A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

جسم سے گرم لہریں نکلنا ، مینو پاز کی ایک علامت

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Ismail Munir

Common Menstrual Myths In The Society

Introduction

If you belong to the latter group, then chances are that once you got over the dying part and gathered the courage to speak to a family member, they informed you of your body&#39;s natural function and likely a few additional pieces of information regarding menses. As per results from a recent study, only 28% of women in Karachi, Pakistan had adequate menstrual health knowledge prior to their first <a href="https://www.merisehat.pk/article/natural-remedies-to-help-regulate-your-periods">period</a>.<a href="#accordion">[1]</a> 
&nbsp;

Understanding Myths Associated With Menstruation

Almost 50% of Pakistan&#39;s population is composed of females.<a href="#accordion">[2]</a>&nbsp;Despite the high prevalence of females, awareness of women&#39;s health issues is limited. There is an unfortunate stigmatization of menstruation in low-income countries, for e.g., sanitary napkins are often sold in brown paper bags and menstrual concerns are not a widely discussed topic. This stigmatization of menstruation and lack of awareness leads to the spread of incorrect practices and knowledge among women. This could be a source of concern as these practices can later have harmful implications on the lives of women and girls.&nbsp;

Every woman has been likely exposed to several myths and superstitions pertaining to periods. The following article will help to shed light on some of these myths.&nbsp; 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>No Baths Allowed</h5>
	</li>
</ul>

A multi-center study conducted on menstrual hygiene practices among Pakistani girls reported that 39% of girls avoid bathing during menstruation.<a href="#accordion">[3]</a>The most common reason for avoiding taking a bath is that it can cause an irregular flow.<a href="#accordion">[1]</a>&nbsp;However, such practices can affect one&#39;s hygiene and predispose girls to reproductive tract infections. Moreover, research has pointed out that there is no link between irregular flow and bathing during menstruation. Instead, warm baths are often encouraged to help relieve painful menstrual cramps in women.<a href="#accordion">[4]</a>&nbsp; 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Don&#39;t Eat The Pickle</h5>
	</li>
</ul>

Cold water, pickles, eggs, and milk are just some of the food items various cultures advise against consuming during menstruation. Approximately 50% of Pakistani girls report avoiding &#39;cold foods&#39;(e.g., yogurt, ice cream) as they fear that it will stop their periods and increase the chances of blood clots.<a href="#accordion">[3]</a>&nbsp;Similarly, &#39; hot foods&#39; (e.g., liver, eggs, dry fruits) are also avoided for fear of menstrual irregularities. However, there is a lack of scientific evidence linking cold or hot food to menstrual cycle abnormalities.&nbsp; 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Avoid Exercising</h5>
	</li>
</ul>

Among the general population in Karachi, approximately 53% of women restrict physical activity during menstruation to avoid heavy periods.<a href="#accordion">[1]</a>&nbsp;Walking, sitting, and lifting weights are some of the commonly avoided physical activities among girls and women. However, research shows that aerobic exercise can be beneficial for painful menstrual cramps.<a href="#accordion">[5]</a> 
&nbsp;

Conclusion

In many low- and middle-income countries, periods are considered impure and a process of dirty or impure blood leaving the body. This is likely due to a lack of education regarding reproductive health. Young adolescent girls are often too shy or scared to discuss menstrual issues with their mothers. Moreover, a majority of adult women are also not aware of the physiology of menstruation or good hygiene practices. As a result, there is a high prevalence of misinformation among girls and women. Almost 70% of Pakistani university-going girls believe the source of bleeding in menstruation to be the vagina instead of the uterus.<a href="#accordion">[3]</a>

Therefore, there is a need for the introduction of regular menstrual education awareness programs in schools and universities. Furthermore, primary care physicians should be aware of the common myths and misconceptions regarding menstrual health in a population. Health education campaigns on a community level can ultimately help destigmatize reproductive health issues.&nbsp; 
&nbsp;

Key Points

<ul>
</ul>

<ul>
	<li>Menstruation is a natural phenomenon in a woman&#39;s life that is often stigmatized in various cultures.</li>
	<li>A lack of awareness has led to the development of various myths and practices regarding menstruation. The most common of which is avoidance of taking a bath during periods, not eating certain foods, and avoiding exercise.</li>
	<li>Community-based health education programs can help destigmatize menstruation and propagate correct information and practices among girls and women.</li>
</ul>

[1] Ali, S. A. et al., 2020. Perceptions, Practices, and Challenges Regarding Menstrual Hygiene Among Women in Karachi, Pakistan: A Comparison Between General Population and Healthcare Workers. Cureus, 12(8).

[2] Pakistan Bureau of Statistics, n.d. Census 2017. [Online].

[3] Mansoor, H. et al., 2020. Menstrual knowledge and practices of Pakistani girls: A multicenter, cross-sectional study. Heliyon, 6(1).

[4] Jo, J. & Lee, S. H., 2018. Heat therapy for primary dysmenorrhea: A systematic review and meta-analysis of its effects on pain relief and quality of life. Scientific Reports, Volume 8.

[5] Dehnavi, Z. M., Jafarnejad, F. & Kamali, Z., 2018. The Effect of aerobic exercise on primary dysmenorrhea: A clinical trial study. Journal of Education and Health Promotion, 7(3).

Nimrah H. Sattar

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

Mental Health Tips For Dysmenorrhea

If you&#39;re a woman in your 20s, 30s, or really any age, there must have been days when you struggled with your mental health. Dark thoughts, anxiety, low mood, an inability to carry out normal day-to-day chores, chances are you&#39;ve experienced them all. And if you suffer from <a href="https://www.merisehat.pk/disease/dysmenorrhea">dysmenorrhea</a>, then the chances of anxiety, irritability, etc. become much higher. Despite society conditioning us into thinking that period pain is a part of life, there is nothing okay about having to deal with debilitating pain on a monthly basis.

<a href="https://www.merisehat.pk/disease/dysmenorrhea">Dysmenorrhea</a>, also called painful menstruation, affects more than 50% of university students in Pakistan<a href="#accordion">[1]</a>. Along with severe pain, many women also report sleep disturbances, difficulty concentrating on work or studies, and frequent leaves from work or school<a href="#accordion">[2]</a>. Additionally, women with dysmenorrhea have higher depression and anxiety scores<a href="#accordion">[3]</a>. Thus, significantly impacting their quality of life.

So, if you&#39;re someone struggling with dysmenorrhea and its mental health effects, here are some of the things you can do to feel better.

&nbsp;

Understanding Dysmenorrhea And Mental Health

Over five thousand years ago, people in Northern India developed what we now call yoga. The exercise and relaxation method has evolved over the years, but what has remained the same is its ability to help people heal, both physically and emotionally. Yoga isn&#39;t just some exercise. It is also a way for people ground themselves and connect with their thoughts.

In dysmenorrhea, the increased levels of prostaglandins and estrogen cause the uterine muscles to contract. As these muscles contract, they push against the surrounding blood vessels, temporarily cutting off the oxygen supply to the muscle. Thus, resulting in pain around the lower abdomen and back.&nbsp;

Various yoga poses can help relax the muscles and improve the blood supply to the pelvic region. Moreover, the various stretches also help calm the mind and revive your energy. However, no one&#39;s asking you to twist your body into crazy positions. You can start by practicing simple poses such as the pigeon pose, fish pose, bound angle pose, and child&#39;s pose. It&#39;s best to avoid leg lifts and any rigorous physical activity during the first few days of your periods.&nbsp;

&nbsp;

Deep breathing exercises involve a combination of slow, deep inhales and exhales. They help increase blood flow in the blood vessels, relax muscles, and reduce pain perception. Thus, relieving anxiety and depression symptoms among people. It is also one of non-pharmacological methods of reducing pain in women with dysmenorrhea.

&nbsp;

Here&#39;s a simple deep breathing exercise you can try next time you feel anxious or low on emery:

<ol>
	<li>Lie on your back in bed or on a yoga mat.</li>
	<li>Inhale and exhale to relax your body.</li>
	<li>Now place a hand on your belly.</li>
	<li>As you take a deep breath in, feel your belly rise into your hand.</li>
	<li>Breath out slowly and feel the belly move down as the air exits your body.</li>
	<li>Take three more breaths like this, focusing on the movement of your belly and feeling the air filling your body and leaving with every exhale.</li>
</ol>

&nbsp;

Dysmenorrhea can be an extremely debilitating condition for women. Coupled with pain, women are also affected with mental health disorders such as depression and anxiety. Therefore, it is important to increase awareness about the mental health implications of this gynecological disorder. Moreover, researchers believe that psychiatric intervention can help women and adolescent girls suffering from dysmenorrhea have a better quality of life.

<ul>
</ul>

<ul>
	<li>Dysmenorrhea, defined as painful menstruation, is associated with higher depression and anxiety levels among women.</li>
	<li>Yoga is a simple exercise technique that can help relax muscles and calm the mind, helping ease symptoms of depression and anxiety in women with dysmenorrhea.</li>
	<li>Deep breathing exercises involve slow, deep breaths that increase oxygenation of muscles and blood vessels; thus, relaxing muscles and reducing anxiety and depression.</li>
	<li>There is a need for a multidisciplinary approach in women suffering from dysmenorrhea. Psychological intervention can help improve their quality of life.</li>
</ul>

&nbsp;

[1] Yasir, S., Kant, B. & Dar, M. F., 2014. FREQUENCY OF DYSMENORRHOEA, ITS IMPACT AND MANAGEMENT STRATEGIES ADOPTED BY MEDICAL STUDENTS. Journal of Ayub Medical College Abbotabad, 26(3).

[2] Unsal, A. et al., 2010. Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. Upsala Journal of Medical Sciences, 115(2), pp. 138-145.

[3] Sahin, N. et al., 2018. Assessment of anxiety-depression levels and perceptions of quality of life in adolescents with dysmenorrhea. Reproductive Health, Volume 15.

Medilink Consultant clinic

Saad Ullah Siddiqui

Managing Pain In Dysmenorrhea

<a href="https://www.merisehat.pk/disease/dysmenorrhea">Dysmenorrhea</a> is a common occurrence among adolescent girls<a href="#accordion">[1]</a>. Also called painful menstruation, the condition affects 50% of university students across Pakistan<a href="#accordion">[2]</a>. In the majority of women, the pain is also associated with nausea, vomiting, fatigue, and mood disturbances.&nbsp;

Dysmenorrhea is of two types: primary and secondary. Primary dysmenorrhea develops in the absence of any underlying medical condition and is usually caused by an increase in prostaglandin activity. On the other hand, secondary dysmenorrhea results from pelvic pathology such as fibroids, endometriosis, pelvic inflammatory disease (PID), ovarian cysts, or several others.&nbsp;

While the level of pain varies from person to person, in many the symptom of dysmenorrhea significantly impacts their quality of life. Difficulty concentrating on studies, sleep disturbances, limited participation in sports, and frequent class and work absenteeism are common feature<a href="#accordion">[3]</a>.&nbsp;

Therefore, effective pain management techniques are highly important in helping women achieve some normalcy in life. There are several pharmacological and nonpharmacological methods available to help relieve pain.&nbsp;

&nbsp;

Understanding Dysmenorrhea And Pain Management

These include conventional treatments such as over-the-counter pain relief medications and hormonal contraceptives:

&nbsp;

<h5>1. Pain Relievers</h5>

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are effective at reducing the levels of prostaglandins in the body. This in turn reduces uterine contraction and helps relieve dysmenorrhea. They are used for both primary and secondary dysmenorrhea. However, their use is contraindicated in people with gastritis, peptic ulcer, renal problems, or bleeding conditions due to adverse effects. Moreover, for many women NSAIDs fail to provide the desired effect of pain relief.&nbsp;In some women, doctors may also prescribe analgesics such as aspirin and acetaminophen in combination with NSAIDs or alone.

