Adolescence issue 10

Issue 10 | 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

President FOGSI 2014...

Message from

Secretary General's Desk...

From the Editor’s Desk Dr. Roza Olyai

Prof. Dr. Suchitra N. Pandit President FOGSI 2014

M.S. MICOG, FICOG, FICMCH Vice President FOGSI (2014) Member Board of Governing Council Indian College of Obst. & Gyn.(ICOG 2012-15) Member “Anti-Violence against Women Cell” of FOGSI (2013-15) National Chairperson Adolescent Health Committee FOGSI (2009-12) Director Olyai Hospital,Gwalior-MP India E-mail: rozaolyai@gmail.com http://www.youtube.com/watch?v=NsR0H0ril20

Dr. Nozer Sheriar Secretary General FOGSI Dear Friends,

It is a great pleasure to write this for Adolescent Health Magazine.

Adolescence is a transitional period between childhood and adulthood, and it responsibility of the society, parents, healthcare workers to get the young adolescents ready for adult roles It involves education, training, as well as a gradual change of roles and responsibilities. So this magazine makes very good reading and gives food for thought. Hearty congratulations to Dr. Roza Olyai for the good information given through this magazine.

We all agree that the youth are the future of tomorrow. In keeping with our commitment towards empowering and educating the youth, we have initiated the concept of “Youth Mela” for young boys and girls (16-24 years) and I hope to reach out to various parts of India.

Some of the topics which we will be addressing in 2014 during the Youth Mela are: Communication skills, Know Your Body, Healthy Diet, Protecting yourself from an unwanted Pregnancy using Contraception, Prevention of HIV/Sexually Transmitted Infections/Cancer Cervix, Staying fit, Self-defense, Prevention and protection from sexual abuse and First Aid.

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

Prof. Dr. Suchitra N. Pandit President FOGSI 2014

FOGSI's Adolescent Health Committee The adolescent health committee of FOGSI has been doing impressive work to improve the health and well being of adolescents through education and basic health screening initiatives under the sterling leadership of Dr Roza Olyai and her colleagues. They have undertaken activities to increase access to comprehensive sexual and reproductive health and overall health information and services through study days and the use of mobile technology among young people. This no doubt would result in safer sex practices and improved reproductive health outcomes as well as better nutritional practices.

On the long run we need to promote the positive roles that young men can play in improving their own sexual and reproductive health and those of women and children. I am sure the committee will seek to work with both young men and young women. Sexual and reproductive health topics are rarely covered in a comprehensive non-judgemental manner. In order to dispel the myths and misinformation surrounding these issues and to promote a positive approach to adolescent sexual and reproductive rights a range of issues from contraception to sexual violence has been discussed by the committee members via the FOGSI branches. This ensures a holistic approach to be adopted for improving adolescent health, issues around good nutrition and overall healthy behaviour.

Generations of adolescents may benefit if the current activities are shown to be successful, can be sustained and reproduced in more and more centres in the country. To this goal I wish the FOGSI's Adolescent health committee the very best to continue with their excellent and forward thinking activities.

With best wishes and kind regards,

Message from

Chairperson (2013-15) Dear Fogseans,

Sir Sabaratnam Arulkumaran President, FIGO Professor Emeritus, St George's University of London

2013 has seen great activities under the leadership of Dr. Hema Divakar. The process of implementation took a lead in reducing the maternal deaths due to two important preventable causes of Postpartum Haemorrhage & pregnancy induced hypertension. Effective training to reduce both were given training to the doctors and nurses wherever possible under the banner of HMS i.e. HELPING MOTHERS SURVIVE.

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 have been privileged to be the south zone coordinator of the project, through which I could not only impart training in south, but also in the East and north zone, totally 55 training programs have been done by me and my team, the highest number on record. I thank President Hema Divakar, secretory Nozer Sheriar, and Emcure pharma for their support for this work. We are privileged to have this workshop at RCOG International conference at Hyderabad in 2014 march.

