Adolescence Issue 04

Issue 04 | Pages 20

ADOLESCENCE

Adolescent Health Committee FOGSI

4 Pelvic Inflammatory Disease in Adolescents 5 Adolescent Endometriosis 7 WHO ASRH Expert Panel Meet Geneva 9 Reconstructive Surgery 11 Adolescence - Effect of Socio Economic Factors 13 Understanding and Meeting Needs of Adolescents 14 Vaginal Discharge in Adolescents - What to do? 15 Laparoscopy for Adolescents a voyage for the future 16 Abortion and Young People

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 From the

From the

Hon'ble Minister of State (C&I)

President FOGSI 2011

Dr. P. C. Mahapatra Professor, Obstetric & Gynecology S.C.B. Medical College, Cuttack President, FOGSI – 2011

a m ¡ ` _ ßà r d m o U ¡ ` E d ßC ⁄ m {J ^ m a V g a H $ m a

¡ ` m {o V a m o X À ` _ m . o g ßo Y ` m JYOTIRADITYA M. SCINDIA

Minister of State for Commerce & Industry Government of India

13th October, 2010

MESSAGE

My hearty congratulations to Adolescent Health Committee of the Federation of Obstetric & Gynecological Societies of India, for bringing out an informative and educative publication on adolescent health issues. I am sure this magazine will be useful informative guide to the adolescent girls, parents and doctors.

Our country is one of the youngest in the world. Our effort must be channelize the energy of youth to be creative and constructive while guiding them appropriately as they tread the path of adolescence. It is,

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.

therefore, essential that they have access to relevant, up-to-date and timely advice on such matters. This magazine is an outstanding effort of the Adolescent Health Committee FOGSI in this direction.

I extend my full support to Chairperson, Dr. Roza Olyai & her team of the Adolescent Health Committee FOGSI and congratulate them once again on their commendable efforts.

(Dr. P. C. Mahapatra)

From the

Secretary General's desk...

Dr. P. K. Shah Professor, Dept. of Obstetric & Gynecology Seth G.S.M.C. & K.E.M. Hospital Mumbai.

Jyotiraditya M. Scindia

Udyog Bhawan, New Delhi-110011 Phone : 91-11-23061194, 23062166 Fax : 91-11-23062321

The Fourth issue of “Adolescence” Magazine is in your hands. I do not recollect any committee Chairperson of FOGSI having published four issues of a magazine in the past within a year.

Efforts are being made by Dr. Roza Olyai, Chairperson of Adolescent Health Committee and her team to give you better and superior reading material compared to the previous ones. I have a unique memory of all the past three magazines and I am sure this one is even better. Superb quality of publication that will enrich the knowledge of our members. I congratulate Dr. Roza Olyai and her team of Adolescent Health Committee of FOGSI for bringing out this magazine punctually.

Dr. P. K. Shah 1

Secretary General, FOGSI

From the

From the

President FOGSI 2010

Chairperson's desk...

Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH National Chairperson Adolescent Health Committee FOGSI National Trainer Adolescent Health, FOGSI-IMA-IAP & WHO WHO Consultant Expert Panel ASRH, Geneva-2010 Convener Adolescent Friendly Health Centers India

Dr. Sanjay Gupte President, FOGSI – 2010 The adolescence magazine has become a regular feature from Dr. Roza Olyai, the Chairman of the Adolescence Committee and I'm sure each FOGSI member must be eagerly waiting for the same. All of us in small bits and pieces are making efforts to teach this young group in whatever effort we can; and I feel we must continue to do so and increase our awareness to this age. It especially has a huge meaning in our country which is reeling under a very high maternal mortality rate and large numbers of adolescent motherhood. This magazine has become a sort of a regular reminder to all of us to continue in our endeavor. I thank Dr. Roza for her efforts for actively lighting this path of enlightenment.

(Dr. Sanjay Gupte)

Dear Friends, It gives me great pleasure to share with you the fourth issue of the news magazine of the Adolescent Health Committee FOGSI. This issue will be released during the All India Congress of Obstetric & Gynecology (AICOG 2011) at Hyderabad. We have received very warm response from our dear readers not only in India but from different parts of the world & the previous issues of the magazine have been well appreciated.

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

In this issue we have covered important topics as suggested by many readers focusing on recent untouched issues like reconstructive surgery to Endoscopic surgery in Adolescents & some related social issues.

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. Recently I had the privilege to represent the International Federation of Gynecology & Obstetric (FIGO) in the Expert Panel meet by WHO at Geneva in making Guidelines for reducing complications related to early teenage pregnancy specially in developing countries. I am thankful to FIGO to have chosen me to represent them at this prestigious meet.

Office Bearers of FOGSI for the Year 2011 Dr. P.C. Mahapatra President Mobile : 09437013591 ctk_purnam@sancharnet.in

Dr. Nandita Palshetkar Vice President No. 1 Mobile: 9820032315 nanditapalshetkar@hotmail.com

Dr. Milind Shah Vice President No. 2 Cell : 098220 96280 drmilindshah@gmail.com

Dr. Mala Arora Vice President No. 3 Mobile:09818676801 drmalaarora@noblehospital.com

Dr. Krishnendu Gupta Vice President No. 4 Mobile : 9830049388 Krisim007@gmail.com

Dr. Gupte Sanjay Anant Immediate Past President guptehospital@rediffmail.com / guptehospital@gmail.com

Dr. P.K. Shah Secretary General President Elect - 2012 Mobile : 9323803665

Am very grateful to Hon'ble Minister of State for Commerce & Industry Government of India, Shri Jyotoraditya M. Scindia for his constant encouragement & support towards the activities am involved with & also by sharing his message with our readers. His loving adorable wife Mrs. Priyadarshini Raje Scindia has been a constant support to my activities towards the Adolescent health programs for which am thankful to her.

nsheriar@vsnl.com

Sharing information & updating our knowledge from time to time is very important & am glad through this magazine the Adolescent Health Committee FOGSI is able to achieve this. Am very grateful to Emcure Pharma, specialy 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.

Dr. Hrishikesh D. Pai Treasurer Mobile : 9820057722

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.

ifumb@bom5.vsnl.net.in

Dr. Nozer Sheriar Deputy Secretary General Mobile : 9821097536

hdpai@hotmail.com

Wish you all a happy reading!

Dr. Janmejaya Mohapatra Jt. Secretary Mob: 09437020333 dr.janmejayamohapatra@ hotmail.com

Dr. Roza Olyai National Chairperson Adolescent Health Committee FOGSI 2

Adolescent Health Committee FOGSI

ADOLESCENCE From the

Director General IPPF

From the

Vice President FOGSI Dr. Nandita P Palshetkar Vice President FOGSI Hon Secretary - AMOGS (2010-2012) Managing Committee Member – IAGE & ISAR Medical Director - Bloom IVF, Lilavati Hospital, Mumbai.

Dr. Gill Greer Director General of the International Planned Parenthood Federation (IPPF) Dear Dr. Olyai, I have gone through the previous issues of the Adolescence Magazine Published by you & I found it extremely informative, academically rich & tastefully designed. Must congratulate you & your team for doing such wonderful work.

We at IPPF are working towards many aspects of Reproductive health issues & one such area is Unsafe abortions. Unsafe abortion is a major public health and human rights problem that disproportionately affects young women and girls. Working towards a meaningful and sustainable solution to this issue is one of IPPF’s core commitments as a global service provider and a leading advocate of sexual and reproductive health and rights for all.

As such, when it comes to issues such as sex and reproduction, we know that young people need health care programmes and providers that are informed about the realities of young people’s lives and that adopt an approach which respects young people’s dignity and autonomy. Through our global network of youth friendly clinics and continued efforts to ensure access to comprehensive sexuality education, IPPF Member Associations play a key role in upholding the sexual and reproductive health rights of young people.

Moreover, having gained an indicator for young people – the adolescent birth rate – under Millennium Development Goal 5b, universal access to reproductive health, we now have even more opportunities for ensuring that young people’s sexual and reproductive health needs and rights are not forgotten. With young people as partners and by investing in them, we have the chance to ensure individual, family and community health and wellbeing.

To achieve this, we must act now to ensure the development, implementation and monitoring of policy and programmes that meet the needs of young people, including the provision of comprehensive sexuality education.

