Adolescence Issue 09

Issue 09 | Pages 20

ADOLESCENCE

Adolescent Health Committee FOGSI

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

Adolescent Health Committee FOGSI

ADOLESCENCE Message from

Message from

President FOGSI 2013...

Secretary General's Desk...

Dr. Hema Divakar President FOGSI 2013 Dear FOGSIANS, Greetings for all times in future !

Coming together in FOGSI is the beginning of the Mission and we remain together to accomplish our Vision for making a positive difference to Women’s Healthcare in India.

When we reflect on the varied health scenarios in our country and acknowledge and accept that there are many "Indias" within "the India" and the diversities between INDIA and BHARAT pose a challenge to health equity issues - what is available in the tertiary centers in metros is quite different from what is available at the primary health centers in rural parts.One has to figure how one can offer the best - but at a low/ reasonable cost and see that it reaches ALL the women of India and makes an impact on health indices of our Nation.

We need to "innovate" and see what works for us. We need to "implement" in novel ways - educating the masses on their right to "safe mother hood" and empowering frontline health workers to offer care in the community We need to study the "impact" of preventive healthcare on reducing the burden of many of the morbidities and mortality. We always seem to think that it is someone else's job !

My sincere appeal to all FOGSIan's. Let's do our bit as "Change Makers". Let us help in shifting the focus to "preventing illness and promoting wellness".

Let us be contributory to the wellbeing of women in India. Let us target the adolescents and DELIVER A HEALTHY FUTURE!

Dr. Nozer Sheriar Secretary General FOGSI Dear Colleagues and Friends, 'Whether you think you can, or that you can't, you are usually right.'

- Henry Ford The adolescent health activities of FOGSI have of course been very effectively managed by the Adolescent Health Committee under the stewardship of a series of very dynamic chairpersons. The committee has striven for greater heights under Dr. Roza Olyai with regular publications, advocacy and national and international recognition. As the Website Coordinator, I have seen the great response of netizens to the eight issues of the Adolescence Newsletter in our publications section.

Am very happy to see that Dr. Jayyam Kannan the newly elected Chairperson is continuing with the publication of the Adolescence Magazine. I wish the committee my very best and thank them on behalf of FOGSI for doing this very important work so sincerely.

Keep up the good work!

Dr. Nozer Sheriar Secretary General FOGSI

Message from

Chairperson (2013-15) Dr. Jayamkannan Chairperson Adolescent Health Committee FOGSI (2013-15) Emeritus professor, Tamil Nadu MGR medical university Member PMNCH WHO programme Web coordinator FOGSI Member antiviolence cell FOGSI

I must congratulate Dr. Jayyam Kannan, Chairperson Adolescent Health Committee FOGSI (2013-15) in continuing the most useful informative and educative Magazine on adolescence.

I am sure this Magazine will be a good, useful informative guide to Adolescent girls, parents and doctors. I wish Dr. Roza Olyai, Editor of the Adolescence Magazine and her team the very best for their future endeavors to continue the good work they are doing.

Best wishes and warm regard,

Adolescents constitute 22.8% of population of India as on 1st march 2010.

Dr. Hema Divakar President FOGSI 2013

They are not only in large numbers but are the citizens and workers of tomorrow.

FOGSI Office Bearers 2013

1

Dr. Hema Divakar

President

Dr. Ashwini Bhalerao Gandhi

Vice President West Zone

Dr. Alpesh Gandhi

Vice President West Zone

Dr. Jayant Rath

Vice President East Zone

Dr. Maninder Ahuja

Vice President North Zone

Dr. S. Shantha Kumari

Vice President South Zone

Dr. P. K. Shah

Immediate Past President

Dr. Nozer Sheriar

Secretary General

Dr. H.D. Pai

Deputy Secretary General

Dr. Jaydeep Tank

Treasurer

Dr. Madhuri Patel

Jt. Treasurer

Most Adolescents in India are out of school, malnourished, get married early, working in vulnerable situations, and are sexually active, exposed to tobacco or alcohol abuse.

We have to impart Sexual & Reproductive health education services like : contraception, pregnancy testing and option, MTP, STD/HIV screening counseling and treatment, prenatal & postpartum care, well baby care, nutritional services, growth & development monitoring.

To achieve all these we need, friendly health workers who are knowledgeable, presentable, with good communication skill to maintain confidentiality and be non-judgmental!

Welcome...

From the Editor’s Desk

Newly elected Chairperson...

Dr. Jayyam Kannan the newly elected dynamic & energetic Chairperson of the Adolescent Health Committee FOGSI was welcomed by the invited faculties from FIGO & Dr. Roza Olyai immediate past Chairperson during the Adolescent committee workshop at AICOG Mumbai. Memorable moment to pass the baton to her with flower welcome & gold medal.

Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH Vice President Elect FOGSI (2014) Member Board of Governing Council Indian College of Obst. & Gyn.(ICOG 2012-15) Member antiviolence cell FOGSI Director Olyai Hospital,Gwalior-MP India Email: rozaolyai@gmail.com Dear Friends, It gives me great pleasure to share with you the 09 issue of the news magazine of the Adolescent Health Committee FOGSI. Am very happy to welcome Dr. Hema Divakar President FOGSI (2013) with her team &Dr. Jayyam Kannan as the newly elected Chairperson of the Adolescent Health Committee for 2013-15. Am sure the committee will reach its greater heights under their able leadership & I will be very happy to continue my support of activities during their tenure.

Young Women's club is a subsidiary club of the Adolescent Friendly Health Centers a National Project of the Adolescent Health Committee FOGSI which was established since 2010 has now spread in more cities in 2013.

FIGO News Letter May 2013 issue highlights the Adolescent Health committee FOGSI workshop organized on ARSH held during AICOG 2013 in Mumbai & shares detail report of the same. We are grateful to FIGO for their constant encouragement & guidance.

We have included interesting articles in this issue such as : “Programmatic Experiences in Adolescent Sexual and Reproductive Health”by Professor Hamid Rushwan, Chief Executive of FIGO, “ACT and IMPACT- Vision 2022” by Dr. Hema Divakar President FOGSI which highlights strategies for overcoming violence against women & other health related issues, other articles of interest compiled are: “Obesity In The Adolescent & Young Girls”, “Congenital Uterine Anomalies and Reproductive function”, “Digital world of Adolescents and social media”, “Aberrant eating habits in Adolescent girls”, “Adolescent Contraception” “Adolescent Endometriosisin” & “Robotic Gynaecological Surgeries: The Teenage Years”.

We are thankful to our esteemed authors for their contributions. One of our major project is“Challenges for the youth today & tomorrow”.

We were able to cover more girls in the coming months through the various school/ college health talks, sharing with them the informative booklets which our committee has prepared.

Am very grateful to Emcure Pharma, specially Mr. Arun Khanna, the COO of Emcure Pharma for his personal interest in supporting the activities of the Adolescent Health Committee FOGSI & helping to spread the message across the country through this magazine for the betterment of the youth.

Your suggestions & feedback will be of great help, kindly share your articles& achievements with us.

Wish you all a happy reading!

Through our Adolescent Health committee FOGSI let us all strive to do our best and train more professional health workers.

The footsteps which are well designed by my predecessors will go a long way in helping me to shape our future workforce of my country.

Dr. Roza Olyai Dr. Jayamkannan 2

Adolescent Health Committee FOGSI

ADOLESCENCE

FIGO participation on ARSH during Adolescent

The Adolescent Health FOGSI Committee workshop was held on 17th January 2013 at the Trident Hotel, Bandra (E) Mumbai during the AICOG 2013 Mumbai which was a great success with good number of participants involved.

The first session was chaired by Professor Dr. Alka Kriplani, HOD AIIMS Delhi &Professor Dr. Walker, Senior Vice President of the RCOG, UK. Due to an important FIGO commitment Prof. Hamid Rushwan Chief Executive FIGO could not come for the workshop but he was kind enough to share his presentation which was well covered by Professor Dr. C.N. Purandare, President Elect FIGO talked in detail on the topic of “Adolescent Sexual Reproductive Health Global views”. We are very grateful to Prof.

Purandare for the same.

The second session was chaired by Professor Dr. Walker, Dr. Duru Shah (past president FOGSI & past FIGO representative )& Dr. Millind Shah (Past VP FOGSI).

