Adolescence Issue - 3

Protecting the Sexual & Reproductive Health of Adolescent Women in India Adolescent Sexual and Reproductive Health : FIGO ASRH Workshop The UNFPA Vision for Youth Polycystic Ovarian Syndrome in Adolescence Clinical Observation of Pregnancy Outcome Amongst the Teenagers Teenage Pregnancy in Indian Scenario Why are Some Girls Fat, Hairy and Have Irregular Menses Address for correspondence : Olyai Hospital, Hospital Road, Gwalior- 474009 (MP) India. Phone : (91) -(751)- (2320616)

Issue 03 | Pages 16

ADOLESCENCE

Adolescent Health Committee FOGSI

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

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Adolescent Health Committee FOGSI

ADOLESCENCE From the

President's desk...

From the

Secretary General's desk...

Dear Colleagues,

Dear friends, 'Adolescence volume three' is yet another newsletter that Dr. Roza Olyai has brought about for the members and speaks volumes about her dedication for the purpose. She has worked relentlessly towards reaching out to every member with awareness about the adolescent health issues and her efforts I truly appreciate.

An adolescent friendly clinic is the need of the time. I have directed Dr. Roza to create guidelines for the establishment of the same and we are in the process of establishing such a facility as an ideal setup for everyone to follow .The requirements of Adolescent Friendly Clinics are different and the functioning too has to be different . It has to be in tune to the requirement of the place where these clinics are established to be able to reach out this age group. It is only correct that FOGSI takes the initiative to establish guidelines for such facilities. We hope we are able to achieve these soon.

It has been well understood that this is the age group which if empowered with health especially reproductive health awareness a lot can be achieved to curb the maternal mortality and morbidity in our country .It has to be a multipronged approach and I am sure FOGSI can do a lot on this front .Recently at the review meeting of the Managing Committee of FOGSI at Mumbai we have finalized the policy statement on gender violence which includes the need of adolescent awareness. I quote -FOGSI acknowledges the existence of gender violence in the community and abhors these injustices meted out to women. Every FOGSIAN is sensitive to this and other issues relating to domestic violence and is on guard regarding the same being encountered in his /her day to day clinical practice. The gynecologist will identify, assess ,counsel and address such an issue. FOGSI opposes any kind of media display be it through movies , TV programmes ,news papers ,magazines , websites etc; which is gender based and trivializes women. FOGSI offers to join hands with stakeholders to offer technical assistance and guidance to establish Adolescent Friendly Clinics and Centers. FOGSI appreciates the importance of empowering the adolescent population with the knowledge of life style skills which include sexuality, contraception, STDs, gender violence, general health care measures. This statement is available for ready reference on the website.

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After reading the first two issues of Adolescence Magazine, the expectations of all the readers have gone up & are eagerly awaiting arrival third issue of the same. I assure you hat-trick of excellent reading material by Dr. Roza Olyai & her team of Adolescent Health Committee of FOGSI. I admire Dr. Roza's capability to get superb work done on time from her committee members and contributor to this third issue of Adolescence Magazine.

Dr. Roza deserves pat on her back for arranging finance for such fantastic FOGSI publication. I wish her & her team of Adolescent Health Committee all the very best for her future endeavors. I will appreciate feedbacks & constructive critism from readers to present better reading material in future.

With regards, Yours sincerely,

Dr. P. K. Shah Secretary General, FOGSI

From the

World Association for Sexual Health Dr Rosemary Coates President 1/3 King Edward St South Perth Western Australia 6151

Dear Dr Olyai, Many congratulations on your excellent Newsletter addressing the important issue of adolescent sexual health. During this critical development period of life young people have the most need for sound and safe advice. It is the case, however, that in many countries insufficient resources, including sound sexuality education is devoted to adolescents.

It is important that every FOGSI member is aware of the needs of the adolescent age group and has a definitive action plan to deal with them in their very busy practice.

While their elders express great concern about inappropriate behaviours they are less prepared to encourage healthy dialogue and positive guidance. Your work provides an outstanding example of opening the way forward. Thank you!

Let us empower the young!

Kind regards

Dr. Sanjay Gupte President FOGSI

Dr. Rosemary Coates

From the

From the

FIGO Chief Executive

Chairperson's desk...

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

Professor Hamid Rushwan MD.,FRCOG Chief Executive, International Federation of Gynecology and Obstetrics (FIGO), UK.

The International Federation of Gynecology and Obstetrics (FIGO) feels strongly that Adolescent Sexual and Reproductive Health (ASRH) is a major area of concern for women and youth in general in the world today.

It is gratifying to see that the Federation of Obstetric and Gynaecological Societies of India’s (FOGSI) Adolescent Health Committee is undertaking vitally important work to enhance the information, education and services to young people in the areas of sexual and reproductive health. These are experiences which should definitely be shared with other countries in the developing world where more efforts are still needed to strengthen ASRH services.

Adolescents experience many challenges in their sexual and reproductive lives - appropriate and timely specialist advice and care can do much to alleviate problems and misconceptions, and enable young people to move forward with their lives in confidence. FOGSI’s Adolescent Health Committee is an admirable example of teamwork in this crucial area, and should be congratulated on its impressive endeavours.

FIGO is in an excellent position to play a major role in strengthening the networking and collaboration between member associations in different regions to enable them to undertake active roles in their own countries.

FIGO is happy to extend its support to FOGSI in all areas of its valuable work. My very best wishes.

Kind regards,

Professor Hamid Rushwan

Dear Friends, Am happy to share with you the third issue of the “Adolescence” News Magazine. We have received very warm response from our dear readers not only from India but also from the other countries as well & am thankful for all your feedbacks & encouraging emails.

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.

The International Federation of Gynecology & Obstetrics (FIGO) has resolved, with the support of UNFPA, to strengthen the capacity of FIGO member associations to support ASRH interventions at the national level.

The Adolescent Health Committee of FOGSI aims to take this opportunity by establishing Adolescent Friendly Health Centers at present in few selected cities initially as a pilot project.