&nbsp;

<h5>2. Hormonal Contraceptives</h5>

These work by blocking ovulation and decreasing menstrual flow; thus, alleviating pain. Some options include oral contraceptive pills, hormonal intrauterine contraceptive devices (IUCD), and hormonal injections. While they can provide better relief of pain than NSAIDs, they are associated with side effects such as weight gain, menstrual irregularities, and mood changes. Moreover, they are often prescribed to women not looking to conceive.&nbsp;

&nbsp;

Over the years, the use of nonpharmacological methods which commonly involve complementary and alternative medicine has steadily increased<a href="#accordion">[4]</a>.&nbsp;Bed rest is one of the most common methods employed by university students in Pakistan for pain management followed by oil massage, drinking turmeric milk, and using hot water bottles<a href="#accordion">[5]</a>.&nbsp;

 
Generally, at-home treatments for relieving dysmenorrhea include:

<ul>
	<li>Placing a heating pad or hot water bottle on the pelvic and back area can help reduce muscular spasms.</li>
	<li>Massaging the abdomen and back using essential oils such as lavender, rose, and peppermint.</li>
	<li>Taking warm baths.</li>
	<li>Taking vitamin B1 (thiamine) supplements daily.</li>
	<li>Avoiding caffeine, smoking, and alcohol.&nbsp;</li>
	<li>Daily exercise can also help prevent painful menstrual cramps.</li>
</ul>

&nbsp;

<ul>
	<li>
	<h5>Ginger</h5>
	</li>
</ul>

The use of ginger has also been shown to cause a significant reduction in pain. Researchers attribute the effects to ginger&#39;s anti-inflammatory action that is brought about by the inhibition of prostaglandin synthesis. In a study, ginger was shown to be as effective as ibuprofen and mefenamic acid in relieving pain in women with primary dysmenorrhea<a href="#accordion">[6]</a>.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Complementary Methods</h5>
	</li>
</ul>

Some alternative or complementary methods may also be employed for dysmenorrhea. These include:

&nbsp;

<h5>1. Yoga</h5>

Several yoga poses can provide relief from painful menstruation. The gentle exercise has been linked to the release of endorphins and reducing menstrual pain.

&nbsp;

<h5>2.&nbsp;Acupuncture And Acupressure</h5>

Certain acupuncture points help reduce muscular contractions by regulating blood flow to these areas. Thus, reducing pain.

&nbsp;

<h5>3. Herbs</h5>

Herbal remedies such as chamomile tea, fennel seeds, and cinnamon have anti-inflammatory and antispasmodic action that reduce muscular contractors and relieve pain.&nbsp;

&nbsp;

<h5>4.&nbsp;Transcutaneous Electrical Nerve Stimulation (TENS)</h5>

Through electrical pulses, the body is stimulated to release endorphins which help reduce pain.

&nbsp;

Menstrual pain is often dismissed as a normal part of women&#39;s lives. This results in young women never seeking medical attention for dysmenorrhea. Thus, causing significant physical and emotional distress. Not only can dysmenorrhea affect one&#39;s academic performance but also limit their day-to-day functioning.&nbsp;

Despite the high prevalence of dysmenorrhea, there is a lack of awareness among women about the various pain management methods available to them. The majority of women self-medicate with NSAIDs or analgesics. However, these often cause side effects and/or fail to provide relief. Therefore, there is a need for more effective and safe pain management strategies. Moreover, women should be counseled about the various complementary and alternative medicine methods such as yoga and breathing exercises that can provide relief of symptoms.

&nbsp;

<ul></ul><ul><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Dysmenorrhea is defined as painful menstruation and leads to significant reduction in quality of life.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Pharmacological methods for pain relief involve the use of over-the-counter pain medications such as NSAIDS and hormonal contraceptives.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Since pharmacological therapies can have side effects, many women resort to home remedies such as massage, heating pads, massage, and exercise.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Complementary and alternative medicine methods such as yoga, acupuncture, and herbal supplements are also gaining momentum for treatment of dysmenorrhea.</li></ul>

[1] Ullah, A. et al., 2021. Prevalence of Dysmenorrhea and Determinants of Pain Intensity Among University-Age Women. Pain Medicine, 22(12), pp. 2851-2862.

[2] Yasir, S., Kant, B. & Dar, M. F., 2014. FREQUENCY OF DYSMENORRHOEA, ITS IMPACT AND MANAGEMENT STRATEGIES ADOPTED BY MEDICAL STUDENTS. Journal of Ayub Medical College Abbotabad, 26(3).

[3] Unsal, A. et al., 2010. Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. Upsala Journal of Medical Sciences, 115(2), pp. 138-145.

[4] Yu, A., 2014. Complementary and alternative treatments for primary dysmenorrhea in adolescents. The Nurse Practitioner, 39(11), pp. 1-12.

[5] Mansoor, H. et al., 2020. Menstrual knowledge and practices of Pakistani girls: A multicenter, cross-sectional study. Heliyon, 6(1).

[6] Jenabi, E., 2013. The effect of ginger for relieving of primary dysmenorrhoea. Journal of the Pakistan Medical Association, 63(1).

Iqra Mazhar

I’m Hot. It’s Not Summer, It’s Just Menopause

<a href="https://www.merisehat.pk/disease/menopause">Menopause</a> marks the evident end of regular menstrual cycles. The term can depict any progressions one goes through nearing the end of menstruation, or what one may experience closely after it, indicating the completion of your reproductive years and stages.&nbsp; 
&nbsp;

Menopause and perimenopause can cause side effects like nervousness, mood swings, mind haze, hot flushes, and irregular periods. These side effects can begin a long time before the end of the menstrual cycle and continue a while later. Menopause and perimenopause side effects can hugely affect the individual&rsquo;s life, including social interactions and work. However, there are multiple ways that can help you deal with these side effects. Several medications, for instance, can help replace the missing or reduced chemicals associated with menopause and help ease the unavoidable signs and symptoms.

&nbsp;

Understanding menopause and how to deal with its symptoms

Menopause is a natural process that all menstruating women must go through. It may occur due to one of the following reasons: 
&nbsp;

<ul>
	<li>Natural Menopause: During their 40s, most women observe changes to their regular cycles. The cycles may become longer or more limited, heavier or lighter, more frequent or with much significant dry spells, until the ovaries stop producing eggs and menopause commences. This occurs, on average, by the age of 51 years<a href="#accordion">[1]</a>. 
	&nbsp;</li>
	<li>Surgical Procedures: Surgical procedures such as oophorectomy or removal of ovaries are also associated with causing menopause. The ovaries are responsible for producing hormones, including estrogen and progesterone that control, monitor, and synchronize the monthly menstrual cycle. Thus, medical procedures to remove the ovaries cause early and prompt menopause. The monthly periods halt, and the person goes through the various menopausal signs and symptoms<a href="#accordion">[1]</a>. 
	&nbsp;</li>
	<li>Chemotherapy Or Radiation Therapy: These disease treatments can affect menopause by causing side effects such as hot flashes during or not long after the course of treatment. Following chemotherapy, the stop to the monthly cycle (and fertility) is not necessarily irreversible or long-lasting, so contraceptive measures might be needed<a href="#accordion">[1]</a>. 
	&nbsp;</li>
	<li>Primary Ovarian Insufficiency: Early menopause might result from the inadequate production of reproductive hormones by the ovaries, a condition called primary ovarian insufficiency. It can result from hereditary elements or immune system illness. Hormone treatment is regularly suggested until the normal period of menopause to safeguard the cerebrum, heart, and bones<a href="#accordion">[2]</a>.&nbsp;</li>
</ul>

&nbsp;

Menopause is not easily self-diagnosed and missing a period for more than three months is a concerning state. The most common symptoms of menopause include: 
&nbsp;

<ul>
	<li>Hot Flashes</li>
	<li>Insomnia</li>
	<li>Vaginal Dryness</li>
	<li>Urinary Incontinence</li>
	<li>Mood Changes 
	&nbsp;</li>
</ul>

An individual may experience one or more symptoms and should consult medical healthcare providers to confirm the suspicion of menopause. They will monitor and examine your symptoms to guide you towards an efficient treatment.&nbsp; 
&nbsp;

While certain lifestyle changes and drugs may forestall menopause, it is a natural and inevitable process every menstruating woman must go through. However, certain measures may help alleviate its symptoms.

&nbsp;

<h5>1. Hot Flashes</h5>

Hot flashes are the most prevalent symptoms of menopause. It is the unexpected sensation of warmth in the chest area, but is normally experienced with a greater sensation over the face, neck, and chest. Your skin can blush, as though you are becoming embarrassed. A hot flash can likewise cause extreme perspiration. Assuming you lose a lot of body heat, you can feel chills a short time later. Night sweats are hot flashes that occur at night<a href="#accordion">[3]</a>. 
&nbsp;

Phytoestrogens naturally occur in plants and certain food sources. Research suggests that these substances can, to some extent, reverse the hormonal imbalance associated with menopause<a href="#accordion">[4]</a>. Soy-based food varieties contain elevated degrees of phytoestrogens, so eating loads of tofu is recommended to decrease the overwhelming effects of hot flashes. Moreover, it is highly recommended to stay away from food triggers that can make you sweat as they increase your basal temperature. These include hot drinks, spicy food, and liquor. And remember to stay hydrated! 
&nbsp;

Exercise likewise facilitates the discomfort of hot flashes by bringing down levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Try to get at least 20 minutes of physical activity, three times each week. As per the National Center for Complementary and Integrative Health, acupuncture can also help reduce hot flashes in postmenopausal women<a href="#accordion">[5]</a>. 
&nbsp;

<h5>2. Insomnia</h5>

During menopause, it appears as though you are constantly drained and exhausted. To exacerbate the situation, hot flashes and various other side effects disrupt a person&rsquo;s sleep. Having a consistent sleep routine helps individuals to get the necessary amount of rest, especially during menopause when they are fatigued. To adhere to a timetable, set up your brain and body for rest by fostering a soothing bedtime ritual that starts around a similar time each night. For instance, clean up, listen to calming music, read a book, or do different exercises that help you relax. These practices indicate to your body that it&rsquo;s almost time to sleep. Thus, helping you to nod off with ease. 
&nbsp;

Once you get in bed, abstain from staring at the TV, using your laptop, or checking your phone. The blue light from gleaming electronic screens smothers your body&#39;s development of melatonin, a hormone that affects sleep. Moreover, try to abstain from working, eating, and having a serious conversation with anyone especially your spouse once you have settled into your bedroom. Reinforcing the relationship between your bed and rest might assist you with clearing your brain at bedtime. Ensure you are in a comfortable atmosphere by adjusting the temperature of the AC or heater, and getting a new fluffier pillow. If you live in a metropolitan city, get ear plugs so that the noises outside do not disturb you, and drink a cup of chamomile tea before going to bed.&nbsp; 
&nbsp;

<h5>3. Vaginal Dryness</h5>

The vagina might become dry, or irritated because of menopause and perimenopause. A GP can prescribe estrogen medicines that can be placed into the vagina, in the form of a tablet, cream, or ring. This multifaceted treatment can also help alleviate any urinary side effects of menopause and perimenopause, such as urinary incontinence. These vaginal estrogen medicines cannot enter the circulatory system and just have a local effect. Moreover, they do not have a rigid time frame and can be used throughout the post-menopause stage. Discontinuing the use of the product might bring back the unpleasant symptoms. There have not been any recorded repercussions, therefore, vaginal estrogen is safe to be used with hormone replacement therapy (HRT)<a href="#accordion">[6]</a>. 
&nbsp;

Over-the-counter vaginal lubricants are recommended to address vaginal dryness experienced during intercourse. These items lower the frictional erosion associated with vaginal dryness and prevent any sexual discomfort. It should be noted that only water-soluble lubricants are recommended as the counterpart oil-soluble items, for example, Vaseline increases discomfort and make the situation more complex. Reach out for products intended for the vagina; keep away from hand creams and moisturizers containing alcohol or those that are scented. These can disturb the vaginal tissue and disrupt the vaginal pH<a href="#accordion">[7]</a>.&nbsp;&nbsp; 
&nbsp;

<h5>4. Urinary Incontinence&nbsp;</h5>

While it is characterized as the constant and uncontrollable urge to urinate, most individuals would agree that urinary incontinence is an unwanted disturbance. Fortunately, there are systems to assist with various types of incontinence without drugs or medical procedures. Ensure you are drinking satisfactory water to keep urine diluted. This can be confirmed if the urine is clear or has a light-yellow hue. Keep away from food varieties or refreshments with a high acid or caffeine content, as that can disturb the bladder lining. These include grapefruits, oranges, tomatoes, coffee, and caffeine-containing sodas. Likewise, attempt Kegel exercises to reinforce your pelvic floor muscles and diminish incontinence episodes<a href="#accordion">[7].</a>&nbsp; 
&nbsp;

<h5>5. Mood Changes</h5>

Discussing your mood swings with a healthcare professional can assist you with recognizing the reason, gauging the probability of depression, and settling on the most suitable mediation. For depression, treatment would be different as your doctor might prescribe drugs that alter the chemical imbalance associated with menopause. Normally, these medications take half a month to bring about any noticeable improvement. A few antidepressants have, likewise, been found to treat hot flashes.&nbsp;Antidepressants work best when combined with therapy or psychotherapy. 
&nbsp;

When you reach menopause, you might anxiously wait to transition to post-menopause. This is the period after menopause. However, that does not guarantee complete liberty from discomforting menopausal symptoms. 
&nbsp;

There is no conclusive timetable for when menopausal symptoms begin and end. Your experience generally depends on hereditary qualities. Figuring out how to adapt to your symptoms can bring you long stretches of solace as you progress to the next chapter of your life. 
&nbsp;

While there are no treatments to reverse menopause, an individual can make certain changes in their lifestyle to alleviate the persisting symptoms: 
&nbsp;

<ul>
	<li>Stay hydrated and wear light clothes to avoid intense hot flashes. Also, keep away from spicy food and hot beverages.</li>
	<li>Try to include physical fitness and exercise into your routine to help with hot flashes and insomnia.</li>
	<li>Do not be fickle with your sleep routine. Adhere to a consistent cycle, even on weekends, to get uninterrupted sleep.</li>
	<li>Schedule an appointment with a counselor or therapist to address mood changes in a comfortable and safe environment.</li>
	<li>Engage yourself in social gatherings to increase serotonin.</li>
	<li>Try Kegel exercises to strengthen pelvic bone muscles and reduce the recurrence of urinary incontinence.</li>
</ul>

&nbsp;

[1].Mayo Clinic. (2022). Menopause.

