likely account for different conclusions
Weak evidence of neonatal benefit

45. REASONS WOMEN OPT FOR CESAREAN DELIVERY ON REQUEST include :
• Convenience of scheduled delivery
• Fear of the pain, process, and/or complications of labor and vaginal birth
• Prior poor labor experiences
• Concerns about fetal harm from labor and vaginal birth misconception that CS is safer for the baby;
• Concerns about trauma to the pelvic floor from labor and vaginal birth, and subsequent development of
symptoms associated with pelvic organ prolapse
• Concerns about the need for and risks of emergent cesarean or instrument-assisted vaginal delivery
• Need for control
• Other cultural factors are more country-specific
A patient's statement during a case conference published in a journal aptly summarizes the opinion of many
women who choose cesarean delivery: "I feel like there's a lot more that can go wrong in a natural birth for the
baby than can go wrong in the C-section for the mom, and I feel like I'm more willing to take something
happening to me than something happening to my baby"[8
Ecker J. Elective cesarean delivery on maternal request. JAMA 2013; 309:1930.

46. Update
• Estimates of the prevalence of cesarean delivery on maternal request
range from 1 to 18 percent of all cesarean deliveries worldwide, National
Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006.
Obstet Gynecol 2006; 107:1386.
• The prevalence of the procedure appears to be increasing and
correlated with increasing affluence Alves B, Sheikh A. Investigating the relationship between
affluence and elective caesarean sections. BJOG 2005; 112:994.

47. “Morbidly Adherent Placenta “
first do no harm …..
As the incidence of CS continues to rise worldwide, the problem of
placenta previa and placenta accrete and consequently caesarean
hysterectomy is likely to become more common. Are we ready to face
these future consequences of today’s decision of performing caesarean
section ?
Q .4. To begin with
Are we using standard uniform terminology ?

48. Standard Terminology
• MAP is exclusive of invasive
accreta.
• AIP is exclusive of adherent
accreta (abnormally invasive
placenta (AIP) + advanced invasive
placentation + abnormal
myometrial invasion. )
• PAS Adherent & invasive villi may
co-exist in the same placenta
accreta. => PLACENTA ACCRETA
SPECTRUM (PAS)

49. PAS disorders were first defined by Luke et al. to include both abnormally
adherent and invasive placentas. Three categories are now considered
(1) adherent placenta accreta, also described by pathologists as “placenta creta,
vera or adherenta” when the villi simply adhere to the myometrium;
(2) placenta increta, when the villi invade the myometrium; and
(3) placenta percreta, when villi invade the full thickness of the myometrium
including the uterine serosa and sometimes adjacent pelvic organs.
• Variations in the lateral extension of myometrial invasion also divide PAS
disorders into the focal, partial, or total categories, depending on the number of
placental cotyledons involved.
• the degree of villous adhesion or invasion is rarely uniform throughout the
placenta, limiting the accuracy of microscopic diagnosis when the whole
uteroplacental interface is not available for analysis.

50. Q.5. How would you diagnose /screen for PAS disorders ?

51. • Recent population studies have shown that placenta accreta
spectrum (PAS) disorders remain undiagnosed before delivery
in half
1Bailit JL, Grobman WA, Rice MM, et al. Morbidly adherent placenta treatments and outcomes. Obstet
Gynecol. 2015;125:683–689.
• To two thirds of cases
• Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 3Thurn L, Lindqvist PG, Jakobsson M,
et al. Abnormally invasive placenta – prevalence, risk factors and antenatal suspicion: Results from a large
population‐based pregnancy cohort study in the Nordic countries. BJOG. 2016;123:1348–1355.

52. PAS : Ultrasound or MRI
• Current prenatal diagnosis rests on subjective interpretation of
“typical” sonographic findings or signs with two‐dimensional
(2D) grey‐scale and color Doppler imaging
• MRI not widely available and too expensive for screening
• the results of well‐conducted prospective cohort studies by Finberg
and Williams and Comstock et al. indicate that the sensitivity and
specificity of grey‐scale imaging alone in screening for placenta previa
accreta are high when performed by expert operators.

