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Teenage Pregnancy and its impact on Reproductive Health of Adolescents Teenage Sex Education : A Dilemma Endometriosis in Adolescence A Night to Remember... During AICOG 2010, Guwahati FIGO ASRH Initiative with Adolescent Health Committee FOGSI Approach to a Patient with Polycystic Ovarian Syndrome in Adolescents Adolescence - Handle with Care Address for correspondence : Olyai Hospital, Hospital Road, Gwalior- 474009 (MP) India. Phone : (91) -(751)- (2320616)

Issue 02 | Pages 16

ADOLESCENCE

Adolescent Health Committee FOGSI

http://adolescenthealthindia.org http://www.youtube.com/watch?v=NsR0H0ril20

5 6 7 10 11 12 14


Adolescent Health Committee FOGSI

ADOLESCENCE From the

From the

President's desk...

Secretary General's desk...

Dear FOGSIANS, It is with great pleasure I interact with you from the platform of the Adolescent Newsletter by Dr. Roza Olyai. I congratulate Dr. Roza for her endeavors as the Chairperson of the Adolescent Committee of FOGSI. We talk of reducing the maternal mortality and morbidity all the time. One of the important interventions towards this is empowering our adolescents. Today in India we still have girls marrying at the age of 15 and 16 (5%-11%) and imagine that out of the billions of India. we therefore need to address this age group which is not so young nor so old with compassion, care and responsibility. It is indeed nice to know that Dr. Roza has continued to strive for the cause on behalf of FOGSI. The Month of March saw the first focused conference at Jaipur which is the first successful event of FOGSI reaching the unreached initiative. It also fulfilled the objective of the focused conference. It was a successful event not only due to the participation of the FOGSI member but also due to the presence of government officials, policy makers and stake holders taking the standards of the conference on a very high plane I have always appreciated the Vast expanse of our organization and the diversity of our Country . Two months in office as the President has made me still aware of this fact with much more intensity. We as FOGSI are a very strong group of academicians and professionals and I have always maintained that we need to assert ourselves to be able to achieve what we strive for. The first very step as the member of FOGSI would be to update your own information at the FOGSI office .It has been extremely important to be able to reach out to each and every member of FOGSI. Without the correct information it is just impossible to do so. We as the responsible members of an illustrious organization as FOGSI need to take this as an important responsibility and update our contact information to the FOGSI office

It is well said that “catch them young”. If we inform, educate and keep our youths healthy, a major burden of health care will be looked after. Looking at the commitments of Adolescent Health Committee of FOGSI in providing holistic approach to health for the adolescents, I am sure the future for the youths of our Nation will be bright and in able hands. I wish Dr. Roza and her team very successful & eventful tenure as Chairperson of the Committee.

Dr. P. K. Shah Secretary General FOGSI

From the

Vice-President FOGSI Dr. Sekharan Adolescent Health-Nations Wealth! India is having 22% of its population of the ONE Billion (2000) as adolescents. Future of our country depends on their health and behavior. We have to focus on our adolescents to promote a healthy lifestyle, healthy eating habits and exercise. They should be given proper sex education and proper advice to avoid adolescent sexuality which will lead to adolescent pregnancy, unsafe abortion, STI and HIV and social problems. Rural adolescents are having the problems of malnutrition, illiteracy, teenage marriage, and teenage pregnancy with added perinatal and maternal mortality.

It is truly heartening to know the fact that many members have actively volunteered to participate in all the projects scheduled this year. I thank them all for their enthusiasm. I urge you all to continue to be a part of this initiative and it is easy to do so. One has to visit the www.fogi.org and click on I want to participate and choose your field of interest

The Adolescent Health Committee FOGSI is doing many good projects and I wish to congratulate Dr. Roza Olyai, Chairperson Adolescent Health Committee FOGSI, for highlighting these aspects of Adolescent health issues in their projects.

Warm regards

With Warm Regards and Best Wishes,

Dr. Sanjay Gupte President FOGSI

Sekharan P K Vice-President FOGSI

From the

Vice-President FOGSI Dr. Tushar Kar MD,MICOG,FICMCH Fellowship, Lparoscopic surgery (USA) Associate Professor & Unit Head, Dept. of Obstet & Gynecology, SCB Medical College, Cuttack

1

At the outset let me congratulate Dr. Roza Olyai & her team for bringing out excellent first issue of “Adolescence” News Magazine. Superb designing of cover page, packed with well balanced information, making it a very useful reading material. As promised, 2nd issue of “Adolescence” News Magazine is in your hand in three months time. Again it is noteworthy that the team of Adolescent Health Committee is working very sincerely to give us such an informative material on time.

At the outset, I congratulate the Adolescent Health Committee of FOGSI, specially Dr. Roza Olyai, Chairperson for the excellent work she is doing for the adolescents of our country. One of the examples beside many of her projects that she is doing is bringing out a news magazine “Adolescence”. I am sure it will carry out the message amongst all doctors and public across the country about the importance of adolescent health problems. In spite of definite health problems the adolescents do not access the existing sources. In India there have not been any designated services for this age group so far, leading to substantial unmet service needs.It is high time we as FOGSIANs should come forward to support these labile adolescents with the help of the Government and other Non-governmental organizations with definite strategies for this noble cause. We must sensitize the youths of our country and public through various programmes giving importance to different aspects of health, physical, mental , social, spiritual, reproductive and sexual health and well being. “Catch them young” is the truth and reality; our country can only prosper if we reach out each and every adolescent through our efforts.


Adolescent Health Committee FOGSI

ADOLESCENCE From the

Vice President FOGSI Dr. Rishma Dhillon Pai Vice President FOGSI

From the

Chairperson's desk... Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH National Chairperson Adolescent Health Committee FOGSI Olyai Hospital,Gwalior-MP Email: rozaolyai@gmail.com Website: http://adolescenthealthindia.org/ http://www.youtube.com/watch?v=NsR0H0ril20

Adolescence represents an inner emotional upheaval, a struggle between the eternal human wish to cling to the past and the equally powerful wish to get on with the future. Louise J Kaplan Adolescence is the transitional stage of development between childhood and full adulthood, representing the time during which a person is biologically adult but emotionally not at full maturity. Major psychological, cognitive and behavioural changes take place during this period and also the person's body undergoes dramatic changes.

Dear Friends,

There are many issues which arise at this phase, which are of direct concern to the doctors dealing with the adolescent age group.

It gives me great pleasure to share with you the second issue of the news magazine of the Adolescent Health Committee FOGSI. We have received very warm response from our dear readers across the country which has encouraged us to pursue more creative ideas as suggested by them.

Increased interest in sexual activities, sometimes leading to misuse of hormone pills, unplanned pregnancies, abortions and risk of exposure to STD's., possibility of drug and alcohol abuse, mental problems such as eating disorders and depression.

Our mission is to sensitize the youths of our country through various project, we will be dealing in different aspects of health : Physical, Mental, Social , Spiritual, Reproductive , Sexual Health and Well being throughout their lives.

Emotional instability can also drive some adolescents to crime. Adolescents often search for a unique identity. They may acquire role models such as TV and movie stars, sports players, rock stars etc . Often a wrong role model can lead them astray.

It has been seen that in all regions adolescents are reaching puberty earlier and marrying later so they are sexually mature for longer before marriage. Differences between groups of adolescents e.g. urban/rural, in-school/out-of-school, girls/boys influence access to health care and sources of education, information and support.

