Issue 06 | Pages 20
ADOLESCENCE
Adolescent Health Committee FOGSI
Address for correspondence : Olyai Hospital, Hospital Road, Gwalior- 474009 (MP) India. Phone : (91) -(751)- (2320616) http://adolescenthealthindia.org • http://www.youtube.com/watch?v=NsR0H0ril20
Adolescent Health Committee FOGSI
ADOLESCENCE
Message from
Secretary General's Desk... From the
Past President FOGSI Dr. Nozer Sheriar Secretary General FOGSI 2012 'Whether you think you can, or that you can't, you are usually right.' Henry Ford When I was invited to contribute a message for the Adolescence Newsletter by Dr. Roza Olyai, I was taken back in time to an afternoon in 1998 when Dr. Mehroo Hansotia, Dr. Tank and I were brainstorming possible themes for the FOGSI year 1999 when she was to be FOGSI President. Adopting a focused theme for the FOGSI year was a new concept introduced in 1997. After considering many options, we kept coming back to adolescence - the one time in a woman's life when timed intervention would not only prepare her better for womanhood and motherhood, but empower her with information and confidence to be making the choices she would soon be faced with. FOGSI celebrated 1999 as the FOGSI Year of the Adolescent Girl – Education and Empowerment and the rest is history. After a formal launch at the AICOG in Hyderabad we had the year focused on and dedicated programmes and activities addressing the needs of young girls and women. The logo we created was a pretty pink bud ready to blossom. We had partnerships with the Government, UNICEF and Proctor and Gamble. We conducted a country wide adolescence education programme, published a FOGSI Focus on Adolescence and distributed an elegant poster committing ourselves to working for adolescence. The response was overwhelming. The age specific adolescence education programme with a standard set of AV slides had two targeted presentations – a basic level more focused on menstruation and health issues for students in Standards VI and VII and an advanced level also addressing unwanted pregnancies and their prevention for students in Standards VIII and IX. Self confidence and safeguards against abuse were inculcated at every level. It was a special day for me when I conducted the programme for the Class VI of my own daughter. Through her I received appreciative feedback from a class of very judgmental 11 and 12 year olds. I believe that experience made a great difference to her, her classmates and me. In a timely follow up in 2006, Dr. Duru Shah revisited the theme with the FOGSI Year of the Youth - Making the Majority our Priority. This time in a national drive to address the academic needs of our membership, the FOGSI Youth Express conducted workshops on reproductive health of youth in member societies across India. This with Youth Connect programmes for young people and an initiative formulate guidelines for Youth Friendly Clinics and a pilot project initially independently and later with FPA India kept FOGSI's commitment going. The adolescent health activities of FOGSI have of course been very effectively managed by the Adolescent Health Committee under the stewardship of a series of very dynamic chairpersons. The committee has striven for greater heights under Dr. Roza Olyai with regular publications, advocacy and national and international recognition. As the Website Coordinator, I have seen the great response of netizens to the five issues of the Adolescence Newsletter in our publications section. I wish Roza and the committee my very best and thank them on behalf of FOGSI for doing this very important work so sincerely. As we plan strategically for our federation may be it is time to bring back focus on a few vital issues rather than dealing with a panoramic agenda each year. Our panoramic activities would of course continue through our programmatic backbone – our FOGSI committees. This would allow us to focus on making pregnancy and delivery safer for women in India and the positive benefits of adolescent education and health promotion as near term goals.
Dr. P. C. Mahapatra Professor, Obstetric & Gynecology S.C.B. Medical College, Cuttack Past President, FOGSI Adolescence, a period of transition from childhood to adulthood is by far one of the crucial period in the life of human being and more so in girls. This period of transition undergoes a rapid as well as a radical physical and psychosexual changes. Our organization FOGSI is very much concerned about the Adolescent Health right from the year 1998. The Adolescent Committee of FOGSI under the dynamic leaders has done lot of academic activities, awareness programmes and educational forums for last few years. I must give a special credit to Dr. Roza Olyai, Chairperson of Adolescent Committee and all the members of that committee for their efforts in imbibing a positive thought in this regard. I am sure that this committee will continue to do a lot of activities with special reference to holistic approach in bringing out a transformation in the attitude and behavior of Adolescent Girls in terms of good moral values apart from physical and psychological upliftment so as to have an excellent social reforms in future. Needless to mention that this issue encompassing various practical aspects of Adolescent problems will certainly be beneficial for our members of the Federation. Lastly, I congratulate Dr. Roza Olyai, Chairperson of Adolescent Committee for her commitment, dedication and positive attitude for the benefit of Adolescent girls of India.
(Dr. P. C. Mahapatra)
From the
Vice President's Desk...
Dr. Mandakini Megh Vice President FOGSI 2012 India's 22% of population are Adolescents with health challenges related to this group in particular to under - nutrition, anemia, increased maternal mortality largely owing to early pregnancy & sexually transmitted infections including HIV. Providing healthy, safe and supportive environment to adolescents is imperative to enable this generation contribute significantly to societal growth. India's progress towards achieving the Millennium Development Goals – MDG 4 for reducing child mortality and MDG 5 for improving maternal health requires major efforts. I congratulate Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI for making significant efforts to enhance the accessibility of quality Adolescent friendly Health Services. Dr. Mandakini Megh
Dr. Nozer Sheriar Secretary General FOGSI 2012 1
Vice President FOGSI 2012
From the
From the
President FOGSI 2012
Chairperson's Desk... Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH National Chairperson Adolescent Health Committee FOGSI WHO Consultant Expert Panel ARSH, Geneva Convener Adolescent Friendly Health Centers India Director Olyai Hospital,Gwalior-MP Email: rozaolyai@gmail.com Website: http://adolescenthealthindia.org/ http://www.youtube.com/watch?v=NsR0H0ril20
Dr. P. K. Shah Professor, Dept. of Obstetric & Gynecology Seth G.S.M.C. & K.E.M. Hospital Mumbai. Wishing you all a very Happy & Prosperous New Year. It gives me immense pleasure to write a few words for the Magazine on “Adolescence”. Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood (age of majority), but largely characterized as beginning and ending with the teenage stage. Adolescence is usually accompanied by an increased independence allowed by the parents or legal guardians and less supervision, contrary to the preadolescence stage. Adolescent Health Committee of FOGSI is playing vital role in imprinting knowledge to these Adolescent girls by organizing interactive workshops, seminars at the schools. It is our responsibility to share the feelings of these adolescents and their parents. In the concept of 'Maternal Health' the adolescent age is also included. I must congratulate to Dr. Roza Olyai, Chairperson – Adolescent Health Committee in bringing out the most useful informative and educative Magazine on adolescence. I am sure this Magazine will be a good, useful informative guide to adolescent girls, parents and doctors. I wish Dr. Roza and her team very successful & eventful tenure as Chairperson of the Committee. With regards Yours sincerely,
Dear Friends, It gives me great pleasure to share with you the sixth issue of the news magazine of the Adolescent Health Committee FOGSI. We have received very warm response from our dear readers not only in India but from different parts of the world requesting this magazine to be a regional issue which I hope we could make it in the near future. Am very happy that this year the committee has been awarded the prestigious Dr. Mehroo Dara Hansotia Prize –for the Committee chairperson's Best Activities for the year 2010-11. Our recent publication for the book title “Recent Advances in Adolescent Health” foreworded by Dr. Hamid Rushwan, Chief Executive FIGO, has been awarded the prestigious Dr. D.C. Dutta Prize for FOGSI Best Publication 2011. All this has been possible with your good wishes & support. Young Women's club is a subsidiary club of the Adolescent Friendly Health Centers a National Project of the Adolescent Health Committee FOGSI which will be established in more cities in this year. In this issue we have covered important topics such as the new GDM initiative which Dr. Hema Divakar has under taken by involving our committee, we have also tried to focuss on variety of articles from latest advances in IUD use in Adolescents, Menarche, Eating Disorders, Puberty Menorrhagia to an interesting article on Sex ratio in Hong Kong & other related social issues.