53. Unified descriptors (EW‐AIP suggestions) for ultrasound
findings in placenta accreta spectrum (PAS) disorders.
2D grey‐scale
• Loss of the “clear zone”
• Abnormal placental lacunae
• Bladder wall interruption
• Myometrial thinning
• Placental bulge
• Focal exophytic mass
Color Doppler imaging
• Uterovesical hypervascularity
• Subplacental hypervascularity
• Bridging vessels
• Placental lacunae feeder vessels
3D intraplacental hypervascularity

54. PRENATAL SCREENING FOR PAS DISORDERS
Clinical screening
• Several risk factors for PAS disorders have been identified. These include
advanced maternal age, multiparity, previous uterine surgery including
curettage, assisted reproductive techniques, and previous cesarean
delivery.
Jauniaux E, Jurkovic D. Placenta accreta: Pathogenesis of a 20th
century iatrogenic uterine disease. Placenta. 2012;33:244–251.
• The most commonly described risk factor is the combination of previous
cesarean delivery and placenta previa.
Silver RM. Abnormal placentation: Placenta previa, vasa previa, and
placenta accreta. Obstet Gynecol. 2015;126:654–658.

55. Biomarkers in the maternal serum of women with PAS
disorders
• At 11–12 weeks of pregnancy,
• human chorionic gonadotropin (hCG) and its free beta‐subunit (β‐hCG) are lower
• pregnancy‐associated plasma protein A (PAPP‐A) is higher
• At 14–22 weeks, women presenting with a placenta previa are at higher risk of
PAS disorders if serum β‐hCG and alpha‐fetoprotein (AFP) are above 2.5
multiples of the median (MoM) (OR 3.9, 95% CI 1.5–9.9; and OR 8.3, 95% CI
1.8–39.3, respectively).
• No difference has been found in the amount of cell‐free fetal DNA (cffDNA).
biomarkers could be used with ultrasound imaging to screen for PAS disorders
prenatally in a model similar to that used for aneuploidy screening; however, the
benefit of this remains unknown until more prospective data are available.

56. Recommendations for prenatal diagnosis and screening of placenta accreta
spectrum (PAS) disorders
• Ultrasonography should be the first line for the diagnosis of PAS disorders
• Women diagnosed with cesarean scar pregnancy in the first trimester should be counselled and
should be referred to center with experianxe
• At the mid‐trimester examination for fetal anomaly, all women with previous c-section should
have a careful assessment of the placental implantation site especially if it is anterior, low lying,
or previa
• The ultrasound signs observed for the diagnosis of PAS disorders should be described using
standardized protocols
• The recorded presence or absence of each ultrasound sign will be influenced by the operator's
interpretation of what constitutes that marker
• MRI is not essential for making a prenatal diagnosis of suspected PAS disorders but may be
useful in evaluating the pelvic extension of a placenta percreta or areas difficult to evaluate
on ultrasound
FIGO 2018

57. Q.6 what does the current conservative management of PAS include
?

58. Conservative management of PAS
Four different primary methods of conservative management have
been described in the international literature:
(1) the extirpative technique (manual removal of the placenta);
(2) leaving the placenta in situ or the expectant approach
(3) one‐step conservative surgery (removal of the accreta area)
(4) the Triple‐P procedure (suturing around the accreta area after
resection).
These methods have been used alone or in combination and in many
cases with additional procedures such as those proposed by
interventional radiology.

59. The triple-P procedure
The main steps of this procedure include:
(1) perioperative placental ultrasound localization of the superior
edge of the placenta;
(2) pelvic devascularization involving preoperative placement of
intra‐arterial balloon catheters (anterior division of the internal
iliac arteries);
(3) no attempt to remove the entire placenta with large
myometrial excision and uterine repair. If the posterior wall of
the bladder is involved, the placental tissue invading the
bladder is left in situ to avoid cystotomy.

60. Tamponade techniques
 Small case series have also reported the successful use of
compression sutures, Using the cervix as anatural tamponade by
inverting it into the uterine cavity and suturing the anterior and /or posterior
cervical lip into the anterior and orposterior walls of the lower uterine wall
El Gelany SA, Abdelraheim AR, Mohammed MM, et al. The cervix as a natural tamponade
in postpartum hemorrhage caused by placenta previa and placenta previa accreta: A
prospective study. BMC Pregnancy Childbirth. 2015;15:295.