Adolescence is a cultural and social phenomenon. With India changing dramatically in the last few years ,with increased exposure to different cultures through media, travel, internet etc the Indian adolescent is struggling for an identity. Moral values are changing. There is a lot more money, freedom and exposure and it is often difficult for the adolescent to cope. There is a tussle between conservative's traditions and modern lifestyle. This coupled with difficult communication between adolescents, parents and teachers makes this phase of life very vulnerable. All of us are seeing this dilemma among adolescents, in our day to day practise, so I really appreciate Dr. Roza Olyai 's efforts to reach out to adolescents and their parents, teachers and health care professionals to better understand and deal with this complex issue. My best wishes to her for this wonderful newsletter, may it help spread a lot more awareness than there is and open the channels of communication between adults and adolescents.

From the

Vice-President FOGSI 2009 Professor Alka Kriplani MBBS, MD, FRCOG, FAMS, FICOG, FICMCH, FIMSA Profssor & Head Unit-II Department of Obstetrics & Gynaecology All India Institute of Medical Sciences Ansari Nagar, New Delhi-110029

Adolescent sexual and reproductive health (ASRH) forms a major component of the global burden of sexual ill-health but has historically been overlooked in terms of sexual and reproductive health interventions FIGO has recently done an International survey on Adolescent Sexual Reproductive Health ( ASRH) in various countries including India & is now including ASRH as an important component of health in all its major projects internationaly. Sharing information & updating our knowledge from time to time is very important & am glad through this magazine the Adolescent Health Committee FOGSI is able to achieve this. Am very grateful to Emcure Pharma , specially Mr. Arun Khanna, the COO of Emcure Pharma for his personal interest in supporting the activities the Adolescent Health Committee FOGSI & helping to spread the message across the country through this magazine for the betterment of the youths. Your suggestions & feedback will be of great help, kindly share your articles & achievements with us. Do visit our website & share it with other adolescent girls. Wish you all a happy reading!

Dr. Roza Olyai National Chairperson Adolescent Health Committee FOGSI

Greetings for the year 2010. It gives me immense pleasure to congratulate Dr.Roza Olyai and her team of Adolescent Health Committee of FOGSI who has taken this endeavour to start a quarterly maganize “Adolescence� to especially address problems pertaining to adolescents. Since problems related to adolescents are on the rise, clinicians need updated knowledge, guidelines as well as concise and precise information. I feel that this magazine will be very helpful to all the practicing doctors. I wish all the best for this new venture.

Nothing happens by accident EVERYTHING HAS TO BE

PLANNED

2


Adolescent Health Committee FOGSI

ADOLESCENCE Office Bearers of FOGSI for the Year 2010 Dr. Gupte Sanjay Anant (Pune) President Mobile : 9822030238 guptehospital@gmail.com

Dr. P. C. Mahapatra (Cuttack) President Elect -2011 Mobile : 9437013591 ctk_prachee@rediffmail.com

Dr. Rishma Dhillon Pai (Mumbai) Vice President No.1 Mobile : 9821016005 rishmapai@hotmail.com

Dr. P.K. Shah (Mumbai) Secretary General Mobile : 9323803665/ 9322234814 ifumb@bom5.vsnl.net.in

Dr. Jaideep Malhotra (Agra) Vice President No.2 Tel : (0562) 260275 mnmhagra10@gmail.com

Dr. Nozer Sheriar (Mumbai) Deputy Secretary General Mobile: 9821097536 / 9323803662 sheriar@bom7.vsnl.net.in

Dr. P.K.Sekharan (Calicut) Vice President No.3 Mobile:09447156954 drsekharanpk@hotmail.com

Dr. Girija Wagh (Pune) Jt. Secretary Mobile : 94220 00584 girijawagh@gmail.com

Dr. Tushar Kar (Cuttack) Vice President No.4 Mobile : 9437034520 drtusharkar@yahoo.co.in

Dr. H.D. Pai (Mumbai) Treasurer Mobile : 9820057722 hdpai@hotmail.com

Dr. C.N. Purandare (Mumbai) Immediate Past President Mobile:9323803663 / 9820088183 dr.c.n.purandare@gmail.com

Message across the borders... From Nepal... Dear Dr. Roza Olyai, Congratulations to the Adolescene Health Committee FOGSI for being able to come up with such a nice and useful publication. We have also worked to some extent on adolescent Health and Development. I wish we could further work together in this area in Nepal too. With Best wishes, Prof Chanda Karki MBBS, DGO, MD, FRCOG, FICS Kathmandu Medical College Director, OWMAN Pvt Ltd. (organisation working for mothers, adolescents & newborn) Past President, NESOG (Nepal Society of Obstetricians & Gynaecologist)

From Bulgaria... Dear Dr. Olyai,

Message Dr Hema Divakar Hon Sec ICOG I do not know of any committee that has achieved success without a long journey of aspiration, hard work, commitment, focus, hope, confidence, humility and sacrifice. To rally people to commit to a regimen which will make a perceptible difference to adolescent healthcare and health seeking behaviour requires great leaders in our organisation and we are proud of Dr. Roza Olyai. For all of us who work with her in the FOGSI Adolescent Committee , there is no greater joy than being with the young and the learned. I have tremendous confidence in the power of youth ,in the energy, confidence ,determination and enthusiasm that every one of our young citizens posses in abundance. It is indeed a mammoth task for this committee to harness these and do what the previous generations have not done! I appreciate that Roza has created excellence in all projects that she has taken up for the cause of Adolescents. The mantra is “Catch them Young” and empower them to be aware and make responsible decisions in their lives and the committee is moving ahead with achieving these goals. Pledging all support at all times

Well Done !! Dr. Gracy Thomas, Executive member Adolescent Health Committee FOGSI receiving three awards : Dr. Duru Shah's Trophy for the Best Adolescent Activities in 2009, also selected for the Best Society Award & Dr. T. K. Tank's Trophy for the best social activities for reproductive health promotion from FOGSI during AICOG 2010 3

It was a great pleasure to read your journal. We, in Bulgaria, unfortunately do not have such specialized adolescent journal...reading the inaugural issue has encouraged me & my colleagues to have similar journal in Bulgaria. I would like to send you and your colleagues two invitations for two Congresses. We shall be very glad if we succeed to create a link between our two countries in relation with Adolescent health. Sincerely yours, Prof. Milko Sirakov President Bulgarian Society of Pediatric & Adolescent Gynecology Secretary General European Association of Pediatric & Adolescent Gynecology

INAUGURATION Inauguration of first issue of the “Adolescence” Magazine during managing committee meeting at the AICOG 2010, Guwahati


Adolescent Health Committee FOGSI

ADOLESCENCE Sharing Experience

ACADEMIC BONANZA !!

Include boys in our program Dr. JayamKannan had a good experience starting her new year with a wonderful day on 6th Jan.,wherein she had to talk to adolescent boys too as they demanded a programme! Our next plan in Adolescent Health Committee will be to include both boys & girls for health talk & involve paediatricians as well. Dr. Jayamkannan Executive member Adolescent Health Committee FOGSI

Panel discussion on Recent Advances on Adolescent Gynecology at AICOG Guwahati 2010, Moderated by Dr. Roza Olyai, Chairperson Adolescent Health Committee FOGSI & Dr. Madhuri Patel, Chairperson Breast Committee FOGSI

AMOGS - 2010 Dr. Gauri Karandikar Executive Committee Member Adolescent Health Committee FOGSI, Nasik -

A panel discussion on Various issues regarding health of the adolescent was held at The AMOGS2010, the Annual Conference of the all Maharastra Association of Obstericians & Gynaecologists on 6th Feb. 2010 at Nashik. 800 delegates attended the conference from all over Maharashtra. The panel was moderated by Dr. Pankaj Desai.

-

The panelists were Dr. Nimesh Shelat, Dr. Ashwini Bhalerao, Dr. Kanikar (Paediatrician and Master Trainer for AFHS), Dr. Anjali Barve (Dermatologist & Cosmetologist), Dr. Jaya Gogate (Reproductive Endocrinologist) and Dr. Gauri Karandikar.