Professor Dr. Lesly Regan, FIGO Committee on Women's Sexual & Reproductive Rights, spoke on the topic of “Adolescent health issues in UK, the need for prevention and life skills approach to women's health” The Adolescence magazine issue 08 was released in presence of the invited guest speakers & faculty

3

Health Committee workshop AICOG 2013 Mumbai

members by Dr. Narendra Malhotra past president FOGSI & FIGO representative who praised the work done by the committee & encouraged the members for their continued good efforts.

At the end, Dr. Roza Olyai, Vice President Elect FOGSI 2014, shared overview of the Adolescent Health committee FOGSI activities of which she has been the chairperson since 2009 till date. This was followed by a special award ceremony for the advisors & members of the committee. Dr. Jayyam Kannan the newly elected dynamic Chairperson of the Committee was welcomed & it was time to pass the baton to her with a flower welcome & gold medal. The good work of Emcure Pharmawas well appreciated by everyone & on this occasion Dr. Roza Olyai highlighted the activities & support of Emcure Pharma & specially thanked Mr. Arun Khanna COO Emcure Pharma for his constant encouragement & support, Mr. Atul Kichlu for his excellent coordination, Mr. Harshal, Mr. Kedar & their team for their wonderful execution of this project since 2009 till date.

Special thanks were given to Dr. Hamid Rushwan Chief Executive FIGO & Dr. Arulkumaran President FIGO under whose guidance the Adolescent Health committee FOGSI was doing it's projects.

On this occasion FIGO guest members present were honoured. The program ended by vote of thanks & high tea.

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Adolescent Health Committee FOGSI

ADOLESCENCE

Programmatic Experiences in Adolescent Sexual and Reproductive Health

Professor Hamid Rushwan Chief Executive of the International Federation of Gynecology and Obstetrics (FIGO) Adolescent sexual and reproductive health (ASRH) has been overlooked for many years as a major component of the global burden of sexual ill-health. However, international agencies such as the United Nations Population Fund (UNFPA) and the World Health Organization (WHO), as well as international and national nongovernmental organisations (NGOs), are now focusing on improving ASRH and on providing programmatic funding for interventions.

The International Federation of Gynecology and Obstetrics (FIGO) -the only organisation bringing together professional societies of obstetricians and gynecologists on a global basis -is currently strengthening its partnerships with other international professional organisations, including UN agencies, to strengthen the capacity of FIGO country offices to support ASRH interventions at the national level. This complements FIGO's wider objective of strengthening its capacity to support national societies and, alongside this, increasing national societies' capacity to play a major role in advocacy, training, policy development and promoting reproductive health programmes.

In our review of the experiences of countries in tackling the ASRH issue, I quote here briefly examples from three countries representing Asia, Latin America and Africa.

NAFCI success has been linked with strong leadership at all levels, political support, collaboration with stakeholders, youth and community involvement, and provision of technical support.

Costa Rica

1.

2.

3.

4.

The National Adolescent Friendly Clinic Initiative (NAFCI) uses a certification and assessment system to help improve the quality of health services to youth at public clinics. It was envisioned as a national programme from the outset. After an 18-month pilot period, moving from single districts to larger areas, NAFCI had the participation of 350 clinics with 171 associated clinics by late 2005.

The programme, which is part of the larger 'LoveLife' programme, addressing young people's sexual health through multiple approaches, is implemented through the Department of Health. The departmental link helps ensure sustainability. Passage of positive youth health policies helped to facilitate the launch. A majority of the clinics that have been externally assessed (212) complied with 80 to 90 percent of the NAFCI standards for youth-friendly clinics. The

5

Ensure age-appropriate approaches for different groups of young people, bearing in mind that it is easier to influence behaviour before sexual activity starts Abstinence-only programmes have not been shown to be effective: a better method is to combine abstinence messages with clear communication on the importance of reduction in the number of partners, condom use, and dual protection to prevent HIV/AIDS/STIs and pregnancy: this is best achieved through a life-skills approach. Sex education programmes should offer accurate, comprehensive information while building skills for negotiating sexual behaviours

My dear FOGSI'ans, I have said it before and I say it yet again: "Hurt me with the truth - I don't mind ..... But don't comfort me with a lie " We can never ever say we have done enough with respect to womens healthcare until we prevent every single preventable death This is our professional responsibility and what is expected of us by the society .

But we recognise that our roles in caring for a woman , extend beyond medical care - because, a womens well being is intertwinned with a complex ramification of social, legal, economical inequities.

Awareness about the fact that "change is constant" and change will happen in due course of time - and for this ,we have to ACT Now and the generation next will see the IMPACT

"Violence against women" ... the recent happenings in the country tops the list of the emerging new concerns for girls and women in our country. As always , we focus on solutions rather than lamenting about the existing problems.

6.

Essential components of ASRH programmes include information and counselling, access to STI/HIV treatment and care, contraception provision, and maternal health services

(2)

Access to education is crucial, going by example of neighbouring countries like srilanka who have made great strides in uprooting the bias and empowering the girls without compromising on quality of life.

Situation analyses and needs assessment exercises carried out in different parts of the world point to shortcomings in the professional capabilities of healthcare providers working with adolescents, and in their 'human qualities', as a result of which they are unable, and often unwilling, to deal with adolescents in an effective and sensitive manner. All adolescents need access to quality youth-friendly services provided by clinicians proficient in working with this population: healthcare providers catering to adolescent populations need to be specially trained on how to work with youth - they must be non-judgemental in their interactions, sensitive to youth needs and technically competent

9.

Monitoring and evaluation methods should be developed from the start of the programme, rather than as an afterthought, and, where possible, using a randomised comparative methodology to measure effectiveness and outcomes of programmes

will go a long way in quick reporting, swift actions against the accused and the required medical care for the victim, inclusive of psychological support.

Act and Impact!

Eradication of gender bias lays the foundation for change.

Feticide is an act of violence when in the womb itself !

8.

FIGO Chief Executive

Our roles beyond medical care:

(1)

Adolescent- or Youth-friendly health services have been shown to be effective when certain characteristics are present: they need to be located in suitable places where they can be easily reached, but not too obvious; they should be free of cost or very affordable; they should be attractive to youth with a warm, informal atmosphere; they should guarantee privacy and confidentiality; and they should have a sufficient range of services and supplies to meet the multiple needs of that particular youth population

Professor Hamid Rushwan

Dr. Hema Divakar President FOGSI 2013

Peer education and outreach are effective methods and can be combined with non-peer education methods

7.

Most importantly, obstetricians and gynecologists - through their national associations and through FIGO at the international level have an important role to play in the advancement of ASRH services.

ACT and IMPACT - Vision 2022

There is no single 'fixed menu' suitable for every country but each country must develop its own specific package according to the local economic, epidemiological and social context Conduct assessments of local stakeholder and institutional capacity for supporting, implementing and evaluating ASRH programmes, and involve young people, families and communities in designing interventions

and it is time to improve our understanding of them, and to focus our energies on the alleviation of these problems.

Violence Against Women

5.

Costa Rica has a strong programme for adolescents based on a solid political, legislative and social structure. Key success factors and results include: this is a comprehensive service covering the whole country; there is broad political commitment to the needs of adolescents; a national training programme is being implemented for health workers; young people receive training to provide leadership on health; and Costa Rica is supporting efforts to build adolescent programmes in other countries South Africa (NAFCI)

The message from FIGO's ASRH Initiative is clear: there are currently innumerable health and social challenges facing youth of all countries,

The facts revealed during our review of programmatic experiences in various countries reveal some key principles and actions that should be observed in order to provide effective SRH interventions for adolescents:

Thailand In Thailand, the Ministry of Public Health has developed 350 Health Promoting Hospitals, committed to health promotion and to making health services more user-friendly. In 2001, the Department of Health began to introduce 'Friend Corners' outside school and college hours in local shopping malls and community housing areas. The first point of contact is with adolescents trained as peer counsellors. Health staff are also on hand to provide counselling or basic primary care or to refer adolescents to specialised services as necessary. The 'Friend Corner' website combines music, fashion and health information, and has been praised for making information accessible in an attractive way.

10. Girls and boys also need equal access to youth development programmes that connect them with supportive adults and with educational and economic opportunities; ASRH programmes can be complemented with additional supportive measures in the community, with the media, and with local institutions; and scaling up of successful initiatives should be planned from the start with adequate attention to costing, documentation, involvement of a wide range of committed partners, and confirmed support from government

(3)

Active management of crisis situations by all stakeholders family, police, legal, medical fraternity and the society at large

Vision 2022 ...