61. Q.7 what are some of the precautions we need to take before &
during hysterectomy when managing PAS .

62. • the optimal management of PAS disorders remains undefined and is
determined by the capacity to diagnose invasive placentation
preoperatively, local expertise, depth of villous invasion, and
presenting symptoms
• a primary elective cesarean hysterectomy is the safest and most
practical option for most

63. • There is increasing evidence that the management of women with
PAS disorders by multidisciplinary teams in centers of excellence
decreases maternal morbidity and mortality when compared with
standard obstetric care.
• This can only be arranged when the diagnosis is made prenatally.
• New imaging techniques have played an increasing role in the
prenatal diagnosis of this condition,

64. Recommendations Resource
settings
Quality of evidence and
strength of recommendation
Women presenting with PAS disorders with or without placenta previa should have their delivery scheduled in a Center of
Excellence with a dedicated multidisciplinary team and care plan
High Moderate and Strong
The care plan for women with PAS disorders should include logistic support for access to blood products, capacity to
perform complex pelvic surgery, intensive care facilities (adult and neonatal), and obstetric anesthetists
High Moderate and Strong
Surgical expertise in complex pelvic surgery should be available throughout the surgical procedure All Moderate and Strong
Scheduled nonemergent delivery is advisable for women with PAS disorders as it is associated with a reduction in
complications related to blood loss
All Low and Strong
Deliberate cystotomy and excision of involved bladder may be considered in cases of percreta villous tissue involving the
bladder
All Low and Strong
A midline skin incision should be considered for invasive PAS disorders and anterior low‐lying placenta or previa accreta
when the superior margin is outside the lower uterine segment
All Low and Weak
Recommendations for the surgical nonconservative management of placenta accreta spectrum (PAS)
disorders
Figo consensus guidelines on placenta accreta spectrum disorders : non conservative surgical management

65. Recommendation Resource
settings
Quality of
evidence and
strength of
recommendation
Where available, tranexamic acid should be administered (1 g slow IV or 1000–1300 mg orally) immediately prior to or
during cesarean delivery for PAS disorders
All High and Strong
The role of bilateral internal iliac artery ligation at the time of cesarean hysterectomy for PAS disorders is currently unclear All Low and Weak
When available, cell salvage may be utilized or be on “stand‐by” during cases of cesarean delivery for PAS disorders High Low and Strong
In the absence of spontaneous placental separation, the placenta should be left in situ to minimize blood loss during
planned immediate cesarean hysterectomy and uterotonics should not be used
All Moderate and Strong
Total hysterectomy with placenta in situ is preferred over subtotal hysterectomy in cases of placenta previa increta or
percreta
All Low and Strong
In cases of placenta percreta with extensive pelvic invasion, delayed hysterectomy with placenta in situ may be considered High Low and Weak
Recommendations for the surgical nonconservative management of placenta accreta spectrum (PAS)
disorders
Figo consensus guidelines on placenta accreta spectrum disorders : non conservative surgical management 2018

66. The way Forward
Q.8 what are some of the strategies to reduce the rising trend of C-
section?

67. Strategies to reduce rising trend of C-Sections
• The proliferating increased rates of caesarean section have not only
affected the developed countries but also expanded to developing
countries like south Asia.
• Health education especially antenatal education regarding safety of
vaginal delivery and the cons of caesarean section would be a
valuable tool to be offered at population level.

68. • Factors associated with higher rates of vaginal deliveries may include
strict policies on “maternal request” CS, cultural or social pressure,
and strategies favouring home births or a midwifery-led approach to
births .
• having guidelines may protect doctors against another driver of C-
sections: the malpractice lawsuit.
• professional associations should release recommendations for the
safe prevention of primary caesarean sections .