The XIIth European Pediatrics & Adolescent Gynaecological Congress Union of scientific medical societies of Bulgaria Bulgarian Society of Obstetrics and Gynecology 2, Zdrave St. Sofia 1431, Bulgaria Dear Dr. Roza Olyai, I am glad to have the opportunity to write you. I would like to inform you that the 12th European Congress of Pediatric and Adolescent Gynaecology, organised by the European Association of Pediatric and Adolescent Gynecology (EURAPAG) and from Bulgarian Association of Pediatric and Adolescent Gynecology (BULPAG), will take place in Plovdiv, Bulgaria on May 26 - 28, 2011. The venue of the congress is Hotel Novotel. I would like to invite you and your colleagues to participate in the Congress with lectures, free communications, films or posters. It will be the excellent opportunity to create a contact between our two nations and professional societies. I would be very glad if you can answer me if you, or your colleagues intend to accept our invitation. With best regards

Prof. N. Milchev President of the Congress

Date and Venue of the Congress The XIIth European Pediatrics and Adolescent Gynaecological Congress will take place from 26-29 Mayð 2011 at Hotel Novotel Plovdiv, Bulgaria (http://www.novotel.com/gb/hotel-0463-novotel-plovdiv/index.shtml) Address: 2 Zlatiu Boyadjiev Street, 4003 PLOVDIV, BULGARIA, Tel (+359)32/934444; Fax (+359)32/934346; E-mail Reservation@novotelpdv.bg Location & access: GPS N 42° 8' 39.12'' E 24° 44' 56.05'' Scientific Correspondence Prof. Milko Sirakov Univ. Ob.&Gyn. Hospital, 2, Zdrave St. 1431 Sofia, BULGARIA Phone (+359)2 9172231; Fax (+359)28517271 E-mail: bsobgyn@abv.bg; URL www.bsobgyn.com Congress Organisation and Accomodation Congess organisation, Novotel, Plovdiv 2 Zlatiu Boyadjiev St. 4003 Plovdiv, BULGARIA Tel (+359)32/934444; Fax (+359)32/934346 E-mail: Reservation@novotelpdv.bg 4


Adolescent Health Committee FOGSI

ADOLESCENCE Teenage Pregnancy and its impact on Reproductive Health of Adolescents Professor Suneeta Mittal MD, FRCOG(ae), FICOG, FAMS, FICMCH, FIMSA Head, Department of Obstetrics & Gynecology & Director-in Charge, WHO-CCR in Human Reproduction & Chief, ART Centre & IVF Facility All India Institute of Medical Sciences, New Delhi-110029 Introduction A teenage pregnancy, considered as a high risk pregnancy is not only a medical entity, but in reality is a social problem. In recent years the incidence of teenage pregnancy has significantly risen with devastating consequences for adolescent mothers, their infants and the society as a whole. Teenage is time of emotional upheaval, when a dual adjustment required as the girl herself is growing up. Incidence There is a significant rise in the number of teenage pregnancies in the recent years. U.K. has the highest birth rates among teenagers in the western world (8.3/1000 live births). In 1996, in USA the birth rate between 15-19 years was 56.8 live births/1000 girls (i.e. 1 in every 18 girls). In developing countries more teenage pregnancies are in married girls compared to West where most teenaged are unwed mothers. Studies in India show the incidence ranging from 3.2-11.8%. Leading Causes of Teenage Pregnancy 1.

Physiological

a. b.

Dramatic physical & psychological changes Early sexual activity

2.

Social Influences

a. b. c. d. e.

Cultural & religious Early marriage Exploitation of youth by media Early age pregnancy in mother Peer pressure

3.

Socio-economic factor

a. b. c.

Poor employment Poverty Housing conditions

4.

Access to health services

a. b.

Lack of health and sex education Lack of awareness and availability of contraception

5.

Individual

a. b.

Poor academic performance Low self esteem

6.

Sexual Abuse

a. b. c.

Common antecedent 66% in all US pregnancies Sex against will - 7 4% <14, 60% <15 (boy friends, husbands)

Factors contributing to teenage pregnancy Many factors are associated with early sexual relationship and teenage pregnancy. These include: social influences like peer pressure, deprivation, early marriage, poor socioeconomic condition, lack of health and sex education, lack of awareness as well as non availability of contraception, lack of self esteem and poor academic performance at school. These factors may contribute to teenage pregnancy as well as the outcome of it, making it a vicious cycle. The primary factors for 5

teenage pregnancy in India are poverty, illiteracy, early marriage and lack of contraceptive awareness. Adverse effects of Teenage pregnancy: Teenage pregnancy can have adverse consequences both for the adolescent mother and her child, including lower educational attainment, limited career opportunity, poverty, lack of prenatal care, low birth weight, preterm delivery, family conflicts and depression. Higher incidence of pre-eclampsia, anemia and sepsis are reported in adolescent mothers. A study of 102 teenage pregnancies (between 14-19 years) at AIIMS revealed that 27.4% were unmarried, rest were married. Of these 28.4% opted for induced abortion, 14.7% had spontaneous abortions and 6.8% reported in emergency with septic induced abortion. Of all induced abortions 78.5% were in unmarried. Only 58 went to delivery, of these 11 had pre-eclampsia, 48 anemias, 22 intrauterine growth retardation and 10 preterm deliveries. 79.4% were from low socio-economic status, 70.5% had no knowledge of contraception and 9.6% had failure of contraception. Overall obstetric outcome is poor with relative risk of low birth weight 1.7, Preterm - 1.9 and small for gestational age - 1.3. Poor antenatal care partly contributes to it, however risk is high even with adequate ANC, outcome worse between 12-15 vs 16-19 yrs. A case control study from Shimla compared the outcome in young teenage (<19) and older (20-30) with 80 cases in each group and found that booked cases were 40.0% & 56.2% respectively, anemia was present in 27.5% and 11.2%, IUGR - 27.5% and 8.7% and PIH in 15.0% and 8.7% respectively. Forceps delivery was required in 17.4% and 6.2% and 1.2% stillbirth occurred in younger group with none in the older. Neonatal Outcome is also adversely affected with high mortality & morbidity due to prematurity and low birth weight. The risk of early neonatal death is 2 times and sudden infant death 2.5 times. Children also suffer from lower intelligence, behavioral problems, school drop outs and various psychological maladjustments. Abortion risk is also higher teenage pregnancy with spontaneous abortion in 10% and induced in 39%. As majority of induced abortions take place under unsafe conditions for issue of secrecy there is high abortion related mortality and poor psychological outcome. At least 13% attempt suicide due to unwanted pregnancy. Reproductive tract infection incidence is high with 1:4 adolescents in USA reporting with RTI. Risk of C. trachomatis infection is 3 times. AIDS is 3rd leading cause of death amongst adolescents. Adverse effects of teenage pregnancy can be summarized as 1.

Social

a. b. c. e.

Lower educational attainment Limited career opportunities Poverty d. Depression

2.

Medical

a. c. e.

Lack of prenatal care Pre-eclampsia Low birth weight

b. d. f.

Family conflicts

Preterm delivery Anemia Sepsis


Adolescent Health Committee FOGSI

ADOLESCENCE Prevention Prevention of teenage pregnancy is important a requires a multifaceted approach including education, focused health services, socio-economic support and contraceptive counseling. Different sages of prevention would include:

no formal sex education. In young sexual relationship is linked to social relationship with focus on present not future, sex usually forced or peer-pressured, mostly occasional & accidental and promoting awareness of emergency contraception is appropriate as first encounter is usually accidental & unprotected. Timely usage of emergency contraception prevents mental, social & physical agony of having an 'unsafe abortion'.

1.

Primary Prevention

a. c. e. f.

