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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Onset and Progression of Urogenital Symptoms after Surgical Menopause: A Prospective Cohort Study
Correspondence Address :
Dr. C Anjana,
Chalappurath House, Azhinhilam PO, Farook College Via, Malappuram Dist-673632, Kerala, India.
E-mail: anjanac18592@gmail.com
Introduction: Surgical menopause is the cessation of menstruation resulting from the surgical removal of the uterus and bilateral ovaries, which leads to a sudden decrease in oestrogen levels and its subsequent effects. Urogenital symptoms are chronic and progressive, but only a few women seek medical care for these symptoms, which are often overlooked during routine follow-ups.
Aim: To investigate the onset and progression of various urogenital symptoms after surgical menopause.
Materials and Methods: A prospective cohort study was conducted in the Department of Obstetrics and Gynaecology at Government Medical College, Thrissur, Kerala, India from January 2020 to December 2020. A total of 110 women who underwent Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo-Oophorectomy (BSO) for benign conditions were included in the study. The women were asked about the onset of urogenital symptoms at six weeks and 12 weeks after surgery. They were required to indicate whether they experienced four urogenital symptoms (vaginal dryness, frequent urination, urinary incontinence, and reduced sexual desire) using a menopause rating scale. The severity of symptoms was categorised as none (0), mild (1), moderate (2), severe (3), or very severe (4). The progression of symptom severity from six weeks and 12 weeks of follow-up was analysed using Chi-square tests.
Results: Urogenital symptoms that developed after surgery included vaginal dryness, dyspareunia, bladder symptoms, and reduced sexual desire. At least one of these symptoms developed in 95 (86.4%) women by 12 weeks. Vaginal dryness was reported by 40 subjects (36.4%) at six weeks, with 36 (32.7%) reporting mild symptoms, 4 (3.6%) reporting moderate symptoms, and none reporting severe or very severe symptoms. At 12 weeks, vaginal dryness was reported by 61 subjects (55.5%), with 21 (19.1%) reporting mild symptoms, 18 (16.4%) reporting moderate symptoms, 20 (18.2%) reporting severe symptoms, and 2 (1.8%) reporting very severe symptoms (p-value <0.05). Other symptoms showed a similar pattern of progression.
Conclusion: Urogenital symptoms can start as early as six weeks after surgery and can worsen in severity if left untreated.
Dyspareunia, Menopause rating scale, Urinary incontinence, Vaginal dryness
Menopause is defined as the point in time that follows one year after the complete cessation of menstruation (1). This can occur naturally or be induced by surgery, chemotherapy, or radiation. Although many conservative procedures are available for managing benign conditions of the uterus, hysterectomy remains one of the most commonly performed surgical procedures (2). Bilateral oophorectomy is often performed concurrently with hysterectomy for benign conditions, even when the ovaries are normal. This procedure can protect women from the risk of developing ovarian cancer later in life. Another reason for performing bilateral oophorectomy is to avoid potential surgeries for benign ovarian pathologies in the future (3).
In natural menopause, there is a period of menopausal transition. Additionally, the postmenopausal ovary remains intact and continues to produce a limited amount of hormones (4),(5). However, surgical menopause results in the complete absence of any steroid production and can cause menopausal symptoms to appear at an earlier age and with greater severity (4),(5). This abrupt decline in oestrogen levels can lead to many short-term and long-term complications. Women experiencing surgical menopause often present with vasomotor and urogenital symptoms that significantly impact their quality of life. The surgical removal of ovaries also eliminates the protective effect of estradiol on bone metabolism and the cardiovascular system. Long-term observational studies have demonstrated that surgical menopause is associated with accelerated cardiovascular changes and increased cardiovascular mortality (6),(7),(8).
Urogenital symptoms are common problems faced by women after undergoing surgical menopause. These symptoms are chronic and progressive, worsening if not properly addressed. They encompass a range of physical changes and symptoms associated with oestrogen deficiency, such as vulvovaginal dryness, burning or irritation, dyspareunia, and urinary symptoms including urgency, dysuria, and recurrent urinary tract infections (7),(8). Women who undergo surgical menopause often experience more severe urogenital symptoms compared to those experiencing natural menopause, due to the abrupt and persistent decline in hormone levels and an additional 50% decrease in circulating androgen levels (9).