Yuva activities have taken good shape from July 2013. One full conference on Yuva was focussed at west Zone YUVA FOGSI at Bhopal. Fogseans were bubbling with enthusiasm at this conference and presented papers on different problems of youth. Dr. Ashwini Bhalerao Gandhi, Vice President 2013,in charge of the adolescent committee has taken steps to come out with a good module on adolescent health, which is getting piloted at Mumbai and Delhi.

Yuva clinics are actively functioning at many centres; many state governments are also supporting this in the Primary health centres. I will be continuing these activities in 2014 as well under Dr. Roza Olyai Vice President in charge of the Adolescent Health Committee FOGSI. Our President Dr. Suchitra Pandit has already been active in adolescent health activities by conducting youth Mela at 4 zones of Mumbai which we hope to carry out in other cities in India in 2014.

Credit goes to the untiring efforts of the members of the committee, without whom this success cannot be achieved. Thanks to Dr. Ramanidevi, national coordinator for organisation of rallies in Trichy District.

Dear Friends, It gives me great pleasure to share with you the 10th issue of the news magazine of the Adolescent Health Committee FOGSI. Am very happy to welcome Dr. Suchitra Pandit President FOGSI (2014). I will be very happy to continue my support of activities during her tenure as Vice President FOGSI. To begin with, I would like to invite you all to the YUVA FOGSI West Zone which will be held in Nasik on 12-14 Sept. 2014 with the theme focused on Adolescence & youth. We hope to have a youth mela with lots of fun activities & galaxy of good faculty.

I would like to congratulate Dr. Hema Divakar President FOGSI 2013 for doing such wonderful focused work specially towards the Adolescent & youth activities in 2013. I would also like to appreciate the work done by Dr. Ashwini Bhalerao Gandhi, Vice President 2013 for taking out good module on adolescent health which was well implemented in many cities.

Dr. Jayyam Kannan the dynamic Chairperson Adolescent Health Committee FOGSI has been actively involved in carrying the committee activities to greater heights, specially supporting the Adolescence magazine to be continued as an ongoing publication of the committee for which am thankful to her.

Young Women's club is a friendly club for girls in between age groups 19-30 yrs where in they meet once in three months to discuss other than health issues important social related issues, cooking, life skill development, premarital counseling etc. There is a format made for the same, I would request you all to have this club inaugurated in your cities & for the details you can contact me.

We have included interesting articles, events& informations in this issue such as theformation of the new FOGSI Anti Violence against Women Cell with it's members, interesting topics to read like :“New Opportunities for advancing adolescent health “Contraception in Adolescents” other articles of interest compiled are: “Thyroid Disorders in Adolescence”, “Dysmenorrhea”, “Examination of a rape victim. We are thankful to our esteemed authors for their contributions.

FOGSI Office Bearers 2014 Dr. Suchitra Pandit Dr. Roza Olyai Dr. Ritu Joshi Dr. Indrani Ganguli Dr. Gokul Chandra Das Dr. Sheela Mane Dr. Hema Divakar Dr. Prakash Trivedi Dr. Nozer Sheriar Dr. Hrishikesh D. Pai Dr. Jaydeep Tank Dr Gorakh Mandrupkar Dr. Madhuri Patel

President Vice President Vice President Vice President Vice President Vice President Immediate Past President President Elect (2015) Secretary General Deputy Secretary General Treasurer Jt. Secretary Jt. Treasurer

One of our major project is “Challenges for the youth today & tomorrow”. we were able to cover more girls in the coming months through 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!

Dr. Roza Olyai

Wish you all a prosperous new year!

1

2

Adolescent Health Committee FOGSI

ADOLESCENCE Message from

The Secretary ICOG

Message from

The President IPA

Dr. Jaideep Malhotra Sec. ICOG President Elect ASPIRE Dear friends Greetings!

Our world is an adolescent world, especially in developing countries.

One of every five human being on planet earth is adolescent (about 1.1 billion) and 85 % of these are in developing countries, India accounting for half of this.

Adolescents for our country are the biggest asset in form of demographic force and economic force.

This force has to be harvested and guided properly and correctly.