In this Project our committee will be collaborating with FIGO at the International. This was following a Regional workshop organized

by FIGO in which India was represented by President of FOGSI Dr. Sanjay Gupte & myself. In continuation of this workshop a two day inter-regional workshop for the Asia Africa region has been scheduled to be held in Istanbul, Turkey in coming months to discuss further objectives and outcome of previous regional workshop. Adolescent Health Committee FOGSI is also collaborating with WHO & the Government of India at the National level which will be in form series of consultative meetings.

Disseminating knowledge & helping our Adolescents to be empowered has been the goal of the Committee & one such endeavor has been reaching to our colleagues through this magazine. 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!

"The earth is but one country, and mankind its citizens."

Dr. Roza Olyai National Chairperson Adolescent Health Committee FOGSI Mobile : +91-9425112617.

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Adolescent Health Committee FOGSI

ADOLESCENCE

From the

Past President FOGSI

From the President & CEO of

The Guttmacher Institute

Dr. Shirish N. Daftary Past President FOGSI

It gives me great pleasure in acknowledging the fact that as president of FOGSI, I had the privilege to establish the Adolescent Health Committee under the chairmanship of Dr.(Mrs) Usha Krishna. This dedicated committee provided yeoman service to the federation by bringing to the forefront and highlighting the problems facing the adolescent girl, and emphasizing the need for setting up centres for dedicated health services targeted to take care of the reproductive healthcare needs of this segment of the population. In the year 1991, the adolescent health care committee of FOGSI, under the guidance of Dr.(Mrs) Usha R. Krishna brought forth its first publication entitled The Adolescent Girl under the FOGSI banner. This book was ably edited by Dr. Usha Krishna, Dr. Shashank Parulekar and Dr. Vinita Salvi. The book was dedicated to the Adolescent Girls in India with the prayer that “May they bloom and play a fulfilling and vital role in society”. This book had 37 chapters covering diverse topics ranging from endocrinology, menstrual disturbances, puberty problems, sexually transmitted diseases, endometriosis, pelvic pain and dysmenorrhoea, genital tuberculosis, tumours in childhood, teenage pregnancy and other miscellaneous topics ably covered.

Chairpersons of this FOGSI Committee who followed in the footsteps of Dr. Usha Krishna enlarged the scope and activities of this committee. The efforts to bring forth public awareness to provide for the special needs of this segment of the population has received a great boost as a result of FOGSI involvement. The youth of India comprises the single largest group in our country, hence the importance of providing for their special health needs.

Seminars, workshops and conferences have been conducted under the aegis of FOGSI to sensitize the medical profession towards this rapidly emerging medical speciality. Efforts by dedicated professionals has resulted in the establishment of Dedicated Clinics for adolescents in many centres. The public awareness programs and the Reproductive Health education programs initiated by our members in several educational institutes (high schools and junior colleges)has succeeded in bringing this problem to the attention of our educationists, legislators and health care providers.

The efforts to detect the incidence of HPV infections in our community, to propagate the benefits of mass immunization and to reduce the cancer load from cervical cancer – a leading cause of cancer in women in India in the coming years holds a bright future for our women. I congratulate Dr. Roza for enhancing the prestige of this committee. I am sure that this issue of the FOGSI Magazine- “Adolescence” will help to enhance FOGSI's continued devotion to the adolescent girls of our country.

Shirish N. Daftary Past President FOGSI

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Throughout most of the world, and especially in developing nations, adolescents confront barriers that limit their ability to protect their sexual and reproductive health. Lack of information and services, a very early start to marriage and childbearing, and unwanted pregnancy can result in curtailed lives. As Dr. Susheela Singh and her co-authors report in their article "Protecting the Sexual and Reproductive Health of Adolescent Women in India", these are the circumstances in which many young Indian women live. Their findings make clear the urgent need for better policies and programs to reduce early marriage and provide India's adolescents the information and reproductive health services they need to safeguard their futures.

These findings also serve to underscore the importance of the Adolescent Health Committee's newsletter and its work in general, as well as the contribution that committed obstetricians and gynecologists can make, to improving the health of adolescent women.

Promoting the health of India's young women is indeed a noble mission.

Sharon L. Camp Ph.D. President & CEO, Guttmacher Institute 125 Maiden Lane, New York, NY 10038

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. Tushar Kar (Cuttack) Vice President No.4 Mobile : 9437034520 drtusharkar@yahoo.co.in Dr. C.N. Purandare (Mumbai) Immediate Past President Mobile:9323803663 / 9820088183 dr.c.n.purandare@gmail.com

Dr. Girija Wagh (Pune) Jt. Secretary Mobile : 94220 00584 girijawagh@gmail.com Dr. H.D. Pai (Mumbai) Treasurer Mobile : 9820057722 hdpai@hotmail.com

Protecting the Sexual and Reproductive Health of Adolescent Women in India

By Susheela Singh, Usha Ram, Ann M. Moore and Haley Ball Dr.Susheela Singh Ph.D Vice President for Research Guttmacher Institute 125 Maiden Lane, 7th Floor New York, NY 10038 Adolescence, the period between childhood and adulthood, is often a time of great physical, mental and social development. Yet, for many young Indian women, this period is cut short by early marriage and childbearing. The information presented here is largely based on analyses of the National Family Health Surveys (1992–1993, 1998–1999 and 2005–2006), and is abstracted from a recently published report.1 These data provide a nationally representative picture of the sexual and reproductive health of adolescent women in India and highlight the need for improved policies and programs to help reduce early marriage and unplanned adolescent pregnancies, and provide married and unmarried young women with necessary sexual and reproductive health information and services.

In most Indian states, adolescent women aged 15–19 make up at least 10% of the population—a total of 50.5 million nationwide, as of 2005. Two-thirds of these young women live in rural areas. Their life trajectories—which are shaped by many factors, including their educational attainment and the extent of their exposure to the mass media (an indication of modernization and connectedness)—vary substantially according to their area of residence. Thirty-seven percent have had less than six years of education; the proportion ranges from 19% in urban areas to 45% in rural areas. The proportion exposed to radio or television at least once a week ranges from 73% in urban areas to 33% in rural areas. These and other characteristics influence young women's likelihood of becoming a wife and mother at a young age.

