Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411421EnglishN2022November10Healthcare Relation between Prakriti and Mental Health: An Observational Study     English0107Jyoti YadavEnglish K. N. SinghEnglish Introduction: Mental Health issues are the chief reason for many health diseases. The list of health problems ranges from anxiety, heart disease, hypertension, and diabetes. Ayurveda cleaves up the population on the basis of the Prakriti. There are seven types of Prakriti. All the Prakriti has different psychosomatic combination. The Prakriti of an individual can be evaluated with the help of the traits that are explained in ancient Ayurveda literature. The evaluation of Prakriti can be helpful in knowing the Mental Health Status (MHS) of an individual and lastly helping them to maintain their Mental Health Status and keep Mental Health issues away. Aim and Objective: The aim of the study was to see the relationship between Prakriti and Mental Health Status. Material and Methods: Questionnaire of Mental Health Inventory and Prakriti were distributed to 380 educated unemployed youth aged between 21 to 35. Prakriti and Mental Health Status were evaluated from the received responses from the respondents. The data was analyzed to see if there is any relationship between them. Conclusion: The study shows that in the psychosomatic combination of an individual KaphaPrakriti is said to be the most important factor and Vata Prakriti is more prone to negative Mental Health Status. They face more mental issues. The frequency of negative Mental Health Status can be reduced with proper care and management. EnglishPrakriti, Mental Health, Mental Health Issues, Psychosomatic Combination, Unemployed Youth, Panchmahabhuta INTRODUCTION Ayurveda, the Indian traditional medicine system contemplates Panchmahabhuta (i.e., Aakash, Vayu, Jal, Prithvi, Agni) to be the basic charter of the physical universe comprising the human body.1 These Mahabhuta are apparent in Tridhosa (i.e., Vata, Pitta, and Kapha).2 Thought all three Doshas remain in each human being, but the dominancy of one decides the Prakriti of an individual. Prakriti is determined on the basis of physical, physiological, psychological, and behavioral characteristics.3 Prakriti of a person decided by genetic and acquired factors. The genetic factors it is based on Shukra (sperm) and Shonita (ovum), while acquired factors include heredity, age, season, race, climate, and region.4 Prakriti is an important notion of Ayurveda that explains individuality. There are seven types of various combinations of Doshas and the dominancy of Doshas from the different types of Prakriti. The seven types of Prakriti are as follows Vata, Pitta, Kapha, Vata- Kapha, Pitta- Kapha, Vata- Pitta, and Sama Doshas Prakriti.5,6 The physical and Mental traits of every single Prakriti are explained in Ayurveda. The traits of physical Prakriti comprise physical attributes as well as psychological attributes.7 The capacity to manage mental health status is different in every single person. Mental Health Status (MHS) can differ with the types of Prakriti.8 This particular study is commencing to see if there is any relation between Prakriti and the Mental Health Status of a person. OBJECTIVE OF THE STUDY Mental Health Status is the main factor for many health issues. If we could be able to guess the Mental Health Status of an individual, we would be able to prevent Mental Health induced diseases. The objective of the study is to assess the Prakriti and the Mental Health Status of the volunteers. MATERIAL AND METHODS Population- For the current study (Ethical No. Dean/2020/EC/2334) the Educated Unemployed Youth of Varanasi City were considered, aged between 21 to 35 with a total number of 380 sample size. Sampling Method- In the present study Cluster sampling technique were used. Assessment of Prakriti- We have taken the Prakriti Questionnaire originally developed by Kishor Patwardhan and Rashmi Sharma which is later on modified by Piyush Kumar Tripathi, Kishor Patwardhan from the Dept. of Rachana Sharir, Faculty of Ayurveda and Girish Singh of Dept. of Biostatistics and Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi. The questionnaire was used as it was