Dr. P. K. Shah President, FOGSI 2012
FOGSI Office Bearers 2011
FOGSI Office Bearers 2012
Dr. P.C. Mahapatra President
Dr. P.K. Shah President
Dr. Nandita Palshetkar Vice President No. 1
Dr. Mandakini Parihar Vice President No. 1
Dr. Milind Shah Vice President No. 2
Dr. Laxmi Shrikhande Vice President No. 2
Dr. Mala Arora Vice President No. 3
Dr. Prashant Acharya Vice President No. 3
Dr. Krishnendu Gupta Vice President No. 4
Dr. Mandakini Megh Vice President No. 4
Dr. Gupte Sanjay Anant Immediate Past President
Dr. P.C. Mahapatra Immediate Past President
Dr. P.K. Shah Secretary General
Dr. Nozer Sheriar Secretary General
Dr. Nozer Sheriar Deputy Secretary General
Dr. Hrishikesh D. Pai Deputy Secretary General
Dr. Hrishikesh D. Pai Treasurer
Dr. Jaideep Tank Treasurer
Dr. Janmejaya Mohapatra Jt. Secretary
Dr. Parikshit D. Tank Jt. Secretary
One of our major project this year is “Challenges for the youth today & tomorrow”. With encouragement & support from Dr.P.K Shah President FOGSI we will be covering more girls in the coming months through various school/ college health talks, sharing with them the informative booklets which our committee has prepared. Sharing information & updating our knowledge from time to time is very important & am glad that through this magazine the Adolescent Health Committee FOGSI is able to achieve this. Am very grateful to Emcure Pharma, specialy Mr. Arun Khanna, the COO of Emcure Pharma for his personal interest in supporting the activities of the Adolescent Health Committee FOGSI & helping to spread the message across the country through this magazine for the betterment of the youth. Your suggestions & feedback will be of great help, kindly share your articles & achievements with us. Do visit our website & share it with the adolescent girls. Wish you all a happy reading!
Dr. Roza Olyai National Chairperson Adolescent Health Committee FOGSI
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Adolescent Health Committee FOGSI
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From the
Vice President's Desk
From the
Vice President's Desk...
Dr. Mandakini Parihar Vice President FOGSI 2012 Dr. Prashant Acharya Vice President FOGSI 2012
“Knowledge rests not upon truth alone, but upon error also.” The adolescence stage is considered one of the most crucial periods in a person's life as it represents the transition from childhood to adulthood. It is a time when important social, economic, biological and psychological events occur and finally pave the way to adult life. There are 225 million adolescent comprising nearly 1/5th of India's total population, 12% belong to 10-14 age group and nearly 10% are in 15-19 age group The pervasiveness of discrimination, lower nutritional status, early marriage, complications during pregnancy and childbirth among adolescents contribute to female mortality in this age group. With increasing urban migration, mobility and media exposure there are concerns particularly for unmarried adolescent, about the consequences of irresponsible sexual behavior such as early child bearing, unsafe abortion and risk of contracting STD such as HIV/AIDS as well as malnutrition and anemia. These factors have serious social, economic and public health implications. This magazine “Adolescence” edited by Dr. Roza Olyai, Chairperson of the Adolescent Health committee of FOGSI has successfully managed to address all these issues and bring about sensitization for special health needs of adolescents. I congratulate Dr. Roza Olyai for bringing out this magazine and for all her work in the field of adolescent health. With warm regards,
Hearty congratulations to the Adolescent Health Committee FOGSI in making "Adolescence" a popular extension amongst the Committee’s numerous and laudable activities. I was very happy to go through the previous issues of the “Adolescence” magazine which is a National FOGSI publication of the Adolescent Health Committee FOGSI under the able leadership of Dr. Roza Olyai Chairperson of the committee. I have observed the activities of this Committee in the past few years & have been impressed by the enthusiasm of the Chairperson & the members of the Committee. Practice oriented workshops were carried out by the Committee, few of which I had also participated in. Looking at the commitments of Adolescent Health Committee of FOGSI in providing holistic approach to health for the adolescents, am sure the future for the youths of our Nation will be bright and in able hands. I wish Dr. Roza a very successful & eventful tenure as Chairperson of the Committee & wish to see that she continues her activities in FOGSI for many more years! With best wishes,
Dr Prashant Acharya Vice President FOGSI 2012
Dr. Mandakini Parihar Vice President FOGSI 2012
From the
Vice President' Desk...
Congratulations... S.S.Rathnam Young Gynecologist Award during AOCOG 2011 Taiwan
Dr. Laxmi Shrikhande Vice President FOGSI 2012 Dear Dr. Roza Olyai, I congratulate you for bringing up adolescent health issues to the forefront of the FOGSI activities. This is the need of the hour today as after all they are the future of this great country. In this regard we also need to equally focus on the boys. We conduct so many school health programmes for girls & I feel that boys are often left behind. I understand we feel awkward to talk to boys but then we can also rope in our pediatrician colleagues for this noble cause to increase area of coverage & awareness. It is time we educate boys about family values, gender discrimination, save girl child campaign apart from the physical & psychological issues about Growing up. FOGSI adolescent health committee is doing commendable work under the able leadership of Dr. Roza Olyai. I wish all her activities to be continued even after she finishes her tenure! 3 cheers to the Adolescent Health Committee FOGSI for all the hard work they are doing since last 4 years. Yours sincerely, Dr. Laxmi Shrikhande 3
Congratulations to both the Executive members of the Adolescent Health Committee FOGSI, Dr. Basab Mukherjee & Dr. Ramaraju. H.E, along with Dr. Manila Jain Kaushal for their achievements.
High Sex ratio at birth in Hong Kong? Dr. KY Leung MBBS, FRCOG, FHKCOG, FHKAM (O&G) Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong President, The Obstetrical & Gynecological Society of Hong Kong The usual sex ratio at birth (SRB) across populations is between 103 and 107 males per 100 females.1 However, imbalance in sex ratio at birth (SRB) was found in many countries, mainly in South and East Asia.2 This imbalance will result, after a few decades, in a large excess of men for whom marriage and parentage is denied, and thus adverse effects on individual psycho- social well-beings, societal stability and security. In a large population study in China involving 4.7 millions people, the SRB was closed to normal to first order birth but was high for second order births, especially in rural area, where it reached 146.3 This study also showed that under-registration of girls was not a major contributor to high SRB. This imbalance was attributed to the practice of sex-selective abortion following prenatal sex identification. The strong socio-cultural preference for sons in China is the likely underlying reason. The relation between SRB and one child policy is complex.3 The highest SRB was observed in provinces that allowed rural inhabitants a second child if the first is a girl, a variant of the one child policy.3 In Hong Kong, the majority of the citizens are Chinese who have received Western as well as Chinese education and culture. While the one-child policy does not apply, is imbalance in SRB found in Hong Kong? In a study on the deliveries in a Hong Kong public hospital from 1996 to 1998, a total of 2604 women of parity 1 and 752 women of parity 2 were analysed.4 Balanced SRB was observed in women having their first and second babies. On the other hand, the parity 2 women with two daughters were significantly more likely to have sons.4 As the biological or parental factors were unlikely to play important roles in affecting the sex of the third child, the authors suggested a possibility of sex selection or sex-selective abortion. A socio-cultural preference for sons was probably an important factor. Besides, a desire for a balanced SRB in a family might be another. This study also showed that the parity 2 women were significantly more likely to have third children if their previous children were of the same sex.4 The finding of this small scale study in one hospital was confirmed by another study of a larger sample size collected in several hospitals from 2003 to 2007.5 Of 194,602 babies studied, 140,962 (72.4%) were Hong Kong Chinese. The SRB (defined as males per 100 females) in Hong Kong Chinese was 106, 107 and 118 for parity 0, parity 1 and parity 2 or above respectively.7 Imbalance SRB was observed in women after having their second children.