Acting as swiftly as possible, Alerting the stakeholders, Acknowledging that you can not only save lives but do more Awarding and rewarding the Champions who Help this cause, This completes the spectrum for Vision 2022 My congratulations to Dr. Roza Olyai, Vice President Elect FOGSI 2014, for leading many initiatives through the Adolescent Committee FOGSI - with Passion and Commitment. We need to figure out what works for us - move from Innovation to Implementation.

My sincere request to all FOGSI'ans to ACT and IMPACT Coz I truely believe that our efforts can make a difference to Womens HealthCare in India.

Memories of Adolescent Health Committee Workshop, AICOG...

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Adolescent Health Committee FOGSI

ADOLESCENCE

Obesity In The Adolescent & Young Girls

Congenital Uterine Anomalies and Reproductive function

Prof. Rubina Sohail Professor of Obstetrics & Gynecology, Services Institute of Medical Sciences, Lahore, Pakistan Hon. Secretary SAFOG Obesity in childhood and adolescent is increasing in the developing countries around the world. Obesity is a condition in which excess of body fat accumulates to the extent that it may have an adverse effect on health. Obesity is measured by using Body Mass Index (BMI) = weight (kg) / length (m)2.BMI>25-29.9 is over weight and a BMI >30-34.9 is classified as obesity. Around80% of obeseadolescents turn out to be obese adults.

There are various causes of obesity in childhood and adolescence. One of the factors is genetics and studies have shown that predisposition towards obesity can be inherited. Although several genes have been identified, but most believe that one gene is not responsible for the entire obesity epidemic. Currently a change in the life style pattern of adolescents is considered a significant factor in determining obesity.

The prevailing wave of obesity is influenced by the way the children are brought up. Children lead more sedentary life style. Now days the burden of studies has increased and they pay less time on physical activities. Schools have fewer playgrounds so the physical activity in the children and adolescent has also reduced. Along with this, computer games have also become more popular and the children and young adolescents are spending more time in front of the computers, television or video games. Fast food has gained immense popularity and newer chains are cropping up resulting in intake of high calorie fast food and carbonated drinks. The eating habits and diet and reduced physical activity, both contribute in the weight gain. To top this all is the threat of terrorism and lack of security, which is an important contributory factor in limitation of physical activity and contribution to obesity in young girls and adolescents. Medical disorders such as hypothyroidism and intake of dugs such as antidepressants with antipsychotic drugs may also contribute to the condition. Another determinant to obesity is the socio cultural milieu especially in some countries of the South Asian region as Pakistan, where the misconception prevails that a healthy child is an obese child. It is for the same reason that pregnant women are encouraged to eat way greater than the normal requirement during pregnancy and also the children if possible are also fed more than their fair share of calories.

Prevalence: According to studies one out of every six adolescents is overweight and one out of every three is at risk. Since the 1980, the proportion of overweight children has steadily increased. Childhood obesity was found to be highest in South Asia, with eight out of 10 states with highest rates of obesity being in the South Asian region.

According to a cross sectional study carried out in India in 2008, the over all prevalence of obesity and overweight was 11.1% and 14.2% respectively. According to a study carried out in Pakistan, the prevalence of overweight children was found to be 18% amount school going children from 6th-10th class.

Implications of obesity - Short term Social implications: Being overweight during adolescence has major psychological and social, repercussions, which may also produce an economic impact in young age. Obese girls maybe shy and lacking in confidence that sometimes may affect their academic performance and psychological functioning. Obesity can also have implications such as less like hood of marriage, lower wages and less education.

Medical implications: Obese adolescent girls are more likely to suffer from PCOS. Polycystic ovary syndrome (PCOS) is marked by hyperandrogenemia, obesity and menstrual irregularities specially oligomenorrhoea oramenorrhoea. It may first manifest during adolescence, and both peripubertalhy perandrogenemia and obesity are considered to be risk factors for the development of PCOS. However, the causes of peripubertal obesity-associated hyperandrogenemia, and mechanisms by which hyperandrogenemia 7

could support progression to PCOS, is not known.

Long Term implications Type 2 Diabetes: The increasing prevalence of obesity is accompanied by an increasing prevalence of type 2 diabetes. Obesity not only increases the risk of developing type 2 diabetes but also compounds its health risks and complicates its management Hypertension: Obesity and hypertension are closely associated.

Hypertension in adolescence generally leads to hypertension in adult life. There are two reasons for concern about the relationship of obesity to hypertension. Weight gain in young adult life is a potent risk factor for later development of hypertension. Weight reduction in obese hypertensive persons often reduces arterial pressure.

Pregnancy complications: Overweight and obese women are at an increased risk of several pregnancy complications including, gestational diabetes mellitus, hypertension, pre-eclampsia, caesarean delivery, prematurity, stillbirth, congenital anomalies, macrosomia, and complications of anesthesia. In addition obese women are less likely to initiate and sustain breast feeding.

Management of obesity: Treatment goals should be realistic, focused on modest reduction of intake, changes in eating habits, and the incorporation of a healthy exercise-oriented lifestyle. The three pronged approach to the problem works well for obesity reduction. These comprise of dietary modification, greater physical activity and psychological support and encouragement.

Specific treatment for obesity will be determined by doctor based on: • Adolescent's age, overall health, and medical history and extent of the condition • Treatment planning to address the above components often includes the involvement of a nutritionist, qualified mental health professionals, and an exercise specialist • Individual or group therapy focused on changing behaviors and confronting feelings related to weight and normal developmental issues • Nutritional and individual diet counseling • Modification of diet and caloric content • Increased exercise or participation in an appropriate exercise program • Support and encouragement for making changes and following recommended treatment recommendations Recommendations 1. Creating awareness in women, young adolescents and families regarding causes and implications of obesity.

2. Writing the amount of calories on fast food and other food products.

3. Speaking on media and other forums about the related problems of obesity and medical implications.

4. Regulations of schools for providing for extra curricular activities in the curriculum.

5. Making sure that, schools, colleges and universities focus on sports and physical activities in addition to the studies.

6. System of annual physical exam in schools including height and weight and calculation of BMI. 7. Providing opportunities for diagnosis of obesity and support and health in management of the issue at institutional and professional level.

Dr. Sonal Bathla MD, FICOG, FICMCH, FIMSA Consultant Obstetrician & Gynaecologist Sant Parmanand Hospital Delhi Secretary Indian Menopause Society New Delhi Chapter The congenital abnormalities of uterus result from abnormal differentiation of the mullerian system in utero. These abnormalities interfere with the uterine structure or function, thus contributing towards infertility, pregnancy loss or preterm delivery. While present at birth, these anomalies remain asymptomatic or undetected until investigations are initiated for infertility or pregnancy losses.1 This article reviews the relationship of abnormalities of uterus to infertility or pregnancy loss and presents evidence for standard treatment options.

Embryology The mullerian ducts derive from invagination of the coelomic epithelium on the lateral surface of the paired urogenital ridges in the fifth week of embryonic life. The mullerian ducts migrate caudally and medially as they enter the pelvis. By the eighth week of embryonic life, the mullerian ducts fuse in the midline to form a single structure, the origin of the urogenital canal. By the 10th week, the intervening septum degenerates to form a single endometrial cavity. Smooth muscle appears in the walls of the genital canal between 18 and 20 weeks, and by 24 weeks the uterine muscular wall is well developed.

Cervical glands appear by 15 weeks and endometrial glands by 19 weeks, although the endometrium remains poorly developed until puberty2.

The congenital uterine abnormalities resulting from aberrant differentiation of mullerian system as per American Fertility Society are shown in Table 1.3

Table 3 Pregnancy Outcome with Untreated Congenital Uterine Anomalies Pregna- SAB (n) Preterm Live ncies deliveries (n) births (n) Population -based Comparsions

10-15%

9-12%

82%

Unicornuate uterus

393

34% (135)

43% (170)

54% (213)

Didelphys uterus

86

21% (18)

24% (21)

69% (59)

Bicornuate uterus

56

25% (14)

25% (14)

63% (35)

Septate uterus 1459

76% (1105/1459) 10% (146/1459) 58% (90/155)

Arcuate Uterus 283

20% (57/283)

5% (10/195)

66% (129/195)

Derived from U.S National Vital Statistics database, 1976-2001.

Source: Adapted from Ref. 5 Investigations Hysterosalpingography, MRI, Transvaginal sonography, Renal scan and IVP are the prescribed investigative modalities for accurate diagnosis for uterine anomalies. Laparoscopy & Hysteroscopy are the gold standard.