Early marriage—marriage before age 18—poses a great challenge to the reproductive health of young women: It can expose them to unintended pregnancy and sexually transmitted infections, as well as greatly reduce their chances of continuing school, limit their autonomy and put them at increased risk for domestic violence. Despite the fact that 18 is the legal age for marriage, nearly half (45%) of adolescent women are married before their 18th birthday, with 28% of women marrying early in urban areas vs. 53% in rural areas. Differences by state are also stark. Few women (12%) marry before age 18 in Goa and Himachal Pradesh, while about three-fifths (57–61%) do so in Rajasthan, Jharkhand and Bihar. While early marriage is becoming less common, the pace of that decline is extremely slow—it dropped only five percentage points from 1992 to 2006—and the trend is not consistent: Goa, Punjab and Gujarat actually experienced small increases in early marriage during that period.

Young women are typically expected to begin childbearing soon after marriage. Some 22% of Indian women bear a child before age 18, and more than two-fifths (42%) become mothers by age 20; nearly all of these pregnancies occur within the context of marriage. Childbearing at an early age can endanger both mother and child, and the probability of negative health outcomes are often amplified when a birth occurs too soon or when it is not wanted at all. These unplanned births account for 14% of all births among adolescent women.

A majority (61%) of married adolescent women do not want a child in the next two years—mainly because they have already had one child and want to wait at least two years before having a second birth. Yet, overall, only 7% of married 15–19-year-olds use a modern contraceptive method. An additional 6% use a less effective traditional method. As a result, 43% of married adolescents have an unmet need for modern contraception—that is, they want to postpone

or prevent a birth but are not using an effective method of contraception. This high level of unmet need is partly caused by problems of cost and access, but also by the social isolation and lack of control over reproductive decisions that characterize the situation of many married adolescent women.

Because sex outside of marriage remains a highly stigmatized topic in India, much less is known about the sexual and reproductive health of unmarried young women than about their married counterparts. One recent, large-scale study conducted in six states found levels of premarital sexual experience ranging from 2% to 7% among 15–24year-old women,2 though these proportions are most likely underreported, given the strong social sanctions against sexual activity among young women before marriage. Because of the stigma surrounding premarital sex, unmarried sexually active adolescents may face particular challenges to safeguarding their reproductive health, including difficulties obtaining related health services and a greater probability of turning to unsafe abortion.

Improving the sexual and reproductive health of India's adolescent women—through postponing marriage and providing the contraceptive services young women need to avoid unintended pregnancy and unplanned childbearing—will lead to healthier pregnancies, stronger families and improved life prospects for the women themselves. It is encouraging that there are a large number of progressive policies and small-scale initiatives and programs directed toward improving adolescent reproductive health, but India has a long way to go to secure adequate provision of confidential, youth-friendly sexual and reproductive health care to all adolescents.

To achieve this goal, the nation must strengthen mechanisms for ensuring that the legal minimum age for marriage is enforced, while implementing interventions—such as programs to support girls' education, employment and economic independence—to provide young women with alternatives to early marriage and improve women's status generally. Furthermore, policymakers must address the needs of all adolescents, married and unmarried, for comprehensive and accurate information to protect their sexual health. Sexual and reproductive health services must also be tailored to the special needs of adolescent women: For married adolescents, this means adapting existing health services to address high levels of unmet need, while overcoming the lack freedom of movement, autonomy and access to resources that these young women often experience. For sexually active unmarried adolescent women, this includes addressing this group's particular needs for confidentiality and support from health care providers to safeguard their long-term sexual and reproductive health.

1.

Moore AM, Singh S, Ram U, Remez L and Audam S, Adolescent Marriage and Childbearing in India: Current Situation and Recent Trends, New York: Guttmacher Institute, 2009, <http://www.guttmacher.org/pubs/2009/06/04/AdolescentMa rriageIndia.pdf>, accessed June 7, 2010.

2.

International Institute for Population Sciences (IIPS) and Population Council, Romance and sex before marriage among young women and men in India, Youth in India: Situation and Needs 2006–2007, Policy Brief, No. 34, 2010, <http://www.popcouncil.org/pdfs/2010PGY_YouthInIndiaBrief 34.pdf>, accessed June 7, 2010.

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Adolescent Health Committee FOGSI

ADOLESCENCE Adolescent Sexual and Reproductive Health : Bangalore first to benefit from FIGO ASRH workshop

Professor Hamid Rushwan Chief Executive of the International Federation of Gynecology and Obstetrics (FIGO), UK The adolescent population across the globe is hugely significant: there are more than 1.5 billion people between the ages of 10 and 25, and more than half live on less than $2 per day.

In April 2010, the International Federation of Gynecology and Obstetrics (FIGO), the only global organisation representing professional associations of gynecologists and obstetricians - of which I am Chief Executive - held its first Adolescent Sexual and Reproductive Health workshop in Bangalore, India, funded by the United Nations Population Fund (UNFPA), and facilitated by Dr Kamini Rao. The aim of the workshops is to strengthen the capacity of FIGO member associations to support ASRH interventions at the national level. Two more workshops are taking place this year, one in Khartoum, Sudan, and one in Santiago, Chile.

A challenging area of health FIGO has long considered the subject of Adolescent Sexual and Reproductive Health (ASRH) to be a major world health issue that has historically been overlooked. It is a particularly complex major world health issue. The experiences of young people while in the throes of safely and successfully navigating their transition into adulthood are complicated by many factors: these include age, sex, marital status, education, economic vulnerability, living arrangements and migration.