Looking forward in collaborating with you in this regard.

Regards, Dr.Gill Greer Director General of the International Planned Parenthood Federation (IPPF) 4 Newhams Row London SE1 3UZ

3

Adolescence is a time of major transitions and rapid changes, when young people develop many habits, patterns of behavior, and relationships that affect not only the functioning and opportunities of adolescents themselves, but also the future quality of their adult lives.

The three leading causes of death in adolescents - motor vehicle crashes, homicide, and suicide - are all tied to risky or unhealthful behaviors.

Same time, adolescence is also a critical period for developing positive habits and skills that create a strong foundation for healthy lifestyles and behavior over the full life span.

For many adolescents, health services are not accessible,appropriate, effective, or equitable.

One must appreciate the fact that Dr. Roza Olyai, Chairperson of the Adolescent Health Committee FOGSI has spearhead the adolescent Health Committee to greater heights, whose work speaks in length about her as a sincere and a dedicated FOGSI member, needs to be applauded.

She has been working tirelessly towards the goal of achieving a healthy adolescent.

Congratulations to Dr. Roza Olyai & her team for bringing up such an informative & tastefully designed magazine.

Dr Nandita P Palshetkar

Meeting with Jt. Sec. MHFW, Govt. of India Guidelines are set for Establishing Adolescent Friendly Health Centers (AFHCs), formulated by Adolescent Health Committee FOGSI in consultation with WHO in accordance with the Government of India guidelines.

Mr. Amit Mohan Prasad. Joint Secretary, Ministry of Health & Family Welfare, Government of India has given his support and encouragement to adapt the National Standards of Adolescent Friendly Health services and extend appropriate services in the private sector.

The establishment of these AFHCs is a part of the National Project by the Adolescent Health Committee FOGSI in collaboration with FIGO. Dr. Roza Olyai, Chairperson of the Adolescent Health Committee FOGSI is the Convener of these health centers.

Abortion and Young People Kelly R. Culwell MD MPH Senior Adviser, Abortion Upeka de Silva Programme Officer International Planned Parenthood Federation Central Office London, UK Unwanted pregnancy and abortion are topics which are highly stigmatized and rarely discussed and the needs of young women in particular are often not addressed because of reluctance towards accepting their sexuality. As a result, societies are often horrified by an unmarried young woman who is sexually active, who is or is not using contraception, becomes pregnant, becomes a young mother out of wedlock or seeks an abortion. This leaves young women in a no-win situation.

Negative societal attitudes towards young people's sexuality are one of the biggest barriers to achieving young women's sexual and reproductive health rights. This leads to young people becoming sexually active without access to accurate and comprehensive information and services to help them adopt safe and satisfying sexual practices. Young women often lack information on contraception, recognizing pregnancy, the legal status of abortion in their countries and where to go for safe services. Even where adolescents are aware of contraception and safe abortion services, they often cannot easily obtain such services either because they lack the financial means to do so or because they live in countries that require parental consent or set a minimum age for obtaining the services. There is also a serious lack of comprehensive youth friendly services provided by supportive staff (see Box 1). Even when providers aim to be youth friendly, societal attitudes against premarital sex may lead them to focus counselling efforts on the need for young people to avoid sex rather than address young women's contraceptive needs.

Unwanted pregnancies for young women may also occur within marriage. This is particularly significant in South Asia, where 32% of 15-19 year olds are married. Married adolescents may not face the same stigma when faced with an unwanted pregnancy as unmarried young women do. However, the stigma of abortion remains and married young women may face barriers in access to safe abortion services such as lack of financial independence or mobility and mandatory spousal consent.

BOX 1: Youth friendly services Youth friendly services (YFS) are able to effectively attract adolescents, responsively meet their needs, and successfully retain these young clients for continuing care. YFS build on existing resources, facilities and providers and reach youth through a variety of channels. Some essential elements that make sexual and reproductive health services youth friendly include: convenient hours, privacy, competent staff that respect youth and can provide information in language that is easily understood by young people and an accepting environment for asking difficult questions about sex, sexuality, and relationships. YFS offer a wide range of sexual and reproductive health services, ideally in the same clinic. These services should include sexual and reproductive health counselling, contraceptive counselling and provision (including emergency contraception), sexually transmitted infection/HIV prevention, counselling and testing, treatment and care, prenatal and post-partum care, sexual abuse and gender-based violence assessment and counselling, relationship counselling, and safe abortion and abortion-related services. Most importantly, youth friendly service delivery is about providing services based on a comprehensive understanding of what young people in that particular society or community want, rather than being based only on what providers believe they need.

It is also tragic reality that many unwanted pregnancies which may end in abortion or unwanted birth occur after forced intercourse or violence, especially for women who are young or in other vulnerable circumstances. A multi-country study conducted by WHO found that the younger the girl was at the time of sexual initiation, the more likely she was to report her first sexual intercourse was a result of force or coercion. In 8 out of 12 sites of the study, including rural and urban sites in Bangladesh, Namibia, Peru, Samoa and Tanzania, more than 30% of women who reported having had their first sexual experience before the age of 15 years described that sexual experience as forced.

Women in the same sites who reported their first sexual experience between ages 15-17 years described that sexual experience as forced in greater than 13% (and up to 28%) of cases.

The result of these factors is that deaths and injuries from unsafe abortion disproportionately affect young, poor and other socially excluded groups of women. Adolescents are more likely than adults to delay an abortion (due to personal, societal and legal barriers), to resort to unskilled persons to perform it, to use dangerous methods in attempts to self-induce an abortion and to delay seeking care when complications arise after unsafe abortion. In developing regions 46% of the deaths resulting from unsafe abortion occur among young women below the age of 24. Almost 60% of unsafe abortions in Africa and over 30% in Asia (excluding eastern Asia) are among women under age 25. These statistics no doubt contribute to the fact that although adolescents aged 10-19 years account for 11% of all births worldwide, they account for 23% of the overall burden of disease (disability-adjusted life years) due to pregnancy and childbirth. In some countries, complications of unsafe abortion are the leading causes of death among adolescent women as in Nigeria, where a study found that 72% of all deaths among women under 19 were due to consequences of unsafe abortion.

However, when young women are supported to make their own decisions about the outcome of a pregnancy taking into account their evolving capacities and best interests, they are less likely to face the negative consequences of unsafe abortion or being forced or coerced to have an abortion or to carry the pregnancy to term.

In light of the above and in line with its commitment to increasing access to safe abortion and upholding young women's sexual and reproductive health rights, IPPF will continue to • Invest in prevention by ensuring access to affordable and reliable contraception, particularly for poor, marginalized and socially excluded young people.

• Support abortion related research activities that contribute to evidenced based advocacy and awareness raising efforts.

• Build the confidence and skills of service providers to deliver youth friendly sexual and reproductive health services, including comprehensive abortion care services and rigorously monitor the quality of the services provided, ensuring that additional barriers which do not exist in the law (such as mandatory parental or spousal consent) are not added.

• Provide high quality, compassionate post-abortion care as a minimum abortion-related service 4

Adolescent Health Committee FOGSI

ADOLESCENCE • Ensure access to quality non-judgemental and affordable abortion services including post-abortion counselling & contraception.

• Promote comprehensive sexuality education programmes with focus on gender equality and sexual rights and ensure accurate information on abortion is integrated into these programmes • Build the capacity of both adult and youth activists, to advocate for increased access to youth friendly sexual and reproductive health services, including safe abortion services • Challenge laws and policies that place barriers to young women's access to contraceptive services and safe abortion, including blanket age of consent requirements which do not acknowledge the very different circumstances of adolescents' lives and the concept of evolving capacity of young women.

• Let it not become a forgotten fight – promote a zero tolerance approach to unsafe abortion.

We will work with other committed professionals, partners and young people towards a world in which young women's choices are respected and their right to the highest attainable standards of sexual and reproductive health is realized.

References : Klingberg-Allvin M et al. 2006. Perspectives of midwives and doctors on adolescent sexuality and abortion care in Vietnam. Scand J Public Health. 34(4): 414-21.