available as it was already validated by the authors. Assessment of Mental Health Status-The questionnaire which was used for knowing the Mental Health status was developed by Dr. Jagdish, Department of Psychology, RBSPG College, Agra, and Dr. A.K. Srivastava, Department of Psychology, Banaras Hindu University, Varanasi. The Mental Health status was graded as Very Good, Good, Average, Poor, and Very Poor. A total of 380 volunteers were taken and after that Prakriti and Mental Health were evaluated by using the collected data. Seven type of Prakriti was listed and separated. The Mental Health Status of every individual was with their Prakriti. STATISTICAL ANALYSIS Data was collected in Excel Sheet and analysis was done by using SPSS (Statistical Package for Social Sciences) Version 23.0 Software. RESULT A total number of 380 were taken out in which 204 are Male respondents and 176 are Female respondents. The number of Vata Prakriti respondents are 220 and Pitta Prakriti respondents 239 while Kapha Prakriti has 46 respondents. Talking about the subject who have dual Prakriti, there are 32 respondents of Pitta- Kapha, Vata-Kapha had 09 number of respondents, and Vata- Pitta Prakriti had 22 respondents. Talking Sama Prakriti it had 12 respondents.      Total 380 respondents taken participation in the study.(Table 1 and figure 1A). The total number of respondents in Vata Prakriti was 220, PittaPrakritihas 39, and KaphaPrakritihas 46. When we talk about Dual Prakriti people i.e., Vata- Pitta, Pitta- Kapha, and Vata- Kapha were 22, 32, 09 respondents respectively. People with SamaPrakriti(Vata, Pitta&Kapha) were 12 respondents. There are 112(29.5%) candidates having Very Poor Mental Health Status (MHS) ,115 (30.3%) candidates have Poor Mental Health Status and 110 (28.9%) respondents having Average MHS and there are no respondents having Very Good Mental Health Status. (Figure 1B) Table no. 2 and fig. no. 2(A) portrays that out of 380 only 43 participants had good Mental Health Status. There is only one participant with Vata- Kapha Prakriti had Good Mental Health Status. There are no single respondents with Vata, Pitta and Vata- Pitta Prakriti had good Mental Health Status. The highest number of respondents was from Kapha Prakriti. The number of Pitta- Kapha and Vata- Kapha Prakriti was 3 and 1 respectively. 2 respondents with Sama Prakriti (VPK) had Good Mental Health Status. Figure number 2B shows that Kapha Prakriti individual comprises 80.40% of the group, Sama Prakriti people have 16.70%, Vata- Kapha Prakriti people have 11.10% and Pitta- Kapha Prakriti have 9.40% of people having Good MHS. Table no. 3 and fig no. 3A Depicts that out of 380respondents total 110 respondents had Average Mental Health Status (MHS). 14, 7, 8 respondents with Vata, Kapha and Vata- Pitta Prakriti had Average MHS. The highest number of respondents with Average MHS was from Pitta Prakriti with 38 in number. The count of Pitta- Kapha Prakriti, Vata- Kapha and Sama Prakriti was 29, 6 and 8 respectively who had Average MHS. Figure No. 3B: Percentage of Respondents with Average MHS Fig. no. 3B shows that Vata, Kapha and Vata- Pitta Prakriti individual comprises 6.40%, 15.20%and 36.40%respectively of the group, Pitta Prakriti had highest people 97.40% in the group, Pitta- Kapha Prakriti people are 90.6% and Vata- Kapha Prakriti people are 66.70% in the group. 66.70% people with Average MHS had Sama Prakriti. Table no. 4 and figure no. 4A shows that out of 380 respondents 115 respondents had Poor MHS. 101 respondents with Vata Prakriti had poor MHS. Pitta, Kapha and Vata –Pitta had 1,1 and 9 respondents respectively.10 respondents with Vata- Kapha and 2 respondents with Sama Prakriti had Poor Mental Health Status(MHS). Figure no.4B shows that Vata Prakriti had the highest number of respondents having Poor MHS. Pitta Prakriti people are 2.60% and Kapha Prakriti has 2.20% people in the group. Vata- Pitta Prakriti people are 40.90% in the group. No respondents with Pitta – Kapha Prakriti is said to have Poor MHS. 11.10% and 16.70 % of people with poor MHS had Vata- Kapha and Sama Prakriti respectively.    