On the other hand, in 52,741 Mainland Chinese women studied, the SRB was 105, 115 and 175 for parity 0, parity 1 and parity 2 or above respectively.5 It seems that imbalance in SRB was observed in women after having their first child. Besides, the imbalance in SRB was more severe in Mainland Chinese of parity 2 or above than Hong Kong Chinese (175 vs 118).5 It is interesting to note that the SRB was very high when Mainland Chinese had their third baby in Hong Kong in which the one child policy does not apply. The overall SRB in Hong Kong was a bit high (109), while subgroup analysis showed SRB was 108 for Hong Kong Chinese and 112 for Mainland Chinese.5 The rise of sex ratio in Hong Kong can be partly explained by the influx of Mainland Chinese who may have practiced sex selection more than Hong Kong Chinese. The imbalance will be further increased in the future if there are more cross border deliveries. Sex selective abortion is illegal in China, Hong Kong and many other countries. However, it is difficult to differentiate such abortion from abortion for maternal anxiety. Nowadays, sonographic fetal sex determination by an experienced operator is feasible in most pregnancies, and can be very accurate in cases without malformed external genitalia after 13 weeks gestation. Recently, the use of threedimensional ultrasonography of the genital angle can even determine sex with high sensitivity as early as 11 weeks. Furthermore, the assay of cell-free fetal DNA in maternal plasma by real-time PCR can detect fetal sex as early as the seven weeks gestation. Misuse of these medical technologies will facilitate sex selective activities. In Hong Kong, sex selection is illegal. Even though reporting gender after an obstetric ultrasound examination is not prohibited, high SRB was not observed in Hong Kong women of parity of 0 or 1.4,5 Apart from government policy and law, education to promote gender equality can help reduce SRB. Education can be provided in a family, school or by Government. The people's attitudes towards this issue are very important. Medical professionals should not perform sex selection or sex selective abortion. References 1. James WH. The human sex ratio. Part 1: a review of the literature. Human Biology 1987;59:721-725. 2. Arnold F. The effect of son preference on fertility and family planning: empirical evidence. Popul Bull UN 1987; 23: 44-55. 3. Wei Xing Zhu; Li Lu; Therese Hesketh. China's Excess Males, Sex Selective Abortion, and One Child Policy: Analysis of Data From 2005 National Intercensus Survey. BMJ. 2009;338 (b1211) 4. Wong GY, Leung WC, Chin RK. Recent dramatic increase in the male-to-female sex ratio of babies born in Hong Kong. J Perinat Med. 2010;38:209-213. 5. Wong SF, Ho LC. Sex selection in practice among Hong Kong Chinese. Soc Sci Med. 2001;53: 393-397.
FIGO LOGIC Meet FIGO LOGIC Annual meeting held from 12th to 14th October, 2011 at Hotel Trident Mumbai. Dr. Roza Olyai was invited to talk on the youth projects. FIGO has appreciated the activity of the Adolescent Health Committee FOGSI.
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ADOLESCENCE
Self Awareness and Introspection We must learn to keep our eyes firmly on our own plate and not be concerned with what is on anyone else's plate. Mala Arora FRCOG (UK) Vice President FOGSI 2011 Noble Hospital, Sector 14, Faridabad. All that we are is a result of what we have thought -
Lord Buddha
Life is expressed in three fold ways • Thoughts
• Desires
• Actions
Thoughts are the stepping stones of creation. Thoughts are powerful, as every thought sends out a magnetic energy and attracts more of the same. Thoughts arise just like waves on the mental horizon. If you energize any particular thoughts they become more powerful and will lead to appropriate action and creation. If you refuse to energize your negative thoughts they will die down and subside. So watch your thoughts. Practice the art of Mind Watching. Let only positive thoughts dwell in the garden of your mind. Your thoughts create your feelings. What are right thoughts that should be empowered? • Love is the most powerful thought that should be cultivated and transmitted to every person that comes in contact with you. This includes family members, friends, subordinate staff and patients. Love is an all powerful magnet that will attract all positives towards you. In fact Love is God Himself. To be able to give unconditional Love to everyone is a divine quality.
• Self Pity If we harbor self pity, we always take everything personally and feel sorry for ourselves. When we are wallowing in this emotion we are not open to constructive criticism. Defensiveness is a symptom of self pity. Self justification is the urge to always defend and justify our behavior. Resist the compulsion to explain yourself every time you are confronted with your faults and mistakes. Hold back and introspect, maybe that person is right and is acting as your true friend! • Self Importance Attaching too much importance to our accomplishments is being ego centric. This prevents us from building a team and accomplishing goals. “I did this, I originated that idea” creates false pride. As the saying goes “Pride will always lead to a fall.” Desires are born of powerfully energized thoughts. Desires create mental determination to get fulfilled. It is then imperative to guard your desires most stringently. Right desires will lead to right actions and vice versa. Remember, Desires will certainly culminate in Actions. Actions will shape your destiny. Right actions will help you utilize your energy in a proper manner. They will leave a legacy behind……… Have self-awareness and watch your thoughts, then desires and subsequently actions will automatically fall in place. Self Awareness is the honest realization of your strengths and weaknesses. It is the first and most important building block to renovate your personality. Cultivating the art of Introspection requires determination and a desire to improve. Spending a few minutes each night to mentally go over the day's proceedings and identifying areas where your behavior could have improved is an immensely useful exercise. When similar unfavourable situations arise in the future one is automatically better prepared to handle them with self constraint and without losing calm.
• Friendship is the purest form of God's love because it is born of the heart's free choice and is not imposed upon us by familial instinct. Ideal friends never part; nothing can sever their fraternal relationship. To be a true, unconditional friend, your love must be anchored in God's love. Your life with God is the inspiration behind true divine friendship with all. True friends bring mutual progress to one another.
Lastly for those that strive to achieve perfection, do not be too harsh on yourself and learn to forgive yourself, otherwise you will find Introspection an extremely difficult task. For some others I may say learn to excuse the faults of others just as we always excuse our own faults.
• Forgiveness is a healing and powerful quality for both the errant and the forgiver. It takes tremendous soul strength to forgive. We suffer if we don't forgive because we cannot be at peace. Process of forgiveness begins in the heart first, then the head. Reach out to that person and try to create a sense of peace and harmony with that person. The end result – mutual respect and trust. So learn always to be a peacemaker!
It's not what you gather, but what you scatter that tells what kind of life you have lived!
• Honesty Learn to be honest with yourself first and then with others. Never pretend to have qualities that you do not possess. Mahatma Gandhi in his book “My experiments with truth “confessed that I have all my life beheld one principle of truthfulness. And that made him a true Mahatma!
GOGS Activity Report by Dr. Ratna Kaul president Gwalior Obstetric & Gynecological Society
• Patience You can only acquire patience by exercising it. We are all guilty of becoming impatient especially if we are under pressure, or working for a deadline. This is normal human reaction. However impatience can be a real stumbling block in getting along with others and making progress. • Determination For any progress it is important to have a strong determination to achieve your goal. Without this quality one can start many initiatives but they will never reach fruition as we will not be able to overcome all the stumbling blocks. What then are the negative qualities that we should watch out for? If we are aware of them we can gradually eliminate them from our consciousness, by not energizing these thoughts. • Hatred and Resentment These are tremendously powerful and dangerously corrosive character traits. If there is hatred in your heart for anybody, no matter how justified you feel to harbor it, know that you will be tormented inwardly until you overcome it. So eliminate it from your consciousness. As often as it tries to enter, just throw it out. • Jealousy and Envy They often stem from a deep sense of insecurity. 5
Gwalior Obstetric & Gynecological society under auspices of FOGSI had organized a CME on Maternal Mortality. Dr. Sadhna Gupta Chairperson Safe motherhood committee was the invited faculty speaker. The session was chaired by Dr. Manorama Shrivastava & Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI. Other faculty speakers were Dr. Ratna Kaul, Dr. Hema Shobhne & Dr. Charu Mittal.