Population Reference Bureau. 2006. The world's youth: 2006 data sheet. Washington DC. PRB. p 15. http://www.prb.org/pdf06/Worlds Youth2006DataSheet.pdf World Health Organization. Multi-country study on women's health and domestic violence against women: initial results on prevalence, health outcomes and women's response. Geneva; World Health Organization: 2005. Available at: http://www.who.int/gender/ violence/who_multicountry_study/en/index.html Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. -- 5th ed. WHO http:// www.searo.who.int/LinkFiles/Publications_Unsafe_Abortion.pdf Shah I and Ahman E, Age Patterns of Unsafe Abortion in Developing Country Regions, Reproductive Health Matters 2004 12 (24 Suppl) 9 – 17 World Health Organization. Why is giving special attention to adolescents important for achieving Millennium Development Goal 5?

Adolescent pregnancy fact sheet. Geneva, 2008 http://www.who.int/ making_pregnancy_safer/events/2008/mdg5/adolescent_preg.pdf Shane B. Family Planning Saves Lives. 3rd ed. Washington, DC: Population Reference Bureau, 1997.

A wise physician said to me, "I have been practicing medicine for 30 years and I have prescribed many things.

But in the long run I have learned that for most of what ails the human creature, the best medicine is "LOVE.."

"What if it doesn't work..?" I asked..

"Double the dose" he replied...

5

Pelvic Inflammatory Disease in Adolescents Dr. N. Sanjeeva Reddy Professor and Head Dept of Obstetrics and Gynaecology Sri Ramachandra Medical College and Research Institute Sri Ramachandra University Chennai, TN President Obstetrics and Gynaecological Society of Southern India Pelvic Inflammatory disease (PID) is defined as an acute clinical syndrome attributable to the ascent of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, or contiguous structures that result in pelvic and generalized peritonitis.

PID in postmenarcheal girls is a common problem, although the etiology is unknown, the organisms are thought to spread hematogenously, lymphatically, or transmurally from intestines or ascending infection from the vagina. PID occurs primarily in sexually active adolescents at risk for developing ascending infection acquired from STDs. ETIOLOGY : Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in most cases of PID. However, other organisms, such as anaerobes, including Bacteroides species, Pepetostreptococcus species, Gardenella vaginalis, Haemophilus influenza, streptococcus species and enteric gram negative bacilli, genital tract mycoplasmas, including mycoplasma hominis and Ureaplasma urealyticum and cytomegalovirus also are associated with PID. Polymicrobial infection is common.

EPIDEMIOLOGY : The incidence of PID is highest among adolescents and young adults. Bacterial vaginosis is present in many cases of PID. Risk factors for PID include numerous sexual partners, use of intrauterine device in the presence of an existing infection , douching, and previous episodes of PID. Latex condoms may reduce the risk of PID. Other barrier contraceptive methods, such as contraceptive sponge and diaphragm, also have shown to be effective in preventing transmission of STIs. Oral contraceptive pills decrease the incidence.

DIAGNOSIS : The diagnosis of PID usually is made on the basis of clinical findings and supported by laboratory reports.

Ultrasonography and Laparoscopy are useful in differentiating conditions like appendicitis, Ruptured Ovarian Cyst and Ectopic Pregnancy.

The classic manifestation of acute PID is lower abdominal pain, which usually is bilateral and continuous and may worsen with movement.

After the onset of abdominal pain, fever, nausea, and vomiting can develop. The temperature may reach 39°C to 39.5°C. Other common symptoms include vaginal discharge, irregular vaginal bleeding, and urinary symptoms.

On physical examination the patient usually looks sick and uncomfortable. Abdominal examination reveals a tender and tense lower abdomen.

Rebound tenderness indicates generalized peritonitis. The genital examination may show a purulent vaginal discharge. Bimanual rectovaginal abdominal palpation causes great distress. Cervical movement is extremely tender and the Uterus is tense and tender. Palpation of the adnexa may be exceptionally painful.

Common laboratory findings include a leucocytosis greater than 10,000/mm³ and ESR greater than 15mm/hr. Ultrasonography can be useful in ruling out other conditions and defining adnexal masses.

The clinical diagnosis of PID is made by having a high index of suspicion of this. The Clinical criteria developed by Jacobson and Westrom and revised by Centers for Disease Control and Prevention are recommended to aid in making diagnosis.

Clinical Criteria for the Diagnosis of Acute Pelvic Inflammatory Disease Minimal Criteria : Lower abdominal or pelvic pain with one or more of the following :

Uterine, adnexal or cervical motion tenderness.

Additional criteria to enhance specificity : Temperature >101°C, Abnormal cervical or vaginal mucopurulent discharge, Presence of WBCs in vaginal secretions, raised ESR, Elevated C-reactive Protein, Laboratory documentation of cervical infection with Neisseria gonorrheae or Chlamydia Trachomatis.

Specific Criteria : Endometrial biopsy with evidence of endometritis, TVS or MRI showing thickened fluid filled tubes or tuboovarian complex.

Laparoscopic abnormalities consistent with pelvic inflammatory disease.

Differtial Diagnosis : Urinary tract conditions : Cystitis, Pyelonephritis, and Urethritis, Gastrointestinal tract Conditions : Appendicitis, Constipation, Diverticulitis, gastroenteritis, inflammatory bowel disease, and irritable bowel syndrome.

Gynecologic Conditions : endometriosis, endometritis, mittleschmerz, torsion or rupture of an ovarian cyst, ruptured follicle, septic abortion, threatened abortion, and pyogenic sacroiliitis.

TREATMENT : The major goals of treatment of PID are preservation of fertility and prevention of long-term sequelae. The earliar the treatment is initiated, the lower the risk of developing infertility. After one episode, the risk of infertility ranges from 8 to 13 percent; after two episodes, the risk is 20 to 35 percent; and after three or more episodes, it is 40 to 75 percent.

Because the clinical diagnosis of PID is imprecise and the consequences of untreated infection are substantial, most experts provide antimicrobial therapy to patients who fulfill minimum criteria rather than limiting treatment to those who fulfill additional criteria for the diagnosis of PID. The use of broad-spectrum antibiotics to treat polymicrobial disease, careful clinical re-evaluation 48 hours after initiating antibiotic treatment of sexual partners are important.

Patients with PID are often treated on an ambulatory basis. The primary reason to hospitalize an adolescent with PID is to ensure compliance with medication when she is unable to follow or tolerate an outpatient oral regimen because of the seriousness of the sequelae and problems with compliance in this age group. Other reasons for for hospitalization are an uncertain diagnosis, the presence of tuboovarian abscess, pregnancy, infection with HIV, temperature greater

than 38.5°C, nausea and vomiting precluding the use of oral medications, and lack of improvement after 48 hours of oral antibiotic treatment.

The recommendation of PID treatment in Ambulatory and hospitalized treatment are as follows: Ambulatory management of PID Ceftriaxone, 250 mg. IM in a single dose or cefoxitin 2 g IM in a single dose, plus probenecid 1 g orally in a single dose , plus doxycycline 100mg PO two times a day for 14 days with without metronidazole 500 mg PO twice a day for 14 days.

Inpatient Treatment of PID Regimen A : Cefoxitin 2 g IV every 6 hr or Cefotetan 2 g IV every 12 hr plus doxyxycline 100 mg every 8 hr PO or IV. RegimenB: Clindamycin 900 mg IV every 8 hr plus Gentamicin loading dose IV or IM (2 mg/kg) followed by a maintenence dose (1.5 mg/kg) every 8 hr for a total of 14 days.

In patients treated orally or parenterally, clinical improvement can be expected within 72 hours after initiation of treatment. Accordingly, outpatients should be reevaluated routinely on the third or fourth day of treatment.

CONTROL MEASURES : • Male sexual partners of patients with PID should receive diagnostic evaluation for gonococcal and chlamydial urethritis and then should be treated.

• The patient should abstain from sexual intercourse until she and her partners have completely treated.

• The patient and her partners should be encouraged to use condoms consistently.

• The patient should be tested for Syphilis and HIV infection.

• Because of the risk of reinfection , patients with PID whose initial test for Neisseria and Chlamydia was positive be retested 3 months after completing the treatment.

• Unimmunized or incompletely immunized patients should complete human papillomavirus and hepatitis B immunization.

• The diagnosis of PID provides an opportune time to educate the adolescent about prevention of STIs, including abstinence, consistence use of barrier methods of protection and the importance of receiving periodic screening for STIs.