Table no. 5 and figure no. 5A shows that out of 380 respondents 112 respondents had Very Poor MHS. 105 respondents with Vata Prakriti had Very Poor MHS. 5 respondents with Very Poor MHS had Vata- Pitta Prakriti. While Kapha and Vata- Kapha Prakriti had 1,1 respondents in the group. Pitta and Sama Prakriti had zero respondents in the group. The above diagram (figure 5B) shows that there are no respondents with Pitta and Sama Prakriti said to have Very Poor MHS. Vata Prakriti people are 47.70% and Kapha Prakriti people are 2.20% in the group. 22.70% of people with Very Poor MHS had Vata- Pitta Prakriti and 11.10% of people had Vata- Kapha Prakriti.        DISCUSSION Mental Health issues are an inescapable factor in life. One must be knowing the management of it. When the mental status is disrupted homeostasis of hormones as well as important components of (Doshas) the body is also disrupted. Health issues like Heart disease, Migraine, Hypertension, Anxiety, and Diabetes are ill mental health-induced problems. The Psychosomatic combination of an individual explains his/her psychological and physical traits.9-12 The psychological traits of Vata Prakriti person are unstable, impatient, and violent. The person of Vata Prakriti has talkative in nature and experiences anger, irritability, intolerance for cold things, and lesser strength. Their sleeping pattern is not good enough and their mind is never steady.13-16 Pitta Prakriti people are radiant, brave, and have sharp physical strength. They are intolerant of hot things, it is not easy to defeat them easily. They are unsparing to negative people while they behave softly to good people. These individuals have highly intellectual and middling strengths. They are mighty and short-tempered.17-19 The psychological manifestation of Kapha Prakriti individuals is that they are slow in action, and they never get very much depressed. These types of people are patient, hardworking, and never get angry. They easily forgive and are soft in nature and voice. Generally characterized by a pleasing appearance, happiness in the face, stability of the body, and decent. They also have a good sleeping pattern.20-22 The individual having duel Doshas Prakriti have the psychosomatic manifestation of both the Doshas. The dominant Dosha in the duel Dosha Prakriti has more influence on the psychological and physical attributes of an individual. While people having Sama Prakriti had characteristics of all three Doshas. Because of their manifestation, Kapha and Sama Prakriti are said to be the good Prakriti in all types of Prakriti as they are capable in coping with all psychological distress easily in comparison to others.23-25 Individual who has a dominant of Kapha are psychologically strong. Their soft, patient and tolerant nature makes them strong enough to face difficult situations. When an individual has dominancy of Kapha Dosha in their combination, they can handle mental health issues very well. Their quality of good sleep also assists them to maintain hormone levels so they abide calm, and less mental health issues, and stress.26-28 The people having dominancy of Pitta Dosha are brave enough and intellectual. This quality in this individual makes them confident enough for facing the challenges. While Vata Dosha's dominant individuals are psychologically impatient and unstable and intolerant.29 Due to these factors, an individual with Vata dominant Prakriti is bad in facing mental stress and having poor mental health status. But if an individual has Kapha dominant Vata- Kapha Prakriti, the individual gets the benefits of Kapha in Mental Health Status(MHS). The respondents for the present study are educated unemployed youth of Varanasi City. Being educated and having no job hits the mental level of youth very badly. Hence, nobody came under the category of Very Good Mental Health Status(MHS). People having Vata Prakriti are more in this sample. A total of 59.80% of people who had Poor Mental Health status had either Vata or Vata- PittaPrakriti. An individual with Kapha dominated Prakriti had Good MHS. 28.90%people had Average MHS had Pitta or Pitta- Kapha Prakriti dominated Prakriti. Pitta and Kapha dominated individuals with the highest number in Average MHS. The group of Pitta- Kapha Prakriti people was on the second number in the group. An individual having