69. Efforts to address the rising cesarean rate
may benefit from attempts
• to convert subjective indications into objective ones through clearer
evidence-based guidelines regarding fetal status, labor arrest, and
assessment of macrosomia,
• To increase provider accountability for the decision to perform
cesarean at the practice, departmental, hospital, or state level.
• To increase patient education and involvement in decisions during
pregnancy,

70. Birth without advance warning is an event not
provided for
• the increasing popularity of cesarean section is mainly due to changes
in how society views childbirth and the related significant increase in
fear and anxiety among both obstetricians and expectant families
• this is solely due to organizational and economic reasons; there is no
medical rationale for it..
• We need to understand childbirth and rewrite our guidelines

71. Robinson-ten classification
• WHO proposes the use of the Robson classification as the global
standard for assessing, monitoring and comparing CS rates within
healthcare facilities over time, and between facilities.
• Given that Data collection remains an inexact science in most South
Asian countries…
Q 9. would it be possible to incorporate the Robinson Ten –Group
Classification in our respective countries ?

72. Robson’ 10-Group Classification
No Groups
1. Nulliparous,single,cephalic,>37wks in spontaneous labour
2. Nulliparous, single cephalic, >37 wks, induced or CS before labor
3. Multiparous (excluding previous CS), single cephalic, >37 weeks in spontaneous labor
4. Multiparous (excluding previous CS), single cephalic, >37 weeks, induced or CS before labor.
5. Previous CS, single cephalic, >37 weeks
6. All nulliparous breeches
7. All multiparous breeches (including previous CS)
8. All multiple pregnancies (including previous CS)
9. All abnormal lies (including previous CS)
10. All single cephalic, <36 wks (including previous CS)

73. • WHO envisions that the information stemming from the classification
can be a powerful tool to inform practice.
• Only then will we have the data and evidence that will lead us more
clearly to actions to improve care.
• Ultimately, we hope the debate can recommence with more
valuable, solid and informative data to support our discussions

74. Wrap-up : the role of SAFOG

75. Menopause in the context of
South Asia
Moderators
Dr Narendra Malhotra
Dr Shyam Desai
Panelists
Mary Ann Lumsden, Dr Ghazala Mehmood,
Prof S K Zeenat A Nasreen
Dr Harsha Attapatu, Dr Kohinoor Begum,
Dr H D Pai, Dr.Jyoti Unni

76. LIFE EXPECTANCY HAS INCREASED
Women, are currently enjoying a life expectancy of 84.3 years in
developed countries and 69-70yrs in South Asia.
Normal women have menopause at a mean age of 51 years, with 95
percent becoming menopausal between the ages of 45 to 55 years.
Perimenopause, menopause, and postmenopause comprise a half or a
third of a women’s life, particularly in South Asian countries .

77. So have the problems associated with
increasing age

78. The Reality
• Menopause is an event in a Woman's life which denotes a change in the life of the woman and
may alter her sense of wellbeing and affect her lifestyle.
• With the increasing life expectancy the menopausal population is going to be a significant group
which would require special strategic measures for their wellbeing.A woman may be expected to
spend 30 years or 40% of her active in the menopausal era
• Asian women constitute half of the Worlds population of menopausal women.These women
embrace various cultures seen in the Subcontinent.
• As compared to menopausal women in the Western world, the Asian counterparts are different
in several ways and have to be given due consideration if we have to achieve “Health for all by
2030
• S

79. • Menopause is said to bring on symptoms in women that can affect
their day to day life.
• Can you list them?
• s

80. Vasomotor Symptoms
Sleep Disorders
Mood Changes
Vaginal Atrophy
Dyspareunia
Skin Atrophy
Osteoporosis
Atherosclerosis
Coronary Heart Disease
Cerebrovascular Disease
40 yrs 50 yrs
Menopause
60 yrs
Symptoms and Disorders in Relation to Age and Menopause
Adapted from Bungay G et al. Br Med J 1980;281:181–3; Van Keep PA et al. Maturitas 1990;12:163–70.
Menstrual Disorders

81. Huang K, et al. Maturitas 2010;65:276-83 and Genazzani A, et al. Gynecol Endocrinol 2006;22:369-75.
R.J. Baber. East is east and West is west: perspectives on the menopause in Asia and The West. Climacteric 2014;17:23-28.
Prevalence of Menopausal symptoms in Asian and
European women