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6

Adolescent Health Committee FOGSI

ADOLESCENCE Adolescent Endometriosis Current Concepts of Management Dr. Krishna Kavita Ramavath Mayo clinic Visiting Clinician Department of Gynecology Gynecological surgery Scottsdale, Arizona 85054, USA Introduction Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature.

Fig. 1 - Protocol for Evaluation and Treatment of Adolescent Pelvic Pain or Endometriosis:

Prevalence It is seen in 50% of the teenagers undergoing laparoscopy for evaluation of chronic pelvic pain and dysmenorrhea.

Proposed Theories There are many theories proposed for the origin of endometriosis but no one theory accounts for all presentations of endometriosis.

Sampson's theory of retrograde menstruation is supported by the observation of endometrium at the dependent portions of the pelvis.

Though other theories propose various ways, the most recent theories implicate an immune mechanism and suggest a deficiency in the cellular immunity allows ectopic endometrial tissue to proliferate.

Natural Killer cell activity may be reduced, resulting in decreased cytotoxicity to autologous endometrium. Secretion of various cytokines by endometrial implants and oxidative stress may lead to inflammatory reaction.

The possibility of familial tendency cannot be ruled out as women with a first degree relative have 7%higher likelihood of having endometriosis than unrelated population.

Clinical Features In adolescent endometriosis population the presenting pelvic pain is often both cyclic and or acyclic.

Symptoms of Adolescents with Endometriosis Table 1:The common presenting symptoms in the adolescents: PRESENTING SYMPTOMS Acyclic and cyclic pain Cyclic pain Gastrointestinal pain Urinary symptoms Irregular menses Vaginal discharge

PERCENT 62.5% 28.1% 34.3% 12.5% 9.4% 6.3%

Initial evaluation includes a thorough history, a pain diary documenting severity of pain, relation to bowel and bladder, missing school and social activities, indicates a need for intervention.

Physical Examination The goal should be to determine the etiology of pain and to rule out ovarian tumor or torsion or anomalies of the reproductive tract.

Adolescents tolerate recto-abdominal examination better. A Q-tip inserted in the vagina documents a patent vagina without transverse vaginal septum. An ultrasound examination is invaluable in aiding diagnosis of a pelvic mass or a structural anomaly.

Lab Studies Pregnancy test, CBC(complete blood tests),ESR(Erythrocyte Sedimentation rate),Urine analysis, Culture &sensitivity,CA125 Levels in a known case of Endometriosis to follow the disease, Ultrasound, CT Scan with contrast to rule out an appendicitis, and MRI(optional

7

NSAID: Non-steroid anti-inflammatory drugs HT: Hormone Therapy (Oral contraceptive pills, estrogen or progestin patch or ring) GnRH: Gonadotropin releasing hormone Add-back: Estrogen + Progestin or norethindrone acetate alone Fig-1: Management algorithm for the evaluation and treatment of pelvic pain or endometriosis Classification In 1979,American Society of Reproductive Medicine (ASRM), introduced the current classification system and revised in 1996.The system assigns point score based on the size, depth and location of endometriotic implants and associated adhesions.

Typically endometriosis is classified as Minimal, Mild, Moderate or Severe.

Stage 1: Minimal Isolated implants;no significant adhesions Stage 2: Mild Superficial implants less than 5cms in aggregate scattered on the peritoneumand ovaries. No significant adhesions are present.

Stage3: Moderate Multiple implants,both superficial and invasive.Peritubal ,periovaian adhesions may be evident.

Stage 4: Severe Multiple, superficial and deep implants, including large ovarian endometriomas. Flimsy and dense adhesions are usually present.

Treatment Treatment should be individualized. Pain may persist despite medical and surgical interventions. A multidisciplinary approach involving a pain counselor early in the treatment should be considered.

Initial treatment with NSAIDS, and OCP'S is recommended as they decrease the pain intensity due to hormonal suppression.

Adolescents with disabling chronic pelvic pain for 36months,interfering with school and social activities should be subjected to laparoscopic evaluation.

environment and is highly efficient in treating endometriosis. Due to the significant androgenic side effects like weight gain, decreased breast size, depression, acne, hirusitism and irreversible deepening of voice,it is poorly tolerated by adolescents and hence not widely used in the management of endometriosis.

Progestins : Progestational agents include norethinderone acetate(15mg daily orally),Medroxy progesterone acetate(30 -50 mg daily,orally)and depot medroxy progesterone acetate(150mg IM every 1 to 3 months),each of which will improve symptoms in approximately 80%-100%.The long term use may result in loss of bone density and hence monitoring of serum estradiaol and or bone density is advised.

GnRH Agonists : Adolescents above 16years can be given Depot Leupride acetate 11.25mg IM every 3 months. This causes amenorrhea and hypoestrogenic state in 90% of patients. Routine use is not indicated in women below 16years.OCP'S should be continued after completion of this treatment .

Due to its primary concerns of adverse effects on final bone density formation, routine administration of empiric GnRH agonist therapy is not recommended in young women under the age of 18years.

Nafarelin (Nasalspray):One puff twice daily,intranasally ia na laternative GnRHagonist.

Surgical Diagnosis

GnRH side effects can be alleviated by ''add-back therapy''.

Definitive diagnosis is by Operative laparoscopy. Staging should be done at the same time to facilitate follow up and comparison in future.

Cul-de-sac biopsy rules out the microscopic disease. Most commonly found lesions in these adolescents are:

Conclusion

1. Red flame lesions 2. Peritoneal Alan Masters windows 3. Clear Vesicular lesions Surgical Treatment The goal of surgery in these adolescents is to excise all the visible endometriotic lesions and associated adhesions, peritoneal lesions and ovarian cysts and to restore a normal anatomy.

Operative laparoscopy and resection of the endometrial implants through endo coagulation or laser is the most effective way of treatment and it gives a pain relief of 38% to 100%.Microscopic residual disease needs medical management.

Role of Robotics in The Minimally Invasive Surgery Much attention is now paid to the promise of Robotic surgery. The application of Robotics in technically challenging operations like endometriosis with dense adhesions and many other gynecological tumors in the adolescents is safe and effective alternate to laparotomy.

This is being confirmed by many studies in the literature.

• Coping with endometriosis as a chronic disease is an important component of management.

• Empiric treatment includes NSAID'S and Hormonal Therapy.

• Definitive diagnosis is by laparoscopy and the minimally invasive surgical management is revolutionized by the introduction of Robotic technology with superior benefits to the patient and the operating surgeon.

• Medical management is achieved through hormonal suppression.

• Alternate therapies like Acupuncture and herbal medicine may be helpful in pain management.

• A multidisciplinary approach is always helpful to improve the quality of their lives. The website www.endometriosis.org/ support.html provides the list of all self-help groups in the world.

Regular Radio talk show & CME to create awareness towards Adolescent Sexual Reproductive Health in Gwalior being organized jointly by Adolescent Health Committee FOGSI & Gwalior Obstetric & Gynecological Society.

Reported by Dr. Ratna Kaul, President GOGS.

Robotic technology facilitates the surgical approach better in comparison to laparoscopy. Patients benefits include less post operative pain, quick return to normal activities and highly aesthetic as there is no negative body image due to minimal invasion.

The da vinci surgical system utilizes robotic technology to optimize surgical visualization and performance. Three dimensional viewing aids in depth perception and optic magnification and improves precision in ablating endometriotic implants. Instrument articulation allows for seven degrees of freedom for difficult dissection and eliminates tremor interference.

Robotic surgery is the most important advancement of the millienieum in minimally invasive techniques. It gives improved convalescence, favourable aesthetics and outcomes for the adolescent population with endometriosis.

Medical Treatment The goal is to treat pain from post operative residual disease and suppress progression. NSAID'S and OCP'S to women less then 16 years are usually the first line therapy.

OCP'S : They can be safely used for atleast 10years without an associated increase in mortality. Contraceptive patch and vaginal rings also have the same benefits.

Danazol: It is a 17-α ethiny testosterone derivative. It creates acyclic 8

Adolescent Health Committee FOGSI

WHO Adolescent Sexual Reproductive Health Expert Panel Meet Geneva, Switzerland

ADOLESCENCE

Dr. Roza Olyai, National Chairperson Adolescent Health Committee FOGSI, Convener Adolescent Health friendly centers FOGSI represented the International Federation of Gynecology & Obstetric (FIGO) at the WHO Expert Panel meet at Geneva, Switzerland on 2nd & 3rd Nov. 2010.