Adolescents face different problems of general health, malnutrition, menstrual problems, mental and behavioural problems, unprotected sex, teenage unwanted pregnancies and abortions, addictions, sexual and physical abuse, depression, suicide, accidents and also eating disorders.

We need to understand these special needs of our teenagers and need to develop adolescent friendly clinics and services. We need to guide this force of "GEN-Y" towards a healthy and fruitful goal I take this opportunity to congratulate Dr. Roza Olyai Vice President FOGSI for her untiring efforts in highlighting Adolescent health issues in India and also in FIGO and her exemplary work in bringing out this wonderful newsletter.

My message to the adolescent and their parents is: "LET THEM FLY" -JUST GUIDE THE FLITE PATH FOR A SAFE FLITE AND LANDING

Prof. Andreas Konstantopoulos President of the International Pediatric Association (IPA)

Congratulations !!

A thorough physical examination, acquiring somatometric data (height, weight, BMI) and Tanner stage, before examining all body systems and of course the genital area is important. Sufficient clinical information will lead the laboratory work and will help limit unnecessary tests.

Gynecological issues that often occur in adolescence are the following: •

Menstrual Disorders (primary or secondary amenorrhea, dysfunctional bleeding etc) This may be the first symptom of an eating disorder, stress or excessive athletic performance (female athlete triad). Genetic syndromes (Turner, Swyer) and malformations (Rokitansky syndrome) must be ruled out in primary amenorrhea.

Unexpected pregnancy or polycystic ovarian syndrome (PCOs) may be the case, especially in overweight patients.

A bleeding condition (e.g. Von Willebrand’s disease) should be taken under consideration in frequent, prolonged menses. All other conditions of menstrual disturbance may also be the case (e.g. thyroid gland dysfunction, hyperprolactinemia etc )

•

Unwanted pregnancy is a condition that may seriously influence the teen mother’s organic and emotional health, and there are consequences for academic and future choices. It is a high risk situation for the fetus too, and requires very delicate handling by the physician.

•

Sexually transmitted diseases may be asymptomatic (3050%) and may jeopardize health, fertility and sexual life.

Adolescents are especially vulnerable due to physiological, as well as developmental age characteristics.

•

Ovarian cysts and breast conditions are also quite common in adolescent girls.

Research Article Published !!

Congratulations to Dr. Krishna Kavita Ramavath & Dr. Roza Olyai Vice President FOGSI in getting their original research article on 'Knowledge and Awareness of HPV Infection and Vaccination Among Urban Adolescents in India: A cross sectional study'' published!

A global workshop was conducted by Nestlé Nutrition Institute on the theme : “Health and Nutrition for Adolescents and Young Women: Preparing for the Next Generation” which was held in Grand Nikko Bali Hotel, Bali, Indonesia from the 26th–29th November 2013. The main focus was on Adolescent nutrition & focusing on projects country wise in 2014 under the same theme. FIGO was represented by Dr. Hamid Rushwan CEO FIGO & Dr. C.N Purandare President Elect FIGO. Among the other participants invited were Dr. Roza Olyai Vice President FOGSI 2014 & Dr. Shantha Kumari Vice president FOGSI 2013.

Gynecological issues may present in over 50% of adolescent girls (menstrual disorders, bleeding etc), and the gynecologist is often the first physician they visit. It is thus, very essential for gynecologists to have information on the adolescent way of thinking, behavioral patterns and also to have some training on performing the adolescent interview. This given opportunity to approach a young girl and give education on primary and secondary prevention is unique! Screening for high risk behavior or other health issues is also very significant, as well as referring and collaborating within a multidisciplinary network of experts, in order to address the teenager’s problems in an holistic manner. Communicating successfully with youth will lead to compliance, feedback visits and better outcomes of treatment. Sexual education (dealing with peer pressure, contraceptive choices) and knowledge on hygiene, vaccination and prevention strategies, will lead to future quality of life and a healthy, happy adulthood.