[2].Welt, C. (2020, September 8). Clinical manifestations and diagnosis of spontaneous primary ovarian insufficiency (premature ovarian failure).

[3].Santen, R. J., Loprinzi, C. L., & Casper, R. F. (2020, Feburary 18). Menopausal hot flashes.

[4].Chen, M. N., Lin, C. C., & Liu, C. F. (2014). Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric, Vol 18(2), 260-269.

[5].Mudd, L., & Shurtleff, D. (2017, May). Menopausal Symptoms: In Depth. Retrieved from National Center for Complementary and Integrative Health: https://www.nccih.nih.gov/health/menopausal-symptoms-in-depth#hed3

[6].NHS. (2022, May 7). Menopause. Retrieved from NHS

[7].NAMS. (2022). Five Solutions for Menopause Symptoms. Retrieved from The North American Menopause Society:

Zarlish Kazmi

This article or video has been recorded by a subject / domain specialists with a proven track record of excellence in their area. 

To Bleed Or Not To Bleed?

Society, culture, and religion have fixed certain roles for each gender. For women, it is traditionally the role of the mother, the nurturer, and the caretaker. For centuries, they have prioritized family life. Whether they have been asked to, whether there was no other option available, whether out of choice; the thing is many women have come to put others&rsquo; needs above their own. They become givers and, in the process, forget they are also entitled to love and care.&nbsp;

&nbsp;

Moreover, in South Asian communities, women are often restricted in mobility. As a result, they have limited healthcare access, are subjected to male violence, and do not hold the power to make decisions for themselves or their families<a href="#accordion">[1]</a>. This further devalues their role in terms of how they perceive themselves as well as how society perceives them.&nbsp;

&nbsp;

When even their basic needs are not met, women stop paying attention to common and major healthcare concerns. Thus, they are less likely to seek care, especially when it concerns reproductive health. Of course, the existence of cultural taboos does not help this situation; they&rsquo;ve just internalized this lack of confidence along with a poor sense of worth.&nbsp;&nbsp; 
&nbsp;

Understanding Post Menopausal Bleeding

Although menstruation is a natural biological process, in low- and middle-income countries, there are several stigmas surrounding the physiological phenomenon<a href="#accordion">[2]</a>.&nbsp;

&nbsp;

The lack of knowledge regarding female reproductive health and the spread of incorrect information means many women are unaware of when to seek help. A cross-sectional survey conducted at a government hospital in Karachi, Pakistan, found that more than 90% of women had heard of menopause<a href="#accordion">[3]</a>. However, only 30% knew about the symptoms<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

A lack of awareness of <a href="https://merisehat.pk/disease/menopause">menopause symptoms</a> means many women are also unaware of what&rsquo;s normal and what&rsquo;s not. Therefore, they often disregard symptoms such as postmenopausal bleeding.&nbsp;

&nbsp;

But is postmenopausal bleeding a cause for concern? Should you be booking a visit to the gynecologist?&nbsp;

&nbsp;

<h5>Menopause&nbsp;</h5>

Menopause is defined as the cessation of menstrual cycles for a period of 12 consecutive months. Postmenopause is the period following menopause. The average age of menopause is 51 years<a href="#accordion">[4]</a>, whereas in Pakistan, the mean age of menopause for women is 49.3 years<a href="#accordion">[5]</a>.&nbsp;

&nbsp;

The common symptoms of menopause include:

<ul>
	<li>Mood changes</li>
	<li>Hot flashes</li>
	<li>Hair loss</li>
	<li>Vaginal dryness</li>
	<li>Insomnia</li>
</ul>

&nbsp;

Often, these symptoms linger into the postmenopause period.&nbsp;

&nbsp;

IMPORTANT: One thing that&rsquo;s not a normal side effect of menopause, and should be a cause for concern, is the presence of vaginal bleeding.&nbsp;

&nbsp;

<h5>Postmenopausal Bleeding</h5>

Postmenopausal bleeding is defined as vaginal bleeding after a year or more of cessation of menstruation. Approximately 4-11% of postmenopausal women report vaginal bleeding<a href="#accordion">[4]</a>. And about 1-14% of postmenopausal bleeding is secondary to endometrial cancer<a href="#accordion">[4]</a>.&nbsp;

&nbsp;

Although vaginal atrophy is the most common cause of postmenopausal bleeding, 90% of postmenopausal women with endometrial cancer have vaginal bleeding as the presenting sign<a href="#accordion">[6]</a>. Therefore, there is a need for raising awareness about postmenopausal bleeding and its possible causes.&nbsp;

&nbsp;

After menopause, there is a drop in estrogen levels in the body. The tissues lining the vagina and endometrium begin to undergo atrophy. Micro-erosions along with chronic inflammation develop on the epithelial surface. This inflamed endometrium is then prone to slight bleeding.&nbsp;

&nbsp;

Other causes of postmenopausal bleeding include:

<ul>
	<li>Endometrial Or Uterine Cancer:&nbsp;Endometrial cancer could result in a thickening of the uterus lining. It causes the lining to shed and result in vaginal bleeding.&nbsp;</li>
	<li>Polyps:&nbsp;These result from an overgrowth of the endometrium and could appear in the uterus or cervix. They&rsquo;re not cancerous but likely to result in spotting or heavy bleeding.&nbsp;</li>
	<li>Fibroids:&nbsp;Also called leiomyomas, fibroids are noncancerous growth of muscle and tissue that form from the uterine walls. While small fibroids are typically asymptomatic, larger ones could cause vaginal bleeding.&nbsp;</li>
	<li>Endometrial Hyperplasia:&nbsp;Low progesterone levels and too much estrogen result in endometrial thickening. The thickened endometrium is at risk of bleeding and also able to transform into cancer.&nbsp;</li>
	<li>Sexually Transmitted Diseases (STDs):&nbsp;Vaginal bleeding after sexual intercourse might be a result of STDs such as chlamydia and gonorrhea.&nbsp;</li>
	<li>Medications:&nbsp;The use of certain drugs is associated with vaginal bleeding as a side effect. These include tamoxifen, blood thinners, or hormone replacement therapy.</li>
	<li>Pelvic Trauma:&nbsp;Injury to the vagina also causes bleeding.</li>
</ul>

&nbsp;

A cross-sectional study conducted in Mardan, Pakistan, determined the patterns of bleeding and endometrial biopsy in women presenting with postmenopausal bleeding. As per the results, 26% of the patients had atrophic endometrium while 23% had endometrial carcinoma<a href="#accordion">[7]</a>, thus, proving the need for a proper assessment of postmenopausal bleeding in women.

&nbsp;

Another cross-sectional study was conducted among postmenopausal women in Sahiwal, Pakistan. Half of the women were obese, which established obesity as a risk factor for postmenopausal bleeding<a href="#accordion">[8]</a>. Moreover, the incidence of endometrial carcinoma was 7% among women<a href="#accordion">[8]</a>. The study points to the need for endometrial cancer screening programs, especially among menopausal women complaining of vaginal bleeding.&nbsp;

&nbsp;

Regardless of the reason, postmenopausal bleeding is a cause for concern. Therefore, if you notice spotting or vaginal bleeding post-menopause, book an appointment with the obstetrician-gynecologist. Early diagnosis would improve prognosis for the patient, and their overall quality of life.&nbsp;

<ul><li>Postmenopausal bleeding is defined as vaginal bleeding that occurs 12 months after the cessation of the menstrual cycle.&nbsp;</li><li>Vaginal or endometrial atrophy is the most common cause of postmenopausal bleeding. However, 90% of postmenopausal women with endometrial cancer have vaginal bleeding as the presenting sign.</li><li>Other common causes of postmenopausal bleeding include polyps, fibroids, endometrial hyperplasia, medications, and sexually transmitted diseases.&nbsp;</li><li>All cases of postmenopausal bleeding require immediate consultation with the obstetrician-gynecologist. A delay in diagnosis could have a poor outcome for the patient.&nbsp;</li></ul>

[1] Fikree, F. F., & Pasha, O. (2004). Role of gender in health disparity: the South Asian context. BMJ (Clinical research ed.), 328(7443), 823–826.

[2] Arshad Ali S, Baloch M, Riaz L, et al. (August 20, 2020) Perceptions, Practices, and Challenges Regarding Menstrual Hygiene Among Women in Karachi, Pakistan: A Comparison Between General Population and Healthcare Workers. Cureus 12(8): e9894. doi:10.7759/cureus.9894

[3] Karim, F., Ghazi, A., Ali, T., Jabbar, S., Naz, S., & Aslam, R. (2013). Women’s Perception Towards Menopause. Journal of Surgery Pakistan (International), 18(3).

[4] Sung S, Abramovitz A. Postmenopausal Bleeding. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[5] Jadoon AK, Sohail F, Qabulio SN, et al. Perception and Awareness of Menopause among Premenopausal Women of Different Socioeconomic Backgrounds. J South Asian Feder Menopause Soc 2019;7(1):8–13.

[6] ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding. Obstet Gynecol. 2018 May;131(5):e124-e129.

[7] Jadoon S, et al. Postmenopausal Bleeding - A Strong Indicator of Endometrial Carcinoma. Pak Armed Forces Med J 2019; 69 (2): 368-72

[8] Perveen, S., Azhar, M. S., Shah, F., Mahmood, F., & Mahmood, U. (2022). Association of postmenopausal bleeding with endometrial carcinoma. Pakistan Journal of Medical and Health Sciences, 16(3), 103–105.

Menopause And Breast Cancer

According to research, in all of Asia, Pakistan has the highest rate of breast cancer, with 1 in 9 women at risk of getting diagnosed with breast cancer<a href="#accordion">[7]</a>&nbsp;<a href="#accordion">[6]</a>. This is usually because of the myths associated with the condition. Delayed screening means the cancer is diagnosed when it has advanced and there is little chance of survival.

Understanding the link between Menopause and Breast cancer

Age is one of the major risk factors for developing breast cancer. The likelihood of being diagnosed with a malignant tumor in the breast is greatest between the ages of 45 and 55. Unless an individual has previously undergone chemotherapy, surgeries such as hysterectomy or oophorectomy, or possesses a genetic predisposition to experience early menopause, this is when a natural decline in hormone levels occurs.

The decreased production of estrogen and progesterone leads to irregular menstrual periods before they eventually cease. During this phase, one may experience hot flashes, sexual difficulties, insomnia, memory problems, osteoporosis, and anxiety.