The Department of Child and Adolescent Health and Development, WHO had organized a meeting of Experts on making guidelines for "Preventing early pregnancies & poor reproductive outcomes among adolescents in developing countries". The overall purpose of the meeting was to present the summary of the evidence distilled from many systematic reviews and to discuss the draft WHO global recommendations for this area of work. This is the result of the 2009 working process in which FIGO had participated as an expert for scoring the critical outcomes and reviewing the key questions.

The meeting brought together a group of global experts in the field including academics, researchers, policy makers, professional associations, programme managers and partners. Guidelines were reviewed finally amongst the Experts & later will be launched in three International conferences Globally. On behalf of FIGO, Dr. Roza Olyai has assured WHO that FIGO will be jointly involved in collaborating with WHO in the launch of these guidelines Globally & will give its full support towards these activities.

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Participants were asked to comment on the evidence used to inform the Guidelines; advise on the interpretation of the evidence, with consideration of the overall balance of risks and benefits; and agree on final recommendations, taking into account diverse values and preferences. The overall objectives were to provide evidence-based recommendations for each of the topics on the agenda; identify key research gaps relevant to each topic; and agree on key elements of a plan to disseminate the new guidance and to identify key partners for this purpose.

There were 40 participants from various International organizations & NGOs like IPPF, Family care InternationalUSA, UNFPA, USAID Global Health Fellows Program, Guttmacher Institute, Pathfinder, Johns Hopkins Institute, FIGO etc. along with Health Ministry representatives from Australia, U.S.A., Philippines, Finland, Chile, Brazil, Uruguay, France, Switzerland, Nepal, Tanzania, Kenya, Egypt, Uganda, etc.

FIGO Chief Executive Hamid Rushwan said : ‘FIGO is currently in the process of holding several ASRH workshops - funded by the United Nations Population Fund (UNFPA) - across the world; therefore these issues are extremely high on our agenda. We are grateful to Dr. Roza Olyai for her excellent representation at this crucial event.’

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Adolescent Health Committee FOGSI

ADOLESCENCE Reconstructive Surgery for Congenital Atresia of The Uterine Cervix in Young Adolescent Girls : Looking Beyond Hysterectomy

Dr. Dipika Deka Professor Department of Obstetrics & Gynecology, AIIMS, New Delhi Atresia of the uterine cervix is an uncommon Müllerian anomaly. In the presence of a uterine corpus with functional endometrium, blood collects in the cavity after puberty resulting in significant cyclic abdominal pain, reflux of blood retrograde through fallopian tubes, causing intra abdominal adhesions, chronic salpingitis / hematosalpinx and endometriosis. Ovaries, karyotype are normal.

According to the AFS classification, typeI includes all cases of hypoplasia/agenesis; congenital agenesis or dysgenesis of uterine cervix are further subclassified as type IB (American Fertility Society, 1988). Further they have been organized into four categories: cervical agenesis, cervical fragmentation, cervical fibrous cord and cervical obstruction. Cervical agenesis is often associated with upper or complete vaginal aplasia, but in cervical dysgenesis, vaginal aplasia is an unusual finding. Hydrosalpinges, firm adhesions, ovarian endometriotic cysts, and frozen pelvis due to endometriosis in neglected cases, combined in many of these patients with the coexistence of further Müllerian abnormalities, do not offer a favourable prognosis in these cases.

In the presence of functional endometrium, the traditional treatment described is hysterectomy with construction of a neovagina, as it is extremely difficult to maintain patency of neo-cervix. Hysterectomy is also recommended for rudimentary uterine horns with functioning endometrium, and unsuccessful Cervical reconstructions.

However, even in the presence of severely damaged tubes, the restoration of the uterovaginal route and preservation of the uterus offers the possibility of applying IVF for achieving a pregnancy, and very importantly in a country and society of India – the mere presence of menstruation is very salient. Also, the presence of an intact upper female genital tract (corpus uteri, tubes and ovaries) pose a unique therapeutic challenge to restore normality. Conservative surgical management of adolescent girls with these malformations remains controversial. Surgery to preserve fertility has been thought to offer little chance of success at great risk and had not been often attempted.

Surgical approaches involve uterovaginal anastomosis, cervical canalization, and cervical reconstruction. There are very few reports or case series of conservation of the uterus resulting in menses and even pregnancy.

In cases of cervical dysgenesis, where a part or the whole cervix with mucus, if intact and functional cervical segments are present, the

operation consists of an anastomosis or canalization. But in cases of cervical agenesis, where the cervix is absent or there is no functional cervical part, uterovaginal anastomosis - restoration of the genital tract is by direct suturing of the isthmus uteri to the vagina and cervical reconstruction (creation of neocervix). In girls with coexistent vaginal atresia, vaginoplasty - creation of a neovagina is necessary.

At AIIMS, we studied the reproductive outcome of Conservative surgical management of patients with cervical agenesis and functioning uterus in thirty-five young adolescent girls with severe dysmenorrhoea due to hematometra as a result of non-canalised or absent cervix in the presence of functioning uterus, seen over a period from 1997-2010 (Jan). Age at presentation was 11- 21 years (mean 13 yrs), only two women presented at age 25 years. Various types of anomalies and the type of reconstructive surgery performed are shown in Fig. 1.

The chief complaints were: severe cyclical pain abdomen - 35 cases, primary amenorrhoea - 33 cases, normal flow but severe dysmenorrhoea - 2 cases (uterus didelphys, patent cervix in 1 uterine horn, patent vagina) Ten girls had history of previous reconstructive surgery outside, 1-3 times : vaginal approach -5, abdomino – perineal approach in 4, and laparoscopy – 1. Vaginoplasty done alone, with persisting hematometra was seen in 3 cases and restenosis of vagina had occurred in 2 of these 3 cases.

Previous Complications were : vaginal restenosis in all 10, rectovaginal fistula in one case, keloids of skin grafts in 3 girls, black hairy vagina due to skin graft in one girl .

On Clinical examination, all girls had normal secondary sexual characteristics, tender mass of varying sizes in the hypogastrium.

Vagina was blind in most ULTRASOUND showed hematometra, with or without hematosalpinx. MRI was performed in 11 cases to confirm the diagnosis. Examination Under Anesthesia (EUA) was done prior to definitive surgery if required.

Associated vaginal anomalies were very common, there was complete vaginal atresia in 31(89%), partial vaginal atresia in 2, normal vagina in 2 girls.

Procedure of Cervical reconstruction (with or without vaginal reconstruction) : Cervico-Vagino-Plasty (CVP) was attempted in these girls, first by vaginal route under Ultrasound or Laparoscopic guidance, with resort to laparotomy if required.

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Fig. 1 – Atresia/Dysplasia of cervix with functioning uterus; Showing various types of utero - vaginal anomalies and Reconstructive surgery.

Neo - vagina was created and attempt was made to reach cervix from below. If difficulty was encountered, to avoid risk of injury to bladder and rectum laparotomy was done. An opening was made at the lower end of the uterus. It was then connected and anastomosed to the upper end of the neocervix. To keep the cervix and vagina patent, a cervical stent through vaginal mould made of foam was used. The foam mould was replaced by glass mould through which the cervical stent could be passed, after about a week when vaginal epithelisation had occurred. The cervical stent was changed at intervals of 6 months, and the vaginal mould was kept for 2-3 years.

Complications : Intraoperative : Bladder injury - 3, Rectal injury – 1. All repaired in same sitting, no long term complications.

Reproductive Outcome : Successfully reconstructed Utero – Cervico – Vaginal tract – 31 / 35 cases. No functional uterus, normal neo-vagina -rest 4 cases. Normal menses established - 31 /31 successful cases. Married-6, Infertility4, dyspereunia-nil. Pregnancy – 2 cases, one had 2 preterm Cesarean Sections for cervical factor, later hysterectomy at 28yrs age for DUB (inaccessible cervix, vagina); another case had spontaneous abortion at 10 weeks of pregnancy.

I.

Cervical Absence / Aplasia / Agenesis (17 Cases)

II.