Abstain from sex b. Cultural attitudes Avoiding early marriage d. Improved education Health & sex education Improving socio-economic status

2.

Secondary Prevention

a.

use of contraception

3.

Tertiary prevention

a.

Safe Abortion services

b.

emergency contraception

b.

adequate prenatal care

Teenage suffer from a double edged policy in India. Rural youth are married young and are expected to procreate with no sexual or contraceptive awareness. While for Urban youth on one side sex is regarded a taboo and on other side there is media over exposure with

Conclusion Teenage pregnancy is considered a high risk from social and biological point of view with prevention being a challenging task needing special attention. A multifaceted approach involving provision of education, health services and socio-economic support are to be woven together in tackling this problem of teenage pregnancy, Provision of contraception counseling including emergency contraception can be helpful in preventing most of these unwanted pregnancies. There is also a need to strengthen safe abortion services for adolescents. I would like to Congratulate the Adolescent Health Committee FOGSI for having school & college health projects & creating awareness, spreading the message amongst the adolescents of our country.

Teenage Sex Education: A Dilemma Dr. Sadhana Gupta Executive member Adolescent Health committee FOGSI Jeevan Jyoti Hospital & Medical Research Centre Gorakhpur 273 001, UP Tel. Nos. 0551 2330173, 2334233 Email: dr_sadhanag@yahoo.com In last decade in India and all over the world there has been lot of emphasis on Teenage Sex Education. High unplanned pregnancy rate among teenagers in western world and emergence of untreatable sexually transmitted infection like HIV and Hepatitis B in youth has shaken not only the medical personnel but also parents, teachers, social, political and even religious people. Though need for imparting sex education to teenagers is felt by society but its content, method and ways have raised a lot of controversy and debate. And still the question of Teenage Sex Education is unclear in most of the minds. Through my personal experience of ten years of going and talking to school girls of varying socio economic status, rural ,semi urban and urban girls, my approach and views have been constantly changing about the topic so called Teenage Sex Education. I take this opportunity to share these views. First of all when we talk to teenagers, we should never forget that he or she is not only potential catcher of reproductive tract infection but the person whom we are addressing is innocent, psychologically tender and in the way to seeking its identity and role in society. Their concerns are many- academic, sports, friendships, domestic, social and what not. Physical changes of adolescence and psychological turmoil of teenagers are also few of them. We can make their life easier and smoother if we talk with them; just tell about scientific basis of adolescent physical change, menarche, and adrenarche and how they should take care of themselves. This should be done in simple, natural way and one should not bombard them with lot of complexities which are already there in their syllabus. Issue of reproduction, sexual rights and responsibility and of course dreaded reproductive tract infection should be neither in form of any slogan, lecture nor frightening. These issues should emerge naturally as a part of growth of human character, and related to other aspects of

social and moral value like honesty, sincerity and hard work. If adult have the mono-directional approach and think that responsible sexual behavior can be in otherwise irresponsible person, they are at fault. If we remember this in talking to them, we can help a bit in making our future citizen more responsible, hardworking in all the ways. At the same time it is important to emphasize those doctors or persons with good image should be selected for Teenage Sex Education. Beside this in developing country like India the women hardly have any opportunity to talk to doctors or medical personnel. We can talk this opportunity of TSE in diagnosing adolescent menstrual and growth disorder. Anemia, nutritional deficiencies, thyroid disorders, PCOS, genital tuberculosis and infections are main treatable conditions in adolescent. If we educate our teenagers about symptoms of these disorder and necessity of taking advice of doctors, we can give them real benefit of Teenage Sex Education. Adolescent vaccination especially Rubella and now HPV, which can have major preventive role in cancer cervix in future should also be emphasized in this sessions. At FOGSI level, each society can select and prepare few persons who are good communicator and has good knowledge of adolescent problems. These persons can carry out TSE program in schools and colleges. Pediatrician and male gynecologist can be selected for going to boy's schools. Boy's growing up problems is still not the focus of our attention. They are also as or probably more vulnerable. And meeting with them will reveal new facts about adolescence. I congratulate the Adolescent Health Committee FOGSI to take this initiative & bring out the magazine â&#x20AC;&#x153;Adolescenceâ&#x20AC;? which is a good way to create awareness amongst the doctors.

6


Adolescent Health Committee FOGSI

ADOLESCENCE Endometriosis in Adolescence

Brig. (Dr.) Sanjiv Chopra Professor Department of Obstetric & Gynecology AFMC -Pune Introduction

Pathophysiology

Endometriosis is a common yet poorly understood gynaecological syndrome that affects females of all ages who menstruate. Symptoms include progressive dysmenorrhoea, premenstrual syndrome, dyspareunia, chronic pelvic pain and infertility. Endometriosis affects over 17 million women globally. Its complex symptomatology, difficult diagnosis and unclear aetiology obstruct the discovery of disease modifying approaches.

Although the pathogenesis remains unclear, leading theories include retrograde menstruation, haematogenous or lymphatic transport and coelomic metaplasia. Genetics and immunology are important factors to keep in mind. It is frequently seen among sisters and much more if they are twins .Evidence suggests that endometriosis has a genetic basis and results due to reduced immunologic clearance of viable endometrial cells from the pelvic cavity. It is also associated with a state of subclinical peritoneal inflammation and increased local chemical mediators resulting in extension, depth of involvement and adhesion formation.

The lining of the uterus is called the endometrium. When functional endometrial tissue grows extra-uterine it is called endometriosis. Endometrial tissue outside the uterus responds to changes in hormones. It breaks down and bleeds like the lining of the uterus during the menstrual cycle. The endometrial tissue may attach itself to the ovaries, fallopian tubes, the intestines, or other abdominal organs. Rarely, endometriosis occurs outside the abdominal cavity, such as in the brain or lungs. Endometriosis may also develop in surgical scars following surgery on pelvic organs. Symptomatology The main symptom of endometriosis is pelvic pain. Pain may occur during bowel movements or urination, at time of intercourse or just before or during the menstrual cycle. The amount of pain is not always proportional to the severity of the condition. Some patients with slight pain may have severe endometriosis. Others who have a lot of pain may have mild endometriosis. Endometriosis should be strongly suspected in adolescent girls with chronic pelvic pain unresponsive to oral contraceptive pills and non steroidal anti-inflammatory agents. Dysmenorrhoea is to be considered the most important symptom and the most frequent reason for consulting .Cramps progressing in intensity throughout the years, not responding to conventional therapy with diarrhoea, nausea and vomiting, changes in character of premenstrual tension, dyspareunia are present in most of adolescents with endometriosis in different degrees of intensity but at a very high level. They may complain of menstrual irregularities. Menstrual bleeding may occur more than once a month. Pregnancies occurring among adolescents with endometriosis delay the onset of the disease and its evolution for many years .On the other hand, endometriosis may also cause infertility. Many women with endometriosis have no symptoms. In fact, they may first find out that they have endometriosis if they are not able to get pregnant. Endometriosis is found in about one third cases of infertile women. Economic/ Psychological/ Social Implications Endometriosis is a long-term condition. Many females have symptoms that occur off and on until menopause. Coping with this condition adds to stress and deteriorates the quality of life especially in the domains of pain, psychological and social functioning. Women who experience chronic pelvic pain may develop negative effects as anxiety and depression which in turn can adversely affect social, marital and family functioning. Painful intercourse can lead to difficulties in relationships, breakdown of communication and for single women avoidance of relationships. Missing out on activities during adolescence and the critical time of identity formation can affect relationships and self esteem. The economic burden of endometriosis in terms of productivity and loss of work time is tremendous. 7