Added to this, adolescents experience many other challenges in their sexual and reproductive lives including child marriage; harmful traditional practices such as Female Genital Cutting/Mutilation; lack of sexual knowledge/experience; high-risk pregnancies; greater risk of obstetric fistulae; HIV infection; and risk of sexual abuse/assault/exploitation. These all impact on adolescents' ability to acquire and maintain good sexual and reproductive health.

The FIGO Initiative In order to determine how FIGO can effectively contribute to improving ASRH, FIGO undertook: 1. A literature review of adolescents' (10-19 years) attitudes; perceptions of health professionals; and programmes already assessed for effectiveness.

2. A survey of obstetricians' and gynecologists' attitudes, knowledge and perceptions of ASRH. 3. A critical review of existing tools and guidelines for ASRH services, and professional training and education.

1. Literature review Adolescents' health is intrinsically linked to their social, cultural and economic environment. 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 (eg whether rural or urban, girls or boys etc) influence access to healthcare and sources of education, information and support. The risk factors affecting adolescents' health outcomes are: early sexual initiation, substance abuse, depression and ignorance about contraception.

2. The survey: What practitioners are telling us The FIGO survey of obstetricians' and gynecologists' attitudes, knowledge and perceptions of ASRH was responded to by 33 per cent of FIGO membership. The overall thematic analysis indicated that the data does provide meaningful insight into broad areas of adolescent sexual and reproductive health.

The survey explored members' perceptions of national policy, service delivery, professional training and education, and attitudes towards adolescents (ie social and cultural issues).

• National policy: 80 per cent reported that national policy did 5

FIGO INTERNATIONAL FEDERATION OF GYNECOLOGY & OBSTETRICS

address ASRH, but that many countries' rights were hampered by either gender or marital status. The mixed levels of success of many national associations to actively engage in advocacy/lobbying reflect, for example, the willingness of the government to listen, and the level of significance accorded to adolescents, among other factors.

• Service delivery: Fewer respondents said that these rights were translated into equal access to ASRH services eg in some countries, boys were excluded, while in others, girls experience restrictions on mobility and health workers' negative attitudes. Specialised services tended to work well (eg youth friendly services provided by family planning associations), while areas such as school-based programmes, for example, were often not a success, due to insufficient teacher training and time, among other factors.

• Professional training and education: ASRH is an explicit part of training for obstetricians and gynecologists in 37 per cent of countries, and 90 per cent wanted FIGO to develop training modules. FIGO could add value to new or existing tools by investing resources in national associations to adapt them to regional contexts. The development and promotion of tools need to be matched with largescale, well targeted, skilfully facilitated training workshops, with modules including social aspects of health and having a clear focus on male and female adolescents' needs.

• Attitudes towards adolescents: adolescent girls' powerlessness and vulnerability is a key issue, as prejudice exists within government, social and cultural institutions, communities and individuals. This impacts on girls' abilities to access healthcare – as a result, many programmes focus on increasing the access to this healthcare. An unintended consequence of this is to leave boys unable to access services specifically designed for adolescents. There is a need to redress this imbalance. Health professionals and parents often have negative/judgemental attitudes towards giving adolescents sexual and reproductive health information. This is frequently due to anxiety about the impact of this information on sexual behaviour. There is no evidence for this, but many believe this lack of knowledge is an effective deterrent.

3. Tools and guidelines: To develop or adapt?

A framework summarising different category tools was developed, covering areas such as orientation guidelines, support and counselling, peer education etc. A focus of the review was consideration of whether FIGO can add greatest value through developing new tools, or by adapting and endorsing existing tools.

Three holistic, freely available resources were identified as tying in most closely with information requested by participants (WHO, Pathfinder and EngenderHealth). It is recommended that FIGO review these, and take one forward for accreditation by a specialist organisation eg FIGO, RCOG. FIGO's ultimate goal: Adding value to current programmes The recent workshop in Bangalore was well attended and thoughtprovoking, and it is anticipated that the two other workshops held this year will be similarly received. To sum up, FIGO believes it can add greatest value by building on current activities in ASRH. This is most likely to be through improving its existing institutional strengths and expertise, particularly in pre- and in-service training; international advocacy; and development of policy briefs and position statements at international level to support national efforts. FIGO could also optimise the effectiveness of its involvement in ASRH by the development and membership of coalitions; partnering with organisations experienced in programme implementation and management; and participating in multi-disciplinary/multi-sectoral working groups.

The UNFPA Vision for Youth

Dr Derveeuw Marc G.L. Representative A.I., UNFPA India.

Adolescence is a period of many critical transitions, not only physical, psychological, but also economic and social. As childhood is left behind, pressures to forge a unique identity and to become responsible adults intensify. These transitions are mixed with challenges and choices, which are strongly influenced by gender expectations of societies and families. Successfully navigating through these transitions depends, in part, by the support young people receive from families, communities and society at large. UNFPA promotes and protects the rights of young people. It envisions a world in which girls and boys have optimal opportunities to develop their full potential, to freely express themselves and have their views respected, and to live free of poverty, discrimination and violence.

To achieve this, UNFPA works in India across sectors and with many partners to empower adolescents and youth with skills to achieve their dreams, think critically, and express themselves freely. We uphold the rights of young people especially those of the marginalized groups, to grow up healthy and safe to receive a fair share of the social investments and resources which are made available. But most importantly we encourage young people's leadership and participation in decisions that affect them, including the development plans of their societies.

UNFPA's has a holistic, multi-sectoral and collaborative approach which reflects a vision that sees the lives of young people in totality rather than in steps. At the programme level, it advocates for an essential package of social protection interventions for youth that includes education, sexual and reproductive health services and support for establishing livelihoods. At both levels, the Fund encourages intergenerational interactions that pair the energy, perspectives and motivation of young people with the experience and know-how of adult coaches and facilitators.

Young people live diverse lives, they are in a transition and their experiences and perceptions are by no means similar. The experience

of young people to safely and successfully navigate their transition to adulthood are diversified by age, sex, marital status, schooling levels, residence, living arrangements, migration and socio-economic status.