Cervical Dysgenesis (14 Cases)

III. Cx Agenesis (Cervicoplasty/metroplasty not done – cavity minimal, poor prognosis) Cervical Stents used have ranged from Foley's catheter 3, Mallecot's catheter 18, Karman cannula 3, Cu-T 2, PCN cannula - 5 Vaginal mould / graft need to be used 7 : Split skin thickness graft with foam mould - 2, Amnion with glass mould - 6, Amnion with foam mould – 12, Surgicele with foam mould - 9

On follow-up (1yr - 13 years) : Repeat procedures - abdominoperineal Cervico-vaginoplasty- 4, ultrasound guided cervicovaginoplasty – 1, Hysterectomy – 1 case, Pyometra – 1 case.

Premature menopause (chromosomal factor Turner Mosaic), has withdrawl bleeding to hormone replacement therapy – 1 girl.

Hysterectomy - 1/ 31 successful cases; patient was from foreign country, first operated successfully, could not come for Cervical dilatation & follow-up – Cx stenosed. Repeat Cx-plasty, again Cx restenosed- requested hysterectomy, done.

In conclusion, hysterectomy should not be done in cases of Cervical atresia with functioning uterus. Reconstructive surgery of cervical agenesis is a difficult but viable alternative. Coital function, menstrual cycles can be established, though pregnancy may be difficult to achieve.

Regular School Health Talks at Jamnagar Gujarat Report by Dr. kalpana khandheria, Executive Committee member Adolescent Health Committee FOGSI

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Adolescent Health Committee FOGSI

ADOLESCENCE Adolescence Effect of Socio Economic Factors Usha Krishna MD, DGO, FICS, FICOG Consultant, Breach Candy Hospital and Bhatia Hospital Past President, FOGSI and FPAI Past Prof. KEM and GS Medical College We are all conscious and aware of the medical and gynecological problems of adolescent girls as well as their problems related to pregnancies. However, many of them arise due to social as well as economic factors, which create psychological problems. Are we able to prevent these? We will have to keep trying as it is certainly a very difficult task.

Many years ago my elderly maid servant told me that she has to go and get her fourth grand daughter married. She had one son who had 4 daughters and ultimately 2 more children who were sons. The first three daughters got married at the age of 14 & 15 and when she was going to get the fourth one also married early, I stopped her from doing so and explained her the importance of delaying the marriage at least till she is 18 years. After 4 years, she came and told me that she was unable to find a husband for the fourth daughter as she was too grown up and therefore required more dowry for which I should help her.

Even today, child marriages are not uncommon, especially in certain states like Rajasthan, UP, Bihar etc. The deep rooted tradition continuous unabated in several parts of Rajasthan despite a legal ban, last year at Bataru village of Barmer, a mass wedding of 48 children took place amidst celebrations, but no action was taken against the organizers. Official figures say that in Rajasthan, close to 68% girls are married off by the age of 18 – (Times of India, October 2010) Good nutrition is often neglected as boys get priority as nourishing food is served. Nutrients, vitamins, folic acid, calcium, iron, etc. are often insufficient and as high as 60% – 70% of young girls are anemic.

The problem continues through the child bearing age, and anemia is the most important complications causing maternal mortality and morbidity. Besides calcium deficiency will later develop causing osteopenia and osteoporosis, which makes Indian women vulnerable to fractures in their later age.

Discrimination against the female starts even before birth and continues through adolescence and adulthood. Hopefully, the attitudes of the community, the medical system and stringent laws may change the picture. The tradition of early marriage and consequent early child bearing among girls still prevails in our country.

Almost 30 percent of women age 15-19 are married. These girls have chances of anemia and its consequences such as premature birth, complications during labour and restrictions of fetal growth. Even maternal mortality is about 2-5 times more as compared to women who are pregnant between 18-25 years.

Termination of unwanted pregnancies through induced abortions leads to greater risk to health and life as the young women often resort to unqualified practitioners in clandestine and dangerous circumstances. Such unsafe abortions lead to complications like trauma, hemorrhage, septicemia, tetanus and even maternal mortality as well as long-term morbidity and infertility. Unprotected sex in adolescence has the risk of infection and the major STDs are gonorrhea, Chlamydia infection, syphilis, herpes and HIV/AIDs. The adolescents are especially vulnerable when they indulge in high risk behaviour. Most of the problems can be avoided by family life and sex education. We need to counsel not only the adolescent girls but also their families and community at a large.

It is not unusual to read about child abuse and it is unfortunate that although social activists are doing their best, this behaviour of some men continues to ruin the lives of many growing happy girls.

The provision of information, education and communication to young people should be linked with the health services locally available.

Therefore education and change in the attitude of community are most essential to let the adolescent girls grow into young healthy adult women with excellent reproductive health.

The socio economic problems of adolescent from well to do families in cities can be quite alarming too. The importance of parent's love and understanding is most essential to groom the young girls correctly. We do see many adolescent girls having premarital sex, drugs, and even alcohol, and using emergency contraceptive pills liberally. They are often obsessed to achieve weight loss and develop anorexia nervosa, which ruins their health. They certainly loose discretion for right or wrong and really need with love and guidance. Counselling for psycho-social problems, advice for proper lifestyle and exercise and good communication with the young girls and their parents is essential. It is often essential to refer the young girl for medical care if she has heavy menstrual bleeding causing anemia or delayed or absence of menstrual period, stunting of growth and symptoms and signs of vaginal pelvic infection.

During adolescence, the young girls need opportunities to get good nourishment, proper education and develop self esteem and decision making abilities. As this is a period of rapid, physical, emotional and psychological development and a period of adjustment with family and society, it is essential to have positive physical and mental health and appropriate attitudes.

Adolescent Health Programme at Navi Mumbai Report By Dr. Anu Vij, Secretary Navi Mumbai Obstetric & Gynaecological Society

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Many colleges were covered under the banner of the Challenges for youth project this year with the help of many doctors who had volunteered from Navi Mumbai society.We plan to have more of these activities in 2011 & support the activity of the Adolescent Health Committee FOGSI.

Understanding and Meeting Needs of Adolescents Dr. Kavita N Singh MS, Phd (Gyn.Oncology), FICMCH, MICOG Associate Professor, Obstetrics and Gynecology NSCB Medical college Jabalpur, MP. Email:drkavitasingh@rediffmail.com The term Adolescence derives from the latin word Adlolescere, which means to grow into maturity and adulthood. This is stressful period of life characterized by many needs and changes, that place specific demands on the individual.

One fifth of world population, - early one billion is between ages of 10 and 19. As these individuals mature and become sexually active, more young people face serious health risks, most face these risks with too little factual information, too little access to health care.

Meeting young adults diverse needs, challenges parents, communities, health care providers and educators.

Important concerns related to adolescence are: a) Nutrition related concerns – The body of adolescents is critically in need of appropriate nutrition in view of accelerated growth spurt.

In developing world, due to gender discrimination girls are more affected by malnourishment, anemia and other deficiencies that adversely affect their health and entire well-being. In western world obesity and anorexia nervosa are important issues. b) Health related concerns – As a group, young people are among the healthies member of their communities, having survived infancy and early childhood diseases, they have the lowest mortality rates of any age group across the world. A generation ago, infectious diseases predominated as major source of morbidity and mortality globally; today social, behavioral and environmental factors predominate, for diseases and death in young people. They are mainly accidental injuries (unintentional as road accidents and intentional as suicide) AIDS, homicide, selling sex, sexual and drug abuse, early and unwanted pregnancy with related complications.

What can be done? To young people to help them learn a healthy approach to sexuality and life.

I. Efforts by the parents • Parents should be themselves well informed about reproductive health matters.

• Talk and answer all question related to reproductive health and sexuality fully and accurately.

• Listen to them compassionately, without dismissing their concern as childish or improper.

• Encourage health, safety and intellectual development of their daughters as well as their sons, development of their sensed of self esteem.

• Teach sons that it in irresponsible to make a girl pregnant if they are not going to marry her or support her and the, newborn child.

Discourage premarital sex encounters and encourage cultural values related to marriage and importance of family.

• Parents should also adopt responsible sexual behavior themselves, towards children.

II. Efforts by the political leaders • Improve young peoples access to reproductive health information and services.

• Prohibit the abuse of young people, including sexual abuse and female genital mutilation.