Congratulations... AWARDS WON by the Adolescent Health Committee FOGSI 2011
Mehroo Dara Hansotia Prize FOGSI Best Committee Activities Award for the Year 2010-11
Dr. D.C. Dutta Prize : FOGSI Best Publication 2011 Book title “Recent Advances in Adolescent Health” is Foreworded by Dr. Hamid Rushwan, Chief Executive FIGO was released during the AICOG 2011. The Editor of the book is Dr. Roza Olyai & the co-editor is Dr. D.K Dutta. The book is published by Jaypee publishers covers many aspects of ARSH.
Our Heartfelt Thanks to all the Advisors, Committee members, City Coordinators & all those well wishers who were part of the various projects of the Adolescent Health Committee FOGSI. We would also like to thank the Companies for their support towards the various projects of the Committee.
AOCOG 2011 TAIWAN
a true academic feast & the India night a memorable event never to be forgotten!
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Time to Reconsider Intrauterine Contaception for Adolescents
Dr.Tony Tizzano, MD Medical Director - Wooster FHC, Cleveland Clinic Women's Health Center- USA The central goals of contraception are to maximize the number of planned pregnancies while minimizing the number of unplanned pregnancies. Clearly, adolescents are a population at particular risk for unintended pregnancy. Traditionally, few healthcare professionals would consider the use of intrauterine contraception (IUC) for nulliparous women let alone entertain its use in adolescents. Concerns regarding pelvic inflammatory disease (PID), sexually transmitted infections (STI's), infertility, and difficult insertion have limited consideration of IUCs in this population. However, a new generation of these devices has been quietly gaining momentum for use in adolescents, fueled in part by an ACOG panel of experts who concluded that both nulliparous and parous adolescents are appropriate candidates for intrauterine contraception. Similarly, the World Health Organization advocates the use of IUC in women from menarche to 20 years, stating that the benefits of IUC generally outweigh the actual and theoretical risks. Intrauterine contraception in particular, when compared with other classes of reversible contraception, offers adolescents safe, long-term, cost-effective, highly reliable and effective birth control. Historically, the use of IUC in adolescents has been plagued by misperceptions. Use of these devices does not increase the adolescent's risk for PID and STIs. Past experiences with the Dalkon Shield have served to popularize and perpetuate this myth. It now appears that these alleged risks were attributable to bias, methodologic errors, inappropriate comparison groups, over diagnosis of salpingitis, and inability to control for the effects of sexual behavior. On the contrary, the risk of PID rises above baseline only at the time of insertion. Accordingly, within the first 20 days the risk of PID was 9.7 per 1,000 women years; from 21days to 8 years, the incidence of PID was 1.4 per 1,000 women years, the same as that found in the general population. Case reports reveal that women with positive Chlamydia cultures recognized at the time of intrauterine contraceptive device (IUCD) insertion are unlikely to develop PID if the infection is treated with the IUCD retained. Moreover, several studies suggest that the use of the LNG-IUS may actually reduce the risk of PID by thickening the cervical mucous and thinning the endometrium. Only nine cases of infection with group A. Streptococcus have been reported in 9.9 million LNG-IUS users, constituting a risk of approximately one infection for every one million users.Accordingly, prophylactic antibiotics at the time of insertion are neither advised nor necessary. However, considering the increased prevalence of Chlamydia tracomatis and gonococcal infections in adolescent women The use of IUCs in adolescents does not adversely affect fertility when compared with other methods of reversible contraception. The presence of chlamydial antibodies was associated with infertility in both users and nonusers of IUCDs as demonstrated in a case-control study.Upon removal, fecundity rates rapidly return to normal. Discontinuation of all contraceptive methods is more problematic among adolescents than adult women. Whenever possible, products such as IUCs, with their extended dosing intervals can enhance compliance and reduce contraceptive failures associated with typical use. Spontaneous expulsion does contribute to failure with a risk of 1 in 20. Thus, women with a history of prior expulsion and those of younger age are at somewhat increased risk. Nonetheless, a history of prior expulsion should not negate consideration for a new IUCD provided that patients are given appropriate counseling including selfexamination to confirm the presence of strings and close follow-up.
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Adolescent Health Committee FOGSI
ADOLESCENCE Emergency contraception (EC) is popular among adolescents. The copper IUD confers powerful protection against pregnancy provided that it is inserted within 5 days of unprotected intercourse. Additional benefit was had as copper IUDs inserted for EC were maintained for long-term contraception in 86% of parous women and 80% of nulliparous women. The LNG-IUS should not be used for this purpose. Subsequent to abortion and immediately after child-birth, women are highly motivated to consider and initiate effective contraception. Immediate initiation of an IUCD postpartum or post abortion is safe and effective for adolescents. Although, spontaneous expulsion may be increased when compared to remote insertion, the advantages of enhanced motivation, convenience, and comfort during insertion are worthwhile /considerable benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS), in addition to providing excellent contraception and potentially lowering the risk for PID, reduces menstrual blood loss by 75% at three months and ultimately results in amenorrhea in a significant number of women. It is more effective than oral progestins in controlling excessive uterine bleeding. This may be of added value in populations where anemia is common and to reduce the occasion for surgical approaches to these problems. Finally, the LNG-IUC has been shown, in two randomized controlled trials (RCT), to favorably address pain associated with endometriosis compared with watchful waiting post laparoscopic ablation and when comparable to the use of leuprolide acetate for same. Consideration of IUCDs for adolescents and nulliparous women deserves special consideration with respect to counseling and manner of insertion. Ideally, a cycling women should have her IUCD inserted during the first 7 days of menses. Placement in nulliparous women may be enhanced by pretreating her with misoprostol approximately one or two hours beforehand. Providing gentle traction with a tenaculum facilitates insertion as it serves to stabilize the cervix and to straighten the cervical-uterine axis. Careful uterine sounding is needed to evaluate the uterine cavity to identify any significant distortion of the cavity and to ensure appropriate uterine size. Uterine perforation is rare and is minimized by waiting a minimum of ten seconds for the arms of the device to fully extend within the uterine cavity before advancing the device to the fundus. Fundal placement minimizes the potential for migration and insures that the tail strings will be sufficiently long to remove the device regardless of where it settles. LNG-IUSs placed within the lower uterine segment remain effective and require removal only when a portion protrudes from the cervix or when the women experiences excessive cramping. Findings from the 1995 National Survey of Family Growth (NSFG) indicate that the risk of contraceptive failure among oral contraceptive (OC) users less than 20 years of age is 55% greater than it is among users 20 to 24 years of age. Furthermore, adolescent OC users reported difficulty remembering to take the pill every day and continuation rates are low, ranging from 9% to 12% in large urban clinics to 34% in one case-control analysis. The LNG-IUS is highly effective and is associated with important noncontraceptive benefits. It is comparable to the copper IUD in terms of efficacy and tolerability. It is FDA-approved for 5 years of use, with a cumulative 5-year failure rate of 0.7 for every 100 women and with one small study demonstrating potential efficacy for up to 7 years, with a 1.1% pregnancy rate. The progestin component conveys additional benefits, including a reduction in menstrual bleeding, and dysmenorrhea, treatment of endometriosis, and protection against PID. Although irregular spotting, primarily in the first 3-6 months, is reported approximately 20% of users will become amenorrheic by 12 months of use, an effect that is highly desirable for many, but may be troubling to some. Clearly, with increasing prevalence of adolescent pregnancy and and growing interest in long-acting reversible contraception world-wide, it is time to set aside our unfounded historical conventions and reconsider intrauterine contraception for adolescents and nulliparas as a safe and effective method of choice.