Vata-dominated Prakriti is least in the Dwandaj (Duel) Prakriti group with an Average MHS. The Pitta- Kapha Prakriti person assessed themselves as Average in MHS. Total of 11.30% of individuals had Good MHS had Kapha-dominated Prakriti. Kapha Prakriti had the highest number of people having Good MHS. The group of Sama Prakriti have the second number in the group. There is no single individual with Vata-dominated Prakriti had Good MHS. Interestingly, The Good MHS group had a dominancy of Kapha, the Average MHS had a dominancy of Pitta and the Poor MHS had a dominancy of Vata Prakriti. The psychosomatic manifestation of Vata Dosha is characterized by bad MHS. Précised systematic conditions need heedful meticulous like Anxiety, Hypertension, Renal and Respiratory diseases, and heart diseases.30-32 Many studies related to this are available.33-38 CONCLUSION Anxiety Test, IQ tests and many psychological test are customary assessment tool in our society that are used for many years. If the individual’s Prakriti is assessed at early age, we can able to get a hint regarding their Mental Health status (MHS). Maintaining their MHS is very important in this modern developing world. The youth is under massive mental health problems due to their job, education and carrier. By conducting the Prakriti assessment, we can able to steer clear of Mental Health related issues. Scope for further study: For more accurate results one can give a try with a bigger sample size. Acknowledgment: We thank Bajrang B. Yadav (Biostatistician), Anurag S. Gautam (Research Scholar) and Divya Jaiswal (Psychologist) for their immense support. Conflict of Interest: None Source of funding: None Authors’ Contribution: Jyoti Yadav, the corresponding author has done the review of the literature with collection and analysis of the data. She has also prepared the result and reported the findings. Dr. K.N. Singh has designed and supervised the study. Englishhttp://ijcrr.com/abstract.php?article_id=4621http://ijcrr.com/article_html.php?did=4621

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411421EnglishN2022November10Healthcare Malignant Peripheral Nerve Sheath Tumour of the Scalp with Bone Metastasis English0811Abhishek Raghava K SEnglish Introduction: Malignant Peripheral Nerve Sheath Tumour (MPNST) is a malignant tumour arising from a peripheral nerve or showing a nerve sheath differentiation, with the exception of tumours originating from the epineurium or the peripheral nerve vasculature. Most of these tumours arise on the trunk, extremities, or head and neck regions. MPNST of the scalp is very rare. Case Report: We, report the case of a 71-year-old woman with a lesion in the scalp over the occipital region with FNAC showing the features of MPNST. Wide local excision and split skin grafting were done. Histopathological analysis of the resected specimen strongly supported the diagnosis of MPNST. The patient received adjuvant radiotherapy and was disease-free for 2 years and later presented with bone metastasis. Discussion: MPNSTs are rare soft tissue tumours that arise in proximity to large peripheral nerves and account for 3-10% of all soft tissue sarcomas. Primary MPNST of the scalp is extremely rare and very few cases have been reported in the literature. In this report, we have described the clinical and pathological characteristics of this rare tumour. We have also discussed the various treatment options offered. Conclusion: Scalp MPNSTs are aggressive lesions, and multimodality approaches including surgery and adjuvant radiation are necessary to optimize outcomes. Every attempt should be made to obtain wide and negative margins since positive margins are significantly associated with a poor outcome. EnglishMalignant peripheral nerve sheath tumour, Scalp, S100, Bone metastasis, MPNST, CD34 Introduction             Malignant peripheral nerve sheath tumours (MPNSTs) are uncommon malignant spindle cell tumours that account for 5% to 10% of all soft tissue sarcomas.1,2,3 MPNST arise from nerve trunks located mainly in the trunk and extremities, such as the buttocks, thighs, brachial plexus, sciatic nerve and paraspinal region. Superficial primary MPNSTs with a cutaneous or subcutaneous origin represent a small subset of MPNSTs which is derived from cutaneous neurofibromas or small peripheral nerves.1 Primary MPNST of the scalp is extremely rare, with only 14 cases reported to date in English literature.             