Despite the abundance of literature on urogenital symptoms and their prevention (9),(10),(11), it has been found that only 25% of women seek medical care for these symptoms (12). This underdiagnosis is primarily due to sexual embarrassment and the sensitive nature of discussing these topics (12). However, it can have negative effects on partner relationships and self-esteem. This study sheds light on these undisclosed problems, which may later impact the psychosocial well-being of women. The study also emphasises the importance of specifically inquiring about these symptoms using well-phrased questions during early follow-up visits. The majority of women undergoing oophorectomy do not receive necessary information, support, or treatment for sexual consequences (13).
There is the need to educate women undergoing surgical menopause about these symptoms. This study aims to explore various urogenital symptoms after surgical menopause, their onset, and the progression of severity over a period of 6 to 12 weeks following surgery.
A prospective cohort study was conducted among 110 women who underwent TAH and BSO for benign conditions at the Department of Obstetrics and Gynaecology, Government Medical College, Thrissur, Kerala, India during a one-year study period (January 2020 to December 2020). The study protocol was submitted to the Institutional Research Committee and Ethical Committee of Government Medical College, Thrissur, and approval was obtained on 20-12-2019 (Order no.B6-155/2019/MCTCR(16)).
Inclusion criteria: Patients who underwent TAH+BSO for benign conditions (only patients who had not reached natural menopause were included). Patients who provided informed written consent were included in the study.
Exclusion criteria: Patients who were unable to comprehend and respond to the questionnaire, those who received any hormone replacement treatment after surgery, those who had already reached menopause or had urogenital symptoms prior to surgery were excluded from the study.
Sample size: According to Özdemir S et al., hot flushes were observed in 76.5% of women after surgical menopause. Changes in sexual desire were reported by 64.8%, vaginal dryness by 53.1%, and urinary complaints by 48.9% (14). Vaginal dryness was selected as the major problem to calculate the prevalence. The sample size was calculated using the formula- N=4pq/d2
q=100-p=100-53.1=46.9.
d=allowable error, 20% of p=10.62.
n=4*53.1*46.9/10.62*10.62=88.3.
Considering a 20% potential loss to follow-up.
88.3*20/100=17.66.
Sample size=88.3+17.66=105.96.
Therefore the sample size for this study was rounded to 110.
Data collection and analysis: All patients enrolled in this study received standard care. Awareness regarding the study and its relevance in the present scenario was provided to all participants. Strict confidentiality was maintained, and the investigator alone handled all data containing personal identification details of the patients.
The patients were followed-up and interviewed using a questionnaire at six weeks and 12 weeks after surgery during their routine follow-up visits. They were asked to respond “yes” or “no” to four urogenital symptoms: vaginal dryness, frequent urination, urinary incontinence, and reduced sexual desire at six weeks and 12 weeks. The severity of urogenital symptoms was assessed using the Menopause Rating Scale (15), which consists of 11 questions related to menopausal symptoms, including urogenital symptoms. The respondents marked their personal perception of severity by checking the five possible boxes for each item and recorded their responses in the corresponding columns. The severity was assessed using the Menopause Rating Scale, focusing only on urogenital symptoms.
Statistical Analysis
Chi-square tests were used to analyse the onset and progression of symptoms. Data was entered into Microsoft Excel sheets and analysed using Statistical Package for Social Sciences (SPSS) Statistics Version 20.0.
A total of 110 patients who underwent hysterectomy and BSO for benign conditions were included in the study. Among them, 95 developed at least one urogenital symptom after 12 weeks (86.4%). The mean age of the study population was 45.20±3.881 years. The majority of the study subjects (90 out of 110) underwent hysterectomy for fibroids (81.8%) (Table/Fig 1).
Out of the 95 individuals who developed at least one urogenital symptom after 12 weeks of surgery, 40 (36.4%) reported vaginal dryness at six weeks. Among them, 36 (32.7%) classified it as mild, and 4 (3.6%) had moderate symptoms. None of the patients had severe or very severe symptoms at six weeks. At 12 weeks, 61 subjects (55.5%) experienced vaginal dryness, with 21 (19.1%) reporting it as mild, 18 (16.4%) as moderate, 20 (18.2%) as severe, and 2 (1.8%) as very severe (Table/Fig 2),(Table/Fig 3).