84. Original
Mid-age health in women from the Indian subcontinent
(MAHWIS): general health and the experience of menopause
in women
Dr. P. Gupta, D. W. Sturdee & M. S. Hunter
Pages 13-22 | Received 15 Aug 2005, Accepted 08 Dec 2005, Published online: 03 Jul 2009
Download citation https://doi.org/10.1080/13697130500515776
Objectives First, to examine the experience of menopause and quality of life in a migrated Asian population from the Indian
subcontinent living in Birmingham, UK, and, second, to compare their experience with a matched sample of Caucasian women
living in the same geographical area and also with a sample of Asian women with similar socioeconomic background living in Delhi,
India.
Methods In this cross-sectional study of 153 peri- and postmenopausal women aged 45–55 years, 52 Asian women originating
from the Indian subcontinent living in Birmingham (UKA, mean age 51.4 years), 51 Caucasian women (UKC, mean age 52.3
years) and 50 Asian women living in Delhi, India (DEL, mean age 49.72 years) were interviewed to collect information about their
lifestyle, general health, menopause experience and help-seeking behavior. The Women's Health Questionnaire and the
Menopause Representation Questionnaire (both translated and linguistically validated in Hindi) were used to examine the
prevalence of physical and emotional symptoms and the extent to which these were attributed to the menopause.
•

85. Results The two Asian groups (UKA, DEL) reported poorer health and generally more physical and emotional symptoms than the
UKC group. However, for menopausal symptoms (hot flushes and night sweats) there was a different pattern; the DEL group
reported significantly fewer symptoms compared to the UKA and UKC groups (hot flushes: UKC 60.8%, UKA 75%, DEL 32% (p <
0.001); night sweats: UKC 50%, UKA 56.9%, DEL 24% (p = 0.002)). The prevalence of vaginal dryness was highest in the UKA
group and lowest in the DEL group (UKC 21.6%, UKA 38.2%, DEL 7.3% (p = 0.005)). The number of symptoms attributed to
menopause was significantly lower in the DEL group (9.3 ± 7.8) compared to the two UK groups (UKC 18.9 ± 7.4, UKA 19.8 ±
10.7), but the UKA women tended to attribute some physical symptoms to the menopause such as breathlessness, weight gain
and stiff joints that might have other causes.
Conclusions The UK Asian women's experience of the menopause is more similar to the Caucasian women in the UK than that
of the women in Delhi. However, Asian women living in the UK and the Indian subcontinent shared the experience of poor health
and reports of more physical and emotional symptoms in general.

86. • How do women in the Menopausal population in the
Asian subcontinent cope with these symptoms ?
• S

87. Study of menopausal symptoms, and perceptions about menopause
among women at a rural community in Kerala
The mean age of attaining menopause was 48.26 years.
Prevalence of symptoms among ladies were:
Emotional problems (crying spells, depression, irritability) 90.7%, Headache 72.9%, Lethargy
65.4%,
Dysuria 58.9%, Forgetfulness 57%, Musculoskeletal problems (joint pain, muscle pain) 53.3%,
Sexual problems (decreased libido, dyspareunia) 31.8%,
Genital problems (itching, vaginal dryness) 9.3%,
Changes in voice 8.4%.
Only 22.4% of women knew the correct cause of menopause.
Sagar A Borker et al , Journal of midlife health 2013

88. • Asian women accept menopause stoically, treating menopause as just
another milestone in their lives another inevitable part of ageing to
be embraced rather than struggled against
• Menopause is found to be much easier for Asian women as compared
to Caucasian women Asian women infact welcome the phase in their
lives when she no longer has to undergo the discomfiture of
menstruation, and often are happy that sexual activity is on the wane

89. • Hormonal therapy does alleviate many of the symptoms of
Menopause such as Vasomotor symptoms and psychological
problems and is widely prescribed and used in the Western world
• It is popular amongst the Asian women and if not why?
• S