Although the incidence of MPNST of the scalp is very low, it is highly malignant and is associated with a poor prognosis. We report a rare case of primary MPNST of the scalp and review the relevant literature regarding the clinical presentation, pathological features and outcome for MPNSTs in this anatomic location. In addition, we have also reviewed the various therapeutic strategies for treating these unusual lesions. Case Report                     A 71-year-old woman presented with complaints of pain and an increase in the size of swelling over the scalp in the occipital region of two months duration. She gave a history of swelling over the scalp in the occipital region since childhood. Physical examination revealed a firm, mobile, non-tender mass. The haematological and biochemical tests were normal. FNAC from the lesion revealed discrete, as well as clusters of spindle cells exhibiting a moderate degree of pleomorphism with the features of spindle cell sarcoma. Metastatic workup was negative. The patient underwent Wide Local Excision (WLE) of the lesion with split skin grafting.             A gross pathological examination of the WLE specimen revealed a whitish-grey lobulated glistening unencapsulated mass with a deep resected margin 0.2cm away from the tumour. Microscopic examination revealed spindle cells exhibiting a moderate degree of nuclear pleomorphism with the high mitotic activity of 12 mitoses per 10 high-power fields (Fig I, II). Superior, inferior, medial and lateral soft tissue resected margins and skin were free of tumour. Immunohistochemical analysis of the tumour cells yielded positive staining results for S-100 and CD 34 and negative for Neuron Specific Enolase and Smooth Muscle Actin suggestive of a high-grade MPNST, WHO grade IV.7                       In view of the close deep resected margins and the high grade of the tumour, the patient was planned for adjuvant RT. She received 50Gy in 25 fractions at 200cGy per fraction. The patient was on regular follow-up. In May 2014, she presented with complaints of low back ache and increased frequency of urination. Bone scan showed increased tracer uptake in the right clavicle, multiple ribs, L1, L2, and L5 vertebra, bilateral sacroiliac joints, and upper half of the shaft of the right femur (Fig III). Another metastatic workup was normal. She did not have any local recurrence. The patient was planned for palliative RT 30Gy in 10 fractions to the lumbosacral spine. She completed palliative radiation to the spine without any complications. In view of advanced age and patient refusal, palliative chemotherapy was deferred. Discussion                   MPNSTs are rare soft tissue tumours that arise in proximity to large peripheral nerves and account for 3-10% of all soft tissue sarcomas.2,3 These tumours arise usually arise from major or minor peripheral nerve branches of the trunk, extremities, or the head and neck region. Primary MPNST of the scalp is extremely rare and less than 14 cases have been reported in the literature. Superficial primary MPNSTs is derived from either a cutaneous neurofibroma or arise de-novo from small peripheral nerves.1 Since our patient had a history of scalp swelling since childhood, the MPNST probably arose as a result of the malignant transformation of a pre-existing neurofibroma.                  Palisading arrangement, nuclear atypia, bizarre giant cells, mitotic figures and necrosis facilitate the histologic diagnosis of MPNST. These tumours are characterised by morphological heterogeneity. Staining patterns of MPNSTs reveal spindle cells with fascicles. The S- 100, EMA, Vimentin (VIM) and CD34 antibodies are highly specific to MPNST.5,6 For most MPNST cases, tumour cells exhibit differentiation towards Schwann cells, which is represented by immunoreactivity for S-100 protein and ultra-structurally by the presence of long cytoplasmic processes that are closely invested by a well-formed basal lamina. In some MPNST cases, tumour cells differentiate toward perineural cells, evidenced by immunoreactivity for EMA and ultra-structurally by the presence of tight junctions, abundant pinocytotic vesicles and an interrupted basal lamina. If tumour cells are not immunoreactive for either the S-100 protein or EMA but are positive for vimentin, CD10, and CD34, these cells are considered to correspond to endoneurial fibroblasts. Desmin and SMA are used to exclude smooth muscle tumours.8 Our patient showed positivity for both S 100 and CD 34 but SMA was negative ruling out a smooth muscle tumour.                     