However, menopause itself is not our concern here. Menopause itself is not related to a higher risk of getting cancer. It&rsquo;s the fact that 1 out of 8 cases of breast cancer occur during their lifetime, mostly in women over 50, that&rsquo;s worrisome<a href="#accordion">[8]</a>. This is why the age factor is important &ndash; a girl who starts menstruating before 12 and/or experiences menopause after 55 will have an increased number of ovulations and, thereby, increased exposure to hormones like estrogen.

And then there&rsquo;s the issue of medications or treatments like hormone replacement therapy one may be taking to manage the menopausal symptoms, which increases the risk of breast cancer. 
&nbsp;

While menopause is a risk factor for breast cancer, interestingly, breast cancer can also induce menopause. Treatments like chemotherapy, ovarian suppression (through surgery, hormone therapy, or radiotherapy), and hormone therapy (e.g., anastrozole, exemestane, letrozole, and tamoxifen) cause menopausal symptoms<a href="#accordion">[9]</a>.&nbsp; While each woman reacts differently to therapy, premature menopause due to breast cancer may be permanent (rather than temporary) if they&rsquo;re closer to the natural age of experiencing it. 
&nbsp;

Menopausal signs that are frequently experienced include:

<ul>
	<li>Joint pain</li>
	<li>Night sweats</li>
	<li>Anxiety and irritation</li>
	<li>Mood change</li>
	<li>Heart palpitations</li>
	<li>Change in libido</li>
	<li>Hot flushes</li>
	<li>Changes to hair and skin</li>
	<li>Weight gain, especially around our waist</li>
	<li>Difficulty sleeping</li>
	<li>Memory issues</li>
	<li>Vaginal dryness 
	&nbsp;</li>
</ul>

The onset of these symptoms can be gradual or sudden. It is worth mentioning that not all individuals experience all the listed symptoms, and the severity of symptoms can vary among individuals. 
&nbsp;

The estrogen-driven breast cancers, also known as estrogen-receptor-positive cancers, are a more common occurrence than aggressive cancers. They tend to develop gradually and have a lower mortality rate. In other words, they require less aggressive therapy and have a better outlook and reduced chance of recurrence.

According to studies, if you&rsquo;re overweight or obese post-menopause, you have a 20-60% greater risk of developing breast cancer than those who are lean<a href="#accordion">[10]</a>. This extra fat is the main source of estrogen at that time. It also produces proteins that increase inflammation throughout the body, which causes breast cancer to recur. 
&nbsp;

<h5 style="text-align:justify">Medications</h5>

There are two distinct kinds of drugs, and they both function differently. Aromatase inhibitors (AIs) reduce or halt the body&#39;s production of estrogen, which causes the tumors to die. Tamoxifen prevents estrogen from acting on breast cancer cells.

Both tamoxifen and an aromatase inhibitor can be used to treat postmenopausal individuals with estrogen-positive breast cancer. However, aromatase inhibitors are generally more effective and do not increase the risk of blood clots or uterine cancer<a href="#accordion">[10]</a>. 
&nbsp;

Exercising, a balanced diet, quitting smoking (including avoiding passive smoking) and drinking alcohol, and relieving stress can help breast cancer patients deal with the symptoms. 
&nbsp;

Menopause can be a risk factor for breast cancer and vice versa. However, you can overcome both issues with a balanced diet, a healthy lifestyle, proper checkups, and the right therapy.

[1]Sohail S, Alam SN. Breast cancer in Pakistan-awareness and early detection.

[2] Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International journal of cancer. 2010 Dec 15;127(12):2893-917

[3] Clemons M, Simmons C. Identifying menopause in breast cancer patients: considerations and implications. Breast cancer research and treatment. 2007 Aug;104:115-20.

[4] Biglia N, Bounous VE, Sgro LG, D'Alonzo M, Pecchio S, Nappi RE. Genitourinary syndrome of menopause in breast cancer survivors: are we facing new and safe hopes?. Clinical Breast Cancer. 2015 Dec 1;15(6):413-20.

[5] De Villiers TJ, Pines A, Panay N, Gambacciani M, Archer DF, Baber RJ, Davis SR, Gompel AA, Henderson VW, Langer R, Lobo RA. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2013 Jun 1;16(3):316-37.

[6] Academic.oup.com.

[7] Khan NH, Duan SF, Wu DD, Ji XY. Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women. Cancer Manag Res. 2021;13:2125-2129. Published 2021 Mar 2. doi:10.2147/CMAR.S270671

[8] NHS choices.

[9] Menopausal symptoms and breast cancer. Breast Cancer Now.

[10] Stepko B, En español , español E, 03 O. Dealing with breast cancer after menopause. AARP

Syeda Qurat-ul-Ain

Humza Khizer

First Period? No Worries, We Got You Covered

Menarche &ndash; first menstrual period &ndash; is a normal phenomenon for girls. It is significant because it implies growth, both physically and socially.&nbsp; 
&nbsp;

Menstruation is the &quot;periodic discharge of blood from the uterus.&quot; It may or may not occur as a monthly cycle and continues for the entirety of the women&rsquo;s active reproductive life&quot;<a href="#accordion">[1]</a>. 
&nbsp;

Periods can be very challenging to manage, regardless of how long you have had them; but they are especially difficult the first time when you are totally unprepared for them.&nbsp; 
&nbsp;

In this article, you&#39;ll find everything you need to know about your periods &ndash; from finding the right menstrual products, including napkins and tampons, to managing pains and preserving stained clothes.&nbsp; 
&nbsp;

Puberty is the main cause of menstruation. This is the stage when the girl&rsquo;s body becomes capable of reproduction. The estrogen (female hormone) levels increase in the female body due to the beginning of the menstrual cycle, which plays an important role in the thickening of the endometrium or the inner lining of the uterus.&nbsp; 
&nbsp;

The main purpose of the endometrium lining is to aid a fertilized egg during pregnancy. In case the sperm does not fertilize the ovum (egg), the thickened lining is broken down by your body&#39;s natural mechanism and pushed out of your uterus in the form of periods. 
 
&nbsp;

<h5>When Will I Get My First Period? 
&nbsp;</h5>

Girls start menstruating when they reach the age of puberty, between the ages of 12 and 13<a href="#accordion">[2]</a>. Typically, menstruation takes place 2 years after the development of your breasts. 
&nbsp;

<h5>What Symptoms Should I Look For? 
&nbsp;</h5>

Some girls would not experience any symptoms. Their periods start abruptly and without warning. Other girls experience some symptoms in the days preceding their periods, otherwise known as Premenstrual Syndrome (PMS).&nbsp; 
&nbsp;

Symptoms of PMS include:

<ul>
	<li>Skin problems</li>
	<li>Abdominal bloating and pain</li>
	<li>Breast tenderness</li>
	<li>Pain in the lower back</li>
	<li>Constipation</li>
	<li>Diarrhea</li>
	<li>Fatigue</li>
	<li>Mood swings, feeling sensitive or irritable</li>
	<li>Food craving, especially sweets</li>
	<li>Transparent or white discharge from the vagina 
	&nbsp;</li>
</ul>

To avoid being caught unprepared when your period starts, you should start keeping a &quot;<a href="https://merisehat.pk/article/a-guide-to-period-products">period kit</a>&quot; in your bag as soon as you reach that age and feel that your body&rsquo;s changing. This kit should include: 
&nbsp;

<ul>
	<li>A pair of clean underwear</li>
	<li>Pad, menstrual cup, or tampon</li>
	<li>Cleaning wipes</li>
	<li>Over-the-counter pain relievers, such as ibuprofen 
	&nbsp;</li>
</ul>

<h5>What Should You Do For Your First Period? 
&nbsp;</h5>

Try not to panic if your menstruation has begun and you don&#39;t have anything to utilize for the blood. Until you can obtain a good pad or tampon, you can make a temporary pad out of toilet paper to tide you over. 
&nbsp;

A quick tutorial: 
&nbsp;

1. Fold the layers of a long piece of toilet paper (at least 10 squares) over one another.

2. Place this on your underwear where the napkin would be placed &mdash; down the central part of your underwear, along the piece of fabric between your legs (known as the gusset).

3. Use a second toilet paper to wrap the pad and your underwear repeatedly. This will help keep the tissue in its place.

4. Finish the wrap by tucking the tissue&#39;s end into the top. Now, you have a temporary pad that you can easily manage and remove.&nbsp;

You might think of asking your teacher /school nurse/ friends for a pad if you are at your school. It&rsquo;s nothing to feel ashamed or embarrassed about.&nbsp; 
&nbsp;

Understanding How to Deal With the First Menstrual Cycle

Your first period would continue for a few days. It takes some time for your period to become regular and consistent. Usually, periods last between 2-7 days every month when they become regular.&nbsp; How Much Blood Will Be Lost From Your Body? The first few periods are considered typically light compared to those later in your life and only bring a few patches of red-brown blood throughout the week.Once the hormones have stabilized, your cycle will follow a schedule that will be more predictable. However, it is possible to experience a strong flow in the first few months and it's not always a problem if the bleeding is heavier. But, if you believe you are bleeding too much, you need to inform your parents or consult the school nurse.You can also tell any adult whom you trust if you:<ul><li>Have to replace/change your sanitary napkin and tampon every couple of hours.&nbsp;</li><li>Feel giddy</li><li>Feel dizzy</li><li>Feel heart palpitation</li><li>A period of bleeding that lasts more than 7 days.&nbsp; </li></ul>You might need to be taken to the gynecologist by your guardian to discuss your signs. The doctor can also prescribe some medicines to help you with your symptoms.&nbsp;

In this section of the article, several menstrual products have been outlined. Your choice of product depends on a variety of factors such as flow, pain, comfort etc. It is important to bear in mind that your preferred option might change down the line.&nbsp; 
&nbsp;

<h5>Period Underwear</h5>

The concept of period underwear is quite recent. The only difference between it and conventional underwear is that it is made of a unique fabric that absorbs menstrual blood and keeps it inside the fabric. 
&nbsp;

Period underwear caters to all girls and women, i.e. they have different levels of absorbency of blood. If your first period is light, you might be able to rely solely on these. But, if you feel it&rsquo;s a heavy flow, then period underwear is a great backup; it&rsquo;s pretty helpful in preventing accidental leakage.&nbsp; 
&nbsp;

There are numerous brands available, but they all function similarly. Choose one according to your flow and comfort. 
&nbsp;

<h5>Sanitary Napkins And Panty Liners</h5>

Rectangular pieces of absorbent material that you can stick on the inside your underwear are called sanitary napkins. Every pad has a sticky strip on the underside, allowing for the pad to remain attached to your underwear. Some pads may include &quot;wings&quot; on the sides that you drape over the borders of your underwear. This aids in keeping the pad in position and also prevents leakage. 
&nbsp;

There are many different sizes of pads. Each size is specifically designed to accommodate various degrees of blood flow. The amount of blood a pad can absorb varies depending on its size and is usually indicated on the box/cover 
&nbsp;

You&#39;ll most probably use different sizes of pads within one cycle for example at the start of the cycle, you will need more absorbent pads since the flow is heavy, while towards the end of the cycle a lighter absorption pad would be adequate due to less flow.&nbsp;&nbsp; 
&nbsp;

Most women prefer using pads at night compared to tampons as it is easier to change and if left overnight will not cause any health related issues.&nbsp; 
&nbsp;

At the start of your cycle, you will notice some spotting. To prevent staining your underwear due to spotting, you can use panty liners. These are thinner and more compact. They can also be used towards the end of your periods when your bleeding could be sporadic.&nbsp; 
&nbsp;

<h5>Tampons</h5>

Tampons are menstruation products that are tube-shaped and absorbent. They are placed within the vagina to soak up menstruation blood before it gets to your underwear. 
&nbsp;

Applicator tubes made of cardboard or plastic are often sold with tampons. These tubes have been made to aid you in inserting the tampon into your vagina. A string is on one end of every tampon to help you remove it easily.&nbsp; 
&nbsp;

Tampons are available in various sizes and levels of absorbency. Beware of scented tampons, though, as your vagina might become irritated by fragrance. 
&nbsp;

When it&#39;s time to insert the tampon, carefully press it inside your vaginal canal until only the string is left exposed.&nbsp; If your tampon has an applicator, gently pull it out by holding onto the tube. You should let the tampon stay in your vagina so that it&#39;ll absorb the blood.&nbsp; 
&nbsp;

When it is time to take it out of the vagina, just pull the string till the tampon is free.&nbsp; 
&nbsp;