Increasing incidence of diagnosis Environmental factors, increased awareness and diagnosis have caused the incidence of endometriosis to increase. There is an increasing incidence of visual diagnosis of endometriosis at laparoscopy. Earlier, the diagnosis of endometriosis was only verified by laparotomy and therefore the patient had to be experiencing severe symptoms or have a large pelvic mass before such an intervention would be considered. It is with the advent of endoscopy which has precipitated the debate as we can now visualise the pelvis easily and often do so in women with no symptoms. Direct visualization confirmed by histopathological examination, especially of lesions with non-classical appearance remains the standard for diagnosing endometriosis. Visual inspection as the sole means for diagnosing endometriosis requires an experienced surgeon familiar with the protean appearances of endometriosis. Correlation between visual inspection and histopathological confirmation is imperfect. Sensitivity of ultrasonography in detection of focal endometrial implants is poor. However there is good sensitivity and specificity in detection of endometriomas. General guidelines for management Treatment for endometriosis depends on the extent of the disease and symptoms. Treatment options include medical therapy and or surgical intervention. Although treatments may relieve pain for a time, symptoms recur after treatment. Medical therapies do help in alleviating symptoms and improve the quality of life but have little role to play in management of endometriosis associated infertility. Hormones may be used to relieve pain. They help slow the growth of the endometrial tissue and prevent the growth of new adhesions. Some of the hormones prescribed include oral contraceptives, gonadotropin-releasing hormone (GnRH) and progestin. Surgery may be done to remove endometriosis and the scarred tissue around it. In most severe cases of endometriosis, surgery often is the best choice for treatment. The goal of conservative surgery is to remove all apparent endometriosis from the abdomen and pelvis and restore normal anatomical relationships. Surgery most often is done by laparoscopy which has the advantage of reduced hospital stay, less post op pain and adhesions. During laparoscopy, endometriosis can be removed or burnt away by excision, vaporization or fulguration. It is due to the fact that during the last decade, endometriosis has been diagnosed among adolescents, surgical laparoscopy followed by medical treatment and a close follow-up to avoid a relapse, seem to be the ideal treatment regimen.


Adolescent Health Committee FOGSI

ADOLESCENCE Peer Education …what I learnt! Dr Rajal Thaker Associate Professor in Obstetrics & Gynaecology, Sheth V S General Hospital & Sheth Chinai Maternity Hospital, Smt N H L Municipal Medical College, Ahmedabad 6, Gujarat, India National Trainer ~ Adolescent Health Executive Member ~ Adolescent Health Committee of FOGSI Chair Person ~ Adolescent Committee of AOGS A Friend in need is a Friend in deed It was indeed a learning experience for me when I met Britta who is a chief coordinator of Project Sex P 6 (sex is pronounced as six in Swedish) at Lund University in Sweden in November 2008. She is just 21 and a student but she manages the project with so much confidence! The P 6 has a coordinator and board members who are students from different faculties. Every year there is an election and a new coordinator is selected. Thus, the ownership of project is with students. There are subject experts who guide these members. Activities include individual consultation and information on issues related to Sexual & Reproductive Health (SRH) and distribution of condoms as well. The volunteers go to the local pubs on Saturday and Sunday to distribute condoms. They talk about sexuality, talk about body, relationships and arrange discussion current topics. They also offer workshops, events, web page and media campaigns. Every year when new students are enrolled at Lund University (It the largest university in Scandinavia) these volunteers help them in adaptation in new area along with information on issues related to SRH. Thus, the students are helping and guiding other students which is truly a friend in need a friend in deed action. Adolescent/ Youth Friendly approach by themselves/for themselves/of P 6 coordinator of 2008 themselves is called Peer Education and P 6 has distributed more than is an accepted strategy world wide to 40,000 condoms in 2008 address issues related to SRH. •

Pic 3: Counselor's room at a youth center in Sweden

The youth centers are thus providing services that are friendly, maintain privacy & confidentiality along with easy accessibility. It provides services free of charge at timing that is convenient to Adolescents / Youth and are located closer to where Adolescent / Youth gather. Easy access to contraceptives & other reproductive health services in Sweden, France, Canada and Great Britain contributes to better contraceptive use & therefore lower teenage pregnancy rates than in the United States We too can incorporate the Adolescent/Youth friendly attitude and can provide services that are Adolescent/Youth Friendly. Let's become a friend of an Adolescent!

Adolescent Health Activities…

A peer is one that is of equal standing with another. The person belongs to the same social group as another person or group. The social group may be based on age, sex, sexual orientation, occupation, socio-economic or health status, and other factors. Education refers to the development of a person's knowledge, attitudes, beliefs, or behavior as a result of the learning process through counseling, facilitating discussions, mobilizing for advocacy, lecturing, distributing materials, making referrals to services & providing support.

Dr Neeta Dhabhai Executive committee member Adolescent Health Committee FOGSI, Faridabad 1.

Therefore, Peer Education means process whereby well-trained and motivated young people undertake informal or organized educational activities with their peers

Pic 2: Waiting room with helpline numbers, posters, magazines, games and interiors that provide friendly environment to Adolescents/Youth

International TOT (OP) in Philippines Sept 7-11 2009, Participated as a Facilitator/Master Trainer team of WHO (WPRO-West Pacific Region Office) Trained a group of 28 doctors and health workers of the Dept of health(Philippines) on Adol health.

2.

Attended the 9th World Congress on Adolescent health IAAH (International Association of Adolescent Health) in Malaysia 28th -30th October and participated in an Panel Discussion on service Delivery needs of Adolescent Health

3.

Smart Diet for teens City coordinator, We covered 4 schools and 322 girls (Nov-Dec 2009)

4.

Growing up Covered 200 girls in 3 schools (as a part of the general program) Nov-Dec 2009

5.

Challenges for youth Today and Tomorrow 9th Oct 2009, With sponsors from Rotary Club Faridabad, done in Govt girls college Faridabad

6.

Protecting young girls Did a session in Ashoka Memorial School, covering 100 girls on Jan 9th 2010 8


Adolescent Health Committee FOGSI

ADOLESCENCE Lets learn from them...

Health camp for a good cause! Dr. Kalpana Khandheria Executive Committee member Adolescent Health Committee FOGSI, Jamnagar, Gujarat On the eve of International women’s day she organized a free camp where 2500 girls had been examined. 25% to 30% of girls had Hb 10 gm% & less, were then further investigated for special investigation for the cause of anaemia free of charge. Medicine for 3 months were also given.

Marvelous Achievements... Dr. Basab Mukherjee Executive Committee Member Adolescent Health Committee FOGSI, Kolkata

Dr. Usha Valadra Here with I am sending some activities for adolescent health promotion during the year Jan-Dec '09 in SuratGujarat. 1.

Author Chapters on Menopause & HRT in Handbook of Obstetrics and Gynaecology for Asia Oceania Editors – Dr. Amar Bhide, Dr. Hema Divakar, Prof. S Arulkumaran (Jaypee Brothers Publication)

More than 500 girls from village scholls examine for Hb% estimation. 70-80% girls were mild to moderate and 20% were severely anaemic less than 6gm Hb%.

2.

On 1st Aug adolescent day panel discussion and phoning program at local T.V channel.

Public Awareness

3.

4th Oct CME on adolescent gynaecnology Dr Usha Krishnan, Dr Mandakini Parihar, Dr Drashna Thakkare & Dr Kiran Shah haematolgist were invited

4.

On "World Aids Day" panel discussion on T.V channel and audio video visual program at Vinay high school,Sultanabad. More than 500 boys and girls attended this.