There is a paucity of data regarding the management of MPNST of the scalp. The International Consensus Group has recommended the guidelines for the management of MPNST. The principles of management are similar to that of any other soft tissue tumour. Surgical excision of the lesion followed by reconstruction remains the mainstay of treatment. In the case of MPNST of the scalp, reconstruction involves free flaps, skin grafts, or cranioplasty in case of significant calvarial destruction. The goal is to achieve complete surgical excision of the tumour with negative (wide) margins.3 Our patient underwent wide local excision of the tumour with split skin grafting. In her case, the deep resected margin was only 2mm. In a study by Kumar et al, positive tumour margins were the most important prognostic factor associated with a poor prognosis and every attempt should be made to obtain adequate negative margins of 2cms.8 We offered the patient re-excision of the tumour but the patient refused further surgery. Adjuvant radiotherapy should be considered for all intermediate- and high-grade lesions as well as low-grade tumours with positive margins.3 The supportive literature is generally in the context of sarcomas and not specific to MPNSTs. In view of the close deep resected margins and high-grade tumour, the patient was planned for adjuvant RT.                    In MPNST the role of chemotherapy is usually limited to the treatment of metastatic disease. The survival rates of patients with MPNSTs were significantly better for superficial tumours, such as MPNST of the scalp.2,4 The possible reasons include the early detection and the greater possibility of achieving wide tumour margins without a disabling excision at these superficial sites. Moreover, clinical recurrences are also easier to detect because of the superficial location. However, the metastatic rates are similar to deep-seated MPNSTs. Our patient developed bone metastasis 2 years later. Conclusion  MPNSTs should be considered in the differential diagnosis for any patient with a rapidly enlarging and painful soft tissue mass of the scalp, particularly with a background of pre-existing neurofibroma. Scalp MPNSTs are aggressive lesions, and multimodality approaches including surgery and adjuvant radiation are necessary to optimize outcomes. Every attempt should be made to obtain wide and negative margins since positive margins are significantly associated with a poor outcome. Acknowledgement: The authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to the authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of funding: Nil Conflict of interest Nil Consent Written informed consent was obtained from the patient to publish this case report. Authors’ Contribution: Abhishek Raghava K S has collected the case details, pathological images, bone scan images and conducted a comprehensive literature search and added to the intellectual content of the study. Englishhttp://ijcrr.com/abstract.php?article_id=4622http://ijcrr.com/article_html.php?did=4622 1. Allison KH, Patel RM, Goldblum JR, Rubin BP. Superficial malignant peripheral nerve sheath tumor: A rare and challenging diagnosis. Am J Clin Pathol 2005;124: 685–692. 2. Pisters PW, Leung DH, Woodruff J, et al. Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996; 14: 1679–1689. 3. Stoeckle E, Coindre JM, Bonvalot S, Kantor G, Terrier P, Bonichon F et al. Prognostic factors in retroperitoneal sarcoma: a multivariate analysis of a series of 165 patients of the French Cancer. Center Federation Sarcoma Group. Cancer 2001; 92: 359–368. 4. Anghileri M, Miceli R, Fiore M, Mariani L, Ferrari A, Mussi C et al. Malignant peripheral nerve sheath tumors: prognostic factors and survival in a series of patients treated at a single institution. Cancer 2006; 107:1065-1074. 