• Endorse and support realistic, compassionate solution to young adults problems.

• Prohibit child marriage and raise the minimum legal age at marriage.

• Insist that news and entertainment media provide more responsible coverage and treatment sexual behavior.

• Increase commitment for coeducation with adequate reproductive health education genders appropriately.

III. Efforts by the community and religious leaders • They should make community aware that there are social as well as personal causes of young peoples reproductive health problems.

• Advocate and organize substantial reproductive health programs in schools.

• Condemn strongly a double standard that encourages boys sexual activity while punishing girls only.

IV. Efforts by the educators • Develop School curricula that give students age appropriate information about reproductive health.

• Train and support teachers preferably female teachers for girls and male teachers for boys so, that they can teach about reproductive health and contraception accurately and comfortably.

IV. Efforts by the young and adolescents themselves • Work with parents, community leaders, teachers and doctors/health care provides to design mutually acceptable approach to meet their own reproductive health needs.

• Act responsibly in secual matters for their own sake and that of others.

VII. Efforts by the medical professionals • Adolescents who live in gray zone between pediatrics, gynecology or young adulthood are often neglected, and many of the problems are ignored and trivialized as being a part of growing up.

• Should participate and guide in school health clinics, for girls and boys separately and few topics in common.

• Gynecologists are privileged to being associated with all the vital landmarks in woman life. There support in adolescent age group when a girl grows from child hood to womanhood has great implication on her health and over all development; hence special attention should be given to this age group.

• Medical professional can pay key role between policy makers, parents, educators and young adolescents.

Sex education and reproductive health programs for young adults often face opposition, but research shows that these programs do not lead to more frequent or earlier sex, as opponents fear.

To win public support, such programs must work with parents, medical professionals and within community norms.

My experience as a gynecologist suggests, need for compulsory interaction with young girls in school, especially between 10 to 17 years of age. Making them aware of normal physiology of the reproductive health and discussing all issues related to sexuality and contraception. This can contribute significantly to their safe and confident entry into adulthood. Services for young people should always be youth friendly which means that attention needs to be given to six C's i.e, confidentiality, convenience, care, counseling, costs and community support.

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Adolescent Health Committee FOGSI

ADOLESCENCE Vaginal Discharge in Adolescents What to do?

Dr. Madhuri Chandra Professor Obstetrics & Gynaecology Gandhi Medical College, Bhopal Adolescence is the period of life during which the carefree child becomes a responsible adult. It roughly ranges from 13 to 19 years of age i.e. the teen ages. Adolescent girls are brought to the gynaec OPD for menstrual problems, urinary complains, pain in abdomen and frequently for discharge per vaginum.

Vaginal discharge is highly subjective, depending on patients concept of hygiene, powers of observation, some girls are fastidious and complain with minimal discharge while others may be ignore mucopurulent smelly discharge.

In evaluating a complain of vaginal discharge, it is important to note the amount, color, consistency, odor, presence of pruritus and relationship to the menstrual cycle. The discharge that appears at vulva is a composite of vulval secretions from Bartholin's gland, sweat, sebaceous & apocrine glands, vaginal transudate consisting of epithelial squames, electrolytes, proteins, lactic acid, Doderlien bacilli, cervical mucus secretion and endometrial fluid.

A certain amount of vaginal secretion, enough to cause a moist feeling is normal. This clear white discharge may be increased in ovulatory and premenstrual phase of menstrual cycle but this physiological increase “leucorrhea” is never associated with odor or itching. In young girls it may present premenarchal where it signifies the onset of folliculogenesis and steriodogenesis by ovary. In fact a certain amount of discharge can occur in the female newborn in the first few days due to effect of maternal/placental hormones. Leucorrhea is also seen in pregnancy, sexual excitement and cervical ectropion. It is associated with anemia, chronic ill health, anxiety and use of external hormones like OCPs. Pathological causes of vaginal discharge could be : Trauma – foreign bodies, wounds, abrasion, chemical burns etc, any young child presenting with sudden onset of bloodstained or purulent discharge should have foreign body, trauma or growth excluded.

Infections – Vulvovaginitis due to Trichomonas vaginalis, Bacterial vaginosis, Candida albicans. Cervicitis due to N. gonorrheae, Chlamydia or Endometritis which may be postabortal, postpartum, or due to tuberculosis. In India, any teenager specially a virgin with discharge, chronic pelvic pain and /or amenorrhea should be investigated for tuberculosis.

Tumors which may be benign and malignant. Cervical polyps may present with white, creamy, non offensive discharge but soon get ulcerated and infected with purulent offensive, blood stained discharge. Malignant growths though rare in adolescence may cause profuse bloody discharge. Fistulas cause urinary or faucal discharge, and may be due to development defects, trauma or obstetric injury.

Infections are the commonest cause of vaginal discharge, while vaginal infections like candidiasis, trichomoniasis, bacterial vaginosis give rise to discharge with itching, cervical infection with Chlamydia or N.gonorrhea may present with blood stained, mucopurulent discharge, postcoital bleeding and lower abdominal pain.

Candidiasis or yeast infection occurs in 75% women, once in their life.

It is caused by gram positive fungus Candida albicans. Predisposing factors which disturb the vaginal flora or pH like use of broad spectrum antibiotics, immunosuppressants, corticosteroids, pregnancy, OCPs, endocrinal disorders diabetes, hypothyroidism may be present. Male partner with balanitis is usually an asymptomatic reservoir. There is

15

severe itching with thick white cheesy plaques and underlying erythema and dyspareunia. Itching leads to excoriations and secondary infection. The fungal hyphae can be seen under microscope by taking a drop of vaginal secretion and one drop of 10% KOH on a slide. Treatment is avoiding risk factors, oral antifungals like Fluconazole, Itraconazole and local treatment with Nystatin, Clotrimazole, and Miconazole. Persistent candidial infection may signify HIV AIDS. Trichomoniasis is most common cause of vaginal discharge with pruritus. Infection by Trichomonas vaginalis is sexually transmitted but can occur due to contaminated towels, bed linen, personal clothing, bath tubs, and pools and improperly sterilized surgical instruments. Onset of symptoms is post menstrual, 50% present with profuse thin creamy, frothy malodorous vaginal discharge with burning, itching, dysuria, dyspareunia & lower abdominal pain. There is vulval and vaginal erythema, granular vaginitis, strawberry cervix, urethritis and Bartholinitis. 50% may be asymptomatic; a wet film preparation with one drop of vaginal discharge and one drop of saline showing actively motile flagellates of Trichomonas vaginalis or cytological smear is diagnostic. Coexistent gonorrhea must be ruled out. Treatment is with systemic Metronidazole, Tinidazole, Secnidazole, Ornidazole or local Clotrimazole pessary. Contact tracing and treatment is mandatory.

Bacterial vaginosis though not an STI, is more common in sexually active women. It produces a disturbance in normal vaginal flora which results in loss of hydrogen peroxide producing lactobacilli and an overgrowth of predominantly anaerobic bacteria like Gardenella, Bacteroids, and Ureaplasma. Girls with Bacterial vaginosis are at increased risk of PID, abnormal cervical cytology, pregnancy complications like PROM, preterm labor, chorioamnionitis, and endometritis. There is profuse milky white to grey sticky discharge with fishy odor. The vaginal pH is raised >4.5 and microscopy of vaginal secretions show clue cells (epithelial squames covered by rod shaped bacilli) and absence of pus cells. Addition of KOH to vaginal secretions produces a fishy amine smell the “whiff test”. Treatment is by systemic and local Metronidazole and Clindamycin.

Mucopurulent cervicitis caused by sexually transmitted infection with N. gonorrheae, Chlamydia trachomatis, infected cervical erosion gives rise to discharge which is frankly purulent or thick tenacious and turbid. The cervix is inflamed, erythematous pouting, nabothian cysts may be present, intermenstrual bleed may occur along with systemic signs like fever, malaise, lower abdominal pain, backache, dysuria, dysmenorrhea, dyspareunia and adnexal tenderness. Vaginal cytology may reveal causative organism and increased pus cells, serological tests are required. Prompt and complete treatment of patient and contact is required, to avoid chronic PID and reproductive repercussion.