Young people often represent a disproportionate number of those affected by crises. Programming for the diversity of young people can yield better results in helping young people grasp opportunities and overcome challenges with positive results.

In India, young people have longer intervals between childhood and assuming adult roles. Compared to a generation ago, today's young people are more likely to spend adolescence in school and to delay marriage and childbearing. This means they have more time and opportunities to acquire information and skills that can help them reach their full potential. The growing numbers of young people, along with the longer period of being unmarried (and in many cases sexually active) also means there will be a need for continued investments in education, skills training and health services including to protect sexual and reproductive health.

UNFPA welcomes the initiative of FOGSI to focus on adolescents in their interventions. We encourage the Adolescent Health Committee of FOGSI to strengthen the capacity of their members to provide adapted and appropriate care to the young people but also to give the young people the accurate information not only about reproductive and sexual health, but also about their physical, mental and spiritual wellbeing throughout their lives. We recognize that professional associations such as FOGSI are important stakeholders in the development of the adolescent programmes in the private sector.

Gynecologists are very often the first point of contact when it comes to dealing with delicate issues such as teenage pregnancies, contraception and protection of girls. Therefore, UNFPA looks forward to maintaining a dialogue with FOGSI on working with adolescents and sharing expertise, positive experiences and lessons learned from the field.

Karnataka on the Move...

With the New team of the State Executives of the Obstetric &. Gynecological societies of Karanataka planning to take school & college health projects...

President Dr. Hema Divakar & Secretary Dr. Hiramath

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Adolescent Health Committee FOGSI

ADOLESCENCE Polycystic Ovarian Syndrome in Adolescence

Dr. Prof. Pratap Kumar Professor and Head Obstetrics and Gynecology Kasturba Medical College Manipal 576104, Karnataka Introduction

that both genetic and environmental factors may play a role, resulting in ovarian hyperandrogenism and impaired insulin sensitivity5.

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting women across the lifespan. Originally thought only to impact women of child-bearing age because of the presence of infertility associated with the disease, health care professionals are now realizing that adolescent females are presenting with PCOS and the associated health concerns of menstrual irregularities, obesity, type 2 diabetes, and evidence of hyperandrogenism (hirsutism and acne) with increasing prevalence. PCOS often manifests around the time of menarche as irregular and often lengthened menstrual cycles 1

•

Restoration of normal menses.

What are the symptoms and signs of PCOS?

•

Young women with PCOS commonly have one or more signs. Some of the most common signs include:

Reversing insulin resistance and, thereby, restoring normal metabolic and hormonal function.

•

Preventing the long-term health complications that can occur as a consequence of PCOS

•

Management The goals of treatment for women with PCOS include: •

Weight loss for obesity.

•

Suppression of elevated male hormone levels that cause hyperandrogenism and its associated symptoms, such as hirsutism and acne.

Irregular periods—periods that come every few months, not at all, or too frequently

•

Hirsutism—extra hair on the face or other body parts

•

Acne

•

Weight gain and/or trouble losing weight, and in some cases, obesity

•

Patches of dark skin on the back of the neck and other areas, called "acanthosis nigricans".

Aetiology PCOS is caused by an imbalance in the hormones secreted by the pituitary gland that in turn affects the ovaries. Many girls with PCOS also have higher than normal levels of insulin from the pancreas.

PCOS usually happens when the luteinizing hormone (LH) levels or the insulin levels are too high, which results in extra testosterone production by the ovary.

The onset of pulsatile growth hormone (GH) secretion during early puberty induces the release of IGF-1 (Insulin like growth factor –1) by the liver and most other tissues. GH also provokes insulin resistance, which selectively affects peripheral glucose.

The resulting hyperinsulinaemia acting on IGF-1 causes ovarian hyperstimulation inducing thecal cell hyperplasia and excessive androgen production.

The increased androgens cause follicular atresia and increased circulating estrone levels because of peripheral conversion in adipose tissues. The altered endocrine milieu provokes increased pituitary LH secretion, which aggravates the theca cell stimulation. After puberty the insulin and IGF-1 levels progressively decline in most patients, resulting in normalization of clinical and morphological picture. Only in a few cases PCOS persists.

The Rotterdam 2004 Consensus Workshop (Revised 2003)2 proposed that PCOS is a syndrome of ovarian dysfunction, and recommended that two of the following criteria should be present to establish the diagnosis: 1)

chronic oligo or anovulation for more than 6 months

2)

clinical and/or biochemical evidence of hyperandrogenism, and

3)

polycystic ovaries in ultrasound.

The cornerstone of management of PCOS in adolescence includes either a combination oral contraceptive or progestin. Consideration of insulin-sensitizing agents, antiandrogens, topical treatments for acne, and various treatments for hair removal are dependent on the patient's symptoms and concerns. Healthy eating, regular exercise, and for the overweight adolescent, weight reduction, are encouraged to reduce the risk of cardiovascular disease and type II diabetes mellitus.

Numerous studies have shown that weight loss and exercise decrease androgen levels, improve insulin sensitivity, and lead to the resumption of ovulation. Although initial studies suggest that Metformin may be particularly useful for treating the PCOS adolescent with insulin resistance and obesity, additional studies are needed to determine the efficacy and long-term outcome. Management of the adolescent with PCOS is challenging and requires a supportive, multidisciplinary team approach for optimal results4.

Conclusion Polycystic ovary syndrome (PCOS) usually arises during puberty and is marked by hyperinsulinemia and hyperandrogenism. Adolescents with PCOS are at an increased risk of developing health problems later on in life such as type 2 diabetes, cardiovascular disease, and infertility. Furthermore, the physical signs of PCOS can be detrimental to a teenage girl's self-image. Early diagnosis and treatment of PCOS in adolescents are essential in ensuring adulthood health and restoring self-esteem. Treatments for an adolescent with PCOS include diet and exercise, metformin, and oral contraceptive pills. Each of these options has been shown to be effective in improving certain aspects of PCOS, and probably the best treatment plan involves some combination of them References 1.