5. Gonzalez-Martinez T, Perez-Pinera P, Diaz-Esnal B, Vega JA. S-100 proteins in the human peripheral nervous system. Microsc Res Tech 2003; 60: 633-638. 6. Klijanienko J, Caillaud JM, Lagace R, Vielh P. Cytohistologic correlations of 24 malignant peripheral nerve sheath tumor (MPNST) in 17 patients: the Institut Curie experience. Diagn Cytopathol 2002, 27: 103-108. 7. Rodriguez FJ, Folpe AL, Giannini C, Perry A. Pathology of peripheral nerve sheath tumors: diagnostic overview and update on selected diagnostic problems. Acta Neuropathol 2012 Mar;123(3):295-319. doi: 10.1007/ s00401- 012-0954-z. Epub 2012; Feb 12. 8. Rekhi B, Ingle A, Kumar R, DeSouza MA, Dikshit R, Jambhekar NA. Malignant peripheral nerve sheath tumors: clinical pathological profile of 63 cases diagnosed at a tertiary cancer referral center in Mumbai, India. Indian J Pathol Microbiol 2010 Oct-Dec;53(4):611-8

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411421EnglishN2022November10Healthcare A Case of Mucoid Degeneration of Uterine Fibroid with Hydrosalphinx and Ovarian Cyst English1214Saurabh SuvidhaEnglish Introduction: Uterine fibroids are the most common benign pelvic tumors in women of reproductive age. Most of them are asymptomatic but they are also a major source of clinical morbidity. Aim: We present this case due to its uniqueness and the diagnostic difficulties it posed. Case Report: A 40-year-old female presented to the OPD with complaints of pain abdomen on and off and heavy menstrual bleeding. Physical examination revealed a lump of 14-week size.USG and CT scan revealed intramural fibroid with cystic/mucoid degeneration. The patient had an elective total abdominal hysterectomy with bilateral scalping-oophorectomy. Intraoperatively uterus was enlarged with hydrosalpinx on the right side. Histopathological examination showed mucoid degeneration of fibroid with chronic cervicitis. Discussion: Degenerating changes in fibroids are considered to result from excessive growth that outmatches the blood supply or mechanical compression of feeder arteries. Conclusion: This case illustrates that degeneration of uterine leiomyoma should be considered as one of the differential diagnoses for all women presenting with abdominal pain and a large fibroid mass regardless of hormonal status or age. EnglishTAH BSO, Degeneration, Uterine tumours, Fibroid, Blood supply Introduction        Uterine fibroids are the most common benign uterine tumours. Fibroids are seen in at least 40 -50% of women of 35 years or older. Degeneration of fibroid usually occurs because of loss of blood supply caused by its rapid growth during pregnancy or with oral contraceptive use and so the diagnosis of degenerating uterine fibroid in a non-pregnant woman is often difficult. This case is remarkable as degeneration of fibroid is extremely uncommon in a peri-menopausal woman who is not on hormone therapy and degeneration of fibroid should always be considered in a large fibroid mass as its rapid growth can ultimately lead to decreased blood supply leading to its degeneration. Case presentation       A 40-year-old female presented to OPD with pain abdomen on and off and heavy menstrual bleeding for 4 to 5months. Her last menstrual period was on 8th Jan 22. She was P4L4 all by vaginal delivery at term.       On examination the patient was febrile and all other vital signs were within normal limits. Abdominal examination showed a lump of size 14 weeks, firm, irregular and non-tender. On bimanual examination, the mass was enlarged more towards the right and was about 14-week size. Right fornix was full. Investigations    Routine investigations, as well as special investigations, were done which showed Hb 10.9g/dl, TLC 6000/ul, Platelets 1.05 lac/mm3, ESR 40, CA 125 6.6U/ml, SGPT 46 U /ml, CEA 2.15 ng/ml, S Bil 0.52 mg/dl, PT 15.4, INR 1.3.    