Please make sure to change your tampon every 4 to 6 hours, but no longer than 8 hours. If left for 8 hours, the risk of infections and&nbsp; irritation increases. You also risk developing Toxic shock syndrome (TSS), although it&#39;s rare but it always better to be safe than sorry&nbsp; 
&nbsp;

<h5>Menstrual Cups</h5>

If you are uncomfortable using pads or tampons, another option is menstrual cups. Cups are inserted into the vagina, similarly to tampons, where they collect blood before it leaves the body. 
&nbsp;

Cups normally come in two size options &mdash; small or large &mdash; generally based on the female&#39;s age and previous delivery experience, their menstrual flow, and cervix height. 
&nbsp;

The smaller variant will probably be more convenient, easy to use and more comfortable for you to insert. You should receive step-by-step instructions for your product, but you can also refer to a guide to insertion and removal.&nbsp; 
&nbsp;

One major advantage of these cups over pads or tampons is that they can be washed and used repeatedly. This implies that you only need to remove the cup, clean it, and reinstall it when it&#39;s time to replace it. 
&nbsp;

The lifespan of reusable cups ranges from 6 months to 10 years with proper maintenance depending upon the type of brand and manufacturer of it. In other words, menstrual cups are not only safe and effective, they also save you money and are eco-friendly.&nbsp; 
&nbsp;

No, not always! Before we get into the details, know that it can happen to anyone. 
&nbsp;

When you start your period, you&#39;ll be learning about how much blood will be shed from your body, the amount your menstrual item can absorb, and when your flow seems to be at its heaviest. 
&nbsp;

Keep a few cleaning wipes in your bag if you can. They can help you remove the stain until you can thoroughly wash the fabric.&nbsp; 
&nbsp;

As a temporary solution, you can tie a jacket around your waist to hide the stain&nbsp; 
&nbsp;

Try this technique to remove the stain when you reach home: 
&nbsp;

1. Soak the stained fabric in cold water as soon as possible. Do not use warm water because that would set the stain and make it impossible to get out.&nbsp;

2. Spray a stain remover if it is available. Be sure to soak the affected region thoroughly. Let it sit for the amount of time labeled on the product&#39;s packaging.&nbsp;

3. If you don&#39;t have a stain remover on hand or wish to use two different methods to make it more effective, you can rub a bar soap or dab some liquid soap into the stain-affected region to build up a thin lather.&nbsp;

4. Wash and repeat the process till the stain washes out.

5. Wash your pants in the washing machine if the stain is not completely removed. Just be certain to use cold water rather than warm.&nbsp;

6. Air dry the washed clothes since the dryer&#39;s heat has the potential to set the stain permanently.&nbsp; 
&nbsp;

<h5>Can Other People Tell That I&rsquo;m On My Period?</h5>

Not at all! You don&rsquo;t have a different appearance or fragrance. Someone could smell the blood only if you leave your napkin or period underwear on for a longer period than advised. 
&nbsp;

You should not use scented menstrual products as they can aggravate your vulva.&nbsp; 
&nbsp;

Wash your vaginal area with lukewarm water if you are worried about body odor. Another great alternative is use of baby wipes to clean your intimate regions during periods. 
&nbsp;

<h5>Can I Still Swim And Play Sports?</h5>

Swimming and other physical activities are allowed during your period. It may also have the potential to lessen cramps.&nbsp; 
&nbsp;

Choose a tampon or a menstrual cup to stop leakage in the water when you intend to swim.&nbsp; 
&nbsp;

For the majority of activities, pads or period underwear can be used.&nbsp; 
&nbsp;

<h5>What Can I Do About Cramps?</h5>

Cramps are, without a doubt, uncomfortable. But think about it this way: your body needs periods &ndash; and, therefore, cramps &ndash; to remove the uterine lining. 
&nbsp;

To feel better:

<ul>
	<li>Follow the directions on the label or advice of medical healthcare professionals for use of&nbsp; over-the-counter pain relievers such as ibuprofen.&nbsp;</li>
	<li>Put a heating pad or heating wrap as a source of heat on your lower back or stomach.</li>
	<li>Take a warm bath. 
	&nbsp;</li>
</ul>

Speak to an adult if your cramps are worsening and you feel sick and unable to get out of bed or do routine activities. In some instances, excruciating cramping could signify an underlying illness like endometriosis so don&rsquo;t ignore or take it lightly and consult a gynecologist&nbsp; . 
&nbsp;

<h5>Other Symptoms I Might Have ?&nbsp;</h5>

Besides cramps, you might also experience the following symptoms:

<ul>
	<li>Acne</li>
	<li>Abdominal bloating</li>
	<li>Sore breasts</li>
	<li>Back pain</li>
	<li>Constipation</li>
	<li>Diarrhea</li>
	<li>Fatigue</li>
	<li>Feeling sensitive or irritable</li>
	<li>Food cravings 
	&nbsp;</li>
</ul>

All these symptoms don&#39;t necessarily need to be present when you have your period. They appear or disappear depending upon the hormonal swings.&nbsp; 
&nbsp;

<h5>How Frequently will I Get It?</h5>

The period is basically one part of the menstrual cycle. This implies that your period will follow a more regular pattern over time.&nbsp; 
&nbsp;

Typically, a menstrual cycle lasts for 28 days. But it can be around 21-45 days, which is also normal.&nbsp; 
&nbsp;

Menstruation may not start consistently for about 6 years following your first period. This is because your body has to learn how to control the release of your reproductive hormones.&nbsp; 
&nbsp;

<h5>How Can I Predict When It Will Come?</h5>

It would take a few years for your periods to develop a regular pattern. But you can keep a track of your symptoms, which would prove useful in spotting patterns and getting (mentally) ready for your period till it arrives.&nbsp; 
&nbsp;

This record can also be used to discuss severe pains with the nurse or other healthcare professionals.&nbsp; 
&nbsp;

You can use signs or code words to aid you in symbolizing the start and end of your period if you don&#39;t want people to know what you are tracking. You can maintain it on paper or on a phone. Or you can download an app. Fitbit, for instance, has a tracking option; others like Flo Period &amp; Ovulation Tracker, Clue Period Tracker &amp; Calendar, and Eve Period Tracker App work, too. 
&nbsp;

<h5>Will I Have Periods Forever?</h5>

You won&#39;t have periods for your entire life, but you&#39;ll have them until menopause. The onset of menopause is directly related to the level of hormones that triggered your menarche i.e. Menopause occurs when these hormones start to decrease in your body. 
&nbsp;

Usually, menopause starts between the ages of 45 and 55. But it&rsquo;s not just the age factor; your period may stop/ become irregular due to stress and other medical conditions as well. Talk to your healthcare professional about when you miss a period. 
&nbsp;

Meanwhile, there&rsquo;s the option of hormonal birth control if you want to stop your periods for health reasons/ travel purposes. Again, it&rsquo;s better to get in touch with your doctor first regarding it.&nbsp; 
&nbsp;

You will not have any periods during pregnancy. In case you experience any bleeding or spotting during pregnancy, please consult your doctor immediately. 
&nbsp;

<h5>Can I Get Pregnant After Menstruation?</h5>

The brief answer? Yes. When the semen comes in touch with the vagina, pregnancy is a possibility. Although the start of a period is mostly considered to mark the start of your reproductive years, it is possible to conceive before your period.&nbsp; 
&nbsp;

Hormones determine everything. In some circumstances, your body may secrete ovulation-inducing chemicals before the start of menstruation. Getting pregnant is conceivable even if you have intercourse during your menstruation.&nbsp; 
&nbsp;

Ultimately, it depends on where you are in your cycle. If you want to prevent pregnancy, you can use any of the contraceptive methods suggested by your doctor.&nbsp; 
&nbsp;

Talk to a responsible adult or visit a doctor if: 
&nbsp;

<ul>
	<li>By the age of 15, you have not begun your period.&nbsp;</li>
	<li>It&#39;s been almost 2 years since you have had your periods and they are still irregular.&nbsp;</li>
	<li>Bleeding occurs in between your periods.&nbsp;</li>
	<li>You are in excruciating pain and unable to carry out routine tasks.&nbsp;</li>
	<li>You must replace your pad or tampon every 1-2 hours as you experience heavy intense bleeding.&nbsp;</li>
	<li>You experience periods longer than 7 days.&nbsp; 
	&nbsp;</li>
</ul>

Make sure you&rsquo;ve kept a record of when your last period began and ended, when did the erratic bleeding start, or any other signs you experienced during your cycle. 
&nbsp;

Women in low- and middle-income countries frequently lack access to medical information, particularly regarding menstruation-related hygienic concerns. Lack of formal guidance from the schools, cultural resistance to using alternate menstruation products, a lack of economic resources, and inadequate water and sanitation infrastructure make this natural process difficult for young girls.&nbsp; 
&nbsp;

As a result, a biological process that naturally dignifies women and girls becomes a source of embarrassment and frustration. Such societal stigmas and beliefs make post pubescent girls more susceptible to engaging in unsanitary behaviors that result in various diseases, including those of the reproductive and urinary systems. 
&nbsp;

Hence, this article aims to provide a comprehensive guide to educate young girls about safe menstrual health.&nbsp; 
&nbsp;

<ul>
	<li>It might be challenging for a parent or guardian to know how to help a child during their first period.</li>
	<li>Every woman goes through the period as part of her regular cycle.</li>
	<li>The guardian should keep it factual. Don&rsquo;t let your menstrual past, whether it&#39;s been positive or negative, influence how you think and eventually affect how your daughter feels about menstruation.</li>
	<li>There are various menstruation product options to help you with the process.</li>
	<li>Make a period kit with some underwear, stain remover, and menstrual supplies that they can conveniently put in a locker or backpack.</li>
</ul>

[1] Fingerson, L. (2012). Girls in power: Gender, body, and menstruation in adolescence. SUNY Press.

[2] Marques P, Madeira T, Gama A. Menstrual cycle among adolescents: girls' awareness and influence of age at menarche and overweight. Rev Paul Pediatr. 2022;40:e2020494. Published 2022 Jan 5. doi:10.1590/1984-0462/2022/40/2020494

Neelam Asad

Madeeha Syed

How Your Menstrual Cycle Affects Your Mental Health

Overview

Our mental health is closely linked to the reproductive cycle that our body undergoes every month. Researchers believe this is linked to the hormonal changes that we go through. Rising and falling to varying levels through the month, oestrogen and progesterone impact neurotransmitters in our brain. This impacts a range of emotional and neural parameters, such as energy levels, appetite, and sleep cycle. 
&nbsp;

The Menstrual Cycle

Our menstrual cycle starts with the first day of menstruation, when oestrogen and progesterone are at their lowest in our bodies. Both hormones begin to rise the day after menstruation ends and peak right before ovulation. 
&nbsp;

During the luteal phase between ovulation and menstruation, oestrogen and progesterone begin to drop. They rise again during this period, to a lesser degree, and begin to fall once again reaching their lowest levels during menstruation. This entire cycle unfolds over approximately a month. 
&nbsp;

The luteal phase lasts approximately two weeks before our periods, but this may be longer and shorter for some women. It is during this period that most women begin to experience symptoms of premenstrual syndrome (PMS) or, it&rsquo;s more severe version, premenstrual dysphoric disorder (PMDD). 
&nbsp;

The drastic rise and fall of oestrogen and progesterone impacts the release of two major neurotransmitters &mdash; serotonin and dopamine. Research has shown that lower levels of oestrogen correlates to lower levels of serotonin in particular. Both chemicals have varying functions but generally impact our mood, motivation, and energy. When they are present in low quantities in our nervous system, it can lead to sadness, anxiety, sleep problems, and food cravings. 
&nbsp;

Physical symptoms of PMS and PMDD include:

<ul>
	<li>bloating </li>
	<li>skin breakouts </li>
	<li>cramps </li>
	<li>headaches </li>
	<li>joint and muscle pains </li>
	<li>tender breasts </li>
	<li>nausea </li>
	<li>trouble sleeping </li>
	<li>changes in appetite 
	&nbsp;</li>
</ul>

Mental health symptoms include:

<ul>
	<li>feelings of sadness </li>
	<li>anxiety </li>
	<li>feeling overwhelmed </li>
	<li>emotional vulnerability </li>
	<li>rapidly changing moods</li>
	<li>irritability and stress </li>
	<li>fatigue 
	&nbsp;</li>
</ul>

