Adolescence Issue 05

DESIGNHOUSE 9302107389

Youth Friendly Health Services Adolescent Obesity PCOS In Adolescents

Issue 05 | Pages 20

ADOLESCENCE

Adolescent Health Committee FOGSI

The First Reproductive Health Visit

4 5 7 9

“Role of Exercise & life style changes towards Adolescents health”

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Use of contraception in adolescence

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Address for correspondence : Olyai Hospital, Hospital Road, Gwalior- 474009 (MP) India. Phone : (91) -(751)- (2320616) http://adolescenthealthindia.org • http://www.youtube.com/watch?v=NsR0H0ril20

Adolescent Health Committee FOGSI

ADOLESCENCE Message

From the

from FIGO

President FOGSI 2011

It is with great pleasure I provide this message of congratulations and admiration to the work of the Adolescent Health Committee of FOGSI. Members of the Adolescent Health Committee has achieved immense amount of work under your leadership which will go a long way to improve healthcare for adolescents.

I was amazed and pleased to look at your website. It is one of the best websites I have seen as it provides adolescents with the most wanted information. The projects you have initiated tackle the challenges for youth today and tomorrow. Survey on teen pregnancy status in India, establishing youth friendly centres and clinics across the country and establishment of the website on adolescent health issues are very useful to improve provision of care. I am sure many practicing clinicians, adolescents and their parents will benefit by this contribution.

Adolescent health is quite important as the adolescent becomes the young woman who has to be in prime health to manage the reproductive years. Adolescent age is tracked with conditions like anorexia nervosa, over eating, smoking, use of alcohol and drug abuse brought about by peer pressure if they have bad company.

Appropriate education to avoid such harmful habits and to have better nutrition to avoid becoming obese is major public health issues. There should be advocacy for making HPV vaccines and contraceptives easily available. We talk about osteoporosis much later in life, but nearly 40% of the mineralisation of bones is at the adolescent age. Your programmes and website contribute immensely to convey these messages.

Adolescence, a period of transition from childhood to adulthood is by far one of the crucial period in the life of human being and more so in girls. This period of transition undergoes a rapid as well as a radical physical and psychosexual changes. Our organization FOGSI is very much concerned about the Adolescent Health right from the year 1998. The Adolescent Committee of FOGSI under the dynamic leaders has done lot of academic activities, awareness programmes and educational forums for last few years. I must give a special credit to Dr. Roza Olyai, Chairperson of Adolescent Committee and all the members of that committee for their efforts in imbibing a positive thought in this regard. I am sure that this committee will continue to do a lot of activities with special reference to holistic approach in bringing out a transformation in the attitude and behavior of Adolescent Girls in terms of good moral values apart from physical and psychological upliftment so as to have an excellent social reforms in future. Needless to mention that this issue encompassing various practical aspects of Adolescent problems will certainly be beneficial for our members of the Federation. Lastly, I congratulate Dr. Roza Olyai, Chairperson of Adolescent Committee for her commitment, dedication and positive attitude for the benefit of Adolescent girls of India.

(Dr. P. C. Mahapatra)

Adolescents are hard with unexpected conditions such as irregular bleeding, teenage pregnancies, sexual transmitted diseases, contraception and need for termination of pregnancies. Most clinics see them for one condition e.g. offer termination service but fail to advice appropriate contraception and do not make enquires about other adolescent problems like number of partners, need for screening for sexually transmitted disease and plan for HPV vaccine. Adolescent healthcare has to be comprehensive and integrated and made available by a provider in one clinic during the visit. Your admirable work points towards such comprehensive care and preventive health. Very best wishes for your team to continue with the excellent work.

From the

Yours sincerely

Dear Colleagues,

Sir Sabaratnam Arulkumaran President Elect FIGO

It gives me great pleasure to announce the release of yet another Magazine on “Adolescence” by Dr. Roza Olyai, Chairperson of Adolescent Health Committee of FOGSI. All those who have gone through the previous issues of “Adolescence” magazine, I am sure they have been awaiting arrival of next issue.

I am confident that this magazine will make an interesting reading for all FOGSIANS. I congratulate Dr. Roza Olyai & her team for doing a wonderful job.

Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH National Chairperson Adolescent Health Committee FOGSI WHO Consultant Expert Panel ARSH, Geneva Convener Adolescent Friendly Health Centers India Director Olyai Hospital,Gwalior-MP Email: rozaolyai@gmail.com Website: http://adolescenthealthindia.org/ http://www.youtube.com/watch?v=NsR0H0ril20

Dear Friends, At the onset I must congratulate Adolescent health committee and chairperson Dr. Roza Olyai for magnanimous work done for betterment of adolescents.

We always say a lot about youth power but at the same time it is the group most vulnerable to various problems and issues because of drastic changes in emotional, psychological and physical changes taking place in the body.

In my own clinical practice, I have observed its impact very closely over last 20 years especially while dealing with girls from the underprivileged, illiterate and poverty spectrum.

That's why its very apt what Kamal Bhasin said in one of her quotes in “Our Daughters”, “The adolescent girl still remains a young plant that neither gets light nor water, she remains the flower that could have blossomed but didn't…”

They need special attention and support, rather whatever we try to do is inadequate for them. I am sure the committee will think over it and plan activities focusing on them.

I wish every success and all the best to the committee.

With Regards & Best Wishes, Dr. Milind Shah Vice President FOGSI

Office Bearers of FOGSI for the Year 2011

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

Chairperson's Desk...

Dr. Milind R. Shah Vice President FOGSI

Secretary General's Desk...

Dr. P.K. Shah President Elect & Secretary General FOGSI 1

From the

Vice President's Desk...

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

Sir Sabaratnam Arulkumaran PhD, FRCS, FRCOG President Elect FIGO Dear Dr Olyai,

From the

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

Dear Friends, It gives me greast pleasure to share with you the fifth issue of the news magazine of the Adolescent Health Committee FOGSI.We have recieved 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 Wellbeing throughout their lives.

In this issue we have covered important topics as suggested by many readers focusing on Obesity, Contraception , PCOS, Youth friendly health services & some related social issues.

One of our major project this year is “Challenges for the youth today & tomorrow”. With encouragement & support from Dr. P.C. Mahapatra President FOGSI we will be covering 5,00,000 girls in the coming months through various school/ college health talks, sharing with them the informative booklets the committee has prepared. In the same project we will be sensitizing 100 & more gynecologists through five zonal TOTs on ARSH as per the FOGSI theme developing skills.

Sharing information & updating our knowledge from time to time is very important & am glad that through this magazine the Adolescent Health Committee FOGSI is able to achieve this. Am very grateful to Emcure Pharma , specialy Mr. Arun Khanna, the COO of Emcure Pharma for his personal interest in supporting the activities of the Adolescent Health Committee FOGSI & helping to spread the message across the country through this magazine for the betterment of the youths.

Your suggestions & feedback will be of great help, kindly share your articles & achievements with us. Do visit our website & share it with the other adolescent girls.

Wish you all a happy reading!

ifumb@bom5.vsnl.net.in

Dr. Nozer Sheriar Deputy Secretary General Mobile : 9821097536 nsheriar@vsnl.com

Dr. Hrishikesh D. Pai Treasurer Mobile : 9820057722

Dr. Roza Olyai National Chairperson Adolescent Health Committee FOGSI

hdpai@hotmail.com

Dr. Janmejaya Mohapatra Jt. Secretary Mob: 09437020333 dr.janmejayamohapatra@ hotmail.com 2

Adolescent Health Committee FOGSI

ADOLESCENCE

The First Reproductive Health Visit

From the

Vice President's Desk...