Richardson, M. (2003). Current perspectives in polycystic ovary syndrome [Electronic version]. American Family Physician, 68(4), 697.

2.

Consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Human Reproduction 2004; 19: 41-47.

3.

Franks S. Adult polycystic ovary syndrome begins in childhood.

Best Practice and Research. Clin Endocrinol Metab 2002; 16: 263-272.

4.

Driscoll DA. Polycystic ovary syndrome in adolescence. Ann New York Acad Sci 2003; 997: 49-55

5.

Jahnafar S, Eden JA, Warren P et al. A twin study of polycystic ovary syndrome. Fertil Steril 1995; 63: 478-486.

Other disorders that mimic PCOS phenotype should be excluded.

According to the androgen overexposure hypothesis, PCOS may have its origin already in fetal life, but becomes clinically manifest during adolescence with maturation of the hypothalamic-pituitary-ovarian axis3. The incidence of PCOS among adolescents is estimated to be 11-26 % 4 and about 50 % of the patients are overweight. The pathophysiology of PCOS is still uncertain, although there is evidence 7

A Prospective Study

Clinical Observation of Pregnancy Outcome Amongst the Teenagers

Dr Prof. P. B. Sahay Prof. & HOD, Dept. of Obs & Gynae Rajendra Institute of medical Sciences (RIMS) Ranchi, Jharkhand.

Introduction Teenage pregnancy also known as adolescent pregnancy is pregnancy in the age group of 13-19 years. It is occurs in almost every ethnic, social and group. It is a well known fact that these come under high risk pregnancy group. â&#x20AC;&#x153;SAVE THE CHILDRENâ&#x20AC;? found that annually 13million children are born to women under age 20years worldwide, more than 90% in developing countries. Indian population is 1169 million at present. The age group of 10-14 years constitute 11.2% and age group of 15-19 years constitutes 9.5%. Teenage group constitute about 10.4% of the population (2003-SRS) and their literacy rate is 35% in Jharkhand. There is an inverse relation between educational status and fertility, same holds good for socioeconomic status and fertility. Age at marriage has a great impact on fertility. One in four girls in the world becomes a mother before the age of 19years.Teenage pregnancy is universal in all known cultures past and present, but it has achieved a predictable magnitude in some countries. If this is not controlled it will be associated with adverse perinatal outcome such as low birthweight, anaemia, eclampsia & pre eclampsia.

Objectives Seeing the increasing trend of Teenage pregnancy at the Rajendra Institute of medical Sciences, this study was conducted : 1)

To determine the role of antenatal care in prevention of obstetric and gynecological complications and adverse perinatal outcome in teenage pregnancy.

2)

To know the incidence of unsafe abortion in teenage.

3)

To access the mode of termination of pregnancy and delivery among teenagers.

Obstetric & Gynecology, RIMS Ranchi during the period between August '08 - September '09. Patients were selected randomly both from indoor and outdoor.

Results A total of 120 cases were admitted through OPD and few came directly to the labour room. All were asked about age, educational status, marital status, antenatal checkups, immunization status, duration of pregnancy, gravida and parity, medical, surgical and personal history .

Out of 120 patients: 20 were unmarried,4 were below 14years, 50 from rural area, 66 illiterate, 1.66% were severly anemic,65% had mild anemia, 5% had pre eclampsia, 7.5% had eclampsia, 23 underwent LSCS, 9 cases were due to CPD, MTP 13, 1 presented with septic abortion, 16 preterm delivery, 48 had spontaneous vaginal delivery, perinatal mortality was 7.5%.

Conclusion In spite of repeated efforts by the government only few mothers approach medical facilities for booking & proper antenatal care & not 100% of them are immunized. Age is inversely proportional for development of anemia, pre eclampsia, eclampsia, pregnancy related morbidities and mortality & surgical intervention. Number of unmarried pregnancies are on the rise and majority approached in the second trimester for termination. There was significant decrease in incidence of septic abortions.

I would like to congratulate the Adolescent Health Committee FOGSI for focusing on such important issues & creating awareness not only amongst the Adolescents but also amongst their parents & the Gynecologists.

Method This prospective study was conducted on all teenage pregnant mothers irrespective of their marital status in the Department of

Thrissur, Kerala Launches School Awareness Program The adolescent health Committee FOGSI is happy to announce launch of school/ college health project at Thrissur.Dr. Lola Ramachandran, President of Thrissur Obs. & Gyn. Society will be coordinating the health awareness project in colleges & schools.

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Adolescent Health Committee FOGSI

ADOLESCENCE Teenage Pregnancy in Indian Scenario

Dr. Prof. Mrs. Laxmi Maru Head of Department of Obstetric & Gynaecology M.G.M. Medical College & M.Y. Group of Hospital, Indore Adolescence is the period of life during which the care free child becomes the responsible adult. Puberty is the state of becoming functionally capable of procreation usually accepted as occurring at the age of 12 years in girls and 14 years in boys, but full reproductive capacity is not usually attained untile later.

puerperal psychosis & in infants increased incidence of birth asphyxia, MAS, neonatal Hyperbilirubinemia, neonatal encephalopathy, hypoglycemia, Hypocalcemia, hyperviscosity syndrome, intra cranial hemorrhage, sepsis, respiratory distress, hypoxic encephalopathy (due to IUGR) and preterm labour.

Puberty is characterized by physical sexual differentiation and by the onset of activity of sex organs.

Prevention –

The memarche is the onset of menstruation and is merely one manifestation of puberty. Definite signs of puberty are usually present by the age if 9 to 10 yrs when the breasts develop a bud (thelarche) & soon afterwards they become generally enlarged. By the time hair begins to grow on the body appearing first on the mons veneris (adnerarche).

Adolescent pregnancy has been associated with an increased incidence of both obstetrics and social complication, twice that of women in their twenties and thus is considered as high risk adolescent pregnancy. It surely has a negative impact on the physical, social, emotional, educational & economic condition of teenage woman, too early she becomes a “Child- Mother” with a vulnerable and perhaps neglected and abused newborn . Incidence of teenage pregnancy is high in developed countries, which is mostly due to early sexual activities in unmarried teenagers that too without use of any contraception.