Table 1 Disturbances in Mullerian Development Affecting the Uterus

Mullerian Agenesis

Defect Extent Failure of development of Complete bilateral one or both mullerian ducts Complete unilateral Partial Complete Failure of canalization

Complete bilateral mullerian atresia is the rarest of abnormality which is not amenable to surgical restoration and fertility can be achieved by surrogacy. Focal aplasia or hypoplasia involving cervix, lower uterine segment or endocervical canal may be surgically corrected, menstruation restored, however fertility is rare.

Partial Complete Partial Failure of resorption of the Complete midline septum Partial

Failure of midline fusion

Example Rokitansky-KusterHauser Syndrome Unicornuate Rudimentary horn Rudimentary horn without Functioning Endometrium Cervical atresia Uterine didelphys Bicornuate uterus Septate Arcuate

Incidence: The approximate incidence of congenital uterine anomalies as reported by Grimbizis etal is 4.3% in general population. Septate and arcuate uteri are the commonest (>50%). The incidence of various uterine malformations is depicted in Table 2 4 All anomalies are associated with varying degree of reduction in successful reproduction as shown in Table 3 5 Table 2 Incidence of Various Uterine Malformations All Arcuate Septate Bicor- Unicor- Didel- Agensis cases nuate nuate phys 1392 255 486 362 134 114 40 18.3 34.9 26.0 9.6 8.2 2.9

Total % all anomalies Incidence in 4.3 0.77 1.5 population Sources: Adapted from Ref. 4

1.1

0.41 0.35

0.10

Unicornuate uterus Unicornuate uterus is associated with poorest pregnancy outcome and highest incidence of preterm deliveries.

Various pregnancy complications include spontaneous abortion, preterm birth, IUGR, uterine rupture & ectopic pregnancies. A prophylactic circlage is not precommended in patients with no previous pregnancy loss however a frequent assessment of cervical length & anatomy is recommended during pregnancy.

Approximately 60% of unicornuate uteri have associated rudimentary horn and 40% of those have associated urinary tract abnormalities6.

One third of rudimentary horns contain endometrial tissue and about half of these communicate with the main endometrial cavity. 7 The presence of a rudimentary horn doesnot alter the reproductive potential of unicornuate uterus. An externally separated rudimentary horn with functional endometrium should be excised to alleviate cyclical dysmenorrhea and risk of pregnancy rupture. If functioning rudimentary horn is contained with in the main uterine body, creation of a hysteroscopic communication may be attempted.8 An asymptomatic non functioning rudimentary horn does not require removal.

Uterus didelphys This anomaly is associated with two endometrial cavities, two cervices that are fused in the lower uterine segment, often accompanied by a longitudinal vaginal septum. Uterus didelphys has the best reproductive prognosis amgonst all major uterine malformations. The only potential corrective surgical procedure is 8

Adolescent Health Committee FOGSI

ADOLESCENCE Strassman Metroplasty which is very infrequently performed.

Resection of vaginal septum may be required in symptomatic women.

Renal anomalies particularly renal agenesis is seen in 20% of these patients.9 Bicornuate uterus Bicornuate uterus has two separate but communicating endometrial cavities with external fundal indentation and a single cervix. The reproductive outcome predominantly involves pregnancy loss or preterm delivery rather than infertility. Reproductive outcome improves in subsequent pregnancies in untreated women suggesting a beneficial effect of repeated distension on uterine capacity. 10 Cervical circlage is a much simpler procedure as compared to Strassman unification for better reproductive outcome in women with bicornuate uterus.7 The Strassman unification should be reserved for highly selected patients.

The uterus is an integral organ in human fertility. Various congenital uterine anomalies may interfere with successful reproduction. A surgical correction may be attempted to achieve optimal results and hysteroscopic surgery has come up in a large way to restore normal anatomy and function of uterus. Further investigations that focus on surgical methodology, along with medical adjuvant therapy and patient outcomes is required to optimize counseling and treatment of patients with uterine anomalies.

Dr. Krishna Kavita Ramavath MD, FICOG 2805, Veronia Drive, #103, PalmBeach Gardens Florida, USA 33410

References 1.

Barry Sanders. Uterine anomalies. In: Victor Gomel, Andrew I Brill ed, Reconstructive and reproductive surgery in Gynaecology. London. Informa Healthcare, 2010: 46-61

2.

Robboy SJ, Bentley RC, Russell P.Embryology of the female genital tract and disorders of abnormal sexual development. In: Kurman RJ, ed. Blaustein's Pathology of the Female Reproductive Tract. New York, NY: Springer, 2002:3-36.

Sepate uterus 3.

Septate uterus is the commonest uterine anomaly encountered and is associated with some of the poorest reproductive outcomes especially spontaneous abortions.11 About 15-25% of all spontaneous abortions occur in women with uterine septa, probably because of impaired vascular development of the endometrium over septum.

4.

Grimbizis GF, Camus M, Tarlatzis BC, etal. Clinical implications of uterine malformations and hysteroscopic treatment results.

Hum Reprod Update 2001; 7(1): 161-174.

5.

Lin PC. Reproductive outcomes in women with uterine anomalies. J Womens Health 2004; 13(1): 33-39.

6.

Rock JA, Schlaff WD. The obstetric consequences of uterovaginal anomalies. Fertil Steril 1985; 43(5); 681-692.

Children Adolescents and the Media

7.

Patton PE. Anatomic uterine defects. Clinical obstet Gynecol 1994; 37(3): 705-721.

8.

Sanders BH, Machan LS, Gomel V. Complex uterine surgery: A cooperative role for interventional radiology with hysteroscopic surgery. Fertil Steril 1998; 70(5): 952-955.

According to a recent poll, 22% of teenagers log on to their favorite social media site more than 10 times a day, and more than half of adolescents log on to a social media site more than once a day.

Arcuate uterus Arcuate uterus involves a minor convex change to the fundal contour, approximately 10 to 15 mm of protrusion into the uterine cavity, with no change in the external contour. It is often considered a variation of normal uterus with few reproductive consequences.

Diethyl stil bestrol exposure related Anomalies In utero DES exposed women may have structural anomalies as : (i) Cervix: Hypo plastic or cocks comb cervix or cervical collar pseudo polyp. (ii)

Vagina: Clear cell Adenocarcinoma, adenosis .

(iii) Uterus: T- shaped uterus These women have higher incidence of infertility, preterm delivery, ectopic pregnancy & second trimester spontaneous miscarriages as compared to the general population. A cervical circlage may be required. About 64.5% of such women had term infants as reported

by Kaufman etal. 19

9.

The American Fertility Society. Classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988; 49 (6): 944-955.

The influence of social media on adolescents has been a great concern to parents, health care professionals and teachers recently. There are many recent physician encounters regarding parental concerns about the adolescent's behaviors. But this is a digital world and exposure to media is inevitable and inescapable. This is how a teenager learns to become an adult in the fast and ever changing society. Media is the main vehicle for education, information sharing and entertainment.

Some of the benefits of media are as follows:

The uterine septum may be partial or complete extending through entire uterus, cervix and vagina. The internal contour of uterus is double while the external contour is singular. Combined laparoscopy & hysteroscopy is considered as gold standard diagnostic modality.

It is generally accepted that septate uterus does not cause infertility.

Septoplasty is undertaken to reduce the possibility of subsequent pregnancy wastage both for prophylactic reasons as well in patients with previous reproductive loss. It is conducted under laparoscopy or ultrasound guidance.

Golan A, Langer R, Bukovsky I, et al. Congenital anomalies of the mullerian system. Fertil Steril 1989; 51(5): 747-755.

10. Maneschi F, Marana R, Muzii L, et al. Reproductive performance in women with bicornuate uterus. Acta Eur Fertil 1993; 24(3): 117-120 11. Homer HA, Li TC, Cooke ID. The septate uterus: A review of management and reproductive outcome. Fertil Steril 2000; 73(1): 1-14.

12. Kaufman RH, Adam E, Hatch EE etal Continued follow up of pregnancy outcomes in diethyl stilbestrol exposed offspring.

Obstet Gynecol 2000;96: 483-89.

Bellary, Karnataka Report by: Dr.Ramaraju.H.E, Executive Committee member AHC FOGSI A School talk was organized at the Government model high school Siruguppa taluk, 56 kms from Bellary, about 200 students from 8th-10th std. participated. Dr.Ramaraju announced prizes for best outgoing students every year in memory of his late father Mr. Sreenivasa. H.E.

Congratulations...