Dr. Mala Arora FRCOG (UK), FICOG,FICMCH Vice President FOGSI 2011 Director Noble IVF Centre

Congratulations to Dr. Roza Olyai for this excellent work. As the previous issues this issue brings a wealth of knowledge about Adolescent Health. My plea to all Fogsians is to treat the adolescent with due care, respect and patience when they seek your advice. For those who have spare time, we need to venture out into the community, be it schools or colleges to address their needs and queries. Remember

Congratulations...

Dr. Durga Shankar Dash, Executive committee member Adolescent Health Committee FOGSI has been actively involved in various activities of the Adolescent Health Committee FOGSI & has also been recipient of various awards such as : • Dr. Duru Shah Distinguished Community Service Award 2010

• Dr. R.D Pandit Research Prize 1987

Dr. Mala Arora Vice President FOGSI 2011

Congratulations...

Dr Krishnendu Gupta Vice President - FOGSI Professor of Obstetrics & Gynecology, VIMS & RKMSP, Kolkata Dear Dr Roza Olyai, Hearty congratulations on your efforts in making "Adolescence" a popular extension amongst your numerous and laudable activities as the dynamic Chairman of the Adolescent Committee of FOGSI. I wish you and all the members of your committee every success and the very best in 2011.

Happy reading!!

Thanking you and with warm regards.

Most sincerely Dr Krishnendu Gupta Vice President - FOGSI

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Adolescence (Latin: adolescere = to grow) is that transitionary phase of life that occurs between an individual's carefree childhood and responsible adulthood, the period of which varies in duration from one individual to another, and is hence difficult to define. The WHO defines it as the period between ages 10 and 19 years of life. And so, another description of the adolescent would be the 'teenager'.

A myriad of physical and emotional changes, the rapid mental development and associated curiosity, all make this a very dynamic phase of life. The girl child during her adolescence is differently special here. She is for the first time in her short experience of life, exposed to the occurrence of menarchal bleeding, that she is informed is 'normal' and a to be regular feature, for most of the rest of her life. Amongst all the fear and angst that is bound to happen in the minds of these young girls, there is also the anxiety of the parents, who would like to guide their child through this phase with the utmost care possible.

As parents, teachers and doctors we need to understand and nurture our youth to curb the rising teenage pregnancies and to improve their mental health. After all they are our future!

Vice President's Desk...

Dr Nandita Palshetkar M.D, F.C.P.S, F.I.C.O.G., Infertility Specialist, Lilavati Hospital IVF Centre Mumbai.

1st Vice President FOGSI. (2011) Treasurer MOGS

• KADAMBINEE SWASTHYA SAMAAN 2010

A – Age is tender D- Danger of going astray O – Over confident L - Love is most important to them E – Egoistic S – Sexually inclined C- Copy their peers E- Enjoyment seeking N- Need to be nurtured T- Teach by example only

From the

and physiology of this phase, as also the sexual and emotional changes likely to occur, and the importance of a healthy lifestyle.

Dr. Kalpana Khandheria, Executive committee member of the Adolescent Health Committee FOGSI from Jamnagar Gujrat, has received the prestigious Dr. K.J. Nathwani award for medico Social Work from I.M.A. Gujarat in 2011

The American College of Obstetricians and Gynecologists (ACOG Committee Opinion number 460 – July 2010) recommends that teenage girls first visit a gynaecologist between the ages of 13 and 15, as a routine preventive healthcare visit. In some cases, the first visit may be appropriate earlier, based on concerns of the parent(s). The purpose of this first reproductive health care visit, according to the ACOG is so that the teens may establish a relationship with a gynecologist for their future reproductive health care. This lets the gynecologist address issues that may not be addressed by a general physician and helps ensure that a young woman knows where to turn for information and care relating to pelvic pain, irregular periods, sexually transmitted diseases, contraception and other issues.

Depending on the history given and her stage of development, the topics of discussion can include the normal stages of puberty, menstruation, vaccinations, maintaining healthy eating habits, safe sexual practices, pregnancy prevention and sexually transmitted disease (STD) treatment. Most times, this visit does not include an internal pelvic examination, although examination of the breasts and external genitals for pubertal development may be appropriate. An internal examination should only be performed when indicated by the medical history (eg, pubertal aberrancy, abnormal bleeding or discharge, or abdominal or pelvic pain). If the patient has had sexual intercourse, screening for sexually transmitted diseases (STD) is appropriate, and the patient should have her first Pap test at age 21 years. The visit also gives the parent and the patient a chance to learn what is considered normal development and may reveal a problem that could have remained undiagnosed. It however, is not meant to replace routine visits with the patient's general practitioner or physician, but rather, to complement it.

Subsequent follow-up annual visits are also then recommended.

These visits would again be educative and for screening purposes. A general physical examination is not required at every visit but should be performed at least once during early adolescence (ages 12–14 years), middle adolescence (ages 15–17 years), and late adolescence (ages 18–21 years).

The common signs and symptoms and queries during this/ese visit/s have been briefed below.

1. Normal pubertal changes - On an average, the larche occurs by 10 years of age and menarche between ages 11–13 years. Once this happens, evaluation of the menstrual cycle should be included with an assessment of other vital signs. During this visit it is appropriate to guide the adolescent and the parent(s) regarding the normal anatomy

2. Variations of normal - If a teen fails to show signs of breast development by age 13 years, she should be evaluated by her physician. Delays in onset of puberty may be familial or associated with low body weight, athletic training, eating disorders, or genetic and medical conditions. After an assessment of the external sexual characteristics, that of the internal genital structures (e.g. ovarian pathology, Mullerian anomalies) may be accomplished by Ultrasonography.

3. Pelvic or abdominal pain - If a girl is having abdominal pain, or if there are concerns that she could have a mass or tumor, then she may need a physical exam or further assessment, such as an Ultrasonography.

Dysmenorrhoea may also indicate the need for a pelvic examination.

Severe cramping that does not respond to usual medical therapy could indicate endometriosis.

4. Menstrual irregularities: bleeding disturbances - Primary amenorrhoea i.e. failure of occurrence of menarche by the age of 16 years, needs further evaluation. Also, the occurrence of menorrhagia or irregular menses would need appropriate attention.

5. Obesity - All adolescents should be screened annually for obesity by determining weight and height, calculating a body mass index (BMI), and also for eating disorders by asking about body image and eating patterns.

6. Hair and skin changes - If there is any deviation from the normal changes associated with puberty, this may need counseling regarding the medical management, lifestyle changes and also cosmetic treatment. Especially in the young patient with polycystic ovarian syndrome (PCOS), signs and symptoms mentioned in points 4, 5, and 6 are seen in various combinations, and an early diagnosis can help in various ways.

7. Vaginal discharge, Pruritus vulvae and Repeated urinary tract infections - An external examination is warranted in these cases as also laboratory assessment of the urine sample, and / or smear analysis of the vaginal discharge if any.

8. Education and screening - In addition to a detailed menstrual, reproductive and family history, it is important to discuss a girl's lifestyle, including nutrition, exercise, social activities, medications and use of other substances. Family history is important, since there are some medical conditions that are genetically-based, such as polycystic ovarian syndrome, endometriosis and breast and ovarian cancer, and also since there are certain preventive measures that help improve the long-term health of the individual. Sometimes certain myths and fears are to be dispelled as part of the education during this visit.

The vaccination status should be checked, especially all pediatric vaccines and also additional ones, like Rubella, Hepatitis-B and C vaccines and human papilloma virus (HPV) vaccine. Screening for Tuberculosis (especially if there is an indicative history or symptoms), Osteoporosis, Hypertension and Hypercholesterolemia is indicated in all adolescents.