90. Attitude of Gynecologists for HT prescription in India (N =
321)
Meherishi S, Khandelwal S; Jr of Midlife Health 2012
Concern about MHT Usage of Alternate Therapy
Questionnaire concerning attitudes, management
• 69.04% gynecologists were currently prescribing MHT
• Hot flashes were the most common indication for MHT prescriptions
• 78.57% were familiar with controversies surrounding WHI study
• 61.9% would consider using MHT for themselves
43%
33%
24%
57%
29%

91. Prevalence of Symptoms in India
60.9
40.1
35.4
24.7
20
11.7
9.1
Vasomotor
symptoms
Sleep related
symptoms
Anxiety Depressive
mood
Joint pain Urinary
Symptoms
Irritability
0
10
20
30
40
50
60
70
Ruma Dutta et al., Journal of Clinical and Diagnostic Research. 2012 May (Suppl-2), Vol-6(4): 597-601
N=780

92. • If the Asian women are reluctant to get onto HT does it in any way
compromise on their health in the intermediate and the longterm ?
• N

93. Bone changes in perimenopause

94. Already Osteopenic at 40 plus?
• Osteopenia is already present in women between 40 and 49 years, so
measurement of BMD from the age of 40 years will help in diagnosis at
an early stage.
Unni J, Garg R, Pawar R. Bone mineral density in women above 40
years. J Mid-life Health 2010;1:19-

95. CARDIOVASCULAR PROBLEMS
PSYCHOLOGICAL ,SOCIAL PROBLEMS
COGNITIVE AND MEMORY
SEXUAL AND OTHERS:
VASOMOTOR PROBLEMS
Major killer , maybe more than men
9 % knew about menopause
Only 3 % aware of CVD
No knowledge of risk factors for CVD
Lack of awareness
lifestyle modification
Treatment options
J Midlife Health 2010; 1 ( 1) : 26-29
0
100
200
300
400
500
29-44 45-64 >65
Age, years
Men
Women
No.
X 103

96. By 2020, Death Pattern will be Dominated by Non-
Communicable Diseases
20021990 2020
Predicted
0
40
50
30
Noofdeaths(millions)
10
20
Non-Communicable
diseases
Communicable diseases
& Injuries
20021990 2020
Predicted
0
40
50
30
Noofdeaths(millions)
10
20
33 M 23 M

97. • When a menopausal woman comes for a Routine Checkup what are
the investigations that you would advise?
• N

98. • General examination
• Biochemical tests
• ECG
• Gynaec Checkup

99. • What is the role of a Sonography in a Menopausal woman?
• N

100. • TVS essential with empty bladder Endometrium thin and echo poor.
Ovaries poorly visualised
• Unilocular simple cysts Andolf et al 1987 3 malignancies in 33
patients scanned over 2 years
• Sensitivity and Specificity of Pelvic USG for malignancy is 100%
• Endometrial thickness normally 2-4 mm
• Patients on HT/HRT endometrial thickness monitoring

101. • The menopause does affect the sexual life of a Woman
• How does the Asian menopausal woman adjust to this?
• N

102. Sexuality and the Asian menopausal
woman
• Asian women are more conservative than their Western counterparts.
• Menopause has a negative impact on their sexual lives and the less
educated they are the more severe is the impact.

103. • The educated women realise that medical problems can occur at the
menopause whereas the uneducated do not realise the importance of
being under medical supervision as they believe that menopause is a
completely natural event
• Many attitudes and beliefs can be altered with education.

104. • Hormonal therapy is not a popular option.
• They tend to opt for herbal and other traditional therapies such as
Soya.

105. • Asian women do not pay much importance to changes such as vaginal
dryness and loss of sexual desire
• They do not feel less self confident and 90% of women interviewed by
a Pharma company accepted these symptoms as a consequence of
ageing
• The most common symptoms that the Asian women complain of are
body ache and shoulder stiffness

106. • If Asian menopausal women are reluctant to start HT does it affect
the body in the long term in any way especially referring to the
development of Osteoporosis?
• S