In India, although the legal age at marriage is 18 for females & 21 for males, early marriage continues to be the norm. By the age 15, as many as 26% of females are married. By the age of 18, this figure rises to 54%. Most reproduction in India occurs within marriage, so the low age at marriage automatically links to early onset of sexual activity and thereby high fertility.

In India, teenage pregnancy has a high incidence varying from 3.5 to 8.2%. Rajasthan is the only state in India where age at marriage is lower than the age of menarche & > 61% girls in Rajasthan get married before 18 yrs of age.

Several contributing factors which are held responsible for increase in the incidence of Teenage pregnancy are: 1.

Early Marriage

2.

Decreasing age of menarche

3.

Contemporary urbanization

4.

Lack of education

5.

Poor socio economic status

Symptoms of teenage pregnancy are same as that of normal pregnancy. They include missed periods, fatigue, nausea, vomiting, stomach cramping increased drowsiness and moodiness.

Any teenage girl who experiences these symptoms is advised to undergo a pregnancy test. This test should be done by all the doctors.

Teenage pregnancy is labeled as a high risk pregnancy because of increased maternal, fetal and neonatal morbidity and mortality.

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In teenage pregnancy there is increased incidence of anemia, hypertensive disorders of pregnancy, Antepartum Hemorrhage, IUGR increased incidence of operative vaginal delivery, preterm labour,

Prevention of teenage pregnancy is important as it requires a multifaceted approach including education, focused health services, socio-economic support & contraceptive counseling. Different stages of prevention would include: 1.

Primary Prevention a. b. c. d. e. f.

2.

Secondary Prevention a. b.

3.

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

Use of Contraception Emergency contraception

Tertiary prevention a. b.

Safe Abortion Services Adequate prenatal care

Teenagers 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 & on other side there is media over exposure with 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 hence there is need for promoting awareness for emergency contraception which is appropriate for these young girls as first encounter is usually accidental & unprotected.

Timely usage of emergency contraception prevents mental, social & physical agony of having an 'unsafe abortion'.

Thoughts become Things...

Choose the Good Ones...

Why are Some Girls Fat, Hairy and Have Irregular Menses

Dr. Jaideep malhotra Vice President FOGSI 2010 National Coordinator for PCOS Club Transition from a little girl to a lady is period of great satisfaction and pride for every girl and parents and yet this transition is not as beautiful as it should be or as it sounds, there are hundreds of changes taking place simultaneously in her body and mind and life is not as smooth as it appears to be.

For some of these changes happen as they should, but for some a little deviation from the normal may be there, but for a few precisely 5 – 7 % it may not happen as desired. Their baby fat may not shed, they may become increasingly hairy with dark patches at the back of the neck or axilla, their menstrual cycles may be very irregular generally longer periods and as obesity increases, menstrual cycles also become longer and some may not menstruate without medication and to top it up all crops of acne, pimples hit them straight, making this emotionally fragile period of their lives go for a toss. Parents and relatives pass it off as the growing period and mostly reassure that will settle with time or when she gets married, cycles will get regular, if by chance they land up at a dermatologist or a Gynecologist or a Physician, different modalities of treatment regarding their extra facial hair, acne or pimples or obesity are dealt with and things become complicated as you can't actually get treated for one problem, as the problem in a nut shell, we are dealing with, is known as Polycystic Ovarian Syndrome and has to be taken as a complex endocrine problem with a tendency to land up into a complete metabolic problem, needs to be properly diagnosed which is not difficult at all, a properly taken history, a well done examination and if required one pelvic ultrasound to document polycystic ovaries will clinch the diagnosis and once diagnosed, management is not as difficult as it appears for most. It starts with a good session of counseling which forms the crust of understanding the disease process and the problems associated with it and if not taken care of then what long-term complications can trouble them etc. and I feel this goes a long way in the management.

One needs to understand that diagnosis though is not difficult; the management at every stage of life from adolescent to maturity is different with different issues cropping up at different age & stage.

As an adolescent the main concern of these girls is obesity, acne extra amount of facial and body hair and extremely irregular long cycles and these need to be tackled, life style modification is the mainstay and once they get into that gear it will go a long way in management and also prevention of long term implications and metabolic syndrome.

Let's start with obesity, the hormonal changes, the insulin resistance all make it easier for fat to deposit and more so it is a particular type of visceral fat which is very difficult to shed and needs an extremely dedicated diet modification & exercise schedule which needs to be directed at loosing small amount of weight in short period of time, what we call as achievable small targets to be set and once that sets in the restoration or regularization of menses also starts setting in and a positive track sets in, then it is time for the extra facial hair or body hair to be tackled now for this we need to rule out any adrenal or other ovarian origin of androgens being produced. Once these are ruled out and exercise increases sex hormone binding globulin, which brings down the free testosterone, new downy growth reduces and once this state is achieved then we can think of doing a permanent method of hair removal whether it electrolyses or laser. As far as menstrual irregularities are concerned today we have dedicated pills available which could be prescribed looking at the profile of the girl whether she is more obese or more androgenic and these dedicated pills can be prescribed and once prescribed they should be continued for 3 – 6 months. Any other deviation from normal can be tackled.

Many a times there is a lot of scare which is developed in the minds of these girls regarding their reproductive status and other long term implications, one thing needs to be kept in mind is that, of course this is a deviation from normal and needs extra understanding and care and follow up throughout life time and it is difficult for anybody to put them in two pages or explain in a short time and that is the basic reason we at FOGSI have started FOGSI – MERCK SERONO PCOS initiative and are establishing PCOS clubs to educate these girl on how to look after themselves if they are born with such a condition and manage themselves through adolescents to young adults, through reproductive period and later on. These clubs have been started all over India and time to time follow up & guidance will be provided as and when required. Most of the frequently asked questions about the subject for young girls are covered in a small booklet which can be asked for and also there is a website www. PCOStalk.co.in which can be accessed and queries put in and at any point of time if you require any further information you could email to me at jaideepmalhotraagra@gmail.com.