• Talk on Cervical Cancer Vaccines in Calcutta Medical Research Institute • Co ordinator at Swasthya Mela in Kolkata on Cancer Awareness Speaker – CME • Ghaziabad (Repr Endo FOGSI) - Modern Mx of Rh alloimmunised Pregnancy • Kolkata - Emerging Concepts in Reproductive Health Speaker – Conferences • • • • • • • • • • 9

Activity Report

World Congress on Recent Advances in Obs & Gyn at Mumbai – Newer OCs Bengal Obs Gyn Society Annual Conference – Hormonal Management in DUB AICOG 2010, Guwahati -Dietary Prophylaxis in PCOS AICC RCOG 2010 Kolkata - Adolescent Friendly Health Services Contraception and Beyond @Jaipur 2010 – Contraception & people living with HIV & AIDs Panelist - Profiling Patients for Contraception Selection National Trainer for IUD & MA workshops (FOGSI-FPAI Initiative) Co quiz master at FOGSI J&J National Quiz Teaching Faculty at PG training for Diploma in Family Medicine at Kolkata Scientific Secretary – AICC RCOG 2010 Silver Jubilee Conference Kolkata

Thanking You Dr. Usha Valadra Consultant Obstetrician & Gynecologist Executive member Adolescent Health Committee FOGSI Surat - Gujarat

PUT YOUR TOUGHEST

AMBITIONS On paper and clip them with faith.


Adolescent Health Committee FOGSI

ADOLESCENCE A Night to Remember... During AICOG 2010, Guwahati

Lets learn from them... Dr Rajal Thaker Executive Committee member Adolescent Health Committee FOGSI Associate Professor in Obstetrics & Gynaecology Sheth V S General Hospital & Sheth Chinai Maternity Hospital, Smt N H L Municipal Medical College, Ahmedabad, Gujarat, India

• As a Chair person Adolescent committee of AOGS, she has developed 2 slide shows (Gujarati & English) and has covered 12 schools & 1835 boys & girls. • As a City coordinator of FOGSI’s Adolescent committee’s ‘Smart Diet for Teens’ program, target for the year 2009-10 has been achieved. • Selected as one of the participant of National Training Program on AFHS (LUND university, SIDA & Mamta Health Institute, Smt NHLMMC) and as a part of CHANGE project • Undertaken a research project on HPV with University of South Florida (USF) & Smt NHLMMC . • Invited as a Faculty at various places on Adolescent Health issues: – CME organized by AOGS at Cairo, Egypt 23/10/09, subject: AFHS – State level workshop on ‘strengthening of ARSH Services in RCH program’ subject: History taking & Examination of Teenage pregnancy – Urban RCH Society : Antenatal care & complications, Introduction on AFHS

Meeting of members of Adolescent committee at AOGS office alongwith medical students from UK

Dr. Rajal Thaker & Dr. Kruti Deliwala T Anjuman-E-Islam School, Ahmedabad

10


Adolescent Health Committee FOGSI

ADOLESCENCE FIGO ASRH Initiative with Adolescent Health Committee FOGSI Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI was invited by FIGO to take part in an International Survey on Adolescent Sexual and Reproductive Health (ASRH) which was followed by a telephonic interview. India is now invited to take part in a regional workshop organized by FIGO on ASRH & will be represented by Dr. Sanjay Gupte President FOGSI & Dr. Roza Olyai, Chairperson Adolescent Health Committee FOGSI. This workshop is being convened by Dr. Kamini Rao, Advisor of the Adolescent Health Committee FOGSI. A brief report of the same will be shared with you in the next issue of this magazine.

then fund small regional working groups to adapt the tool for specific regions, followed by funding widespread training workshops at national level.

FIGO members survey and interviews

Knowledge, Attitudes, Practice Survey and Interviews

The survey and interviews explored members perceptions of national policy, service delivery, professional training and education, and attitudes towards adolescents. Thirty three percent of FIGO members participated in the survey and/or interviews.

A letter introducing the study was sent by email to all 113 member associations by FIGO in December 2008. The survey was sent out by email in January 2009 and hard copies were sent by fax or post when email contact was not possible. Two follow-up requests for surveys to be returned were sent out during February.

Three resources (produced by WHO, Pathfinder and Engender Health) were identified as tying in most closely with information requested by participants. All three are holistic in their coverage of clinical and social aspects of ASRH; tested and validated; are available free of charge in a variety of formats i.e. on-line, CD-Rom, hard copy. It is recommended that FIGO review these three and identify one resource to take forward for accreditation by a specialist association e.g. FIGO, RCOG. This would increase credibility and enable training to contribute to continuing professional development (CPD). FIGO could

Adolescent Health Activitiesâ&#x20AC;Ś Dr Ankita Kothe Executive Committee Member Adolescent Health Committee FOGSI, Nagpur As the Chairman of the Public forum committee of the Yuva Fogsi west zone Conference held in Nagpur in November 2009. Dr. Ankita & her team, conducted a Public forum on Adolescent health during the conference for the NMC schools & other schools of Nagpur. Dr Ujjwala Deshmukh, Gynaecologist & Dr. Ankita conducted the proceedings. Dr Chaitanya Shembekar, Dr Sharmila Kulkarni, Dr Shubhangi Deshmane,Dr Sunita Ghike Gynaecolgists,Mrs Alka Dalal from NMC, Mrs Sakolikar,Shri shakti Sanghtana guided the girls in an interactive session. The program was attended by more than 150 girls & boys.

11

In order to determine how FIGO can effectively contribute to improving ASRH, avoid duplication of efforts, and identify potential partners from whom lessons can be learned, FIGO was awarded a UNFPA project grant and commissioned Options Consultancy (Options) to carry out a preliminary study of affiliate associations' views on ASRH. Methods :

Sixty nine member associations were also randomly selected by FIGO to be invited to take part in a telephone interview. The total number of member associations participating in this study (combining surveys returned with the telephone interviews) is 37 (33%) out of the 113 invited to participate in this study FIGO Members' Knowledge, Attitudes and Practice The views expressed were those of individuals, albeit individuals who were nominated representatives of national associations of obstetricians and gynaecologists. Seventy three percent of respondents were male and 87% (n=26) regularly treat adolescents as part of their clinical practice. The average number of adolescents attended to each month was 65, ranging from 3 to 700. Eighty percent of respondents reported that national policy did in some way address ASRH. Conclusion As a global professional organisation with extensive member associations and a high degree of technical competence, FIGO can play an important role in working to improve adolescent sexual and reproductive health around the world. Indeed, this is what FIGO's members would like it to do. Careful consideration, however, needs to be given to where FIGO as an organisation can add greatest value to current activities in ASRH. This is through building on its existing institutional strengths and proven expertise, particularly within the spheres of pre- and in-service training and development of clinical standards and guidelines. A number of training tools already exist and evidence shows that they are effective. As a result there is no need to duplicate effort by developing new tools. FIGO and its member associations are, however, well-positioned to play an active part in adapting these existing tools to ensure that they are appropriate for specific regions, and in implementing, evaluating and monitoring training and capacity-building among obstetricians and gynaecologists. There is also an urgent requirement for other health practitioners, who are often the first point of contact for adolescents when seeking health care and advice, to benefit from FIGO's activities in ASRH. FIGO could optimise the effectiveness of its involvement in these issues and activities by development/membership of coalitions, partnering organisations with existing expertise in programme implementation and management; and participating in multi-disciplinary/multisectoral working groups.


Adolescent Health Committee FOGSI

ADOLESCENCE Approach to a Patient with Polycystic Ovarian Syndrome in Adolescents Dr Prashanth K Adiga, MD Associate Professor, Department of OBGYN Kasturba Medical College, Manipal, Manipal University - 576104 Tel. : 0820-2922211. Email: dradiga@yahoo.co.in Introduction Polycystic ovarian syndrome is one of the most common Endocrinopathies in reproductive age group, and often presents in late adolescence. Polycystic ovarian syndrome is a syndrome of protean manifestation with a variable combination of menstrual irregularity, hirsutism or acne and obesity. The Rotterdam consensus in 2003 revised the diagnostic criteria and declared two of the three following criteria as prerequisites for PCOS1: 1.