Dr. Anupama Dave has received FOGSI Chorion award at AICOG 2013 Mumbai For Best Scientific Research paper in senior category for the paper entitled "Role of Lactate Dehydrogenase in prediction of Adverse outcomes in Preeclampsia and Eclampsia". It includes a trophy and a cash prize of Rs. 75,000/- it is the most prestigious Award of FOGSI 9

Digital World of Adolescents and Social Media

Dr. Rutvij Dalal has received the prestigious Dr. C. S. Dawn Prize Advanced Infertility Management Study - 'Comparison of IVF/ICSI outcomes in patients receiving recombinant LH versus Human Menopausal Gonadotropin (hMG) supplementation - 1st PRIZE, during AICOG 2013.This happens to be his third 1st prize in the C.S.Dawn category over the previous AICOGs.

Benefits of social media to children 1. Growth of ideas from the creation of blogs, podcasts, videos, and gaming sites.

2. Sharing common interests from others of different cultural backgrounds. This helps to know about personal and global problems.

3. Expansion of vision and respect for humanity and tolerance.

4. Increase in communication skills and focusing on new view points

With such a rapid rise in addiction to the media, review of literature indicate that teens spend an average of >7 hours per day with a variety of media; though television viewing has come down, logging to computers, cell phones, and iPads, has become more common.

Present data show that teens send on average over 3,000 texts per month and spend nearly 40 hours per week online, with over 90% using the internet and over 80% owning an iPad and/or game console.

Media can provide positive and negative messages to teens. Since the adolescents do not have acomplete and matured thought process such messages can have an enormous effect on them.

One of the main concerns is about the sexual content found throughout the media to which adolescents are exposed, including Movies, TV programs, music, magazines. In such situations it is very difficult for a parent to control the teen's online exposure to a variety of sexual content.

There are many studies in the literature that have looked at the influence of the media on sexual behaviors in teens and drawn conclusions about cause-and-effect. Although the studies vary in design, the overall conclusions are that the risk of early sexual intercourse is doubled for teens exposed to greater amounts of sexual content in the media. Youth Risk behavior survey indicates that teenage pregnancies are also on rise.

Parental Role Today many parents use this digital technology extremely well and feel comfortable and capable with the programs and online sites that their children and adolescents are using. Nevertheless, some parents may find it difficult to relate to their digitally savvy youngsters online for several reasons. Such parents should have a basic understanding of these new forms of socialization, which are intertwined to their children's lives.

It may be impossible to shield children and adolescents from exposure to all media messages that adults consider inappropriate or potentially harmful, yet it is possible to be aware of those messages and to balance them with appropriate facts and beliefs.

Parents are advised to set clear rules, especially for younger teens, on media use, and schools are asked to create guidelines, especially for use of new social media.

Parents should help their adolescents to find important sites which improve their thinking and knowledge. They should watch their children often when on internet. Today medical information is so much on the doorstep that they can access online information about their health concerns easily and anonymously. Excellent health resources are increasingly available to youth on a variety of topics of interest to this population, such as sexually transmitted infections, stress reduction, and signs of depression. Media is a weapon and if used wisely, no doubt it creates wonders.

Parents play a key role in molding children's interests and attitudes. It is very important for them to work on those gaps and learn new technology. Most important is to set time for them and discuss online topics.

Role of OBGYN'S We as obstetricians are in a unique position to educate families about both the complexities of the digital world and the challenging social and health issues that online youth experience by encouraging families to face the core issues of social media addiction, depression and social anxiety, risk-taking, and sexual development.

We should help parents to understand these core issues and have strategies for dealing with them whether they take place online or offline.

At every office visits, obgyn's should ask how much entertainment screen time the adolescents spend per day and whether there is an internet connection, TV, cell phone, or iPad in the teen's bedroom, and counsel moderation accordingly. We should communicate to clear all the sexual health related issues with them.

Ways in which we can offer assistance to parents include: 1. Advise parents to talk to their children and adolescents about their online use and the specific issues that they face.

2. Advise parents to work on their own participation gap in their homes by becoming better educated about the many technologies their youngsters are using.

3. Discuss with families the need for a family online-use plan that involves regular family meetings to discuss online topics and checks of privacy settings and online profiles for inappropriate posts. The emphasis should be on citizenship and healthy behavior.

4. Discuss with parents the importance of supervising online activities via active participation and communication, as opposed to remote monitoring.

Parents and clinicians should promote advocacy encouraging the entertainment industry to be responsible in limiting sexual content aimed at teens and to embed pro-social health messages in their programming. The schools should focus on sex education and comprehensive sex education awareness involving medical professionals.

An important aspect of correctly managing this situation is recognizing the gaps and trying to bridge them at the most appropriate location.

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Adolescent Health Committee FOGSI

ADOLESCENCE

Adolescent Contraception

Pica: Aberrant Eating Habits in Adolescent Girls

Dr. S. Sampathkumari MD, DGO, FC Diab., Institute of Social Obstetrics & Govt Kasturba Gandhi Hospital for Women & Children, Madras Medical College, Chennai, TN

Dr. Madhuri Chandra Professor Obstetrics & Gynecology Gandhi Medical College, Bhopal, MP About one fourth of the pregnant young persons attending antenatal clinic at Sultania Zanana Hospital, Bhopal have moderate to severe anemia. When their dietary history is taken, majority reported pica.

During our school and college health visits, anemia in young girls was associated with aberrant eating habits. The young girls reported a craving for chalk, batti, multani mitthi, small pebbles, hair, wall paint, ice cubes, etc. Does ingestion of these substances, give rise tomalabsorption, intestinal and digestive upsets and cause them to become anemic or does anemia result in Pica? This question has immense significance as adolescent anemia has many negative consequences.

Anemia in adolescent age has a detrimental effect on growth and development, as well as school and work performance. It is associated with lethargy, limited learning ability, and poor scholastic achievement, impaired motor coordination, decreased attention span ,and increased susceptibility to infections, loss of appetite and inadequate food intake and pica. Adolescent anemia results in inadequate preparation for later motherhood as iron stores are exhausted. Anemia leads to a several fold increase in risk of mother dying in childbirth. It is a contributory factor to the Direct causes and the leading Indirect cause of maternal deaths in India.

I reviewed literature to understand • whether, this is a global phenomenon • the reasons for pica • whether there is any association between anemia and pica • The management of the problem.

Pica is derived from the word “Magpie”, which is a bird reputed for its unusual eating behavior, it can eat almost anything. Pica is common among very young children and pregnant women. Pica is defined as the craving or ingestion of nonfood items, consumption of substances of no significant nutritive value.

Pica or the ingestion of multani mitti has been reported in women of Pakistan by Yasir Faiz. The ingestion of kaolin (white dirt, chalk clay) is widespread in Central Georgia, authors concluded that Kaolin ingestion appears to meet the DSM-IV criteria for a "culture-bound syndrome. "Lithophagia or consumption of pebbles has been reported in a mentally challenged boy.

Pica is associated with poverty, low socio economic strata, cultural influences, psychological and deficiency disorders. In pregnant women consumption of multani mitti has cultural acceptance in many communities. Risk factors for pica include iron deficiency anemia, zinc deficiency, mental retardation, developmental disabilities and OCDs. Pica may be a symptom of iron deficiency anemia in adolescent girls or may be the causative factor of anemia. Psychosocial factors like parental neglect, maternal deprivation, family issues, and disorganized family structure should be investigated. The child less than 2 years frequently puts non food items in mouth, however if the behavior persists beyond infancy into adolescent years it must be considered pica.

DSM IV TR (Diagnostic and Statistical manual of mental disorders IV Edition) in “Feeding and eating disorders of infancy and early childhood”, criteria for Pica as • Persists in eating nonfood substances for at least a month.

• Behavior is inappropriate for child's stage of development.

• It must not be approved or encouraged by child's culture.

• Behavior does not occur exclusively during the course of another mental disorder (e.g., schizophrenia). If pica is associated with mental retardation or pervasive developmental disorder, it must be sufficiently severe to warrant independent clinical attention.

Pica may be due to decreased activity of dopamine system in brain.

Complications of pica depend of substance ingested. Bezoar or mass of indigestible material in stomach or intestinal may occur with consumption of hair, metal and pebbles. Consumption of sharp metallic objects may lead to intestinal bleeds or perforation. Eating dirt, earth, clay could lead to parasitic infections – toxoplasmosis, toxocariasis and trichuriasis. Ingestion of paint or clay causes lead poisoning, malnutrition, impaired physical and mental development.

Chewing ice will result in damaged teeth.

Management • Management includes identification and correction of nutritional deficiency, Iron, calcium, zinc and other mineral supplementation.