South Zone Yuva FOGSI - Chennai Paper presentation & guest lectures on Adolescent Sexual Reproductive Health by Dr. Jayam Kannan & Dr. Roza Olyai
West Zone Yuva FOGSI - Ahmedabad Dr. Roza Olyai chairperson Adolescent Health Committee FOGSI & Dr. Ajay Mane City coordinator Challenges for youth project were the invited faculty speakers for the session on Adolescent health issues.
North Zone Yuva FOGSI - Raipur The Adolescent Health Committee was invited for conducting a panel discussion on: PROBLEMS AT PUBERTY. The panel was moderated by Dr. Charu Mittal and Panelists were Dr. Gurpreet Kaur, Dr. Sunita Kanoi, Dr. Sarita Agrawal, Dr. Neelam Agarwal, Dr. Meena Armo
Conferences & Events to remember...
International Conference on Preventing Pregnancy Wastage at The Hilton Hotel New Delhi. Organized by Dr. Mala Arora Vice President FOGSI. Panel discussion moderated by Dr. V.P. Paily on Preterm birth, panelists were : Dr. Gita Arjun, Dr. Roza Olyai, Dr. Kanwal Gujral, Dr. R. Gupta, Dr. Ashwat, Dr.Usha Gupta
8
Puberty Menorrhagia Dr. Reena J Wani (MD, MRCOG, FICOG, DNBE, DFP, DGO, FCPS) Assoc Professor, I/C Family Welfare Program TNMC & BYLNair Ch. Hospital, Mumbai Executive Member, Adolescent Health Committee, FOGSI Menarche is an important event during adolescence, and usually marks completion of puberty and the onset of reproductive capability and occurs when both breast and pubic hair development are at Tanner stage 4. Menstrual problems are common during adolescence due to slow maturation of the hypothalamic-pituitary-ovarian axis and can last 2 to 5 years after menarche. Although most problems are explained by anovulation, other causes must be considered and excluded in a logical and cost-effective manner.(1) Normal and Abnormal menses Girls are experiencing earlier pubertal development than previously, hence guidelines for the evaluation of potentially pathologic precocious puberty need reassessment. There are racial differences in pubertal development, and most menstrual cycles for adolescents are between approximately 20 and 45 days. We should evaluate adolescents with bleeding that is either too frequent or too infrequent. Attention to pubertal development and menstrual health is an important aspect of primary care for adolescents. Chaotically irregular and unpredictable bleeding is NOT the norm during adolescence. On the contrary, although many early menstrual cycles are anovulatory, most adolescents have menstrual cycles that fall within the parameters of 21-45 days. Adolescents with menstrual bleeding that is less frequent than every 45 days, is prolonged more than 7 days, or is excessively heavy should be evaluated in order to detect conditions such as eating disorders, polycystic ovary syndrome, and von Willebrand disease.(2) Puberty Menorrhagia Menorrhagia is defined as blood loss of 80 ml or more per cycle but quantification of menstrual blood loss is difficult, except in research settings. Hence a subjective complaint of heavy menstrual periods persisting over several cycles, occurring at regular intervals, often with clots, leads to the clinical diagnosis. Young girls may not be able to give proper history without specific questioning, and may present with severe anemia or a prolonged bleeding episode. Evaluation of puberty menorrhagia • Detailed History about bleeding patterns, precipitating factors, associated symptoms, coital and contraceptive history if sexually active, medical history including drug intake and history of a bleeding disorder, family history • Age group is relevant as various possible causes can be stratified according to age. • Physical Examination including signs of chronic anemia, bleeding diathesis (bruising, capillary haemorrhages, hematomas), systemic diseases especially tuberculosis • Tanner's staging of breast and hair development • Pelvic examination may not be possible if the girl is not sexually active. • Basic Lab tests - Hemoglobin estimation - Pregnancy test to rule out pregnancy-related causes if sexually active - Tests for coagulation (abnormality maybe seen in upto 30%) - Other tests as indicated (e.g. thyroid function, blood sugars ) • Ultrasonography although not indicated in all: done on full bladder usually (Transabdominal) but Transvaginal ultrasound (TVS) can distinguish better between structural lesions and assess endometrial thickness • Endometrial sampling or hysteroscopy although often done for persistent abnormal uterine bleeding above age 35 years is NOT usually needed. It may be useful in some cases as indicated (polyp, 9
Adolescent Health Committee FOGSI
ADOLESCENCE hyperplasia) and may be considered in younger patients with risk factors ( chronic anovulation- as in PCOS, obesity, family history of endometrial, breast, colon or ovarian cancer) Medical Treatment (3) • Acute severe episode: if the patient is hemodynamically unstable should be first treated with IV line, fluid replacement, blood transfusion, oxygen etc. For control of bleeding they may respond best to estrogen therapy. Progesterone may not be as effective, but is good for long-term control Dilatation and Curettage is the quickest way to arrest bleeding except in cases of puberty menorrhagia where medical management is preferred. IV Tranexamic acid can be tried before resorting to surgical intervention. • Cyclical heavy bleeding: Several drugs have been demonstrated to decrease menstrual bleeding in patients with menorrhagia. Non-steroidal antiinflammatory drugs (e.g. mefenamic acid)will decrease bleeding by 30% to 50%. Oral contraceptives may be useful to stop acute bleeding and will decrease menstrual flow by approximately 50%. Tranexamic acid, a plasminogen inhibitor approved for the treatment of hemophilia, will also decrease flow by approximately 50%. (4) Other agents used in older women are NOT commonly used, such as - Conventional hormones - Ovulation inducing drugs - Danazol - Gn RH Analogue - Testosterone Less severe bleeding (hemodynamically stable patient) High dose Progestogen: Norethisterone 10 mg 3 times a day until bleeding stops (not >3 days) followed by Norethisterone 5-10 mg. OR Medroxyprogesterone acetate 10 mg per day for 21 days. Withdrawal bleeding occurs after 2-4 days of stopping the drug and stops in 4-5 days. OR Combined oral contraceptive pills (OCs) containing 50 mcg ethinyl oestradiol 1 pill 2 times a day for 7-10 days followed by progestins for 7-10 days, followed by withdrawal bleeding. Other Aspects of Care : • Treatment of anemia Oral iron supplementation is the ideal way but only about 2-3 mg of elemental iron is absorbed, even when 50 or 100 mg are presented to the gut lumen. Replenishing a 1000 mg iron deficit may take most of a year, hence there is a role of parenteral iron supplementation to replenish the stores quickly. • Treatment of adolescent PCOS with menorrhagia: - Weight loss and exercise is a cornerstone of treatment - Healthy approach to eating - COC or progestin to reduce testosterone levels and regulate the menstrual cycle - Insulin-sensitizing agents such as metformin - Antiandrogens as indicated - Topical treatment for acne and excess facial hair Preventive care ACOG has recommended that the initial visit to a gynecologist for health guidance, screening, and provision of preventive services should take place around age 13-15 to provide guidance to young girls and their parents on adolescent physical development, and address menstrual hygiene and emerging adolescent concerns. (4) Timely assessment and supervision will reduce problems of puberty menorrhagia. References 1. Quint EH, Smith YR. Abnormal uterine bleeding in adolescents. J Midwifery Womens Health. 2003 May-Jun;48(3):186-91. 2. Adams Hillard PJ. Adolescent menstrual health. Pediatr Endocrinol Rev. 2006 Jan;3 Suppl 1:138-45. 3. Robins JC. Therapies for the treatment of abnormal uterine bleeding. Curr Womens Health Rep. 2001 Dec;1(3):196-201. 4. Adams Hillard PJ. Menstruation in adolescents: what's normal, what's not.Ann N Y Acad Sci. 2008;1135:29-35.