All adolescents should be asked annually about their involvement in sexual behaviors that may result in unintended pregnancy and STDs, including HIV infection. Sexually active patients must be educated about the safety and efficacy of current contraceptive options.

Pregnant adolescents whose pregnancies are unintended should be counseled about pregnancy options, including termination, raising the baby, and adoption.

References: American College of Obstetricians and Gynecologists. Primary and Preventive Health Care for Female Adolescents. In Tool kit for teen care 2nd edition. Washington, DC: ACOG; 2009.

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Adolescent Health Committee FOGSI

ADOLESCENCE

Youth Friendly Health Services 5. Provision of outreach, as well as Community based services involving peer educators.

Dr. Ashwini Bhalerao-Gandhi MD, DGO, DFP, FCPS, DNB, FICOG Consultant Gynecologist P.D. Hinduja National Hospital & Medical Research Centre, Mahim, Mumbai Ex. Associate Professor of Obst & Gynaec, T.N. Medical College & B.Y.L. Nair Hospital, Mumbai.

Chairperson of Adolescent Health Committee of FOGSI (2004-2008) Vice President of the Mumbai Obstetric & Gynaec Society (2010-11)

Adolescent and young people stand at the threshold of adult world.

People aged 10 to 24 years are called as 'young people' This is a period of rapid and sometimes drastic changes taking place in their body, mind and social life. Many are already exposed to challenges from the adult world. We need to focus our attention towards the health needs of this group (a) to reduce mortality and morbidity now, and during their future lives (b) to respect their rights to health care, in general and reproductive health care, in particular (c) to enable them to pass on good health to their own children as they are the future parents.

Young people face dangers more complex than previous generations faced with less support and safety network.

Characteristics of Adolescent Friendly Health Services : Adolescent friendly health services need to be accessible, equitable, acceptable, appropriate, comprehensive, effective and efficient.

These characteristics are based on the WHO Global Consultation in 2001 and discussions at a WHO expert advisory group in Geneva in 2002. They require : 1. Adolescent friendly health care providers who • Are trained to provide specific promotive, preventive and curative services tailor-made to each client's circumstances and maturity level.

• Are well motivated and supportive.

• Have non-judgmental attitude and are trustworthy.

6. Appropriate and comprehensive services that • Provide umbrella of services looking after physical, mental, social, sexual and spiritual needs of adolescents.

• Provide majority of services under one roof and referring to higher services only if required.

• Avoid unnecessary procedures, investigations etc.

Locations : Adolescent and Youth friendly health services can be offered at various levels and centers. Making existing services more friendly is one option whereas establishing specific stand alone clinics is yet another option available.

• Services at health centres or hospitals : Existing services can definitely take care of the basic needs of young people provided medical and support staff are given proper training. There are also dedicated health centres which provide a full range of services especially for young people.

• Services located at other kinds of centre : As same adolescents are reluctant to visit health facilities, services can also be taken to places where young people already go. e.g. Go 4 Health Youth Clubs of FPA India. Health services in Sweden reach large numbers of adolescents, including an increasing number of boys, through a network of youth centres nationwide.

• Out reach services : These are important to cater for the needs of young people who are unlikely to attend conventional health centres e.g. Friend corners in Thailand were started in local shopping malls and community housing areas. The first point of contact is with adolescents trained as peer

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. With this in mind we have included appropriate topics from normal Puberty to abnormal Menstrual Problems, Reconstructive surgeries, Fertility preservation in adolescents, PCOS, Ovarian tumors, Premarital Counseling, Vaccines, Social Health issues, Life skills, Counseling, Endometriosis, Teenage pregnancy, Anaemia, STD & HIVAIDS, Contraception, Laparoscopic procedure & Robotic surgery new to the field of advances in ASRH & many other interesting topics. The book will definitely be useful not only to the clinicians but to UG/PG students, all public health specialists & NOGs.

• School / College health clinics : Schools and colleges are ideal places to screen for or treat a range of common illnesses, for health education and referral to a higher centre if required

AICOG 2011

Creating awareness and providing specific services catering to adolescent reproductive and sexual health in this manner is the need of the hour. It is essential in transforming today's adolescent boys and girls into tomorrow's responsible citizens, spouses and parents.

• Having good communication skills.

• Can spare adequate amount of time for clients.

• Act in the best interest of their clients.

The book titled “Recent Advances in Adolescent Health” has been edited by Dr. Roza Olyai, Dr. D.K. Dutta & foreworded by Dr. Hamid Rushwan Chief Executive FIGO released during the AICOG 2011.

It is a FOGSI publication

by Jaypee Publishers.

The AICOG 2011 was a memorable event with pictures taken during the workshop panel discussion organized by Dr. Amit Patke Chairperson Perinatology Committee FOGSI & guest lecture on Adolescent Sexual reproductive health by Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI. Release of the 4th issue of the Adolescence magazine was during the managing committee FOGSI by Dr. P.C Mahapatra president FOGSI ,Dr. P.K. Shah General Sec. FOGSI & other office bearers on the dais. The book of the Recent Advances on Adolescent health was also released during the same event.

Congratulations...

• Can respect as well as care for the clients irrespective of their gender, age, religion, culture etc.

• Provide information enabling each adolescent to take a right decision out of their free will.

2. Adolescent friendly health facilities that • Are located at a convenient place with an appealing ambience.

• Provide safe and clean environment.

• Have flexible and convenient hours of working.

• Offer privacy and are devoid of stigma.

• Provide IEC material.

3. Involvement and participation of Adolescent and youth, so that they are • Aware of their rights and services available.

• Encouraged to respect the rights of others and are involved in giving suggestions regarding variety of services provided.

4. To solicit involvement of gatekeepers eg. parents, teachers, social workers, politicians etc .

• So that they develop trust in the health care system endorsing its utilization by the youngsters.

• To diffuse opposition by staunch religious, social and cultural authorities.

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Dr. Krishna Kavita Ramavath Executive member of the Adolescent Health Committee FOGSI is Asst.Prof, Andhra Medical College, presently a visiting clinician at Robotic surgeries Mayo clinic,USA had been honoured with Yuva fogsi- Dr.Kaminirao Oration-2010- South Zone for,Reaching the unreached-The goal of establishing uniform standards in the practice of Obstetrics and Gynecology all over India.

She had also recieved the most prestagious FICOG (Fellow of Indian College of Obstetrician and Gynecologists) for the year 2011, also earlier recieved the prestagious International FIGO Fellowship for the year 2009 at CapeTown for her research paper ''Cancer Cervix-A revolutionary Therapeutic Approach Needed''.

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Adolescent Health Committee FOGSI

ADOLESCENCE

Adolescent Obesity Dr. Krishna Kavita Ramavath Visiting Clinician Mayoclinc Gynecology Robotic Surgery Phoenix 85021 Arizona Usa Adolescence is a time of huge physical, social and emotional changes.

It is normally characterized by low levels of disease and death; it is the period of life when mortality rates are lowest. However many societies in which adolescent girls live are unable to provide optimal conditions for their healthy development. As a result, these girls may miss opportunities to progress successfully through the transition to adulthood, becoming vulnerable to behaviors that put their health at risk. One such is Obesity.

Defining Obesity in Children and Adolescents : Obesity is defined as an excessive accumulation of body fat. Obesity is present when total body weight is more than 25 percent fat in boys and more than 32 percent fat in girls. Although childhood obesity is often defined as a weight-for-height in excess of 120 percent of the ideal, skin fold measures are more accurate determinants of fatness.