Chronic anovulation or oligomenorrhoea for more than 6 months

2.

Clinical or biochemical hyperandrogenism and

3.

Polycystic ovarian morphology

In 2006, the androgen excess society provided a contemporary version of the definition of PCOS and has highlighted hyperandrogenism, clinical or biochemical, in combination with ovarian dysfunction, including both functional and ultrasonographic abnormalities, as the core characteristics of PCOS2. Approach to a patient with polycystic ovarian syndrome in adolescent is based on •

Clinical features

Investigation

Clinical features Symptoms 1.

Menstrual irregularities The onset of PCOS may occur in adolescence beginning with irregular menstrual cycles, which persist for more than 3 years after menarche3. The menstrual irregularities may manifest as • • • •

oligomenorrhea primary amenorrhea secondary amenorrhea dysfunctional uterine bleeding

2.

Hirsutism is a classic feature of the androgen excess of PCOS and is found in about two thirds of cases. Hirsutism is excessive sexual hair that appears in a male pattern .The other cutaneous signs of androgen excess are acne, seborrhea, alopecia, or hyperhidrosis. Signs of androgen excess such as hirsutism or acne, or both, occur with similar frequency in adolescent and adult women with hyperandrogenism3.

3.

Obesity is present in 50% of patients with PCOS, which is typically android in type (central obesity with a waist circumference >88 cm after sexual maturity is attained). This central obesity gives rise to increased waist-hip ratio4. Some adolescents with PCOS have acanthosis nigricans, a velvety hyper-pigmented thickening of the skin, particularly in the intertriginous areas such as the axilla and neck, which correlates with decreased insulin sensitivity5.s

Physical Examination findings Look for • • •

General body habitus (gynaecoid versus android) Obesity and fat distribution (with BMI to be calculated) Acne , Acanthosis nigricans and male pattern baldness

• • •

Thyroid gland enlargement Galactorrhea Tanner staging and the possibility of virilisation (clitoromegaly, voice change)

Sultan and Paris have proposed a definition of PCOS in adolescents, according to which the combination of four from the following criteria comprises the diagnosis of the syndrome6 1.

Clinical hyperandrogenaemia: Persistent and of serious-degree acne and hirsutism;

2.

Biochemical hyperandrogenaemia: levels of serum testosterone >50 ng/dl and LH/FSH ratio >2;

3.

Insulin resistance and hyperinsulinaemia: Acanthosis nigricans, visceral adiposity and impaired glucose tolerance;

4.

Oligomenorrhoea persisting 2 years post menarche

5.

Polycystic ovarian morphology on ultrasound

Investigations In an adolescent patient with menstrual irregularities and symptoms and signs of androgen excess, the diagnosis of PCOS needs to be entertained. The laboratory evaluation of the adolescent patient with suspected PCOS varies depending on the clinical symptoms and examination findings. The following investigations are done in an adolescent with history of menstrual irregularities and or hirsutism. • • • • • •

Testosterone, total and free, Dihydroepiandrostenedione (DHEAS) Fasting 89 AM 17-hydroxyprogesterone Thyroid-stimulating hormone (TSH) Prolactin Fasting glucose* Fasting insulin*

(*Consider if obese, acanthosis nigricans, family history of diabetes.) The purpose of estimating androgens in the workup of PCOS patients with hirsutism is to rule out more serious conditions of androgen excess like ovarian or adrenal tumour. If total testosterone level is higher than 90 ng/dl, there is a good evidence of androgen excess. Total testosterone greater than 200 ng/dL, and DHEAS greater than 6000 ng/mL are suggestive of ovarian and adrenal tumors and require further evaluation. In PCOS, total testosterone can be normal or slightly elevated, but free testosterone is thought to be a more sensitive test for androgen excess. Free testosterone has been reported to be elevated in 60% to 80% of adult women who have PCOS (>10 pg/mL), whereas DHEAS is elevated in only 25% of patients7. Estimation of FSH and Estradiol levels is required in the workup of PCOS to exclude the diagnosis of premature ovarian failure. In girls with irregular menses and thyroid enlargement, TSH and prolactin levels should be measured to exclude a thyroid disorders and prolactinoma. A basal 17-hydroxyprogesterone level is measured during the follicular phase of the cycle to exclude a diagnosis of non-classical adrenal hyperplasia. Exclusion is necessary to establish a diagnosis of PCOS8. Approximately 1 to 8% of hirsute women have non-classical CAH. An elevated basal 17-hydroxyprogesterone level should prompt 12


Adolescent Health Committee FOGSI

ADOLESCENCE an ACTH stimulation test to establish the diagnosis of non-classical CAH8, 9. Testing for evidence of hyperinsulinemia and insulin resistance should be considered in adolescents with acanthosis nigricans, obesity, and a history of premature pubarche. Fasting glucose and insulin levels are recommended8. A fasting glucose/insulin ratio has been proposed as a rapid and easy screening alternative. In obese adult women, a fasting glucose/insulin ratio less than 4.5 suggests insulin resistance, whereas in the adolescent, a ratio less than 7 is suggestive of insulin resistance10, 11 .Adolescents who are obese and have a diagnosis of PCOS should undergo a 2-hour 75-g oral glucose tolerance test (OGTT) 12, as this is a more sensitive test than a fasting blood sugar to detect diabetes and impaired glucose tolerance, a significant risk factor for diabetes13. As per the Rotterdam criteria, ultrasound is mandatory for the diagnosis of PCOS1.The presence of 12 or more follicles with a diameter of 2-9 mm in the ovary is criterion for polycystic ovarian morphology on ultrasound. An increased ovarian volume of greater than 10 mL is also suggestive of polycystic ovarian morphology. The role of ultrasound in the adolescent population is further complicated by the mere fact that many controls have polycystic ovaries that are not pathologic Clinical points •

Rotterdam criteria is used to make a diagnosis of PCOS

Menstrual irregularities, hirsutism and obesity are some of the common symptoms the adolescent patient or the parents of the adolescent patient may complain of

Thyroid enlargement, galactorrhea, BMI, android type of obesity and signs of virilisation should be looked for in general physical examination

• •

Hormonal assay required in the workup of PCOS are : FSH, TSH, Estradiol, Prolactin, 17-OH progesterone, Serum testosterone Ultrasound is required to look for ovarian morphology which may not be very evident on trans abdominal ultrasound

Adolescent Health Activities…

References 1.

The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004; 19(1): 4147. Review.

2.

Azziz R, Carmina E, Dewailly D et al. Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an androgen excess society guideline. J Clin Endocrinol Metab 2006; 91(11): 42374245

3.

Rosenfield RL, Ghai K, Ehrmann DA, Barnes RB. Diagnosis of the polycystic ovary syndrome in adolescence: comparison of adolescent and adult hyperandrogenism. J Pediatr Endocrinol Metab 2000; 13:12851289.

4.

Chang JR, Coffler MS. Polycystic ovary syndrome: early detection in the adolescent. Clin Obstet Gynecol 2007; 50:17887.

5.

DiMartino-Nardi J. Pre- and postpubertal findings in premature adrenarche. J Pediatr Endocrinol Metab 2000;13:12651269

6.

Sultan C & Paris F. Clinical expression of polycystic ovary syndrome in adolescent girls. Fertil Steril 2006; 86(Suppl. 1): S6

7.

Pfeifer SM, Kives S. Polycystic Ovary Syndrome in the Adolescent. Obstet Gynecol Clin N Am 36 (2009) 129152

8.

Azziz R. The time has come to simplify the evaluation of the hirsute patient. Fertil Steril 2000;74:870872

9.