107. Prz Menopauzalny. 2014 Sep; 13(4): 213–220.
Published online 2014 Sep 9. doi: 10.5114/pm.2014.44996
PMCID: PMC4520366
PMID: 26327857
Hormone replacement therapy and the prevention of postmenopausal osteoporosis
Marco Gambacciani1 and Marco Levancini1,2
Fracture prevention is considered one of the public health priorities by the World Health Organization [1]. Osteoporosis is a major healthcare problem
leading to a high incidence of spine, radial, and mainly hip fractures that are causes of morbidity and mortality in ageing population [2–4]. It is recognized
as a systemic skeletal condition characterized by low bone mass, microarchitectural deterioration of bone tissue, and compromised bone strength leading to
enhanced bone fragility and a consequent increased risk of fractures. Bone strength reflects the integration of two main features: bone density and bone
quality [1]. Osteoporosis affects mostly postmenopausal women: 30-50% of women will suffer a clinical fracture and the associated morbidity in the course
of their lifetime and 70% of hip fractures occur in women [2]. Postmenopausal osteoporosis is estimated to affect 200 million women worldwide, 75 million
in Europe, the USA and Japan alone [2].

108. Osteoporotic fractures not only represent a big economic cost, but also lead to long-
term consequences like chronic pain, deformity, depression, disability and death with a
large burden of non-hip fractures being underestimated .
Hip fracture is responsible for a large proportion of the financial burden of osteoporosis to health-
care systems, but other osteoporosis-related fractures, particularly vertebral fractures, cause
considerable morbidity.
Vertebral fractures are often not diagnosed and not treated, although they are common osteoporosis
fractures: a 50-year-old woman has a 16% lifetime risk of experiencing a vertebral fracture and it is
estimated that only about a fifth to half of them are diagnosed and treated .
There are various effective drug treatments for the prevention and treatment of osteoporosis.
Today osteoporosis is under-diagnosed and under-treated notwithstanding the fact that effective
prevention and treatment options are available. Osteoporosis is a global problem that will further
increase over the next 50 years.
Measures are urgently required to avert this trend. Although important organizations are issuing
guidelines and recommendations, increased awareness of the burden of the disease is required.

109. Postmenopausal hormone therapy in the prevention and treatment of osteoporosis
Authors:Harold N Rosen, MDMarc K Drezner, MDSection Editors:Robert L Barbieri, MDWilliam F Crowley, Jr, MDDeputy
Editor:Jean E Mulder, MD
This topic last updated: Jan 09, 2017.
For women with menopausal symptoms, estrogen is often given short term (six months to five years), with the goal of eventual
tapering and discontinuation (unless there is a compelling reason to continue long term). (See "Menopausal hot flashes".)
Prior to the publication of the Women's Health Initiative (WHI), long-term (more than five years) estrogen and combined estrogen-
progestin therapy were routinely prescribed for osteoporosis and coronary heart disease (CHD) based upon observational data
demonstrating a protective antiresorptive effect of estrogen on bone and a positive effect on the heart.
However, currently available data from clinical trials do not confirm that estrogen prevents or delays cardiovascular disease. To the
contrary, the WHI and other trials suggest that combined estrogen-progestin is not cardioprotective and may slightly increase risk
when used for either primary or secondary prevention of CHD. Moreover, combined therapy increases the risk of stroke, venous
thromboembolism, and breast cancer [1], while unopposed estrogen therapy may increase stroke and venous thromboembolism,
but not CHD or breast cancer risk. Of note, follow-up analyses suggest that older, but not younger, postmenopausal women have
excess CHD risk. (See "Menopausal hormone therapy and cardiovascular risk" and "Menopausal hormone therapy and the risk of
breast cancer".)
In light of the WHI data and the efficacy of other antiresorptive drugs, including bisphosphonates and raloxifene, estrogen-progestin
therapy should no longer be used solely for the prevention or treatment of osteoporosis. Exceptions include women with persistent
menopausal symptoms and those who cannot tolerate the other drugs.