Obesity as an Emerging concern : During the past two decades, the prevalence of obesity in children has risen greatly worldwide and this excessive fatness has arguably become a major health problem of both developed and developing countries. Overweight and obesity during childhood is a matter of growing concern in India also.

Overweight is associated with the onset of major chronic diseases leading to complications and also psychosocial problems in children and adults. The greater concern is that the risks of overweight during childhood will persist into adolescence and adulthood. Tackling the problems of the growing numbers of overweight individuals is a major challenge for most countries. Childhood obesity has reached epidemic levels in developed countries.

WHO Report : Obese adolescents tend to grow up to be obese adults and are thus exposed to a higher risk of diseases, such as osteoarthritis, diabetes and cardiovascular diseases, at a younger age than those who are not obese.

Physical activity is not only crucial to avoiding weight gain but is also an important factor in improving adolescents' control over anxiety and depression. Physically active adolescents more readily adopt other healthy behaviours – including avoiding tobacco, alcohol and drug use – and show higher academic performance at school.

Significant rise in childhood obesity in adolescent girls : According to a study by Swedish researchers on BMI figures for more than a thousand children over two decades, it is found that obesity levels had risen significantly among younger children, but that levels were much more constant among teenagers included in the research.

They also found that young girls were much more likely to be overweight or obese than boys.

Studies on urban Indian schoolchildren from selected regions report a high prevalence of obese and overweight children. In addition, studies on Indian school children have also demonstrated that the prevalence of hypertension in overweight children is significantly higher than that among normal children. Till date no nationally representative data have emerged from India, which makes it difficult to project the prevalence of obesity and overweight among children in India.

While adolescent girls in many countries still suffer from under nutrition, data from low- and middle-income countries show that around 12% of school-going 13–15-year-old girls are overweight.

However, data from 36 low- and middle-income countries indicate that 86% of girls do not meet recommended levels of physical activity, which is a far higher proportion than among boys.

Health Risks of Obesity : Concern grows that the current dramatic rise of obesity among children and adolescents portends a future wave of 7

successful strategy for weight loss in children and adolescents unless coupled with another intervention, such as healthy nutrition or behavior modification. However, exercise has additional health benefits. A 50 minute of aerobic exercise three times per week, had significantly decreased blood lipid profiles and blood pressure in them.

successfully applied to children and adolescents are self-monitoring and recording food intake and physical activity, slowing the rate of eating, limiting the time and place of eating, and using rewards and incentives for desirable behaviors. Particularly effective are behaviorally based treatments that include parents in the treatment plan.

Preventive Measures: Obesity is easier to prevent than to treat, and prevention focuses in large measure on parent education. In infancy, during promotion of breastfeeding mother should recognize the signals of satiety, and should delay in the introduction of solid foods. In early childhood, education should include proper nutrition, selection of low-fat snacks, good exercise/activity habits, and monitoring of television viewing.

increasing cardiovascular disease as these overweight youth reach the adult years. Childhood obesity is highly predictive of adult obesity, and among adults, excessive body fat carries multifold risk for morbidity and premature death from coronary artery disease, hypertension, stroke, and renal vascular disease, as well as other disorders.

• Hypertension,

In cases where obesity is due to the influence of hereditary factors, parent education should focus on building self-esteem and address psychological issues.

• Type 2 diabetes mellitus,

Conclusion:

• Dyslipidaemia,

Unless effective interventions and preventive strategies are instituted at the local and national level, the trend of increasing cardiovascular disease in adults observed in recent decades will accelerate even further.

Outcomes related to childhood obesity include :

• Left ventricular hypertrophy, • Non-alcoholic steatohepatitis, • Obstructivesleep apnoea, • Psychosocial problems, • Asthma, • Arthritis, • Neoplasms The causes of Adolescent Obesity : The mechanism of obesity development is not fully understood. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide. In general, overweight and obesity are assumed to be the results of an increase in caloric and fat intake.

On the other hand, there are supporting evidence that excessive sugar intake by soft drink, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world. Consequently, both over-consumption of calories and reduced physical activity are involved in childhood and adolescent obesity.

The development of obesity in childhood and subsequently in adulthood involves interactions among multiple factors. These factors are personal (e.g., beliefs, attitudes, cultural experiences, taste preferences, and dietary composition), environmental (e.g., homes, schools, community, food availability and cost), societal (e.g., cultural norms, advertising and food marketing, social networks, technological developments, economics,) and healthcare-related (counseling and treatment, reimbursement), as well as physiological (e.g., intrauterine and early life “programming”, appetite and satiety mechanisms and regulation, adipose tissue metabolism, genetic predisposition) In light of the recognition of childhood obesity as a major public health problem with multiple etiological factors National Heart, Lung, and Blood Institute (NHLBI) and other NIH Institutes convened a Working Group meeting in 2007. The objective of the Working Group was to identify priorities for future research directions in childhood obesity prevention and treatment. Fig.1 gives a conceptual model of Obesity and CVD. Fig 1 : Obesity and CVD- Conceptual model( courtesy:NHLBI working group report) The goal is not a weight loss program for children and adolescents for obesity treatment . Rather, the aim is to slow or halt weight gain so the child will grow into his or her body weight over a period of months to years. Experts estimate that for every 20 percent excess of ideal body weight, the child will need one and one-half years of weight maintenance to attain ideal body weight.

Three forms of intervention include :

2. Diet Management with caloric restriction : Fasting or extreme caloric restriction is not advisable for children. Balanced diets with moderate caloric restriction, especially reduced dietary fat, have been used successfully in treating obesity. Diet management coupled with exercise is an effective treatment for childhood obesity.

3. Behavior Modification : Many behavioral strategies that have been

A close monitoring of overweight prevalence in children and adolescents and taking timely preventive measures will be an effective approach in dealing with the problem of obesity. Actions are needed to ensure that societies and their health systems respond appropriately to the health and development needs of adolescent girls.

Small lifestyle changes can make a big difference in the overall health of these adolescents.

Project of the Year 2011 “Challenges for the youth today & tomorrow ” FOGSI-Emcure Health Project One of our ongoing project titled “Challenges for youth project today & tomorrow” was started as a pilot project in 2009, seeing to the good result & acknowledgement received by the school & college authorities, this year under guidance of Dr. P.C. Mahapatra President FOGSI we decided to increase the area of activity aggressively expanding to 21 states in India.

As suggested by Dr. P.C. Mahapatra one of our focuses this year will be more on moral values & spiritual health as major part of our talks. The idea is to empower the adolescents to be developed in to good human beings with noble attitudes & ideas which will enable them to overcome peer pressure & put them on the right path. We aim to “help young people form a strong moral identity in their early Adolescent years & empower them to contribute to the well-being of their communities....”

The Challenges for youth Today & Tomorrow project has started now with five regional TOTs in West, East, South, Central & North. Under the Chairmanship of Dr. Roza Olyai as the National Coordinator for the same, the target is to cover more than 500,000 girls in 100 FOGSI societies. Special tool kit & booklets have been prepared by the committee for the same. We are thankful to all the doctors who have volunteered to be part of this project.

The project is being sponsored by Emcure Pharma since 2009 as part of their social corporate responsibility for which we are thankful to them specially Mr. Arun Khanna COO Emcure Pharma for his constant encouragement & support, Mr. Anoop Sood for his excellent coordination, Ms. Charu & her team for their wonderful execution.

1. Exercise : Adopting a formal exercise program, or simply becoming more active, is valuable to burn fat, increase energy expenditure, and maintain lost weight. Studies have not shown exercise to be a 8

Adolescent Health Committee FOGSI

ADOLESCENCE

PCOS In Adolescents

Conferences & Events to remember...