All the best for a happy reading and management of PCOS!

North Zone Yuva FOGSI 23rd and 25th July, 2010 Dr. Basab Mukherjee representing the committee addressing a Seminar on “Adolescence” in The Yuva FOGSI North Zone, Gorakhpur.

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Adolescent Health Committee FOGSI

ADOLESCENCE FIGO Regional Workshop Following the FIGO survey in 2009 a consultative meeting of the International Federation of Gynaecological & Obstetric (FIGO) ASRH Workshop for the Asia Oceania region was held in 2010 at Bangalore. The aim of the workshop was to develop appropriate guidelines and protocols for Adolescent Sexual & Reproductive Health (ASRH), services specific to the Asia Oceania region and then to country level in 2010.FOGSI was represented by President Dr. Sanjay Gupte & Chairperson Adolescent Health Committee FOGSI Dr.Roza Olyai. Dr. Kamini Rao was the convener.

Dr. Hema Divakar, Dr. Sheela Mane & Dr. Venkatesh from Bangalore were also present.

Representatives of Obstetric & Gyn. Societies from Sri Lanka, Malaysia, Nepal, India, & other organizations like UNFPA, WHO, IPPF, FPAI, Chetna, Ipas, INSA, Parivar Seva, etc. also participated.

Policy was made on the following points: 1.

Clinical services and interventions in the health sector to ensure provision of comprehensive, high-quality SRH care.

2.

Education systems to ensure inclusion of comprehensive SRH education.

3.

Youth Development Strategies synergistic with education and participation opportunities.

FIGO ASRH Workshop, Asia Oceania region, Bangalore

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FIGO NIGHT

Rural Health Checkups...

Dr. Gracy Thomas from Kochin has been involved in lots of social activities.Organised 12 medical camps in the adopted village, Keechery and surroundings. Visits old age homes & orphanages, regularly conduct anaemia eradication programmes and supply provisions and help them financially. Gives regular health talks to the villagers, especially to the ladies.

Rural Health Education...

Committee members Activity…Rural Health Education…school Health Program for Adolescents in Government schools in Districts… Jamnagar, Ahmedabad, Gujarat & Gorakpur Dist.- UP.

MMR Vaccination Camp...

MMR vaccination camp & regular hemoglobin checkup camps in Jamnagar & surrounding villages in Gujarat is being organized for the adolescent School Girls by Dr. Kalpana Khanderia, member Adolescent Health committee FOGSI. Total 750 girls were given MMR vaccine.

FOGSI 3 P's Conference...

FOGSI 3 P’s conference Agra, reaching the unreached

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Adolescent Health Committee FOGSI

ADOLESCENCE Tamil Nadu is included for the school/ college project in 2010 A report by Dr. JayyamKannan from Trichy, TN, Executive Member of Adolescent Health Committee FOGSI

PCOS Workshop was held in Trichy Obst. & Gyn. society, over 100 members attended the meeting. Dr. Jaideep Malhotra ,Vice President FOGSI, Dr.Roza olyai Chairman Adolescent Committee FOGSI graced the occasion & interacted extensively with the audience. Dr. Indrani Ganguly reflected her experience on long-term sequale. Dr. Banumathy of Coimbatore high lightened the subject of cosmetics in PCOS. Dr. Charmila, spoke on metabolic sequale, followed by the presentation of Jayamkannan with her data on 900 PCOS, compared with controls, an ongoing study. President Dr.premavathy Prabhu Ilango, secretory Victoria Jhonson coordinated the meeting.

Activities of the FOGSI National PCOS project Coordinated by Dr. Jaideep Malhotra Vice President FOGSI

PCOS FOGSI workshop Jhansi, UP A symposia on PCOS was organized by Jhansi Obstetric & Gyn. Society on 18th August. Chief guest was Prof. Ganesh Kumar , Dean M.L.B. Medical College. The program was coordinated by Dr. S. Sharma President & Dr. Alka Sethi Secretary of JOGS. Dr.Jaideep Malhotra, Dr. Roza Olyai & Dr. Narendra Malhotra were the invited National faculty guest speakers.

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Kerala is included for the school/ college project in 2010 Establishing PCOD Clinics & organizing CME on the PCOS in various societies...

A National PCOS Workshop was organized at Kochi.

Secretary Dr. Gracy Thomas, President Dr. Neena Thomas, city Co-ordinaor Dr. Vijayalakshmy attended the National PCOS workshop with 220 college students & 50 doctors of KOGS. National Coordinator of this workshop Dr. Jaideep Malhotra along with Chairperson Adolescent Health committee FOGSI Dr.Roza Olyai & Dr. Gita Ganguli conducted the workshop and gave talks on various aspects on PCOS. This workshop is being continued in various schools & colleges in Kochi this year.

PCOS Seminar & Workshop Kochin, Kerala, April 2010

PCOS FOGSI Workshop Gwalior, MP As part of the PCOS National FOGSI workshop an awareness program was organized at the Cancer Hospital and Research Institute, Gwalior MP on 19th August. About 100 girls attended the lectures which was followed by a lively question & answer session moderated by Dr. Achla Sahai. The Chief Guest was Prof. Dr. S Sapre Dean Medical college Gwalior, Guests of honors were Shri Shitla Sahai Ji, Dr. B. R Shrivastava, Director of Cancer Hospital.

Following this program a CME for the doctors of Gwalior Obstetric & Gynecological society was organized at Hotel Central park. Dr. S. Sapre presided over the function, Dr. Ratna Kaul president GOGS welcomed the guests, the program was conducted by Dr. Charu Mittal and Dr. S.B.L. Shrivastava. Speakers were Dr. Jaideep Malhotra, Dr. Roza Olyai & Dr. Jyoti Bindal. Vote of thanks was given by Dr. Urmila Tripathi.

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