110. Prz Menopauzalny. 2014 Sep; 13(4): 213–220.
Published online 2014 Sep 9. doi: 10.5114/pm.2014.44996
PMCID: PMC4520366
PMID: 26327857
Hormone replacement therapy and the prevention of postmenopausal osteoporosis
Marco Gambacciani1 and Marco Levancini1,2
Author information ► Article notes ► Copyright and License information ► Disclaimer
This article has been cited by other articles in PMC.
Go to:
Fracture prevention is one of the public health priorities worldwide. Estrogen deficiency is the major factor in the pathogenesis of postmenopausal
osteoporosis, the most common metabolic bone disease. Different effective treatments for osteoporosis are available. Hormone replacement therapy (HRT)
at different doses rapidly normalizes turnover, preserves bone mineral density (BMD) at all skeletal sites, leading to a significant, reduction in vertebral and
non-vertebral fractures. Tibolone, a selective tissue estrogenic activity regulator (STEAR), is effective in the treatment of vasomotor symptoms, vaginal
atrophy and prevention/treatment of osteoporosis with a clinical efficacy similar to that of conventional HRT. Selective estrogen receptor modulators
(SERMs) such as raloxifene and bazedoxifene reduce turnover and maintain or increase vertebral and femoral BMD and reduce the risk of osteoporotic
fractures. The combination of bazedoxifene and conjugated estrogens, defined as tissue selective estrogen complex (TSEC), is able to reduce climacteric
symptoms, reduce bone turnover and preserve BMD. In conclusion, osteoporosis prevention can actually be considered as a major additional benefit in
climacteric women who use HRT for treatment of climacteric symptoms. The use of a standard dose of HRT for osteoporosis prevention is based on
biology, epidemiology, animal and preclinical data, observational studies and randomized, clinical trials. The antifracture effect of a lower dose HRT or
TSEC is supported by the data on BMD and turnover, with compelling scientific evidence.

111. Evidence for protection against of the fracture is limited to standard dosages of conjugated equine
estrogen (CEE) and medroxyprogesterone acetate (MPA), given by the oral route.
In the WHI trial, women assigned to active treatment (CEE, 0.625 mg/day, plus MPA, 2.5 mg/day)
had fewer fractures compared with women assigned to placebo (HR = 0.76; CI: 0.69-0.83) . The
effect did not differ in women stratified by BMI, age, time since menopause. The WHI is the first
randomized trial with definitive data supporting the ability of postmenopausal HRT at standard
doses to prevent fractures at the hip, vertebrae, and other sites. The WHI findings are particularly
relevant since the study subjects were not specifically selected on the basis of a high risk of
osteoporosis and related fracture or a known history of osteoporosis (with or without prior fracture).
Thus, standard HRT is effective in preventing bone loss associated with the menopause and
decreases the incidence of all osteoporosis-related fractures, including vertebral and hip fractures,
even in women not selected for a high fracture risk.

112. • What are the types of HT that are prescribed in todays day and age?
• N

113. BMJ 4 Aug. 2007- “HRT Early Benefits and Late Risks”
MHT the elixir of life ?

114. Today we do understand better…
• In the past few years, the pendulum has swung away from fear of
hormone therapy to a better understanding of indications, risks and
benefits—an understanding driven largely by the evidence-based
position statements of the North American Menopause Society (NAMS).

115. Menopausal Hormone Therapy
Wide range of hormonal products:
• Natural Estrogens
• Progestogens
• Androgens
• Tibolone
Natural Estrogens - Menopausal HT
• Native Estrogen – 17 beta Estradiol, Estrone, Estriol
• Conjugated Equine Estrogen
• Synthetic Estrogens - Oral
contraceptives
• Ethinyl Estradiol
Types Of Estrogens
Dosage—Standard And Low-dose Oral And
Transdermal Estrogens
Estrogens Ultra
low
Low Standard High
Conjugated equine estrogens (mg)-oral 0.15 0.3, 0.45 0.625 1.25
17β-estradiol (mg) oral 0.5 1 2 4
Estradiol valerate (mg)-oral 1 2
Transdermal 17β-estradiol (µg) 14 25 50 100

116. Are we applying what we are learning, to
benefit our women ?
We really need to translate this into mass education for our
lay public ,Whose 35 plus life is full of Myths,
apprehensions and she has a great quest to find herself
and she needs a friend ,a mentor ,a confidante ,who can
steer her through these very taxing years of her life.

118. Because one size cannot fit all…
Today the pendulum is swinging towards
individualised tailored prescription for any
individual.