Supplementation with iron frequently corrects pica. Family education about healthy nutrition practices is advocated. In India pica in pregnancy appears to have a cultural sanction with mother in laws actually purchasing multani mitti for consumption by their pregnant daughter in law. Young girls acquire the habit of putting pebbles in mouth while cleaning wheat or rice. Therefore family counseling about negative effects of pica is important.

• Pica may be a symptom of malnutrition and hunger. Proper diet, mineral and vitamin supplementation should form an important element of School Mid day meal program.

• Pica frequently remits spontaneously in adolescents and pregnant women; however, it may persist in individuals with mental retardation and developmental disabilities.

• Complications of pica like worm infestation, lead toxicity, bowel obstruction or perforation would require individualized treatment.

• For more resistant cases psychiatric evaluation, behavior and environmental interventions, appropriate training strategies are advised. Behavior modification strategies include close observation, discrimination training (food/nonfood), self protection devices that preclude placement in mouth, sensory reinforcement, aversion therapy with negative consequences and punishment or positive reinforcement strategies.

• Medications such as SSRIs are reserved for children with behavior disorders /psychotic disorders with coexistent pica.

Memories of Adolescent Health Committee Workshop, AICOG...

The term adolescence is derived from Latin 'adolescere' meaning to grow, to mature and considered as transition from childhood to adulthood. The progression from appearance of secondary sexual characteristics to sexual and reproductive maturity is the marked feature. Among population 1.10 billion are adolescents i.e., one in every five humans. And 85% are in developing countries. As per WHO, adolescence is 10 to 19 years- Early 10-13 yrs, Middle 14-16 yrs, Late 17-19 yrs.

Centre of Disease Control and Prevention conducted a 'National Youth Risk Behaviour Study (US)' and the results of that study are: 1. Atleast all high school students have had sexual intercourse, 36.9% 9th graders and 66.4% 4th graders reported coital experience.

2. About half of all adolescent pregnancies occur within first 6 months after the adolescent becomes sexually active and 1/5th pregnancies within the first month.

3. Worldwide women aged 15 – 19 yrs give birth to about 17 million of 131 million children born each year. Women in this age group have 10% of all abortions (PAI2001).

Hence, it becomes all the more imperative that use of contraception or its awareness is taught to this section. Selection of contraception is dependent on frequency of intercourse, tolerance to types of contraceptives and its side effects, nature of relationship. Various providers of a wide range of services need to be involved viz, teachers, peer educators, nurses, doctors and community workers. They should educate about the reproductive system, fertility, menstrual cycle, pregnancy and use of contraception – both male and female.

Among adolescent pregnancies of 1 million per year, 85% are unintended, 50% live births, 35% elective abortions and 15% spontaneous abortions.

Reasons for avoidance or aversion to use contraceptives are characteristics of youth, tend not to plan ahead or anticipate consequences, feel invulnerableand think that they are not at risk, embarrassed or not assertive, lack skill and power to negotiate use, social or cultural expectations or beliefs.

Methods of Contraception The role of OGcians is to prevent unintended pregnancies and avoidance of STD among adolescents is very vital and the need of the hour. Hence, she/he needs to propagate use of contraception.

Condoms: Always recommended to prevent pregnancies and STDs. Safe, cheap and easily available, more effective with contraceptive foam. Commonly advised are Condom + OC pills/ injectable progestins/ sub dermal implants/ spermicide. Allergy to latex is the only contraindication. Latex condom is the best barrier method to prevent STI & HIV. Diaphragm, Cervical Cap and female condoms are rarely used. The typical failure rate in the first year of use is 15% male and 21% for female condoms.

Oral Contraceptives: OC pills are combination of oestrogen and progestins. The mechanism is they inhibit ovulation, cervical mucous thickening, endometrium unfavourable for implantation and decreased tubal motility. Newer progestins have many advantages as decreased androgenicity, increased SHBG, decreased free testosterone, improved LDL – HGL ratio and it is best for hirsutism and acne. Most adolescents are comfortable with OC pills than any other and the failure rate with first use is 0.3% only.

OC Pills are very safe and effective when used consistently and correctly, non-contraceptive health benefits for PID, DUB, PCOS,

11

Dysmennorhoea, Endometriosis, Acne, Breast Carcinoma, rapid return to fertility, can be used independent of sexual intercourse and can be used without partners' knowledge.

OC pills are no guarantee against STD infection. Side effects arebreak through bleeding, nausea, breast soreness, headache, weight gain and major side effects as CVS-Venous thrombo embolism, Cancer breast and hepatocellular carcinoma and lipid level changes.

For safety, low oestrogen pills(20-35) are advised28 days packs.

Available PROGESTIN ONLY methods are Minipill; Depoprovera (inj) and Subdermal implant.

MINIPILL - less effective than combination pills, unpredictable menses can occur. OC pills have to be taken at the same time every day. But with Desogestrol time is not a constraint and can be taken within 12 hours.

INJECTABLE PROGESTIN- (DMPA) Medroxy progesterone acetate 150mg IM.First injection should be within 5days of menses and repeated every 12 weeks.It is easy to use and needs no partner cooperation. If used perfectly for one year the failure rate is 0.3% Side effects aredelayed fertility, weight gain, depression, decreased libido, breast tenderness, decreased bone density. Due to effect on bone density this method is rarely used in adolescents SUBDERMAL IMPLANT- Effective for 5 years. Single rod (Implanon) has 3 years life. Not popular among adolescents as it requires surgery for implant and removal. However, implants do not affect BMD. Irregular vaginal bleeding, amenorrhaea, head ache, weight gain, acne, breast tenderness and mood changes are the side effects.

VAGINAL RING- NUVA Inserted for 3 weeks and a ring free week for withdrawal bleeding. Use of vaginal ring when compared to OC pills has better cycle control and less hormone side effect. The disadvantage is increased vaginal discharge and discomfort. Contraceptive patches also have same effect as Nuva ring and are applied over abdomen, upper outer arm, buttocks and upper forearm.

INTRAUTERINE CONTRACEPTIVE DEVICE IUCD counselling is important. Not appropriate for those with high risk behavior(STI).Important to check forsigns for expulsion.99% effective in preventing pregnancy and prevention against STI. Increased risk ofpelvic infection during insertion is 1% so prior screening for infection is needed. Insertion may be difficult in adolescent and had no vaginal exam. Copper T 380A can be used for 10 years and is without hormones. LNG – IUS (Mirena) – This hormonal IUD is costly but protects against upper genital tract infection and corrects anaemia and DUB. American physicians advise that sexually active teen girls' best birth control method is either IUD or Implant EMERGENCY CONTRACEPTION Emergency contraception is the last resort to prevent pregnancy after unprotected intercourse. It is not a regular method and can be used any time during cycle. Still it does not protect against STD.It is most effective when used early after coitus. Mainly used after rape, contraceptive failure, unprotected inter course.2 doses with 12 hours apart, each dose containing atleast 100mcg of Ethinyl estradiol and 500 mcg of Levonorgestrol help prevent 75% of expected pregnancies LAM-LactationalAmennorhoeaMethod is an appropriate choice for post partum adolescents planning to breast feed.

Today's adolescents are tomorrow's parents. It is imperative at this age that they adopt appropriate methods in living their lives. Early pregnancy or an unwanted pregnancy can turn things upside down and their progress itself would be in jeopardy. Repeated abortions or unsafe methods could cause fertility issues in the later part of their life.

Abstinence can't be preached. But creating awareness to safer methods of contraception has become necessary and right use of contraception is the only surest way to fruitful productive life.

12

Adolescent Health Committee FOGSI

ADOLESCENCE

Adolescent Endometriosis 2. Empirical treatment with NSAIDs and OCPs for 3 months can be tried 3. Laparoscopy gives the definitive diagnosis and 69% of girls with CPP have endometriosis

Dr. T. Ramani Devi Executive Member Adolescent & Endometriosis Committee FOGSI Rama Krishna Nursing Home, TRICHY-TN Introduction Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. It can occur in women aged 15-73years.

This may occur at an early age presenting with features of pelvic pain and dysmenorrhea. Endometriosis association registry reports 38% of women who have chronic pelvic pain before 15 years of age have endometriosis. Rarely endometriosis can occur prior to menarche.(1) 50-70% of adolescent patients who are refractory to treatment with OCPs and NSAIDs when subjected to laparoscopy are found to have endometriosis.(2) Advanced laparoscopy and senior surgeon's involvement, pick up rate of adolescent endometriosis has increased. Health care providers who are unaware of adolescent endometriosis can delay the diagnosis over a period of 9-28 years and this can make the disease progress. Early diagnosis and intervention are critical in ameliorating the long term effects of endometriosis like pain, endometriomas , infertility and improves the quality of life.