Dr. Sunita Tandulwadkar M.D., F.I.C.S., F.I.C.O.G. Head of Dept of Obstetrics & Gynecolgy, Ruby Hall Clinic, Pune Polycystic ovary syndrome (PCOS), a heterogeneous syndrome of unknown etiology, is the leading cause of anovulation, hirsutism and infertility in women. This multifactorial syndrome emerges at puberty and has cardiovascular and metabolic sequelae through menopause.

PCOS is increasingly being recognized in adolescent girls seeking treatment for signs and symptoms of hyperandrogenism.

The etiology of PCOS remains unknown, although much research has been directed at finding out why it develops. There appears to be a strong genetic component. Investigators have noted polycysticappearing ovaries in young girls prior to puberty, and have postulated that some girls are born with polycystic ovaries. Some theories suggest that women may develop PCOS from exposure to high androgen levels in the womb.

Insulin resistance is the central feature of PCOS. Many of the signs and symptoms of PCOS, which are essentially due to insulin resistance and hyperandrogenemia, can be detrimental to a young woman's body image. The most notable of these are weight gain, excessive hirsutism, “dirty-looking” patches on skin (acanthosis nigricans, a clinical marker of hyperinsulinemia), and acne. Such clinical features can have a significant impact on the emotional health of an adolescent at a time when self-image is developing. Depression is common among adolescent girls with PCOS, either due to hormonal imbalances or struggles with body image. Moreover, attempts at weight loss can lead to distorted eating practices or eating disorders like bulimia nervosa.

Research has indicated that adolescent girls diagnosed with PCOS had a history of precocious pubarche. Precocious pubarche is defined as the appearance of pubic hair prior to age eight. Growth charts need to be followed longitudinally with these girls. Often adolescents have had no prior history of obesity as a child but gain a significant amount of weight at an accelerated rate following menarche The common features of normal puberty, namely menstrual irregularities obscure the diagnosis of adolescent PCOS, therefore a high index of suspicion is necessary. Given the heterogeneity of the disorder, this condition is often under-diagnosed and mis-diagnosed.

Because PCOS is linked to the development of chronic diseases like type 2 diabetes, heart disease, hypertension, endometrial cancer later in life, recognition and treatment during adolescence is critical to prevent these conditions. Furthermore, since most adult women with PCOS are not diagnosed until after seeking help for infertility, they experience financial and emotional hardships that could have been avoided if PCOS had been detected earlier in life.

Diagnosis of PCOS in adolescents should include a thorough family history, exclusion of other causes of hyperandrogenism, and appropriate laboratory evaluation. PCOS tends to cluster in families and to follow the trend of first degree relatives, especially mothers and sisters of girls diagnosed with the condition. Nevertheless complete social history should be obtained. Areas to focus on include current diet and exercise patterns. Because metformin may be one of the medications prescribed, adolescents should also be asked about patterns of alcohol consumption and tobacco use. Alcohol must be avoided when on metformin because excessive alcohol intake is associated with an increased incidence of lactic acidosis; it can potentiate the effects of metformin on lactate. The scarcity of controlled clinical trials makes treatment controversial. Therapeutic options include dietary intervention, exercises, oral contraceptive pills, and insulin sensitizers.

Several insulin-sensitizing agents have been tested in the

9

management of PCOS. Metformin is the only drug currently in widespread clinical use for PCOS. Metformin exerts direct effects on hepatic glucose and lipid metabolism. It suppresses gluconeogenesis and enhances glucose uptake and glycolysis.

Also, there is evidence of acute and chronic effects of metformin on treatment of lipid metabolism and turnover in skeletal muscles.

Chronic treatment was reported to impede lipid accumulation in skeletal muscles.

Direct inhibition of Adipogenesis and inhibition of intracellular lipid accumulation is observed. Several investigators have ascribed metformin induced attenuation of central obesity and weight loss to the loss of subcutaneous fat rather than visceral fat.

Metformin may inhibit LH receptor expression by reducing insulin levels.

Long term metformin treatment may induce ovulation, improve menstrual cycle & reduce serum androgen levels.

It also improves endothelium dependent vasodilatation Though it is a promising drug till date, lots of new studies are coming up questioning its efficiency in certain clinical outcomes in PCOS. In a high percentage of patients, treatment with metformin is followed by regularization of the menstrual cycle, less pronounced hyperandrogenism and cardiovascular risk factors and some improvement in the response to therapies aimed at induction of ovulation. Adolescent girls who are anovulatory and moderately obese, metformin administration can have a normalizing effect on multiple aberrations within the endocrine-metabolic status. During the reproductive period, metformin administration can improve reproductive function and the establishment of pregnancy.

A role of metformin in prevention of gestational diabetes and hypertensive complications of pregnancy has yet to be shown. Finally, any real benefit of insulin-lowering treatment in terms of lesser cardiovascular risk in women with PCOS women remains to be demonstrated. Long-term follow-up is needed to determine the effectiveness of these approaches in changing the natural history of the reproductive and metabolic outcomes without causing undue harm.

Acknowledgement :

International Congress on Contraception May 6-8 , 2011 at Kolkata -Hyatt Regency Hotel was a great hit with many international & National faculties with various interesting workshops. Enclosed are some pictures capturing the moments. The panel discussion on Newer contraception for Adolescents was made interesting with latest updates being moderated jointly by Dr. Mala Arora & Dr. Sujata Mishra. The expert invited panelists were Dr. Ashwini Bale Rao, Dr. Roza Olyai, Dr. Laxmi Shrikande, Dr. Prakshit Tank, Dr. G. K. Tripathi & Dr. Sanjay Swain. The interactions were good which was a great learning for the delegates.

ICOG Session Report by Dr. Ratna Kaul, President GOGS & AMPOGS ICOG Session - was organized by the Gwalior Obs. & Gyn. society on the topic of “Guidelines” to guide you through Good Clinical PracticesPCOS, Anemia & Adolescent Friendly Health centers on 10th April2011. ICOG Guest faculty were Dr. Hema Divakar, Dr. Uday Thanawala, program was Coordinated by Dr. Roza Olyai Chairperson Adolescent Health committee FOGSI who also spoke about Adolescent sexual reproductive health & highlighted FIGO’s guidelines regarding the same.

Guest speakers on the panel were Dr. Ratna Kaul, Dr. S. Sapre, Dr. V. Agarwal, Dr. Jyoti Bindal, Dr. Charu Mittal & Dr. Urmila Tripati.

Health Education Programme in Trichy Reported by Dr. Jayyam Kannan Executive committee member Adolescent Health committee FOGSI Adolescent Health Programme by Dr. Malathi, Dr.Kavitha, Dr.Punitha, Dr.Victoria, Dr.Padma Priya, Total Number of Girls Covered - 3000, Total Colleges - 6.

Dr. Parag Hitnalikar, Dr. Rahul Gore, Dr. Anuja Joshi

Destiny

is not a thing to be waited for; It is a thing to be

achieved

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Adolescent Health Committee FOGSI

ADOLESCENCE

“Role of Exercise & life style changes towards Adolescents health”

Dr. Shilpa Thaker Executive member Adolescent Health Committee FOGSI Vice President Ob/Gyn society Rajkot Gujarat Women are beginning to domain most professional fields now more than ever before but adolescent girls are less involved in sport than adolescent boys and this gap increases with increasing age. Today, adolescents are victims of a lot of education-related stress and peer pressure. Besides, the advent of the internet technology and the introduction of screen-oriented applications have dominated their leisure time. The importance of physical activity for them cannot be ignored.