Change in sexual desire at six weeks was reported by 37 women (33.6%), with the majority (35, 31.8%) having only mild symptoms. At 12 weeks, 67 women (60.9%) experienced a change in sexual desire, with 25 (22.7%) having mild symptoms, 18 (16.4%) having moderate symptoms, 22 (20%) having severe symptoms, and 2 (1.8%) having very severe symptoms (Table/Fig 2),(Table/Fig 3).
There was a significant progression of symptoms of vaginal dryness and reduced sexual desire from six weeks to 12 weeks (Table/Fig 4).
Vaginal physiology is predominantly regulated by oestrogen. During menopause, when oestrogen levels decrease, significant changes occur in the vulvovaginal tissues. Out of 110 cases, 36.4% of the study subjects had vaginal dryness at six weeks, and 55.5% experienced vaginal dryness at 12 weeks. It is noteworthy that the majority had mild symptoms at six weeks but later progressed to moderate, severe, and very severe symptoms at 12 weeks. This indicates a significant change (p-value <0.05). Studies have shown that urogenital symptoms after menopause may progress and worsen if left untreated (16).
The incidence of vaginal dryness has ranged from 53.1% to 80% in various studies (14),(17),(18). In a study by Kokcu A et al., it was found that 66% of patients with surgical menopause reported vaginal dryness (17). Özdemir S et al., in their study, found that 53.1% of women experience vaginal dryness after surgical menopause (14).
Bharadwaj et al., in their study on urogenital problems among menopausal women (both natural and surgical menopause) in Bhopal, found that 80% of them had vaginal dryness (18). The differences in various studies may be due to socio-demographic changes and women’s knowledge about symptoms.
Studies have shown that urinary symptoms such as dysuria, urinary urgency, urethral eversion or prolapse, frequency, and recurrent UTIs can be observed after surgical menopause, which can be attributed to the thinning of the urethral and bladder mucosa [10,19-21]. In this study, 17.3% had urinary symptoms at six weeks, and the severity of these symptoms was found to progress after 12 weeks. Özdemir et al., in their study, found that 48.9% of women experienced urinary complaints after surgical menopause (14).
The impact of surgical menopause on women’s psychological well-being and sexuality varies and depends on factors such as their preoperative mental health and sexual function, indication of surgery, and type of surgery performed (22). It has been found that there is an approximately 50% decline in testosterone levels, which is an important hormone for sexual desire, after ovary removal (23),(24). Kokcu A et al., in their study, found that 85% of patients reported a change in sexual desire (17). In a study by Castelo-Branco C et al., nearly three out of four women who had undergone surgical menopause were at risk of hypoactive sexual desire syndrome (25). In this study, 33.6% experienced a change in sexual desire at six weeks, with the majority having only mild symptoms that progressed at 12 weeks (p-value <0.05). This difference may be due to the fact that it was only three months after the surgery, and many may have considered it too early to resume sexual relations. It could also be due to a lack of awareness about sexual symptoms and the social and behavioural taboos associated with them. It has been found that approximately 50% of women experience urogenital symptoms after natural menopause. A study by Topatan S and Yildiz H has shown that the proportion, severity, and duration of urogenital symptoms were much higher in the surgical menopause group than in the natural menopause group (26).
There is a need to initiate hormone therapy as early as six weeks after surgery. Additionally, medical professionals should not overlook inquiring about urogenital symptoms during follow-up visits, as these symptoms can cause continued suffering and poor quality of life for women who may be reluctant to discuss them.
Limitation(s)
The findings of the study cannot be generalised as the follow-up duration was short.
The various urogenital symptoms after surgical menopause include vaginal dryness, difficulty in intercourse, increased need to urinate, difficulty in initiating urination, urinary incontinence, and changes in sexual desire. These symptoms can start as early as six weeks after surgery and progress in severity if left untreated. This emphasises the need for our healthcare system to conduct follow-ups with patients and inquire about urogenital symptoms even in the postoperative period, as only a minority seek medical advice on their own.
DOI: 10.7860/JCDR/2024/67141.19076
Date of Submission: Aug 21, 2023
Date of Peer Review: Oct 05, 2023
Date of Acceptance: Nov 30, 2023
Date of Publishing: Feb 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 22, 2023
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• iThenticate Software: Nov 23, 2023 (9%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
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