"A world fit for children is one in which all children including adolescents, have ample opportunity to develop their individual capacities in a safe and supportive environment"

Dr. Jaideep Malhotra Sec. ICOG President Elect ASPIRE

Health and Nutrition for Adolescents and Young Women: Preparing for the Next Generation

Memories of the GOAL Conference on RSH, Beijing China

I would like to congratulate Dr. Roza Olyai for bringing up the Adolescence Magazine issue 10 & creating awareness amongst the Gynecologists.

The above article is published in the Journal of Obstetrics and Gynecology of India: Vol 63,Issue 6(2013), pages 399-404.

With best wishes,

We applaud the publication of the work and sincere thanks to all our well wishers who helped us to complete the project in time.

Prof. Andreas Konstantopoulos President of the International Pediatric Association (IPA)

Happy reading to all our dear readers !

3

4

Adolescent Health Committee FOGSI

ADOLESCENCE

New Opportunities for Advancing Adolescent Health Dr. Harshad Sanghvi Vice President Innovations & Medical Director, Jhpiego An affiliate of Johns Hopkins University 1615 Thames Street, Baltimore, Maryland, USA Many articles about adolescent health in India speak about the vast number of young girls who are married off too early, who risk unwanted pregnancy and sexually transmitted infections from unprotected sex, who are poorly nourished and anemic, and who are more likely not to get a secondary education. Not many mention bright young adults who are transforming themselves and society rapidly and excelling in all endeavors. Few speak about adolescent boys, and while there is a plethora of advice about what government or state should do, there is precious little about what an individual obstetrician and gynecologist, a midwife, or a doctor can do to address some of these challenges. And so let us focus on that.

The challenges to overcome: The adolescent is neither a child nor an adult. Adolescents fall through the cracks between when the pediatrics focus ends reproductive health professional focus starts. Few physicians in India and many countries were given a course in adolescent health during their formative medical education. Training was long on the physiology of adolescence and short on practical advice on how to help teenagers cope with the challenges of coming of age and dealing with the many additional pressures of that stage of development brought about by the lengthened period between reproductive and sexual maturity on the one hand and emotional, mental and intellectual maturity on the other. And although we deal with childbirth and sexually transmitted diseases, many of us are uncomfortable discussing sex with our patients. And like many parents, most of us are unlikely to have discussed sexuality and contraception with our adolescent sons and daughters.

About 22% of India's population is in the age group 10-19, a staggering 243 million of who 48% are girls and potential patients for Obgyns. If we ran our practices as a business, we would be thinking of ways to capture the market for adolescent health care. And well we should -16% of currently married 15-19 year olds have already begun childbearing. Some 20 million adolescent girls will get pregnant this year, and of those, 15 million will give birth. The missing 5 million will suffer the consequences of pregnancy failure or termination, often ending in lifelong physical or mental disability. By every standard definition, these are considered high risk pregnancies, and -should certainly require specialized care. The National Family Health Survey III of 2007 showed that among women aged 15-24, 40 %of girls were sexually active by age 18, and 10% by age 15. Now admittedly, some of these girls are sexually active under the dubious protection of early marriage, which by law is forbidden before age 18. Many are expected to begin childbearing shortly after early marriage. Poor education level, compounded by early pregnancy, and poor nutrition and anemia, all than lead to a vicious cycle of pregnancy loss and maternal morbidity and mortality. And, like adolescents in other nations, a large proportion have unsafe sex. Only 7% of these girls use contraception.

Not only do these girls require protection against sexually transmitted infection and unwanted pregnancy, they also need protection against being married off before it is legal to do so. We know that 27% of married adolescents have unmet need for contraception. In the case of adolescents, our standard definition of unmet need is flawed. Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child. In the case of adolescents below the age of 18, the risks of pregnancy are very high, and for sexually active adolescents, avoiding pregnancy during these years is critical. Any adolescent who chooses to or is forced by circumstances to be sexually active, must have the choice to 5

be protected from pregnancy. The legal age for marriage is 18, yet in one national survey, 46% of women 18-29 were married before 18 years. There really is little value in a law for which there is no will to enforce, or is just not enforceable under current cultural norms.