Genetic predisposition 6.9% first degree female relatives of patients with endometriosis are affected compared to 1% in controls suggesting genetic predisposition. This has been supported with the high concordance of disease among identical twins and familial predisposition with no clear mendilian inheritance, but rather with multifactorial polygenic trait has been detected. Asian women are at high-risk than black women. Smoking, exercise, alcohol, coffee are related to endometriosis. Smoking and exercise reduces the risk. Alcohol, caffeine, red meat increases the risk. Exposure to PCB, Dioxin increases the risk.

5. Surgical management involves diagnosis and ablation of all lesions

and recto abdominal examination in others are a must. Q tip examination into the vagina may exclude congenital obstruction. 11% of adolescent endometriosis is associated with genital tract anamolies. 76% of patients with mullerian anamolies have endometriosis. Classical findings of uterosacral nodularity and adnexal masses are rare.

Investigations • USG • CT abdomen • All these investigations cannot detect peritoneal lesions and stage endometriosis. They can only rule out other causes of chronic pelvic pain • Supportive lab investigations • CBC/ESR • Urine routine and culture and sensitivity • CA125 estimation Treatment NSAIDs are the first line in the management of endometriosis. It can be combined with OCPs for 3months,as per ACOG guidelines .(3) If there is no response, laparoscopy in indicated and 69% of these adolescent girls with CPP are found to have endometriosis. Pick up rate is higher with high resolution scopes and experienced surgeons.

Symptoms • Chronic pelvic pain cyclical (or) acyclical

Further management

• Dysmenorrhoea which interferes with daily activities

Surgical correction should be followed by medical management till fertility in desired. The aim is to maximize pain relief and promote socialization. Continuous OCPS (monophasic progesterone) can be given.(4) If there is no relief, GnRH agonist with add back can be given beyond 18 years.(5) Nuvaring can be continuously used for 3 months instead of OCP. Patients on GnRH agonist (11.5mg Inj once in 3 months) has to be given with calcium 1200mg and Vit D in addition to add back for preserving bone density. Norethindrone acetate (0.5mg) or conjugated Equine estrogens (0.625mg) or MPA 5mg can be used for add back treatment. (6)

Endometriosis origin is explained by coelomic metaplasia theory, Sampson's spill theory and Halbans Lymphovascular metastasis.

Mullerian obstructive anamolies are often associated with adolescent endometriosis and usually resolution occurs after surgical correction.

• Dyspareunia and infertility in sexually active women • Complex pelvic masses • Cyclical rectal pain and constipation • Dyschezia and bleeding per rectum • Bladder symptoms like dysuria, haematuria and urgency are more common Symptoms before 15 years are rare and diagnosis is may be delayed by 9.28 years and delay in seeking the advise may be around 4.67 years.

History Characters of pain, bowel and bladder symptoms, past medical and surgical history, menstrual, contraceptive, sexual and gynaecological history, interference of pain with daily activities has to be enquired.

Family history is very important.

Physical examination Thorough pelvic examination in an adolescent with pelvic pain and persistent dysmenorrhoea is the corner stone in the diagnosis of endometriosis. Bimanual pelvic examination in sexually active women

6. Medical management has to be continued after diagnosis till fertility is desired 7. Long term treatment is needed to improve quality of life and Psycho social support is needed References 1. Batt RE, Mitwally MF. Endometriosis from thelarche to midteens; pathogenesis and prognosis, prevention and pedagogy. J Pediatr Adolesc Gynecol 2003;16:2337 2. Laufer MR, Goldstein DP. “Gynaecological pain: Dysmenorrhea, acute and chronic pelvic pain, endometriosis, and premenstrual

3. American College of Obstetricians and Gynaecologists.

Endometriosis in adolescents. ACOG committee opinion no 310; Obstet Gynecol 2005;105:921-27 4. Vercellini P, Frontino G, DeGiorgi O, et al. Continuous use of an oral contraceptive for endometriosis associated recurrent dysmenorrheal that does not respond to a cyclic pill regimen. Fertil Steril 2003;80:560.

5. Barbieri RL.Treatment of endometriosis with the GnRH agonists.

In Gonadotropin Releasing Hormone Analogs. Applications in Gynecology. Edited by Barbieri RL, Friedman AJ, Newyork:Elsevier science 1991;63-76.

6. Lubianca JN, Gordon CM,Laufer MR. “Add back” therapy for endometriosis in adolescents. J Reprod Med 1998;43:164

• MRI – rule out genital tract anomalies

In women >18 years, who does not want laparoscopy – trial of GnRh agonist with add back therapy can be given. If there is response, then diagnosis of endometriosis can be confirmed. If there is no response laparoscopy has to be done, which is the gold standard in diagnosis and treatment. The implants are clear, red vesicles which are visible when compared to brown, black lesions in adults. Laser gives the best results . Though endometriomas are rare if it is seen, careful cystectomy has to be done preserving the ovarian tissue. If there is no obvious disease during laparoscopy , culdesac biopsy has to be done to rule out microscopic disease (3-6% incidence).

Pathogenesis of endometriosis

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4. Lesions in adolescents differ from adults

syndrome.” In Emans SJ, Laufer MR Goldstein DP. Pediatric and Adolescent gynecology (V edition) Philadelphia:Lippincott Williams and Wilkins Publishing Company, 2005;417-76.

SAFOG conference puts ARSH in spotlight Report by:Dr. JayyamKannan, Chairperson Adolescent Health Committee FOGSI 9th South Asian Federation of Obstetrics & Gynecology Conference was held on 28th Feb.2013 at Agra India. A special session was given to Adolescent Sexual Reproductive health which had important lectures covering all aspects of Adolescent health. The session was concluded by a Panel discussion which was moderated by Dr. Jayyam Kannan Chairperson Adolescent Health Committee FOGSI & Dr.Roza Olyai Vice President Elect FOGSI 2014.Expert panelists were : Dr.Indirani Ganguli, Dr. Pushpa Sethi & Dr.Ghazala Mahmud.The session was well coordinated by Dr. Narendra Malhotra & Dr. Jaideep Malhotra under expert advice of Prof.Dr. Alokendu Chatterjee President SAFOG for which we ate thankful to them.

Progestin only treatment for suppression of ovulation is not ideal in treatment of endometriosis due to its side effects like weight gain and decrease in bone density. Though the efficacy of Danazol is at par with GnRH is should not be used in adolescent girls due to unacceptable side effects. Patients using GnRH agonist report better quality of life.

LNG IUS can be used for post operative medical management.

Keypoints 1. CPP in adolescents should be completely evaluated from history, physical examination, pain diary, radiological examination and laboratory evaluation 14

Adolescent Health Committee FOGSI

ADOLESCENCE

Robotic Gynaecological Surgeries: The Teenage Years Dr Sabhyata Gupta MD,FICOG, Associate Director & Head Dept of Gynaecology and Robotic Surgery , Medanta, The Medicity, Gurgaon Minimally invasive surgical approach for various gynaecological conditions is a well established, time proven, safe, patient friendly approach. Among the various benefits of laparoscopy are keyhole incisions, magnified vision, reduced post operative pain and faster patient recovery. Some limitations of the traditional laparoscopic technique are 2 dimensional vision, contra lateral picture of the operative field, counter-intuitive hand movements, chopstick effect of the stick- like operating tools, longer surgeon learning curve and longer operative time.

The advent of robotic surgery in gynaecology in 1998 when the first tubal anastomosis was performed by Falcone et all, paved the way for its widespread application today for various benign and malignant gynaecological conditions.

The Da Vinci Si Robotic Surgical system is a master-slave relationship wherein the surgeon is the master and always in complete control of the entire surgery and operative system. The Robot or the slave can never function autonomously. Inbuilt system safety features eliminate opportunities for human error.

The main advantages of the robotic system are the 3D enhanced stereoscopic vision, magnification up to 7 times and ipsilateral image of operative field, intuitive movements as the surgeons and hands are aligned with each other, instruments designed with 7 degrees of freedom mimicking the human wrist, thus enabling surgeon dexterity, motion scaling and elimination of hand tremor, less surgeon fatigue and shorter learning curve. Apart from these advantages, the robotic approach incorporates all the benefits of traditional laparoscopy.