Although adolescents can now choose to engage in a wide range of individual and team sports which were not accessible to their parents, there is widespread concern that the well-being of increasing numbers of young people is at risk because these young people are generally less active than previous generations.

The importance of physical activity for adolescents is unparalleled.

The years of infancy, adolescence and the early teens are the only ones with scope for building a good physique through interactive play and communication. Exercise improves their strength and endurance. It builds and tones up their muscles and keeps them fit and healthy.

Exercise refers to a simple exercise regime, play and even leisure time indulgences like gardening, biking, rock climbing, or cycling, swimming, jogging, brisk walking, dancing, playing football, volleyball, badminton and rigorous volunteering etc.

The physiological and psychological aspects of physical activity empower adolescents to take on stress of adulthood and work related restrictions.

Physiological aspects: During the puberty and adolescence period, exercise can be helpful for the reproductive changes occurring in the woman's body and giving her time to adjust to these changes. Menstrual disorders which include dysmenorrhea, menorrhegia, irregular periods and sterility may also be corrected by exercise.

During pregnancy, exercise tones up and strengthens the abdominal, back and the pelvic muscles and thus allays the fears of the mother of a painful delivery. It also facilitates delivery and assures a quick recovery during post-partum phase. A child born to a woman who has been practicing exercise regularly and continues it during pregnancy is bound to be healthy.

Physical aspects: In terms of physiology, physical activity plays a positive role in the prevention and treatment of a range of physical conditions, and a physically active lifestyle does correspond with a healthy lifestyle.

Adolescent obesity predicts adult obesity, which is strongly and independently predictive of cardiovascular risk, and cardiovascular risk in young adulthood is highly related to the degree of adiposity as early as age 13 years. Childhood obesity and excessive exposure to screen-oriented gaming and entertainment need to be addressed with urgency. The kind of steps taken by teens to lose weight fast and address teen obesity is not amusing. They can avoid the whole extra weight gain with regular exercise patterns.

Children who are overweight suffer the risk of reduced life expectancy and quality. Supported by a well balanced diet, physical activity enables parents to reduce the likelihood of health complications setting in early. Exercise is preventive for most diseases and curative for quite a few in their early stages i.e. diabetes, asthma, hypertension, cardiac arrhythmias etc. In moderate and advanced 11

stages of the diseases, exercise helps in reducing the dosage of the drugs thus preventing a lot of side effects of the drugs.

Healthy lifestyle promotion is associate with consistent health conscious behavior like quitting unhealthy behaviors such as smoking, alcohol consumption, or sedentary behaviors; and practicing healthy behaviors like regular exercise, healthy dietary practices, weight control, and managing stress. Exercise also helps in removing the bad habits of smoking and drugs which interferes with good performance in daily activities.

Establishing Adolescent Friendly Health Centers as per FOGSI Guidelines.

Delhi is the first FOGSI society to kick start the project!

A Half-day Orientation workshop for practicing gynecologists was arranged on 23rd October 2010 at VMMC & Safdarjung hospital, New Delhi. Ten doctors from Delhi attended the TOT which was organized by the Adolescent Health Committee FOGSI under Dr. Roza Olyai Chairperson for the National pilot Project – “Establishing Adolescent friendly Health Centers”, Dr. Pratima Mittal , Dr. Neeta Dabhai & Dr. Jain were the fascilitators, Dr. Jayyam Kannan was invited as an observer. Other invited guests were Dr. Rajesh Mehta & Dr. Kiran Sharma from WHO.

This year The Adolescent Health Committee FOGSI in consultation with Dr. P.C. Mahapatra President FOGSI will carry out this pilot project in selected cities.

The release of the Guidelines was done in prescence of President FOGSI Dr. P.C. Mahapatra , Dr. P.K.Shah General Secretary FOGSI , Prof. Dr. M. Parikh past president FOGSI & Dr. Kiran Sharma from WHO on 16th April 2011.The doctors in Delhi who have established their clinics as Adolescent Friendly were given FOGSI Certificate & memento. These doctors are:

Guidelines are set for Establishing Adolescent Friendly Health Centers, formulated by Adolescent Health Committee FOGSI in consultation with WHO in accordance with the Government of India guidelines.

Dr. Alka Jain , Dr. Alka Goel jain,Dr Anita Sabharwal ,Dr Rekha Vaish,Dr Rita Malik ,Dr Poonam Chawla,Dr Rita Khastgir,Dr Ila Gupta,Dr Anju Gupta,Dr Sadhna Sharma.

Early negligence towards establishing the right kind of physical activity results in mental and physical submission to stress later.

Psychological aspects: Turning from the physical to the psychological effects of exercise, in general terms the healthy forms of exercise can play a role in the promotion of mental health and most significantly among those with a predisposition towards mental illness.

When reflecting on the pros and cons of exercise for adolescents, it is useful to distinguish between the effects on the mind and the body, the psychological and the somatic. Regarding the healthy effects of exercise, several thorough reviews have confirmed that various psychological dysfunctions can benefit from an involvement in physical activity, including the following: Depression - Aerobic exercise appears to be most effective and including repetitive activities such as walking, jogging, cycling, light circuit training, and weight training, with regimes extending over several months apparently yields the most positive effects.

Anxiety - Increases in physical condition or improved fitness are likely to facilitate the individual's capacity for dealing with stress.

Mood state - Exercise can indeed have a positive influence on mood state. Various forms of exercise, both aerobic and anaerobic, can be associated with an elevation of mood state in particular circumstances.

Body image - Young women, focus on their body as an aesthetic statement whereas traditionally at least, males have been more likely to attend to the dynamic aspects of their bodies, such as coordination, strength and speed. This emphasis on the female form in exercise settings may foster feelings of social-physique anxiety (SPA), constrain enjoyment of the activity itself, and may even be exacerbated by the nature of the clothing required Self-esteem - The young person's low self-esteem has its roots in poor body image or lack of fitness or weight control then exercise can have a positive effect and the effect appears to be most powerful when aerobic activities are used. Exercise can bolster self-esteem in cases where it is fragile or underdeveloped.

The school teacher as a role model will have a significant impact on the individual pupil's participation for physical activity. School based interventions can be at the individual level of the teacher or they can be at an organizational level.

TOT, Gwalior “Establishing Adolescent Friendly Health Centers” “Establishing Adolescent Friendly Health centers” TOT Gwalior was held on 29th May 2011. The Adolescent Health Committee FOGSI organized a half day TOT on ARSH in Gwalior as part of a pilot project this year. Six selected gynecologists attended the TOT & got training according the guidelines made by the committee to establish their clinics as adolescent health friendly center. Dr. A. Jain from Safdarjang hospital Delhi was the master trainer along with Dr. Roza Olyai chairperson Adolescent health committee FOGSI. Drs. Attended the TOT were : Dr. Ratna Kaul President Gwalior Obst. & Gyn. Society & AMPOGS, Dr. Meena Mundra, Dr. Rama Modi, Dr. Kalpana Bansal, Dr. Kirti Donde, Dr. Anjali Jain & Dr. Sonali Agarawal.

Summary Under the right condition, appropriate physical exercise improves both physical and mental wellbeing of young people. Local authorities, schools and parents should encourage young people to maintain their involvement in physical activity.

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Adolescent Health Committee FOGSI

ADOLESCENCE

Use of contraception in adolescence - what's new?