In the two weeks leading up to our period, the emotional symptoms of PMS can manifest in a number of ways. We may find ourselves crying easily. Criticism may hurt more than usual. The smallest triggers may impact us strongly. Life around us could seem overwhelming, or even empty. We may want to withdraw into solitude. Social gatherings might lose their appeal and we could feel aloof from the people around us. 
&nbsp;

Some of us may want to indulge in unhealthy foods while others might lose their appetites. Sexually intimacy may not appeal to us as much but we might want more affection than usual. We may feel a usually strong dislike of our bodies and be harsh with ourselves. We could become angrier and more easily stressed by situations that would not trigger us usually. As motivation dips, everyday tasks could seem tedious. We might want to slack on work or be unable to focus on it. Everything around us might seem to be going wrong. We could start questioning aspects of our career and relationships. 
&nbsp;
<quillbot-extension-portal></quillbot-extension-portal>

Lifestyle Habits

Symptoms of PMS can be managed by adopting certain lifestyle habits. Tracking your cycle is the first step you can take towards this. If you are aware of the emotional and physical impact of your cycle, you can plan accordingly. In the weeks leading up to your period, you could schedule some extra down time for yourself. You can ensure that you don&rsquo;t have any big or stressful tasks planned. This frees you up to tend to yourself, self-reflecting and doing activities that give you joy and don&rsquo;t require too much effort. This would be a good time to perhaps book a massage, or take a restorative yoga class. 
&nbsp;

<ul>
	<li>Well-Balanced Diet: Eating a well-balanced diet throughout the month may enable your body to cope better with the hormonal changes it undergoes. Eat as many whole foods as possible while avoiding processed foods in excess. Ensure that your diet is rich in protein, essential fats, and fibres. Micronutrients like vitamins and minerals will also help balance your hormones. During your period, it&rsquo;s important to continue such a diet and resist the temptation to indulge excessively in sugar and starchy carbs. Avoid smoking, as well as caffeine and alcohol as these may exacerbate symptoms. 
	&nbsp;</li>
	<li>Exercise: Supplement your diet with regular movement. These can be anything from daily walks to weightlifting sessions. Exercise helps our bodies function optimally. During our periods, movement can be particularly helpful. Apart from the endorphin rush, it can help ground us in the bodies and the present, giving us respite from our feelings and thoughts. 
	&nbsp;</li>
	<li>Getting Enough Sleep: Maintain a regular sleeping routine throughout the month. Try to sleep and wake up at the same time as consistently as possible. During our periods, we may experience increased fatigue while also having a hard time sleeping at night. Creating a calming routing and environment may counter this. Dim the lights in your house at night, turn off devices and screens. Explore different ways to help yourself wind down before bedtime. Take a hot shower, go for a walk before bed, read a book, journal, or listen to some soothing music. Essential oils like lavender can also help you fall asleep. 
	&nbsp;</li>
</ul>

Commonly cited research states that 90 percent of menstruating women experience at least one symptom of PMS. Some women are more sensitive to hormonal changes than others. They may experience stronger symptoms, even if their hormones don&rsquo;t fluctuate more than what is considered average. This may be due to a number of factors. Genetics could determine how sensitive we are to hormonal changes. Women with a history of trauma or mental health struggles may also be more likely to experience mental health symptoms. Since there is so much variation in our individual cycles, PMS can look different for everyone. 
&nbsp;

Sometimes, symptoms of PMS may begin to feel too severe or impact your life and wellbeing. Using over-the-counter medicines and lifestyle habits may not relieve them. In this case, it&rsquo;s advisable to see a healthcare professional. About 10 percent of women may also be diagnosed with PMDD if their symptoms are particularly intense and consistent. 
&nbsp;

A number of factors could indicate the necessity of professional healthcare. Your relationships may start suffering. You could find yourself picking fights that have a lasting impact on your relationships. Increasingly, you may start withdrawing from others and isolating yourself. You could start neglecting necessary tasks at work to the point that your career begins to suffer. Your inner voice may become overwhelmingly critical, tipping you to the point of self-loathing. 
&nbsp;

Anxiety attacks may become common and you might find yourself experiencing heart palpitations and breathing difficulties too often. Feelings of depression and anger may become very intense, making you want to harm yourself or others. In very severe cases, suicidal thoughts might become very loud. 
&nbsp;

Untreated PMDD could lead to acute depression, constant anxiety, causing extreme emotional distress and irreparable damage to your life. Medical help can be crucial in alleviating your symptoms. A doctor can treat you in a number of ways, from hormonal therapy to psychotherapy. 
&nbsp;

Ayesha Binte Rashid

Natural Remedies To Help Regulate Your Periods

You may have heard that your menstrual cycle is counted from the first day of a period to the first day of the next. The average menstrual cycle is 28 days, but this can vary from person to person and month to month.Your periods are still considered regular even if they come every 24 to 38 days. Your periods are considered irregular if the time between periods keeps changing and your periods come earlier or later than expected.The treatment depends on finding out what’s causing your irregular periods, but there are remedies you can try at home to get your cycle back on track. Read on to discover eight science-backed home remedies for irregular periods.

Possible Causes

Diet

<ul dir="ltr">
	<li>
	<h5 dir="ltr">Low-carb Diet</h5>
	</li>
</ul>

A high-fat, low-carb diet can lead to amenorrhea&mdash;a condition where you don&rsquo;t get enough carbs to regulate your menstrual cycle.

Low-carb diets may disrupt thyroid function and lower leptin levels in the body, which can also result in amenorrhea. Leptin is produced by fat cells and helps regulate reproductive hormones.

Experts recommend getting 225 to 325 grams of carbs per day if you&rsquo;re consuming a 2,000-calorie diet. This means you should get about 45 to 65 percent of your total daily calorie intake from carbohydrates. 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>High-fiber Diets</h5>
	</li>
</ul>

Fibers are non-digestible carbohydrates that don&rsquo;t provide us with much nutrition, but they have an important role to play in our health. They help maintain a healthy digestive system, and they can also lower the concentration of certain hormones in your body.

One of these hormones is progesterone, which is produced by the ovaries during ovulation. Progesterone helps prepare your uterus for pregnancy by thickening the lining of the uterus and preparing it for implantation of an egg.

Estrogen is another hormone affected by too much fiber in your diet. Estrogen helps regulate your menstrual cycle and maintain healthy reproductive organs. It also helps protect against breast cancer.

FSH and LH are other hormones that may be affected by high intake of fiber in your diet. These two hormones are released from the pituitary gland and stimulate ovaries to release eggs during ovulation so they can be fertilized by sperm cells from a male fetus (sperm).

Now while these fibers and their impact on hormones may lower the chances of women developing breast cancer, it has a bad impact on your periods starting off with irregular periods. 
&nbsp;

If you&rsquo;re wondering why your periods are out of whack, it might be time to take a look at what you&rsquo;re eating.

What we eat can have a big impact on our hormone balance, and that can affect how often we get our periods. If you&rsquo;re not getting enough nutrients from the food, you eat or from supplements, that may stress your hypothalamus, pituitary, and adrenal glands &mdash; the organs that regulate your body&rsquo;s hormone balance. This imbalance can lead to irregular menstruation or even lead to amenorrhea (when you stop having periods altogether).

But don&rsquo;t worry! Here are a few things you can consume to help keep your hormones in check:

<ul dir="ltr">
	<li>
	<h5 dir="ltr">Cinnamon</h5>
	</li>
</ul>

Cinnamon is a staple in our kitchen, and it should be a staple in your diet too. It&rsquo;s great for helping regulate blood flow to the uterus and may treat irregular periods, abdominal pain, nausea and vomiting <a href="http://merisehat.pk/article/a-guide-to-period-products" target="_blank">during periods</a>.

For best results, add a teaspoon of cinnamon powder to a glass of milk and consume it. Cinnamon can help regulate insulin levels in your body which may have an effect on other hormones and the menstrual cycle. In women with Polycystic Ovary Syndrome (PCOS) who often have high insulin levels and irregular periods, cinnamon can cause a more regular period cycle.

Cinnamon supplements may also reduce pain in women who have painful menstrual periods. 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Turmeric</h5>
	</li>
</ul>

Turmeric is an ancient spice that has been used for over 4,000 years as a natural remedy to help regulate your periods. It can stimulate blood flow in the uterus and pelvic region, helping to regulate your menstrual cycle. Turmeric also contains curcumin, which has been shown to have many beneficial health effects. These include reducing inflammation and improving mood, so taking supplements containing curcumin may decrease symptoms of PMS.

Turmeric is also an emmenagogue, which means it can induce menstruation by stimulating the uterus and expanding it. To reduce irregularity in your cycles, drink haldi doodh (turmeric milk) or turmeric latte regularly! 
&nbsp;

<ul dir="ltr">
	<li>
	<h5>Beetroot</h5>
	</li>
</ul>

&nbsp;Beetroot is a powerhouse of iron, calcium, and folic acid amongst others. This vegetable can reduce water retention and bloating, something which women commonly experience during periods. The iron in beetroot helps to prevent anemia that causes fatigue and weakness during periods. It also provides relief from cramps by improving blood circulation in the body.

Drinking beet juice every day will help improve your health and wellbeing during periods. 
&nbsp;

Bottom Line

When looking for natural remedies to regulate your period, it helps to start with a good understanding of how your body works before you arrive at your ultimate menstrual destination. After all, knowing where you&rsquo;re headed makes sense in travel, and doesn&rsquo;t that make sense in health? Knowing how your body works will help determine what kind of remedy you need, whether it&#39;s a massive lifestyle overhaul or just an indulgence from the kitchen cupboard.

Umna Salah

Is Male Menopause Real?

If you&rsquo;re a middle-aged man who&rsquo;s suddenly having thoughts of buying a leather jacket and riding a Harley Davidson, chances are you&rsquo;re going through a midlife crisis. Or maybe it&rsquo;s just menopause? But isn&rsquo;t menopause a female phenomenon?&nbsp;

Generally, menopause signifies a time in a woman&rsquo;s life when her hormone levels begin to decline and cause symptoms such as fatigue, mood swings, and hot flashes. So, by extension, does it mean that if you&rsquo;re experiencing male menopause, it&rsquo;s basically a reduction in your hormones, too? Yes, perhaps.

The fall in testosterone levels, the main sex hormone in men, is largely blamed for the occurrence of menopause in men. However, there is no specific period that can be labeled as menopause in men as the decline in testosterone is a gradual process. It is unlike female menopause because the reduction in hormones in women is abrupt and results in a complete halt in hormone production.&nbsp;

In your case, for instance, a drop in testosterone levels may simply be a normal part of aging. According to research, men experience a steady decline of less than 2% a year in testosterone levels when they are 30-40 years old<a href="#accordion">[1]</a>; there&rsquo;s no sudden drop that causes symptoms like mood swings and loss of sex drive as it happens with women. Therefore, male menopause is a misleading term to use, mostly because the symptoms of male menopause can be explained by other reasons as well.&nbsp; 
&nbsp;

Understanding Male Menopause ( Andropause)

Also known as andropause, male menopause is a state of low androgen levels, particularly testosterone. Testosterone is the sex hormone which responsible not only for regulating sex drive, but also for muscle and bone growth, fat distribution, and even sperm production in men<a href="#accordion">[2]</a>.&nbsp;

The concentrations of bioavailable testosterone may decrease by up to 50% in men between the ages of 25 and 75 years. Moreover, more than half the men above the age of 50 years suffer from low testosterone levels<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

A decline in testosterone levels may result in:

<ul>
	<li>Mood swings</li>
	<li><a href="https://merisehat.pk/disease/depression">Depression</a></li>
	<li>Irritability</li>
	<li>Fatigue</li>
	<li>Loss of libido</li>
	<li><a href="https://merisehat.pk/disease/erectile-dysfunction">Erectile dysfunction</a></li>
	<li><a href="https://merisehat.pk/disease/infertility-in-men">Infertility</a></li>
	<li>Sleeping difficulty and insomnia</li>
	<li>Difficulty concentrating</li>
	<li>Lack of enthusiasm or energy</li>
	<li>Weight gain</li>
	<li><a href="https://merisehat.pk/disease/gynecomastia">Gynecomastia </a>due to fat redistribution</li>
</ul>

&nbsp;

In rare instances, men may also experience:&nbsp;

<ul>
	<li>Decreased testicle size&nbsp;</li>
	<li>Hot flashes</li>
	<li>Osteoporosis 
	&nbsp;</li>
</ul>

While aging is associated with a drop in testosterone levels, other conditions may also cause a similar effect. For example, late-onset hypogonadism and diabetes. Hence, andropause is more commonly referred to as androgen deficiency, testosterone deficiency syndrome, and hypogonadism.&nbsp;

Hypogonadism is a condition in which the testes produce little to no hormones. The condition may present at birth, but it may also develop later in life due to obesity or type 2 diabetes (late-onset hypogonadism). Hypogonadism present from birth causes delayed puberty and smaller testes.&nbsp;Several comorbid factors high cholesterol levels, high blood glucose concentrations, and higher waist-to-hip ratio may also lead to hypogonadism.&nbsp; 
&nbsp;

The decline in testosterone levels is a normal part of aging, and a simple blood test will quickly detect your testosterone levels. However, if hormonal changes are disrupting your daily activities, your doctors may suggest various treatment strategies.