American Society for Reproductive Medicine. Technical Bulletin: The Evaluation and Treatment of Androgen Excess. Birmingham, AL: ASRM; April 2000.

10. Legro RS, Finegood D, Dunaif A. A fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1998; 83:26948. 11. Legro RS. Detection of insulin resistance and its treatment in adolescents with polycystic ovary syndrome. J Pediatr Endocrinol Metab 2002;15(Suppl 5): 136778. 12. Franks S. Polycystic ovary syndrome in adolescents. Int J Obes (Lond) 2008; 32:103541 13. Palmert MR, Gordon CM, Kartashov AI et al. screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome. J Clin Endocrinol Metab 2002;87:101723

Dr. Darshna Thakker Executive committee member Adolescent Health committee FOGSI Ahmedabad

Medico Social Activities •

3 schools, 1 college, 1 village (800+ girls, 100+ parents) educated thro’ talk & slide show

Assisted “Science Express” project by Vikram Sarabhai Community Science center as Faculty for Teen Age Health Education

Preventive Health projects & Camps •

949 girls vaccinated against Rubella at A’bad

Setting role model college [M P Shah Arts Com Col] where almost all girls vaccinated

CME/ Conference Involvement •

Faculty at Surat OG Soc for CME on Adolescent Gynecology; delivered 2 lectures

SOGOG 2010 at Anand – Guest Lecture

News & Media •

3 live talk show in TV9 [sub: Ca cervix & Vaccine, Birth Control Pills, teen Age Pregnancy]

4 full page coverage in FEMINA being clinician & film maker [Film for youth on “Youth & Safe Sex” – 10min]

Publications • 13

A film [10min] on dealing with HIV+ patient safely – “Be Alert” released at AICOG 2010, Guwahati (Conceived by Dr Riddhi Shukla, Directed by Dr Darshna)


Adolescent Health Committee FOGSI

ADOLESCENCE Adolescence Handle with Care Dr. Mrs. Meera Davar Vice President Family Planning Association of India At the outset, my heartiest Congratulations to the Adolescent Health Committee FOGSI for bringing up the informative news Magazine “Adolescence” which I feel is the need of the hour & the best way to create awareness amongst the gynecologist towards the importance of the sexual reproductive health in the adolescent age group in our country. We at the FPAI would be very happy to associate with the Adolescent Health Committee FOGSI in all their noble endeavors & am very happy that this magazine can make good platform to bring the two organizations to work closer. Friends, we all know that adolescence is a transitional stage of physical and mental human development that occurs between childhood and adulthood. This transition involves certain biological, social and psychological changes that bring tagged along a feeling of uncertainty, insecurity, nervousness and a kind of depression that evolves out of a search for self identity. Pubertal changes taking place in the body that surge hormone production into the blood sometimes leaves the adolescents astonished at themselves and a kind of withdrawal takes place. She becomes a recluse trying to cope up with the hormonal balance/imbalance where she is virtually at the crossroads since she is neither a child nor a fully developed adult. She many times has to face embarrassing situations vis a vis with her own folks, teachers and the peer group as to how she should actually behave. If she acts childish she is admonished that “you are not a child anymore” and if behaves in a matured fashion she is admonished for that too that, “you are still a child and better behave like one”. These controversial statements push her to a seclusion where she is desperately looking for certain answers that elude her. This confusion often is the cause for them to turn to drugs, alcohol or making sexual advances that ultimately result in performing not so well in their schools than their so called “inexperienced” age mates i.e the ones who come to puberty later than the few who develop such symptoms earlier than the rest. Since the early puberants have to behave to show off, they become more confident than the ones who are later puberants. This, inpact is the time when they need lot more care and concern from their parents and teachers who invariably interpret their confusion as indifference and laziness while the adolescents interpret telling again and again as nagging. FPAI a national NGO has a whole set of programmes moduled for the adolescents with a comprehensive inclusion of behavioural, social, psychological and sexual guidelines. Since it is a group that is highly vulnerable due to lack of proper knowledge and understanding of SRH, high instances of gender based violence and sexual abuse including HIV infections are there. FPAI aims primarily at creating awareness amongst them for their sexual and reproductive rights so that they are empowered enough to make use of the informed choices and decisions regarding RSH and SRH and act accordingly. FPAI does so by building partnerships with municipal and government schools to provide SRH education and services to school going adolescents. Developing culture sensitive human sexuality curriculae to be implemented in the schools which is jointly done by the Adolescent Health Committee FOGSI. My best wishes to Dr. Roza Olyai & her team! We at FPAI will look forward to have more of this collaborative projects both at the National & local level where our FPAI branches are functioning.

Need of the Time Cervical Cancer Vaccine Dr. Kawita Bapat MBBS, MS Obst & Infertility Specialist, Indore (M.P.) To creat an awareness for health issues specially at the Adolescent age is the need of todays society at large. Am very happy that the Adolescent Health Committee of FOGSI is doing so through the “Adolescence” Magazine. One such Health issue is creating awareness towards the much talked about Cervical Cancer Vaccine which is available now in India. In India the deadly cancer takes the lives of 8 women in India every hour.WHO estimates that each year over 1.30 lakh Indian women are diagnosed with cervical cancer and over 74,000 die of cervical cancer .Cervical cancer is the most common type of cancer affecting women in India.Worldwide, it was the second-most common cancer after breast cancer. This disease is caused by certain high-risk HPV types that can cause the cells in the lining of the cervix to change from normal to precancerous lesions. If these precancerous lesions are not diagnosed early & treated, they may turn cancerous after a few years. Though there is no known cure for cervical cancer, the recent advances in vaccine technology have made it more or less certain that cervical cancer can be prevented in majority of cases using vaccine.The human papillomavirus, also called HPV, was a common pathogen predominantly affecting women. Approximately 80 per cent of women get one or more types of virus by the age of 50.Reportedly, there are more than 100 types of HPV. Of these, about 15 high-risk types were known to cause virtually all cases of cervical cancer. “Two of these types (16 and 18) are believed to cause 70 per cent of these cases (76.7 per cent in Indian women). The vaccine helps prevent diseases such as cervical cancer; abnormal and precancerous cervical lesions, vaginal lesions, vulvar lesions; and genital warts, caused by these types of HPV. A vaccine that offers protection from the virus responsible for most cases of cervical cancer is the latest addition to the official childhood immunization schedule. The tragedy of cervical cancer is that it often strikes when a woman is still young. She may be trying to raise her family or maybe she hasn't had children yet. The vaccine is recommended for girls ages 11 to 12, although it may be used in girls as young as age 9. This allows a girl's immune system to be activated before she's likely to encounter HPV. Vaccinating at this age also allows for the highest antibody levels. The higher the antibody levels, the greater the protection. At Present there are two types of Vaccines available in India. The cervical cancer vaccine has proved to be remarkably safe. The most common complaint is soreness at the injection site, the upper arm. Low-grade fever or flu-like symptoms also are common. Sometimes dizziness or fainting occurs after the injection, especially in adolescents. However, some serious side effects have been reported, including a severe allergic response (anaphylaxis); neurological conditions, such as paralysis, weakness and brain swelling; and death. The FDA continues to monitor all such reports. They don't appear to be caused by the vaccination itself.Monitoring is ongoing with this vaccine, as with all newer vaccines. The cervical cancer vaccine should be the part of the routine childhood vaccines schedule. This is a really important point that the cervical cancer vaccine isn't intended to replace Pap tests. Routine screening for cervical cancer through regular pelvic exams and Pap tests remains an essential part of a woman's preventive health care. The Adolescent Health Committee FOGSI through their various health projects are sharing this information with all the girls at large. The details of the projects are mentioned in the website which I was able to read & was happy to see the powerpoints carrying this message. Well done & congratulations! 14



Adolescent Health Committee FOGSI