Dr Muralidhar V Pai Professor of Obstetrics & Gynecology Kasturba Medical College, Manipal Karnataka State Introduction The use of appropriate contraception is especially important in adolescents, as this age group matures and becomes capable of reproduction. Fairly good number of sexually active adolescent girls become pregnant each year, and most of these pregnancies occur within the first 6 months of sexual activity. Contraception is consistently used by only a small minority of teenagers. A combination of factors including misinformation that pregnancy cannot occur during ''first time'' or during certain times of the month, fear of side effects, inability to communicate with partner, risk-taking behavior, non availability or shyness to buy, conspire against effective contraceptive use. The American College of Obstetricians and Gynecologists (ACOG) has recently published recommendations for the first preventive visit with a gynecologist to be between the ages of 13 and 15 years1. However in India, that may be too early. Best time to educate them about contraception is during high school.

In the quest for the best contraceptive method, adolescents look for safety, convenience, privacy, and efficacy as the most important factors in choosing a contraceptive method. The purpose of this review is to provide some new information to the reader.

Contraceptives that can be used by adolescents : Condoms They pose no significant medical risk to adolescents and provide protection against sexually transmitted diseases, as well as preventing pregnancy. Condoms do not require a prescription, can be bought easily and kept readily available by adolescents who have intercourse infrequently and sporadically. Female condoms are not available everywhere in India and education is needed about its use.

Even in countries where they are readily available they have not received great popularity.

Hormonal contraceptives Oral contraceptives are the contraceptive method of choice for sexually active adolescent girls. They can be safely recommended to most with only the usual absolute contraindications restricting their use.

All adolescents should be given thorough counseling regarding the possibility of minor side effects such as intermenstrual bleeding or nausea, which can lead to stopping the pills. Similarly, the patient should be reassured that physiologic changes including small elevations in blood pressure or rashes are reversible.

Newer indications, such as premenstrual dysmorphic disorder (PMDD) with a low-dose (ethinyl estradiol, 20 mg) formulation containing drospirenone (3 mg), which has antiandrogenic and antimineralocorticoid properties, in a 24/4 regimen (24 days of active drug/4 days of placebo), have proved to be efficacious in reducing symptoms of PMDD2. This as well as some other formulations, including cyproterone, levonorgestrel, or desogestrel, are efficacious in reducing acne3. Extended regimens, such as the available 84/7day package (ethinyl estradiol [30 mg]/levonorgestrel [150 mg]), have shown similar efficacy and compliance4.

To prevent some of the noncompliance in adolescents, initiation of the pill on the same day (Quick Start) versus the traditional start seems to improve compliance and still maintains an acceptable side effect profile5.

The progestin-only contraceptive pill has been shown to have similar efficacy to the combined oral contraceptives (COCs). Unfortunately, given its short half-life, failure rates may be increased because of patient noncompliance with the proper timing of the pill, which 13

offered to adolescent girls who have had unprotected intercourse.

Ideally the emergency contraception is taken in the first 24 hours after coitus, but it may be given within 72 hours of intercourse. The most efficient method consists of levonorgestrel, 1.5 mg, divided in two doses taken 12 hours apart. A recent Cochrane review showed that taking a single dose of levonorgestrel, 1.5 mg, may be as efficacious as when it is taken in divided doses, possibly increasing compliance12. It is important to inform the adolescents, not to use this as primary method of contraception.

Intrauterine devices

requires taking it around the same time of day (within 3 hours) each day6.

Recent trends in improving COCs have focused on lowering hormonal doses to 20 mcg estrogen, shortening the hormone-free interval (to counter the symptoms associated with lower-dose regimens), introducing new estrogens and progestins, and most recently, developing a quadriphasic regimen.

The short-term adverse effects of COCs, such as nausea and weight gain, are usually transient and may be overshadowed by the beneficial effects of a shortened menses and the relief of dysmenorrheal.

Concerns about weight gain have deterred large numbers of adolescents from using combined COCs. A Cochrane review, updated in 2006, included a large number of trials and found no evidence of a causal association between either oral contraceptives or the contraceptive patch and weight gain7. More serious potential complications of exogenous estrogen such as thrombophlebitis, hepatic adenomas, myocardial infarction, and carbohydrate intolerance are exceedingly rare in adolescents8. An initial thought for younger adolescents regarding the potentially unknown effect of estrogens on epiphyseal growth is no longer a concern8. Hence there is no need to worry regarding bone development and height.

Some long-range beneficial effects of estrogen use include decreased risks of benign breast disease, ovarian disease, and anemia. A beneficial cardiovascular effect occurs for adolescents taking estrogen-containing COCs; these young women have shown higher levels of cardioprotective high-density lipoproteins than controls.

Contraindications to the use of estrogen-containing COCs include hepatocellular disease, migraine headaches, breast disease, any condition in which hypercoagulability may be a problem (replaced cardiac valve, thrombophlebitis, sickle cell anemia) because of the increased levels of factor VIII and decreased production of antithrombin III, and known or suspected pregnancy.

The contraceptive transdermal patch uses the technology of a medicated adhesive that allows the skin to absorb and maintain a constant hormonal level without the fluctuations seen with orally absorbed forms. Given the weekly dosing, many adolescents find this method appealing. Good acceptance, cycle control, and adherence rates have been shown and are greater than those observed with the COCs9.

The vaginal contraceptive ring (ethinyl estradiol [15 mg]/ etonogestrel [120 mg]) is another approved method of birth control. This method requires motivation from the patient to insert and remove the contraceptive device from the vagina once a month and has not been well studied in adolescents. Preliminary results indicate favorable acceptability when compared with the OCP10.

The experience with IUDs and intrauterine systems (IUSs) in adolescents is limited. Traditionally, use of an IUD or IUS has been avoided in adolescents, because of the increased risk of sexually transmitted infections (STIs) in adolescents and the dynamic nature of their sexual relationships. However, in recent studies, there has not been an increase in infertility or STI incidence with the use of these devices13. Most of the ascending infections are probably related to contracting the infection from lack of condom use rather than to the presence of the device facilitating it. In 2007, the Adolescent Healthcare Committee of the ACOG advocated for the increased use of an IUD or IUS in this population and has undertaken a full review on the topic14.

Summary Adolescent contraception is an integral part of education and requires the collaboration between providers, adolescent girls and, sometimes, their parents. New contraceptive methods allow teens to choose from a variety of convenient, safe, reliable, and confidential options.

References : 1. American College of Obstetricians and Gynecologists. The initial reproductivehealth visit. ACOG Committee Opinion No. 335.

Obstet Gynecol 2006;107:745–7.

2. Yonkers KA, Brown C, Pearlstein TB, et al. Efficacy of a new lowdose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol 2005;106:492–501.

4. Stuart GS, Castano PM. Sexually transmitted infections and contraceptives: selective issues. Obstet Gynecol Clin North Am 2003;30:795–808.

5. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills.

Contraception 2002;66:81–5.

6. Graham S, Fraser IS. The progestogen-only mini-pill.

Contraception 1982;26: 373–88.

7. Gallo MF, Lopez LM, Grimes DA, Schulz KF, Helmerhorst FM. Combination contraceptives: effects on weight. Cochrane Database Syst Rev. 2006;CD003987.

8. Kliegman, Contraception: Nelson Textbook of Pediatrics, 18th ed.

2007, Saunders, an imprint of Elsevier 9. Harel Z, Riggs S, Vaz R, et al. Adolescents' experience with the combinedestrogen and progestin transdermal contraceptive method Ortho Evra. J Pediatr Adolesc Gynecol 2005;18:85–90.

10. Stewart FH, Brown BA, Raine TR, et al. Adolescent and young women's experience with the vaginal ring and oral contraceptive pills. J Pediatr Adolesc Gynecol 2007;20:345–51.