“Remove the Bitterness from The Sweet Disease - Prevent Diabetes!�
Dr. Hema Divakar Hon secretory ICOG President Elect FOGSI 2013 Dear FOGSIAN'S, Wake up !!!!!
pre diabetic risk factors of PCOS and Obesity - with an emphasis on the need to change the Life Style.
It is common for us to say -
(2)
wake up - you are late for school Wake up - you are late for work Wake up - you will miss your flight NOW ........
GDM - Screening and Diagnosis GDM - principles in Manaement Impact on Generation Next and long term complications. (3)
We give a wake up call to ALL @ FOGSI Wake up to save generation next !!! It is a call for ACTION! Some new developments in our field have driven us to think that the target group for action is the ADOLESCENTS ! The concept of fetal programming in utero, the thoughts on genetic and epigenetic predisposition, the burning issues of deficiency states in childhood, the concerns about long term problems...have changed our vision about how to save the generation next. We recognise that, if not nipped in the bud, there could be a Tsunami of many disease processes in he generations to come. In order to address the youth health - Uth Healthcare, Emcure's group company, launched an initiative -SINGLE STEP to STOP DIABETES under project G-75 on Saturday, the 24th of december in Pune, where the core group of experts met to discuss the following important topics:
The clear the misconceptions in the areas of:
Scope for RESEARCH on:
Use of oral hypoglycaemics - safety and efficacy and enhanced scope for feasibility for use in rural India was discussed. If we dream of reducing the burden of young diabetics in India, this meeting presided by Dr Sanjay Gupte and myself, provided the crucial blue print ! We recognise that it is not only important to have a dream but also need to have a plan. All the committed core group members PLANNED THE WORK-we now need to WORK THE PLAN ! Hence the CALL for ACTION ! It is a Single Step - but the most Crucial one. I am very optimistic that with the help of EMCURE Uth Health and all FOGSIANs , our efforts will translate into benefits for generations to come. Wishing you all Happy 2012 and welcoming you to join us in our efforts to create healthy future generations!
(1) A number of CMEs titled "Save the Generation Next"under FOGSI- ICOG banner Which would revolve around the prevention of
Glimpses of the GDM Core Group Meet, Pune...
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Adolescent Health Committee FOGSI
Menarche – The ever increasing “little women� Professor Ajay Rane MBBS MSc MD FRCS FRCOG FRANZCOG CU FICOG (Hon) Professor and Head, Obs & Gyn, Consultant Urogynaecologist, James Cook University, Townsville, Queensland, Australia Hon. Treasurer and Board Member, RANZCOG The menarche, more commonly known as a female's first menstrual period, or the onset of menses, signifies the commencement of a female's reproductive life. The onset of the menarche has associated cultural and social implications that vary internationally and with ethnicity. Traditionally it has been recognized that the menarche occurs around the age of 12-13 years however can vary from 11-15 years. Several studies conducted over the last three decade have identified a secular trend in the age of onset of the menarche, with the age lowering, raising questions regarding the reason for this trend and the associated implications of an earlier age of menarche. Why is the age of onset of the menarche lowering? Various studies have been conducted to look at possible determinants such as environmental factors, hormones, childhood obesity and genetics. It has been established that adiposity is an important regulating factor in the onset of menses, with a minimum body mass index (BMI) required for the onset of menarche to occur. Furthermore, it has been highlighted that if the BMI is greater than the minimum such as in childhood obesity, it is associated with both early puberty and earlier age of menarche. 1, 2 A review of available literature on international variability of ages at menarche and associated determinants by Thomas et al concluded that there is significant evidence to support the concept that good nutrition and a high energy intake with a high vegetable calorie consumption results in earlier age of menarche. Furthermore, there was evidence to suggest that excessive childhood physical exercise and stress, such as child labour and poor nutrition as experienced in developing nations, delay the age of menarche. This data also further supports the data surrounding international variability of age of menarche, with data highlighting the age of menarche is lowering in developed countries.3 The precise role of genetics and the age of menarche remains relatively unknown despite numerous international genome trials. A longitudinal study examined data collected over a 74year period to determine the heritability of the age of menarche. The study results supported that of other studies concluding that the age of menarche is due to genetic factors, with half of phenotypic variation in girls with regards to age of menarche being genetically linked.4 The largest and most promising of these genome trials demonstrated that there is a relationship between early age of menarche and chromosome 12q. The role of IGFI gene was observed to have some relationship to age of menarche, however it was concluded that further genome trials are required to further explore this role.5 There have been other genes thought to be associated with age of menarche isolated including Lin28B and Era genes.6 A large trial conducted in the United Kingdom studied the age of menarche of 81,606 volunteers via a questionnaire. The study observed that an early age of menarche occurred in women who were singletons, had pre-natal exposure to cigarette smoke, were not breastfed and were not Caucasian. These results support earlier trials that identified associations with breastfeeding and a later age of menarche and the effect of prenatal cigarette smoke exposure in early menarche.7 The role of plastics and hormone treated meats and their relationship with the age of menarche remains an area of question, with the only clinical trials and studies to explore this theory during the 1970's proving inconclusive. The role of the family structure and psychosocial stresses on the age of menarche has also been well studied. Young women who grow and mature in an environment in which their biological father is absent are known to undergo menarche at an earlier age. The presence of both a half or step brother is also linked with an earlier age of menarche whilst girls who grow up with the presence of older sisters undergo a 11
ADOLESCENCE
delayed menarche. Studies have further demonstrated that young women who are raised by stepfathers and or who are exposed to stressful family environments undergo menarche at an earlier age than those in other altered family structures.6,8 These results have been supported by the psychosocial acceleration theory suggests that children who a raised in a stressful family environment with the absence of a biological father, family conflict and unstable parental relationships develop an internalizing disorder that results in slowed metabolism, weight gain and early menarche. Furthermore the Paternal investment theory suggests that the reproductive developmental pathway is sensitive to the paternal family and parenting role, thus young women who are raised in an environment without a paternal figure, especially biological paternal figure, experiencing earlier age of menarche.8 Furthermore, these studies have proven there is an association between these two theories and teenage pregnancies.8 What are the implications of an earlier age of menarche? It has been established that early age of menarche (defined as <12 years) is associated with increased risk of uterine and breast cancer. Furthermore, research has shown that earlier age of menarche predisposes to increased body mass index, insulin resistance and in turn an increased risk of developing metabolic syndrome.6 It has been hypothesized that this increased risk of breast cancer in young women who undergo early menarche, is associated with excess abdominal adiposity therefore resulting in higher levels of testosterone and insulin like growth factors, generating mammary tissue proliferation, and possibly resulting in carcinogenesis. A large population based prospective trial conducted in the United Kingdom aimed to determine the relationship between early menarche and cardiovascular disease and mortality. 