The first and foremost advice is to adopt a healthy lifestyle. Healthy lifestyle habits include:

<ul>
	<li>A healthy diet</li>
	<li>Regular exercise</li>
	<li>Stress management</li>
	<li>Adequate sleep</li>
</ul>

Additionally, if you have been diagnosed with depression, your doctor may also prescribe antidepressants and therapy. 
&nbsp;

Testosterone replacement therapy is another possible treatment option. If your doctor is hesitant to prescribe the treatment, it may be because of its numerous side effects.&nbsp;Generally, HRT improves your symptoms and restores any physiological changes. It may enhance:&nbsp;

<ul>
	<li>Mood</li>
	<li>Physical activity</li>
	<li>Sexual function</li>
	<li>Cognitive function</li>
	<li>Bone density&nbsp;</li>
	<li>Muscle strength&nbsp;</li>
</ul>

You may receive it in the form of oral agents, injections, transdermal patches, or gels.&nbsp;

However, there is limited evidence on the long-term effect of testosterone replacement therapy. While some studies have reported improvement in the overall quality of life in male subjects, they have also, unfortunately, revealed several adverse effects of HRT on men, including fluid retention causing weight gain, increased cardiovascular disease risk, worsening of sleep apnea, and mood fluctuations<a href="#accordion">[4]</a>.&nbsp;

Besides, there is also a slight risk of HRT causing prostate cancer. It&rsquo;s better to consult your doctor and if it&rsquo;s a suitable treatment in your case, they&rsquo;ll be able to prepare you for evaluation and screening for cancer before the administration of HRT.&nbsp; 
&nbsp;

Since male menopause is a misleading term to describe the low testosterone levels in older men, doctors prefer calling it andropause. However, it’s not easy to diagnose andropause because its symptoms often mimic those of other diseases and medication side effects, and there are no established normal testosterone levels for different age groups.&nbsp;It is important to note that male menopause is not the same as female menopause. In women, menopause signifies an end of the ability to reproduce due to a complete stop in hormone production. On the other hand, in men, the decline in testosterone is a gradual process and, more importantly, the testes do not stop producing the hormone. Another striking difference is while every woman will experience menopause at a particular stage in life, not all men will experience andropause.&nbsp;Hormone therapy may be beneficial in some men suffering from andropause, but it is advised to always consult a doctor before starting any form of treatment. Talk to a healthcare professional who is aware of various alternatives available and who may be able to develop a personalized treatment for individual patients.&nbsp;

<ul><li>Male menopause is also called andropause. The term andropause describes a state of low androgen levels in men, particularly testosterone</li><li>Testosterone is responsible for regulating sex drive, muscle and bone growth, fat distribution, and even sperm production in men. A decline in its levels may cause depression, decreased libido, gynecomastia, insomnia, fatigue, and weight gain</li><li>Men experience a steady decline of less than 2% a year in testosterone levels between 30 and 40 years of age. However, this produces no effect.&nbsp;</li><li>While aging is associated with a drop in testosterone levels, other conditions may also cause a similar effect. For example, late-onset hypogonadism and diabetes. Hence, andropause is more commonly referred to as androgen deficiency, testosterone deficiency syndrome, and hypogonadism.&nbsp;</li><li>Male menopause is considered a misleading term because the symptoms of male menopause may be explained by other reasons as well.</li><li>A healthy lifestyle is often the first treatment advice for patients. Adequate sleep, a healthy diet, regular exercise, and stress management help deal with andropause in men. For those diagnosed with clinical depression, doctors may also prescribe antidepressants and therapy</li><li>Testosterone replacement therapy is another possible treatment option for male menopause. However, doctors are often hesitant to prescribe it due to its possible side effects, which include fluid retention causing weight gain, increased cardiovascular disease risk, worsening of sleep apnea, and mood fluctuations</li><li>It is important to note that male menopause is not the same as female menopause. In women, menopause signifies an end of the ability to reproduce due to a complete stop in hormone production. However, in men, the decline in testosterone is a gradual process, and the testes do not stop producing the hormone</li></ul>

[1] NHS. The Male Menopause. NHS choices.

[2] Understanding how testosterone affects men. National Institutes of Health.

[3] Gould DC, Petty R. The male menopause: does it exist?: for: some men need investigation and testosterone treatment. West J Med. 2000;173(2):76-78. doi:10.1136/ewjm.173.2.76

[4] Brawer MK. Testosterone replacement in men with andropause: an overview. Rev Urol. 2004;6 Suppl 6(Suppl 6):S9-S15.

تعارف

مینو پازیا سن یاس کو باقاعدہ مینیسٹرل سائکل کے اختتام کی نشانی قرار دیا جاتا ہے۔ اس لفظ کا استعمال اس وقت کیا جا تا ہے جب مینسز کا اختتام ہونے والا ہوتا ہےیا ہو رہا ہوتا ہے۔ جو اس بات کی نشانی ہوتی ہےکہ آپ اپنے تولیدی سالوں کے آخری مرحلے پر ہیں ۔&nbsp;مینو پاز یا پری مینو پاز کی حالت میں مختلف ضمنی اثرات بھی سامنے آتے ہیں جن میں موڈ میں تبدیلی ، دماغ میں دھند ، گرم لہریں ، بے قاعدہ پیریڈ شامل ہیں۔ یہ ضمنی اثرات مینسٹرل سائیکل سے قبل ظاہر ہونا شروع ہو جاتی ہے اور ختم ہونے کےبعد بھی ایک لمبے عرصے تک رہتی ہیں۔ مینو پاز اور پری مینو پاز کسی بھی شخص کی زندگی پر بری طرح سے اثر ڈالتے ہیں۔ جو ان کے کام اور معاشرتی رویوں پر بھی اثر ڈالتے ہیں۔ لیکن کچھ چیزیں ان ضمنی اثرات کو کم کر سکتے ہیں ۔ کئی ادویات ایسی ہیں جو مینو پاز کے سبب ہونے والے کم ہونے والے کیمیکلز کی جگہ لے سکتی ہیں۔ اوران علامات میں کمی کا باعث بنتی ہیں۔&nbsp;

مینو پاز اور اس کی علامات کی وضاحت

یہ ایک قدرتی عمل ہے جس سے ہر مینسیز کا سامنا کرنے والی عورت کو گزرنا پڑتا ہے، اس کے ہونے کی وجوہات کچھ اس طرح سے ہو سکتی ہیں۔؛&nbsp;<ul><li style="text-align: right;">قدرتی مینو پاز : چارلیس سال کی عمر میں ، اکثر خواتین کو ان کے سائيکل میں تبدیلی کا سامنا ہو سکتا ہے۔ یہ سائیکل یا تو طویل ہو سکتا ہے یا محدود ہو سکتا ہے۔ یکا پھر بہت زيادہ ہو سکتا ہے یا بہت ہلکا بھی ہو سکتا ہے۔ اس میں بڑا وقفہ بھی ہو سکتا ہےیہاں تک کہ اووری انڈے بنانے بند کر دے اور مینو پاز ہو جاۓ ۔ یہ عام طور پر 51 سال کی عمر تک ہو جاتا ہے(1)۔&nbsp;</li><li style="text-align: right;">سرجیکل طریقہ کار : سرجیکل طریقہ جس میں اوفوریکٹومی یا اووریز یا نکال دینا بھی مینو پاز کا سبب بن سکتا ہے۔ اووریز ہارمون بناتی ہیں جن میں ایسٹروجن اور پروگیسٹرون شامل ہیں۔ جن کا کام ہر مہینے ہونے والے سائيکل کو کنٹرول کرنا ہوتا ہے۔ اس وجہ سے اووریز نکال دینے کی وجہ سے وقت سے پہلے مینو پاز ہو سکتا ہے۔ اور ماہواری کا آنا رک جاتا ہے اور مینو پاز کی علامات ظاہر ہونا شروع ہو جاتی ہیں(1)</li><li style="text-align: right;">کیموتھراپی یا ریڈيشن تھراپی : ان بیماریوں کا علاج اکثر مینو پاز کا باعث ہو سکتا ہے۔ علاج کے دوران جسم میں سے گرم لہروں کا نکلنا اس کی علامات میں سے ایک ہے۔ کیمو تھراپی کے دوران ماہواری کا رک جانا عام طورپر دیر پا نہیں ہوتا ہے اس وجہ سے اس دوران بھی مانع حمل اقدامات کو جاری رکھنا ضروری ہے۔ (1)</li><li style="text-align: right;">ابتدائی اوویرین کمزوری : قبل از وقت مینو پاز کا ایک سبب اووریز کا قلیل مقدار میں تولیدی ہارمون کا پیدا کرنا بھی ہو سکتا ہے۔ جس حالت کو ابتدائی اوورین کمزوری بھی کہتے ہیں۔ یہ کسی وراثتی عنصر یا مدافعتی نظام کی کسی بیماری کے سبب بھی ہو سکتا ہے۔ دماغ ، دل اور ہڈيوں کی بیماریوں سے بچنے کے لیۓ مینو پاز کے حقیقی عمر تک پہنچنے سے پہلے ہارمون ٹریٹمنٹ&nbsp; کوتجویز کیا جاتا ہے(2) </li></ul>

مینو پاز کی تشخیص آسانی سے نہیں کی جا سکتی ہے۔ تاہم تین مہینے سے زيادہ ماہواری کا نہ آنا ایک قابل غور حالت ہو سکتی ہے۔ مینو پاز کی عام علامات کچھ اس طرح سے ہو سکتی ہیں؛&nbsp;<ul><li style="text-align: right;">جسم سے گرم لہروں کا نکلنا&nbsp;</li><li style="text-align: right;">بے خوابی&nbsp;</li><li style="text-align: right;">اندام نہانی کی خشکی&nbsp;</li><li style="text-align: right;">بار بار پیشاب آنا&nbsp;</li><li style="text-align: right;">موڈ میں تبدیلی&nbsp;</li></ul>کسی بھی خاتون کو ان میں سے ایک یا دو علامات کا سامنا کرنا پڑ سکتا ہے۔ اس صورت میں اس کو اپنی ڈاکٹر سے رابطہ کر کے مینو پاز کے امکانات کے بارے میں جان لینا چاہیۓ۔ ڈاکٹر آپ کی علامات اور جانچ کے ذریعے اس حوالے سے موثر علاج تجویز کر سکتے ہیں ۔&nbsp;