11. World Health Organization. WHO statement on hormonal contraception and bone health. Wkly Epidemiol Rec 2005;80:302–4.

12. Cheng L, Gulmezoglu AM, Oel CJ, et al. Interventions for emergency contraception.Cochrane Database Syst Rev 2004;(3):CD001324.

13. Kohler PK, Manhart LE, Lafferty WE. Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. J Adolesc Health 2008;42:344–51.

14. American College of Obstetricians and Gynecologists. Intrauterine device and adolescents. ACOG Committee Opinion No. 392.

Obstet Gynecol 2007;110: 1493–5.

3. Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2007:CD004425.

Report for Panel Discussion on

'Adolescent Health Issues' at SOGOG at Bhavnagar By : Dr. Shilpa Thaker, Executive member Adolescent Health Committee FOGSI Panel discussion was held on 'Adolescent Health issues' at State conference – SOGOG at Bhavnagar which was moderated by Dr. Shilpa Thaker. The Panelist were: Dr. Sudha Mehta (Bhavnagar), Dr. Prashanth Adiga (Manipal), Dr. Usha Valadra (Surat), Dr. Sonal Kotadawala (Ahmedabad), Dr. Jignesh Deliwala (Ahmedabad). All reproductive, social, emotional and economical aspects were discussed. It was very interactive, interesting & well appreciated by all the delegates.

Long-acting injectable medroxyprogesterone acetate is a useful method but weight gain and irregular bleeding are common and unpleasant side effects for adolescents. A recent concern has been the effect of the hypoestrogenic state created by long term use of DMPA on bone density in adolescents. However, The WHO suggests that the advantages of using DMPA generally outweigh the theoretic safety concerns regarding fracture risk in the adolescent population (younger than 18 years of age)11 One must caution the adolescent that the hormonal methods do not provide protection against sexually transmitted diseases, so concomitant use of condoms should be recommended routinely.

Emergency contraception is now readily available and ought to be 14

Adolescent Health Committee FOGSI

ADOLESCENCE West Zone TOT, Pune “Challenges for the youth today & tomorrow ”

East Zone TOT, Kolkata “Challenges for the youth today & tomorrow ”

The West Zone TOT Program was held on 1st May 2011, at Seasons, Apartment Hotel, Pune was a huge success. The meeting was attended by 15 City coordinators. The programme started with formal Inauguration by Dr. P. C. Mahapatra, President FOGSI, Dr. Roza Olyai Chairperson Adolescent Health Committee, Dr. Sunita Tandulwarkar, Chairperson, Infertility Committee, & Mrs. Marzia Dalal a leading advocate in Pune. The introduction & details of this Project was given by Dr. Roza Olyai, Chairperson, Adolescent Health Committee, FOGSI.

The East Zone TOT Program was held on 7th May 2011, at Surjoun Hotel, Kolkata was a great success. The meeting was attended by 15 City coordinators. The program started with formal inauguration done by Dr. P. C. Mahapatra, President FOGSI, Dr. P.K. Shah General Secretary FOGSI , Dr. Roza Olyai Chairperson Adolescent Health Committee, Dr. Ghosh & his team of Bengal Obstetric & Gyn. Society who were invited guests to grace the occasion. The introduction & details of this Project was given by Dr. Roza Olyai, Chairperson, Adolescent Health Committee, FOGSI.

The presentation on Counseling Adolescents was delivered by Dr. Anu vij West Zone coordinator for Challenges for youth project. The City Coordinators' views and inputs were taken. Ms. Marzia Dalal, Advocate, Pune, was the Invited Guest, who gave insights to the importance of adding Spirituality and Morality on these talks. She willingly offered to send her students to talk on Spirituality in our School Programmes as part of the Junior Youth Empowerment program & Ruhi Institute courses which she is personally organizing. All the logistic support will be borne by the students whom she will recommend. Each city coordinator will be taking five sessions to cover 500 girls in each city using a tool kit made by the committee.

The presentation on Counseling Adolescents was delivered by Dr. Durga Shankar Dash East Zone coordinator for Challenges for youth project. The City Coordinators' views and inputs were taken. Each city coordinator will be taking five sessions to cover 500 girls in each city using a tool kit made by the committee. Dr. Roza Olyai thanked all the City Coordinators for coming all the way to attend the TOT, and Emcure for all the logistic help extended towards making the programme a huge success & for all the future TOTs this year under this project.

Health Education in Cochin- Kerala for school boys & girls is a regular feature Report by Dr. Gracy Thomas, Executive Committee member adolescent health committee FOGSI

Gynaecological Endocrine Society of India and Department of Obstetrics & Gynaecology, AIIMS jointly organized a National Conference on Gynae-Endocrinology-2011 under aegis of FOGSI, ICOG and AOGD, on 16h & 17th April 2011.

The Conference was well attended with many interesting lectures & workshop organized by Prof Alka Kriplani & Dr Nutan Agarwal. Panel discussion on newer hormonal contraception was moderated by Dr. P.C. Mahapatra & expert panelists were : Dr.J.B. Sharma, Dr. V. Mishra, Dr. Trivedi & Dr. Roza Olyai.

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Adolescent Health Committee FOGSI

ADOLESCENCE Conferences & Events

Rubella Project (2011) of Adolescent Health Committee FOGSI Report by :Dr. Neerja Pauranik Member Adolescent Health Committee FOGSI Consultant & HOD (OB-GYN), Bombay Hospital, Indore.

First National Health & Happiness conference was held in Pune 1st May at YASHDA, near Pune University. The conference was hosted by Pune Obst. & Gync. Society was well attended with delegates from all parts of the country. Dr. P.C. Mahapatra President FOGSI was the Chief guest, Dr. Roza Olyai spoke on the “Challenges for the Youth” with emphasis on the role of FOGSI in catering to the need of the adolescents & youth of the country. She explained the various projects adolescent health committee is undertaking in this regards with special collaboration with FIGO at the International level. A special dinner was organized by the Pune Society , Dr. Shirish Patwardhan as director of the conference, Dr. C. Joshi & Dr. Sunita Tandulwadkar welcomed the guests.

FOGSI-FPAI Expert Meet A joint FOGSI –FPAI “Expert Committee Meeting” was held to Standardize the “Service Delivery Guidelines on Sexual Reproductive Health Issues in Adolescents” at the FPA India HQs from March 3 – 4, 2011.

Family Planning Association of India( FPAI) has a long tradition of providing services to young people and view the provision of services to young people as one of the core activities.

This year as part of their national project, FPAI has developed a Draft “Service Delivery Guidelines on SRH Issues in Adolescents” to improve the quality services to young people.

Dr. Roza Olyai, Chairperson Adolescent Health Committee FOGSI was invited as an expert to the panel for reviewing the draft “Service Delivery Guidelines on SRH Issues in Adolescents” and for finalizing its content. Other invited members were Dr. Ashwini Bhalerao Gandhi, Dr. Sheela Mane & medical officers from various FPAI centers in India.

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• The Adolescent Health Committee FOGSI under the 'Special International Service Project’ in partner of Rotary District 7530USA & district 3040 of India,has targeted 3 Lac girls to be vaccinated in different schools and colleges in Indore, Bhopal & Ujjain in state of MP. • Up till now nearly 2500 girls are immunized including nursing staff & students of Choithram Hospital, Indore, Bombay Hospital, Indore, girls of Takshashila School, Jeevanjyoti Kendra, Seva Bharti is actively vaccinating girls from Malviya Nagar, Dhiraj Nagar,Badigwaltoli etc.

Barli Gram Rural Institute

SAMS College, Bhopal