12,807 women were included in the study and followed by for a median of 12 years. The study concluded that early menarche was associated with increased risk of cardiovascular disease and mortality.9 Lakshman et al further identified that there was a 4% reduced risk of mortality for each year of delayed menarche, which is supported by two other large similar trials.9 Early menarche can also have a damaging effect on the self-esteem of young women, resulting in negative self thoughts and the feeling of being ostracized for being different, placing young women at increased risk of developing adolescent depression.6 The onset of puberty and the age of menarche appears to regulated by a variety of confounding factors, including genetic influences and environment factors such as diet, lifestyle, socioeconomic status, weight, pre-natal exposures and family environment. It has been well documented internationally that the age of menarche is lowering, however the next question is how much lower will it go and how do we prevent this? With the implications of an earlier age of menarche being the focus of recent trials, it is becoming apparent that the implications are serious. Further studies on the genetic factors implicated in the earlier age of menarche as well as the implications of an earlier age of menarche need to be further evaluated in order to determine whether medical management and public health interventions will be beneficial and how such strategies will be developed. Bibliography 1. Sloboda DM, Hart R, Doherty DA, Pennell CE, Hickey M. Age at Menarche: Influences of prenatal and postnatal growth. J Clin Endocrinol Metab. 2007; 92:46-50 2. Ong KK, Emmett P, Northstone K, Golding J, Rogers I, Ness AR, Wells JC, Dunger DB. Infancy weight gain predicts childhood body fat and age at menarche in girls. J Clin Endocrinol Metab. 2009;94:15271532 3. Thomas F, Renaud F, Benefic E, Meeus T, Guegian JF. International variability of ages at menarche and menopause: patterns and main determinants. Human Biology. 2011;73(2): 271-290 4. Towne B, Czerwinski SA, Demerath EW, Blangero J, Roche AF, Siervogel RM. Heretibility of age at menarche in girls from the Fels longitudinal study. Am J Phys Anthropol. 2005; 128:210-219 5. Anderson CA, Zhu G, Falchi M, Van den Berg SM, Trloar SA, Spector TD, Martin NG, Boomsma DI, Visscher PM, Montgomery GW. A genoma wide linkage scan for age at menarche in three populations of
European descent. J Clin Endocrinol Metab. 2008; 93:3965-3970 6. Karapanou O, Papadimitriou A. Determinants of menarche. Reproductive Biology and Endocrinology. 2010; 8:115 7. Morris DH, Jones ME, Schoemaker MJ, Ashworth A, Swerdlow AJ. Determinants of age at menarche in the United Kingdom: analyses from the breakthrough generations study. Br J Cancer. 2010;103(11):1760-4 8. Mendle J, Turheimer E, D'Onofrio BM, Lynch SK, Emery RE, Martin NG, Slutske WS. Family structure and age at menarche: a children of twins approach. 2006. Developmental Psychology; 42(3): 533-542
9. Lakshman R, Forouhi NG, Sharp SJ, Luben R, Bingham SA, Khaw KT, Wareham NJ, Ong KK. Early age at menarche associated with cardiovascular disease and mortality. J Clin Endocrinol Metab. 2009;94:4953-4960
Acknowledgement: Jessica Eltherington1, Dr Jay Iyer2 MD DNB MRCOG FRANZCOG 1 Year 6 Medical Student, 2Senior Lecturer James Cook University Townsville, Queensland, Australia
â&#x20AC;&#x153;Challenges for Youth Today & Tomorrowâ&#x20AC;? Kanpur, Uttar Pradesh
Patna, Bihar
Report by city co-ordinator Dr. Kiran Pandey HOD of OBGY, Kanpur Medical College
Report by Dr Tripti Sinha city coordinator at Kendriya Vidyalaya, Bailey road, Patna Bihar under the Challenges for youth project.
Jalandhar, Punjab A report by Dr. Sushma Chawla, Jalandhar conducted number of school health programs.
Panaji, Goa
Faridabad, Haryana
Dr. Subodh Kansar conducted the school programme.
Report by : Dr Punita Hasija, City Coordinator and Dr. Neeta Dhabai, North Zone Coordinator in the Manav Rachna International University.
Surat, Gujarat 3 schools covered, one TV talk show, 800 girls/boys attended, Dr. usha Valadra and Dr. Kamlesh Parekh conducted the programme
12
Adolescent Health Committee FOGSI
ADOLESCENCE
Eating Disorders in Teens-Catch Them Early! Dr. Krishna Kavita Ramavath MD, FICOG 2805, Veronia Dr, #103, PalmBeach Gardens Florida, USA 33410 There is very limited data available on the Nutritional situation and Eating disorders in adolescents in general. There are no prevalence or co-morbidity studies on eating disorders in India. This article makes an effort to bring out the importance of dietary intake in adolescents and the most common eating disorders in teens. Serious disturbances in everyday diet can affect young people for a number of immediate health problems such as iron deficiency, under nutrition, stunting. This may also affect concentration, learning and school performance in school going adolescents. Adolescents must be adequately nourished to ensure their growth and development progresses normally. Eating Disorders-Age of appearance Eating disorders typically are first diagnosed between 10 to 19 years of age, with Anorexia Nervosa generally appearing at 13 to 17, and Bulimia tending to emerge between15 to 19.
The following symptoms may develop over time, • Thinning of the bones (osteopenia or osteoporosis) • Brittle hair and nails • Dry and yellowish skin • Growth of fine hair all over the body (lanugo) • Mild anemia and muscle wasting and weakness • Severe constipation • Low blood pressure, slowed breathing and pulse • Damage to the structure and function of the heart • Brain damage
Parents frequently do not know how to identify anorexia nervosa and bulimia in their children as many teenagers hide these serious and sometimes fatal disorders from their families and friends.
• Multi-organ failure
American Academy of child and Adolescent Psychiatry states about the unique Symptoms and warning signs of anorexia nervosa and bulimia as the following:
• Lethargy, sluggishness, or feeling tired all the time • Infertility.
• A teenager with anorexia nervosa is typically a perfectionist and a high achiever in school. At the same time, she suffers from low selfesteem, irrationally believing she is fat regardless of how thin she becomes. In a relentless pursuit to be thin, the girl starves herself. This often reaches the point of serious damage to the body, and in a small number of cases may lead to death.
Bulimia nervosa is recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This is followed by forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors.
• The bulimia patient binges on huge quantities of high-caloric food and/or purges her body of dreaded calories by self-induced vomiting and often by using laxatives. These binges may alternate with severe diets, resulting in dramatic weight fluctuations. The purging of bulimia presents a serious threat to the patient's physical health, including dehydration, hormonal imbalance, the depletion of important minerals, and damage to vital organs. Research shows that early identification and treatment leads to more favorable outcomes. Parents who notice symptoms of anorexia or bulimia in their teenagers should ask their family physician or pediatrician for a referral to a child and adolescent psychiatrist. To catch these disorders early helps to bring a timely change in their life.
• Drop in internal body temperature, causing a person to feel cold all the time
Bulimia nervosa
Unlike anorexia nervosa, people with bulimia nervosa usually maintain healthy or normal weight, while some are slightly overweight. They often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly because it is often accompanied by feelings of disgust or shame. The binge-eating and purging cycle happens anywhere from several times a week to many times a day. Other symptoms include: • Chronically inflamed and sore throat • Swollen salivary glands
Anorexia nervosa
• Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to stomach acid
Characterized by
• Acid reflux disorder
• Extreme thinness (emaciation)
• Intestinal distress from laxative abuse
• A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
• Severe dehydration from purging of fluids • Electrolyte imbalance.
• Intense fear of gaining weight
Binge-eating disorder
• Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight
Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with bingeeating disorder often are over-weight or obese. People with bingeeating disorder who are obese are at higher risk for developing cardiovascular disease and high blood pressure. They also experience guilt, shame, and distress about their binge-eating, which can lead to more binge-eating.
• Lack of menstruation among girls and women • Extremely restricted eating. Many people with anorexia nervosa see themselves as overweight, even when they are clearly underweight. Eating, food, and weight control become obsessions. People with anorexia nervosa typically weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia 13
nervosa may also engage in binge-eating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas.
Treatment of Eating Disorders: With comprehensive treatment, most teenagers can be relieved of the symptoms or helped to control eating disorders.