طرز زندگی میں تبدیلی اور ادویات کا استعمال مینو پاز کو روک سکتا ہے۔ مگر یہ ایک قدرتی عمل ہے جس کا سامنا ہر ماہواری سے گزرنے والی عورت کو کرنا پڑتا ہے۔ تاہم کچھ اقدامات سے اس کی علامات کی شدت کو کم کیا جا سکتا ہے۔&nbsp; 1: گرم لہریںجسم میں سے گرم لہروں کا نکلنا مینو پاز کی سب سے عام علامت ہے۔ یہ چھاتی کے علاقے میں اچانک محسوس ہونے والی گرمی ہوتی ہے۔ عام طور پر اس احساس کو چہرے ، گردن اور چھاتی پر محسوس کیا جا سکتا ہے۔ جلد سرخی مائل ہو جاتی ہے۔ اس کے ساتھ ساتھ شدید پسینہ بھی آسکتا ہے۔ ایسا محسوس ہوتا ہے کہ جیسے جسم میں سے گرمی نکل رہی ہے۔ مگر کچھ ہی دیر میں ٹھنڈک محسوس ہونے لگتی ہے۔ اسی طرح سوتے ہوۓ پسینہ آنا بھی اسی کے سبب اور علامت ہوتی ہے(3)۔&nbsp;فائٹوایسٹروجن عام طور پر پودوں اور کچھ غذاوں میں پایا جاتا ہے۔تحقیق کے مطابق، یہ مادہ کسی حد تک ، ہارمون کی بے اعتدالی کو جو مینو پاز کے سبب ہوتی ہے کم کر سکتا ہے(4)۔ سویا پر مشتمل غذا جسم میں قائٹو ایسٹروجن کی مقدار کو بڑھا سکتی ہے اس وجہ سے بڑی مقدار میں ٹوفو کے استعمال کو جسم کی گرم لہروں کو روکنے کے لیۓ تجویز کیا جاتا ہے۔ اس کے علاوہ ایسے تمام کھانوں سے پرہیز کرنے کا مشورہ دیا جاتا ہے جو جسم کے درجہ حرارت کو بڑھا کر پسینے کا سبب بنتی ہیں ۔ جن میں گرم مشروبات ، مصالحے دار کھانے اور دیگر مشروبات شامل ہیں۔ زيادہ پانی کا استعمال کریں اور پر سکون رہیں ۔&nbsp;باقاعدگی سے ورزش، جسم میں فولیکل اسٹیمیولیٹنگ ہارمون (ایف ایس ایچ ) اور لیوٹینیزنگ ہارمون (ایل ایچ ) کے لیول کو کم کر کے، جسم میں سے گرم لہریں نکلنے کے عمل کو اور اس کے سبب ہونے والی بے چینی کو کم کرتی ہے۔ دن بھر میں کم از کم 20 منٹ تک جسمانی سرگرمی یا ورزش&nbsp; ہفتے میں 3 سے 4 بار ضرور کریں ۔نیشنل سینٹرآف کمپلیمنٹری اور انٹرگیٹو ہیلتھ کے مطابق ایکوپنکچر مینو پاز کے دوران ہونے والی گرم لہروں کی علامت میں کمی کر سکتا ہے۔ (5) 2: بے خوابی&nbsp;مینو پاز کے دوران مستقل طور پر کمزوری اور تھکاوٹ محسوس ہوتی ہے۔ جس کو بڑھانے میں گرم لہریں اور دوسرے ضمنی اثرات بھی اپنا کردارادا کرتے ہیں۔ جو کہ انسان کی نیند پر اثر ڈالتے ہیں۔ پرسکون نیند کی عادت کسی بھی فرد کو ضروری آرام فراہم کرتی ہے، خاص طور مینو پاز کی حالت میں جب کہ تھکاوٹ بڑھ جاتی ہے۔ پرسکون نیند کے لیۓ ایک ٹائم ٹیبل بنائيں ، اور اپنے جسم اور دماغ کو اس کے استعمال کا پابند کریں۔ تاکہ آّپ ہر رات سکون سے سو سکیں۔ اس کے لیۓ پرسکون میوزک سنیں ، یا کسی کتاب کا مطالعہ کریں یا پرسکون ہونےکے لیۓ ورزش کریں تاکہ اس سے آپ کے جسم کو اس بات کا اندازہ ہو سکے کہ یہ سونے کا وقت ہے۔&nbsp;ایک دفعہ بستر پر جانے کے بعد ٹی وی دیکھنے ، لیپ ٹاپ استعمال کرنے یا اپنے فون کو چیک کرنے سے پرہیز کریں۔ ان الیکٹرونک اسکرین سے نکلنے والی نیلی روشنی میلا ٹونن نامی ہارمون کی مقدار میں اضافہ کرتے ہیں جو نیند کو بھگا دیتا ہے۔ اسی طرح بستر پر لیٹنے کے بعد کام کرنے ، کھانے پینے اور اپنے شریک حیات سے سنجیدہ موضوع پر بات چیت کرنے سے احتراز کریں ۔ سونے کے وقت میں اپنے بستر اور اپنے آرام کے درمیان کسی کو حائل نہ ہونے دیں۔ اسکے لیۓ کمرے کے درجہ حرارت کو نارمل رکھیں ۔ بستر اور تکیہ آرام دہ حالت میں لیں ۔ اگر آپ کسی میٹروپولیٹن شہر کے باسی ہیں تو کانوں میں ائير پلگ بھی لگا لیں تاکہ نیند خراب نہ ہو۔ سونے سے قبل ایک پیالی کیمومیلا چاۓ بھی معاون ثابت ہو سکتی ہے 3: اندام نہانی کی خشکی&nbsp;مینو پاز اور پری مینو پاز کی حالت میں اندام نہانی خشک ہو سکتا ہے۔ اس حالت میں فزیشن ایسٹروجن ادویات تجویز کر سکتے ہیں جس کی ایک گولی، کریم یا چھلا&nbsp; اندام نہانی میں رکھا جاتا ہے۔ یہ کثیر جہتی طریقہ علاج مینو پاز اور پری مینو پاز کے سبب ہونے والے پیشاب کے راستے کے کئی مسائل کو حل کر سکتا ہے۔ جن میں بار بار پیشاب کا آنا بھی شامل ہے۔ وجائنا کے ذریعے لی جانے والی یہ ادویات دوران خون میں شامل نہیں ہوتی ہیں ۔ اس کے صرف بیرونی اثرات ہوتے ہیں ۔اس کے استعمال میں دورانیہ کی کوئی قید نہیں ہوتی ہے۔ اس یو مینوپاز کے بعد مستقل استعمال کیا جا سکتا ہے۔ اس کےاستعمال کو ترک کرنے کی صورت میں علامات دوبارہ سے واپس آسکتی ہیں۔ اس کے استعمال کے ناگوار اثرات سامنے نہ آنے کے سبب وجائنل ایسٹروجن ہارمون ریپلیسمنٹ تھراپی (ایچ آر ثی) کا استعمال محفوظ ہوتا ہے۔ (6)اس کے علاوہ ڈاکٹر حضرات وجائنل کو چکنا کرنے والی اشیا کا اندام نہانی کی خشکی کے سبب دخول کے دوران بھی کرتے ہیں۔ یہ اشیا اندام نہانی کی خشکی کی وجہ سے جنسی عمل کے دوران ہونے والی رگڑ اور اس دوران ہونے والی تکلیف کو ختم کرتے ہیں۔ یہ بھی نوٹ کر لینا چاہیے کہ صرف پانی میں حل ہو جانے والے لبریکنٹ کو تیل میں حل ہونے والے لبریکنٹ کے مقابلے میں&nbsp; تجویز کیا جاتا ہے۔ مثال کے طور پر ویسلین بے چینی کو بڑھا کر حالت کو مذید پیچیدہ بنا سکتی ہے۔ اس وجہ سے وجائنا میں ہاتھوں پر لگانے کی کریم یا خوشبو دار ایسے مسچرائیزر جن میں الکحل موجود ہو ان کے استعمال سے پرہیز کرنی چاہیۓ۔ ایسی اشیا وجائنا کی بافتوں کو نہ صرف نقصان پہنچاتے ہیں بلکہ وجائنل پی ایچ کو بھی تبدیل کرنے کا سبب بن سکتے ہیں(7)۔ 4: پیشاب کی بے ضابطگی&nbsp;اس حالت میں بار بار پیشاب کا آنا ، اس پر کنٹرول کا ختم ہو جانا کسی بھی فرد کے لیۓ پریشانی کا سبب ہو سکتا ہے۔ خوش قسمتی سے ایسے طریقے موجود ہیں جن کے ذریعے پیشاب کی مختلف قسم کی بے ضابطگی کو بغیر ادویات یا میڈیکل طریقے سے بھی درست کیا جا سکتا ہے۔ اسکے لیۓ ضروری ہے کہ پانی کی مقررہ مقدار پی جا‎ۓ تاکہ پیشاب کے گاڑھے ہونے سے روکا جا سکے۔جس کو پیشاب کے ہلکے رنگ اور اس کی شفافیت سے چیک کیا جا سکتا ہے۔ اس کے علاوہ تیزابیت والی اشیا اور کیفین والی اشیا جو مثانے کو متاثر کر سکتے ہوں ان کے استعمال میں احتیاط کرنی چاہیۓ۔ اسی طرح کیگل ورزش جو پیلوک کے فرش کے پٹھوں کو طاقت دیتے ہیں اس کو بھی باقاعدگی سے کرنے سے پیشاب کی بے ضابطگی کو روکا جا سکتا ہے(7) 5: موڈ میں تبدیلی&nbsp;اپنے موڈ میں اچانک ہونے والی تبدیلی کے حوالے سے اپنی ڈاکٹر سے مشورہ کریں تاکہ وہ اس کی وجہ کا تعین کر سکے ، ڈپریشن کے امکانات کو جانچتے ہوۓ مناسب ترین ادویات اور طریقہ علاج کا فیصلہ کر سکے ۔ ڈپریشن کے لیۓ ، طریقہ علاج مختلف ہو سکتا ہے، ہو سکتا ہے کہ ڈاکٹر ایسی ادویات تجویز کر دیں جو جسم کے اندر ایسی کیمیائی تبدیلیوں کا باعث بن جائيں جو مینو پاز سے جڑی ہوں۔ عام طور پر ان ادویات کے اثرات پندرہ دنوں بعد ظاہر ہونا شروع ہوتے ہیں۔ کچھ اینٹی ڈپریسنٹ ادویات جسم سے گرم لہروں کے نکلنے کا علاج بھی کر سکتی ہیں۔&nbsp;اینٹی ڈپریسنٹ سائيکو تھراپی کے ساتھ اگر استعمال کی جاۓ تو اس کے اثرات بہترین ہو سکتےہیں۔&nbsp;

خلاصہ

جب آپ مینو پاز کی عمر کو پہنچ جائيں تو آپ کو ان تبدیلیوں کا شعوری طور پر انتظار ہو سکتا ہے جو مینو پاز کے بعد ہو سکتے ہیں۔ یہ مینو پاز کے بعد ہوتے ہیں۔ اور اس بات کی کوئی گارنٹی نہیں ہے کہ کسی بھی عورت کو مینو پازکے بعد کی علامات سے مکمل آزادی مل جاۓ ۔&nbsp;ایسا کوئی ٹائم ٹیبل موجود نہیں ہے جو بتا سکے کہ مینو پاز کب شروع ہونگے یا ختم ہو نگے۔ آپ کے تجربے کا انحصار وراثتی خصوصیات پر ہوتا ہے۔ اپنی علامت کو سمجھنے سے آپ کو زندگی کے ایک نۓ سفر کے آغاز میں مدد مل سکتی ہے۔ &nbsp;

اہم نکات

جیسا کہ مینو پاز سے بچنے کا کوئی علاج موجود نہیں ہے، تو خواتین کو اس کے سبب ہونے والی تبدیلیوں کا مقابلہ اپنے طرز زندگی میں تبدیلی کر کے کرنا چاہیۓ<ul><li style="text-align: right; ">پانی زیادہ پیئيں ، گرم لہروں سے بچنے کے لیۓ ہلکے کپڑے پہنیں، اس کے علاوہ مصالحہ دار کھانوں اور گرم مشروبات سے پرہیز کریں۔&nbsp;</li><li style="text-align: right;">اپنی جسمانی فٹنس کا خیال رکھیں اور بے خوابی اور گرم لہروں سے بچنے کے لیۓ باقاعدگی سے ورزش کو اپنی عادت میں شامل کریں۔</li><li style="text-align: right;">اپنے سونے کی ایک روٹین بنائيں اور اس پر سختی سے عمل کریں۔ تاکہ پرسکون نیند کا سائيکل خراب نہ ہو سکے۔&nbsp;</li><li style="text-align: right;">موڈ میں تبدیلی کی صورت میں کسی معالج سے رجوع کریں تاکہ وہ اس کی وجوہات کا تعین کر کے علاج تجویز کر سکے ۔</li><li style="text-align: right;">لوگوں کے ساتھ میل جول بڑھائيں تاکہ سیروٹونین کے افراز میں اضافہ ہو سکے&nbsp;</li><li style="text-align: right;">کیگل ورزش کریں تاکہ پیلوک کے فرش والے عضلات کو طاقت مل سکے اور پیشاب کی بے ضابطگی کا علاج ہو سکے ۔&nbsp; </li></ul>

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