Indications of Robotic Surgery in Young Females Benign Conditions: -Endometriosis: Surgery for endometriosis requires careful dissection and great precision. The surgeon may encounter extensive pelvic disease which warranties peritoneal stripping. Dense adhesions with vital structures like the rectum, colon and ureters are found in cases of deep infiltrative endometriosis and grade IV disease. Such being the nature of the disease, injury to the vital structures during surgery

Dr Shradha Chaudhari MD, FCPS, DGO Associate Consultant Dept of Gynaecology and Robotic Surgery, Medanta, The Medicity, Gurgaon becomes likely, even in the hands of experienced laparoscopic surgeons. The robotic technique allows intricate hand movements allowing for careful thorough dissection of the disease. Injury to the rectum, colon, ureters and major blood vessels greatly reduces due the enhanced 3D vision and technologically advanced design of instruments. The surgeon has both monopolar and bipolar instruments in each hand at a time. He may choose which current he prefers at a particular point of surgery without having to change the instruments. The safety features of the surgical system reduce opportunities for thermal injury. The surgeon is less dependent on the assistant and he has three instruments as well as the camera in his control. The camera, held by the robotic arm is very steady as compared to the camera held by a human hand. This allows for smooth and clean surgery even in cases with prolonged OR time. Good hemostasis is achieved at the completion of surgery. The robotic approach with all its added advantages offers a safe alternative to both laparoscopy and open surgery.

-Nulliparous Prolapse: Sacrocervicopexy performed for nulliparous prolapse may be performed robotically. The laparoscopic surgery is technically challenging and requires great surgeon skill. Robotic surgery allows a wider platform of surgeons to perform the surgery using minimally invasive technique. The mesh is fixed at the level of the internal OS both anteriorly and posteriorly. Various designs of the mesh have been used. The robotic technique has a great advantage of easy needle handling and fast, precise suturing. Handling and suturing the mesh is simple with the robotic system. The tunnel is created after identifying the ureter and the mesh is brought retroperitoneally and fixed at the sacrum with stitches or tackers.

Again, suturing becomes easy at this highly vascular region with vital structures.

-Mullerian Duct Anomalies: Robotic technique has been applied to perform surgeries for congenital uterine malformations. Robotic metroplasties are being done for uterus didelphys. Laparoscopy maybe technically challenging in this infrequently performed complex uterine surgery. Benefits of robotics allow for correct identification of planes, intricate dissection and suturing, thus ensuring promising short term and long term results.

iliac crest. Here, it lies outside the field which requires radiation. The point of transposition is marked with a clip during the transposition for future reference during radiation and ovum pick up during an IVF cycle.

-Ovarian Transplant: The latest success story of robotic approach is ovarian transplant. A case of robotic ovarian transplant of a previously cryopreserved ovary in a breast cancer patient going in for chemotherapy is reported in 2012.

The ovary was transplanted at its original position. After the transplant the patient resumed her mensus and was out of menopausal state.

In conclusion, robotic surgery offers a safe, effective alternative approach to both laparoscopic and open surgery. Both long term and short term results are promising. Randomised trials are necessary to authenticate the available data. The cost factor however remains prohibitive.

When young females are faced with gynaecological conditions and cancers, robotic surgery may help raise her hope and self esteem of body image. The role of body image is even higher in this age group; hence successful robotic surgery may go a long way in building her self confidence and personality.

International Federation of Gynecology & Obstetrics (FIGO) appreciates Adolescent Health Committee FOGSI Activities FIGO News Letter May 2013 issue highlights the Adolescent Health committee FOGSI workshop organized on ARSH held during AICOG 2013 in Mumbai & shares detail report of the same. We are grateful to FIGO for their constant encouragement & guidance.

Malignant Conditions: Fertility Sparing procedures for various malignancies are safely performed using robotic approach with results similar to open technique.

-Early Stage Ovarian Cancers: Staging laparotomy for stage 1 ovarian cancers is now being performed robotically in the west. Small incisions ensure decreased post operative pain, faster recovery and render the patient fit for any further cancer treatment like chemotherapy or radiotherapy. The recommended intra operative precautions to prevent spill and port site metastasis must be incorporated during the surgery. Case reports have shown promising results with survival rates comparable to standard open technique.

-Radical Trachelectomy with lymphadenectomy: Robotic technique for fertility sparing surgery for cancer cervix is now a routinely performed. Small case series have shown that it incorporates all the advantages of minimally invasive route without compromising the future survival rates and quality of life. Randomised controlled trials are required to authenticate available data.

-Ovarian Transposition: Pelvic tumours may occur in young females who desire to preserve fertility. One or both the ovaries can be transposed robotically from the anatomical position to the level of the

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“Challenges for Youth Today & Tomorrow"

Adolescent Health Committee FOGSI

ADOLESCENCE

Gwalior, MP

FOGSI World Congress in OBGYN Vision 2022, Bangaluru, Karnataka

Report by: Dr. Jyoti Bindal President Gwalior Obs & Gyn Society

Report by Dr. Vidya Bhat Joint Secretary FOGSI

Various CMEs , workshops on ARSH with ongoing college & school health projects are regular features in Gwalior OBGY society.

National FOGSI CMEs are being held regularly every month.

FOGSI World Congress in OBGYN VISION 2022, was held in Bangaluru under the ABCD projects.A Congress with a difference under the leadership of Dr. HemaDivakar President FOGSI. Morning session on 8th June 2013 was underthe theme Innovation to Implementation - Adolescent Care!

The workshop was as follows:

Chennai, Tamil Nadu Report by: Dr. S. Sampathkumari, Secretary OGSSI & Dr. P. Meenalochani, AHE Committee Coordinator School Health Camp at Hilton School, Chromepet, Chennai

Session Two – Innovation on - Ways Forward – Making Strategies work: (1)

Adolescent sex education - Dr Jayam Kannan

(2)

Adolescent anemia - Dr. Asha Mallapur

Co-ordinators: Dr Arul Mozhi / Dr Jayam Kannan

Invited Experts –

Chairpersons: Dr. Ashwini Bhalero /Dr. Paiely / Dr. Suchitra Pandit

Drs. Dilip Dutta / Sheela C N / Durgashankar / VidyaThobbi / Shirley Mathen

Session One – implementation - bridging the gap: (1)

Implementing strategies for adolescent care in India - Dr Roza Olyai

(2)

Implementing Uniformity in approach to PCO management - Dr. Arul Mozhi

The program ended with a good discussion & points were noted for implementation. We are very grateful to Emcure Pharma for sponsoring the program.

Association of Madhya Pradesh OBGY Societies (AMPOGS) Jamnagar, Gujarat Report by: Dr. Kalpana Khandheria, Executive Committee member AHC FOGSI Regular projects are carried out in Jamnagar like inaugurating “young women’s club” and “health centers” for various activities related to ARSH. Celebrated 150th year of Swami Vivekanand and International women's day together, with the aim to empower young girls.

It was well appreciated by everyone.

Report by: Dr. Kavita N Singh Associate Professor Department of Obst-Gyn NSCB Govt. Medical College Jabalpur MP Secretary AMPOGS 2013

8th AMPOGS2013 was organized on 30th-31st March 2013 at NSCB Medical College Jabalpur,MP & the theme was “BEHOLD A GIRL BEGIN A TOMORROW". Dr Hema Divakar President FOGSI & Dr Alpesh Gandhi Vice president FOGSI had graced the occasion. Dr. Prof. Shaila Sapre and Dr. Rama Shrivastav received the Life time achievement awards respectively by the hands of Prof. Dr. Shashi Khare President AMPOGS 2013.Young Women’s Club was inaugurated on this occasion in Jabalpur by Dr. Hema Divakar in presence of Dr. Ratna Kaul & Dr. Roza Olyai Past president & Secretary AMPOGS. Hands on workshop on Internal ilaic ligation and B-lynch suture on cadavers and modules was highly appreciated by all, 272 delegates and faculty attended this MP State conference.

Trichy, Tamil Nadu Report by: Dr. Charmila, Secretary Trichy Obst. & Gyn. Society

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TRIOGS conducted the workshop on adolescent health. The national faculty for the workshop were: Dr. Jayyam Kannan, Dr. Vijaya Laxmi Seshadhri from Chennai and Dr. Shantha from Madurai. The local members who participated as faculty were: Dr. Manjula Appadurai, Dr. Shilpa, Dr. Kavitha Senthil & Dr. Vidhya Ravi.

The panel discussion was on pre-marital counseling which was very interactive & appreciated by all.

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