Vaginal discharge in teenagers have varied reasons, it may be an excess of physiological discharge or pathological. A good history and examination (depends on age, symptoms, sexual history) is required, with prompt treatment in order to prevent adverse reproductive sequelae. Sound nutritional advice, anemia prevention, counseling about menstrual, sexual hygiene along with promotion of abstinence, safe sex, and barrier contraception is essential for growing years.

Laparoscopy for Adolescents a voyage for the future Dr. Jayam Kannan Emeritus professor,Tamil Nadu MGR Medical University Managing Director Gharbbha Rakshagi group of organisations South Zone coordinator Adolescent Health Committee FOGSI Secretory,All Tamil Federation of Obstetricians and Gynecologists Tamil Nadu and Pondicherry Adolescent gynecology is not a new subject. But it needs increasing awareness and further attention. Since the problems are specific to this group, setting up of separate adolescent clinics is desirable for efficient management of adolescent gynecology. This sub specialized area of gynecology has still not been explored optimally. The field of general operative gynecology has assumed a jet speed in the development of various aspects of new technology, more so in the field of endoscopic surgery.

Technical development in pelvic endoscopy began in late 1800s However wide applications occurred, during 1960s.Earlier principal procedures were either diagnostic or for tubal interruption. As instrument makers made more and more closely aligned, creative solutions to problems began to appear. Dr. Kurt Semm and other members of his family members were more innovative, physicians from around the world began to visit dr Kurt Semm at Kiel Germany .Techniques have advanced to Single Port Access (SPA) endosonography guided laparoscopy procedures and robotic assisted laparoscopic procedures.

Presently a busy endoscopic surgeon spends 80% of his time in the operation theatre. A keen sense of openness to accept suggestions, is normally a must for surgeon, more so, for a surgeon, deciding to operate on an adolescent girl. Need to do an open surgery should be continuously kept in mind, laprotomy provision must always be kept ready sterile. An atmosphere of confidence in the entire team becomes automatically necessary along with an untold discipline. Three essential requirements for a successful laproscopy are 1.surgical skill, 2.well designed, well equipped theatre, 3.competent surgical team.

Laparoscopy in the pediatric and adolescent population The specialized instrumentation necessary for operating on these patients and preoperative considerations and generalized techniques unique to this population. Although laparoscopy has a myriad d of uses, the main focus is on the diagnosis and treatment of pelvic pain, adnexal masses, and pelvic inflammatory disease & incidental appendectomy.

In this article, an attempt has been made to review the gynecological problems of the adolescent population , amenable to endoscopic procedures through certain studies done. Correct examination procedures are essential for examination of children. Vulvar visualization, Sonography, is excellent noninvasive methods, useful in the diagnosis of pubertal disorders and in follow up of hormonal treatments.

Most common reasons for referral to hospital ,in the adolescence ,in the western scenario are, Abdominal pain 20%,Endocrinological problems 18%, Vulvar symptoms 18%, suspected sexual abuse 17%, Direct referral from primary care..33%, Referrel from other clinical side of the same hospital...67% The Indian scenario is slightly different with the following report of Goswami ET all the profile of adolescent girls with gynecological problems are: Menstrual disorders 58.06%, Lucorrhea 19.35% Ovarian tumors 15.32%, Clitoral abscess 0.80% Teenage pregnancy 4.03%, Sexual assault 2.41%.

Problems requiring surgical care are, Primary amenorrhoea,Acute abdomen, twisted adnexa, suspected appendicitis,endometriosis.In one series of results of laparoscopy in adolescence ,there were,9 adolescents with primary amenorrhea, 7 had hypoplasia or absence of the uterus, and 2 cases of polycystic ovaries were discovered. 11 patients with gonadal dysgenesis who were investigated: in 5 with 45

X/46 XX mosaic constitutions the ovaries were of normal macroscopic appearance; in the other 6, typical streaks were found. In 3 patients of this group with secondary amenorrhea, laparoscopy confirmed the Stein-Leventhal syndrome. Twelve patients under 9 years of age with precocious puberty had normal pubertal ovaries; no tumor was discovered. Laparoscopy was also used for the examination of the internal genitalia in cases of intersexuality.

Another important problem for which laparoscopy is of great help is, in cases of ovarian cysts, dermoids, dysgerminomas and twisted ovarian cysts. Detorsion and conservative therapy for twisted adnexa, is presently done by many laparoscopists. Timely diagnosis and intervention could make the difference between ovarian loss and salvage- an outcome of great importance in adolescence who is at the doorstep of her reproductive life.

Application of laparoscopy for bariatric surgery in adolescents An epidemic increase in adolescent obesity in the United States has resulted in significant obesity-related co morbidities, previously seen only in adults. Although bariatric surgery is an acceptable alternative for weight loss in severely obese adults, no conclusions have been made about the appropriateness of bariatric surgery for individuals younger than 18 years old. Nonetheless, bariatric surgery is increasingly being performed on adolescents with clinically severe obesity and experience suggests that it is effective and safe.

Adolescent endometriosis Endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy will be advised for further evaluation by Laparoscopy. The most constant physical finding preoperatively was tenderness with or without cul-de-sac nodularity.

In one study,eleven patients (17%) with biopsy-proved endometriosis had normal pelvic examinations.

Fifty-eight percent of patients had early and minimal disease (stage I).

In the remaining patients, the disease was more extensive, involving the ovaries, tubes, and/or adjacent pelvic structures (stages II-IV).

Although in most instances the implants were typical in appearance, in 13 patients (20%) the disease was not recognizable grossly, but was confirmed morphologically.

Adolescent Crohn Disease Laparoscopic-assisted ileocolic resection for Crohn disease has been reported as an acceptable alternative to the open procedure in adults.

Abdominal Pain in Adolescent Girls Laparoscopy for Diagnosis and Treatment In one study, 50 girls were selected aged 12 to 18 years old for evaluation of abdominal pain severe enough to warrant hospitalization. In nine patients, a pelvic mass was suspected on physical examination or Ultrasonography. Twenty-three patients had histories of previous episodes of salpingitis, but negative cultures at time of admission. Eighteen patients had no significant past medical history and normal physical findings. Laparoscopy established a diagnosis in 28 of the 50 patients, and in the 32 patients in whom a specific preoperative diagnosis was entertained, laparoscopy proved it to be incorrect in 15. In all cases where laparoscopy resulted in specific treatment, the symptoms were relieved Conclusion Laparoscopic procedures are highly relevant for reproductive life, more so for a girl who is at the doorstep of her reproductive carrier whose anatomy has to be preserved at any cost. Improvements in this field has a great benefit for the adolescence who are at larger number in India ,full of enthusiasm and vigor.

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Adolescent Health Committee FOGSI

ADOLESCENCE Challenges for Youth Today & Tomorrow

Talk Session with Girls at ITM Universe, Gwalior - Great Success

Challenges for Youth Today & Tomorrow at Cochin, Kerla Reported by Dr. Gracy Thomas

Challenges for Youth Today & Tomorrow at St. Mary School, Trissur, Kerla Reported by Dr. Lola Ramachandran

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Challenges for Youth Today & Tomorrow Reported by Dr. Shilpa Thaker, Rajkot Gujarat

“Challenges for Youth Today & Tomorrow� is an ongoing National Project of the Adolescent Health Committee FOGSI since 2009.

We were able to cover ten cities this year with the help of various city coordinators who together with their respective local FOGSI societies were able to cover maximum number of girls. Booklets were distributed amongst the girls following a PowerPoint talk on health issues. We are thankful to all the gynecologists who were part of this noble cause & thankful to Emcure Pharma who had sponsored this project. The various city coordinators of this projects were: Dr. Shilpa Thaker( Rajkot), Dr. kalpana khandheria (Jamnagar), Dr. Thomas Gracy (Kochi), Dr. Ratna Kaul, Dr. Roza Olyai, Dr. Achla Sahai,Dr. Charu Mittal(Gwalior), Dr. Malathy Prasath ,Dr. Jayam Kanna(Trichy), Dr. Lola Ramachandran (Thrissur), Dr.Rekha Kurian (Chennai), Dr. Ratna Thakur, Dr. Shilpa Bandari, Dr. Shilpa Sapre (Indore), Dr. Deepa Singh( Delhi), Dr. Anu Vij (Navi Mumbai)

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