Recommended approach to established or moderated eating disorders includes a team approach; including individual therapy, family therapy and working with primary care physician. Specialists in adolescent medicine, nutrition, psychiatry, and psychology each have a role in the treatment. The first step is to establish a structure to daily activities that ensures adequate caloric intake and limits expenditure of calories. The daily structure should include eating three meals a day, increasing caloric intake, and possibly limiting physical activity. It is important that the patients and parents receive ongoing medical, nutritional, and mental health counseling throughout the treatment. The emphasis of the team approach helps the children and the parents realize that they are not alone in their struggle. Hospitalization, should only be suggested if the child has severe malnutrition, dehydration, electrolyte disturbances, ECG abnormalities, physiologic instability, arrested growth and development, acute food refusal, uncontrollable binging and purging, acute medical complications of malnutrition, acute psychiatric emergencies, and comorbid diagnosis that interferes with the treatment of the eating disorder. Prevention Eating disorders arise from a variety of physical, emotional, social, and familial issues, all of which need to be addressed for effective prevention and treatment. Prevention should be directed not only at eating disorders or obesity. A positive approach emphasizing the benefits of healthy eating and physical activity should be taken up as a team approach by both professionals and parents at home. Research now shows that parents have an essential role in helping their teenager restore weight, as the first step toward recovery.
Leptin, a hormone secreted by fat cells, seems to play a role in Anorexia Nervosa.People with Anorexia or low weight have low serum leptin, consistent with their reduced mass of fat tissue, which increases with weight gain Neuro imaging studies : The most promising technique is functional magnetic resonance imaging (fMRI), which localizes brain activity in anatomically distinct areas of the brain, including activity associated with specific neurotransmitters, such as serotonin. The neurotransmitter serotonin is known to affect appetite control, sexual and social behavior, stress responses, and mood. The major serotonin metabolite, 5-hydroxyindoleacetic acid, is low in people who are underweight with Anorexia. Psychotherapy goals include primary prevention plus early recognition and treatment to prevent long-term sequelae. In the multi-disciplinary management of these adolescents, parents play a major role by helping their kids cultivate healthy attitudes toward food, body and weight by striving to be positive role models for them and avoiding negative messages about food and body image.
Report by Dr. Durga Shankar Dash East Zone Coordinator Adolescent Health Committee
Further Research Researchers find that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. One approach involves the study of human genes. Familial transmission of risk has emerged as an increasing focus of research attention. Multiple case-control studies demonstrate a higher rate of Anorexia and Bulimia in relatives of probands with Anorexia Nervosa.
Having regular health talks, involving many Gynecologists in school/ college health projects, sensitising the youths on ARSH with his creative new ideas in Cuttack Orissa.
“Youth Express South Zone” A report by Dr. Jayam Kannan South Zone Coordinator Adolescent Health Committee FOGSI South Zone launching “Youth Express South Zone” in Nagercoil, Trichy, Madurai, Chennai, Bellari, Coimbator & other cities in South with help of the city. coordinators : Dr. Uma Selvan, Dr. T. Ramani Devi, Dr. Sampath Kumari, Dr. Dilshath, Dr. Chandrakala, Dr. Ramaraju & many others.
Report by Chandrakala Magudapathi, City Coordinator Coimbatore
A joint program was organized by GKNM hospital & Coimbatore OBGY society, at Nirmala college for women involving 1200 adolescent girls along with 30 members of their staff team and their principal. Other guest speakers were COGS president Dr. Banumathy & Dr. Jeeshia.
Report by Ajay Mane, City Coordinator, Aurangabad
Conducted various health talks on challenges for youth project in Aurangabad. 14
Adolescent Health Committee FOGSI
ADOLESCENCE Bangaluru, Karnatka Inauguration of ToT at Bangaluru, Karnatka State for establishing Adolescent Friendly Health Centers with FIGO & FOGSI representatives 2011.
ToT at Bangaluru, Karnatka State for establishing Adolescent Friendly Health Centers. Dr. Roza Olyai, Dr. Jayam Kannan, Dr. Chandrakala were the Trainers.
Ahmedabad, Gujarat ToT at Ahmedabad- Gujarat State for establishing Adolescent Friendly Health Centers. Dr. Roza Olyai, Dr. Darshana Thakker were the trainers.
Navi Mumbai - Maharashtra ToT at Navi Mumbai for Establishing Adolescent Friendly Health Centers. Dr. Roza Olyai & Dr. Anu Vij were the trainers.
15
Max Hospital - New Delhi ToT at Max Hospital -Saket New Delhi for Establishing Adolescent Friendly Health Centers in Delhi on 30th Oct. Dr. Roza Olyai & Dr. Anuradha Kapur were the trainers.
“Young Women's Club” Young Women’s Club inaugurated by Dr. Roza Olyai Chairperson Adolescent Health committee FOGSI on 30th Oct. 2011 at Max Hospital -Saket Delhi as a subsidiary club of the Adolescent Health Center, National Project of the Adolescent Health Committee FOGSI. Aims & Objectives • To spread awareness amongst the Adolescents, youths & young women about the need to look after themselves & to empower them. • To select Adolescents who are more prone to problems related to puberty e.g Obesity, diabetes, drug abuse, breast problems, Bleeding disorder, Hirsutism, Psychological problems etc.
• To educate and eradicate Myths about Puberty & growing up period. • To maintain health record for all these young women and examine them from time to time for management. • For further information please feel free to contact Dr. Roza Olyai, National coordinator Young Women’s Club.
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“Challenges for Youth Today & Tomorrow”
Adolescent Health Committee FOGSI
ADOLESCENCE
Project of the Year In 2011 we had a great learning experience as we were able to cover more than 20 states in India, about 100 local FOGSI societies & in each city having more than 20 talk session in schools/ colleges, covering about 3,00,000 girls with their mothers. Booklets were distributed amongst the girls following a powerpoint presentation health talk by selected gynecologists covering different aspects of health; Physical, Mental, Social & Spiritual.
West Zone
North Zone
Central Zone
East Zone
South Zone
We had Training of Trainers in 5 Zones: North, East, Central, West & South, involving 20 doctors who were are city coordinators from each zone from various FOGSI societies. We want to specially thank our Zonal Coordinators & all the doctors who were part of this project making it a great success. Our heartfelt thanks to Emcure Pharma specially Mr.Arun Khanna COO Emcure Pharma for his constant encouragement & support, Mr. Anoop Sood for his excellent coordination, Ms. Charu & her team for their wonderful execution of this project since 2009 till date enabling both the doctors & the Adolescents to get maximum benefit from the various CME & health projects which were taken up under the “Challenges for youth today & tomorrow” project. Hope to see this project grow to greater heights in years to come!
Amravati, Maharashtra
Ludhiana, Punjab
A report by Dr. Alka Kuthe, City Co-ordinator, Dr. Asha Thakare, President, Dr. Manjusha Bokey, Secretary
A report by Dr. Vaneet Abhrol and Dr. Ginny of their regular activities.
Jamnagar, Gujarat M.P. Shah Commerce College. Dr. Kalpana Khanderia conducted the talk session
Rajkot, Gujarat Total 8 Colleges were covered and more than 2000 girls participated in this project. It was a grand success. Dr. Shilpa Thakker , Executive Committee Member of the Adolescent Health Committee FOGSI spearheaded the programme.
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Chennai, Tamil Nadu Report by : Dr. S. Sampathkumari, Joint Secretary - OGSSI & City Co ordinator Adolescent Healthcare Workshop in Mylapore, Chennai, for students from IX to XII, numbering about 500.
Navi Mumbai A report by Dr. Anu Vij, West Zone Coordinator Adolescent Health Committee FOGSI 12 schools/ colleges were covered. About 1000 students attended the sessions. Thalessemia Screening done. Doctors taking active part were: Dr. Sucheta K, Dr. Mini Nampoothri, Dr. Bharati Morey, Dr. Janaki Patil, Dr. Ambuja M, Dr. Rahul Wani, Dr. V. Parulekar, Dr. Anu Vij.
Jammu, J&K Reported by Dr. Arun Arora, City Coordinator, Challanges for Youth - Adolescent Committee FOGSI. Conducted a program for first year students of a nursing institute of ASCOMS in Jammu. The programme was well attended with around 60 students participating in the event.
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