USG showed a uterus 12x5x9 cm. A large heterogeneous well-circumscribed lesion occupying the whole of the fundus and anterior myometrium with disfigurement of the uterine cavity, 7x8x8 cm suggestive of fibroid. Simple cyst in the right ovary of size 5x6 cm. CT scan shows a bulky uterus with heterogeneously enhancing well-defined lesion in the uterine myometrium of the anterior wall of the fundus and body causing compression of the endometrial cavity posterior suggestive of intramural fibroid with likely cystic /mucous degeneration. Right simple Adnexal cyst and elongated hypodense tubular structure in right adnexa likely hydrosalpinx. Differential diagnosis    A peri menopausal woman presenting with a large fibroid mass raised the concern of leiomyosarcoma. Together with abdominal pain, differential diagnosis includes torsion of pedunculated fibroid, infarction or degeneration as well as a ruptured fibroid. Treatment    TAH BSO was done under combined spinal epidural anaesthesia.14-week size enlarged uterus with hydrosalpinx on the right side was noted. The specimen was sent for HPE which revealed mucoid degeneration of fibroid with chronic cervicitis. The postoperative period was uneventful. She was discharged on the 8th post-operative day. Discussion Degeneration of uterine leiomyoma so occurs when they enlarge in size and outgrow their blood supply. This is commonly seen in pregnant women or women who are taking oral contraceptive pills.1 Hyaline degeneration is the commonest degeneration but can also co exist with other degeneration.2 The diagnosis of degenerating uterine leiomyoma in non-pregnant women is often difficult. The inflammation in case of degeneration can cause abdominal tenderness, localised rebound tenderness on palpating, the elevation of temperature and leucocytosis. All these signs and symptoms are non-specific and all possible causes of an acute abdomen should be considered. On rare occasions, a degenerating leiomyoma can rupture and result in intra-abdominal bleeding.3-5 Pre-operative diagnosis of degenerative leiomyoma is often difficult and they can be commonly misinterpreted as complex adnexal cysts of ovarian origin. 6 This is especially true with CT scans reporting when degenerative fibroids are frequently indistinguishable from cystic ovarian masses.7 When women present with abdominal pain suspected to be of gynaecological origin, ultrasound is highly sensitive and often regarded as the investigation of choice. Conclusion Therefore we conclude that in a woman with a large fibroid mass presenting with acute pain, degeneration of fibroid should be a differential diagnosis irrespective of her age or hormone status. The majority of leiomyomas are symptomless when they are small, there appears no relationship between presenting symptoms and type of degeneration. Symptomatology and severity depend on the size of the leiomyoma rather than degenerative changes.8 Acknowledgement Staff members of the department of Obstetrics and Gynaecology of ESIC Medical College and Hospital BIHTA, Patna Conflict of interest  None Source of funding NIL Footnotes Competing interest – None Patient consent – Obtained Englishhttp://ijcrr.com/abstract.php?article_id=4623http://ijcrr.com/article_html.php?did=4623 1. Rein MS, Barbieri RL, Friedman AJ. Progesterone: a critical role in the pathogenesis of uterine myomas. Am J Obstet Gynecol 1995;172(1 Pt 1):14–18. [PubMed] [Google Scholar] 2. Ramesh B.H, Shashikala P.Study of degenerative changes in uterine leiomyomas IJCRR Vol 03, Issue 02, Feb 2011, pg no 37- 41 3. Tan YL, Naidu A. Rare postpartum ruptured degenerated fibroid: a case report. J Obstet Gynaecol Res 2014;40:1423–5. [PubMed] [Google Scholar] 4. Takai H, Tani H, Matsushita H. Rupture of a degenerated uterine fibroid as a cause of acute abdomen: a case report. J Reprod Med 2013;58:72–4. [PubMed] [Google Scholar] 5. Batsu E, Akhan SE, Ozsurmeli M. Acute hemorrhage related to spontaneous rupture of a uterine fibroid: a rare case report. Eur J Gynaecol Oncol 2013;34:271–2. [PubMed] [Google Scholar] 6. Kaushik C, Prasad A, Singh Y. Case series: cystic degeneration in uterine leiomyomas. Indian J Radiol Imaging 2008;18:69– 72. [Google Scholar] 7. Roche O, Chavan N, Aquilina J. Radiological appearances of gynecological emergencies. Insights Imaging 2012;3:265– 75. [PMC free article] [PubMed] [Google Scholar] 8. Ramesh B.H, Shashikala P. Study of symptomatology of uterine leiomyoma with degenerative changes-IJCRR -Vol 04 Issue 07, April 2012, pg no 104-107.