I have heard that many parents fear that, as their daughters age beyond menarche, the dowry they have to pay gets bigger. Some parents fear that their girls will become sexually active before marriage, bringing shame and dishonor to the family. For so many girls, early marriage, no matter the law, is predestined. And while these traditions are changing especially in urban settings, the change is nowhere near fast enough.

In response to these challenges India has embarked on an ambitious strategy that integrates reproductive, maternal, newborn, child and adolescent health (RMNCH+A) to address the major causes of mortality among women and children.

Jhpiego's country director in India recently met with Ms. Anuradha Gupta, Additional Secretary and National Rural Health Mission Director on this subject. And here is what she says: “In India, a very peculiar challenge is that 70 percent of our adolescents are in rural areas, scattered in more than 600,000 villages in remote areas across the country. Clearly, a program offering facility-based services is not enough. Our earlier strategy for adolescent health was confined to setting up Adolescent Reproductive and Sexual Health (ARSH) clinics. But uptake of these clinics has been extremely limited; what was needed was a community-based approach reaching out to adolescents in their own spaces. As we all know, adolescence is considered a healthy period; nonetheless, more than 33 percent of the disease burden and almost 60 percent of premature deaths among adults can be associated with behaviors or conditions that began or occurred during adolescence. Thus, we need a huge and very comprehensive bouquet of services so that their attitudes change, they become more aware of issues, and they are better equipped to deal with the physiological, psychological and emotional changes that confront them as they enter adulthood”

importantly, it requires skills learnt over time in communicating with young people, discussing sexual and reproductive needs, remaining nonjudgmental, and avoid moralizing on the choices made as well as managing disease conditions. The focus should be on meeting the mastering how best to provide health care protection and enhancement. Really good training materials exist on line, and as a first step, all obgyns should read these.

2. Establish Young Adult Clinics, a safe place for adolescents to seek care: Adolescent care demands collaboration and partnership among biomedical and social professionals. We really need adolescent friendly clinics that cater mostly to normal care, just as we do “well women clinics”. And perhaps it would be good to call these “Young Adult Clinics.” These clinics can than offer a variety of services including reproductive and sexual health, contraception, pregnancy care counselling. Young adults can be counselled on lifestyle choices and connect with better role models. Clinics should run hotlines for adolescents who need anonymous consultations, and also for health providers who need guidance for their own adolescent patients, and parents who may have concerns about their children. Such clinics can then be highly suited for training medical students, residents and OBGYNS in practical care for adolescents.

3. Educate young boys and girls: You can do this through mothers you see, through midwives you work with, and through communities, villages, parents groups, faith-based groups, so that they are better prepared to discuss adolescent RH and sexual health needs of their adolescents. And if every FOGSI member regularly provided one or two hour educational sessions every year to a local middle or high school, and at a nursing school, the impact could be huge. Keep it simple, ask students to write questions down if they are too embarrassed to ask, and spend most of the time in a conversation. And encourage young people to start social media conversations to demystify the subject.

FOGSI Anti Violence Against Women Cell was Formed in 2013 During the Managing Committee FOGSI.

4. Advocate for better care for youth: Currently there are some very good NGO efforts in the area of adolescent health. Unfortunately, these are unlikely to reach the scale of coverage that is needed. As specialists, Obgyns hold a very special place in society. Welltargeted and persistent advocacy and guidance to state health authorities is needed. A national policy on expanding care for adolescents already exists. Now it needs to be implemented at scale and with high quality. Some areas that need strong financial support and commitment to include school health services that include sexual and Reproductive health, school and out of school nutrition and anemia correction campaigns and also easy access to RH services. An early adoption of vaccination of girls against cervical cancer would be an important area to address.

5. Set achievable targets: FOGSI members can work with other health professionals and health services to set better targets, and monitor the achievement of these goals. Here are a few illustrative targets: a. By 2020, achieve universal application of the LAW on marriage, b. This year, provide the HPV vaccine to 50% of daughters of women whom you have delivered c. This year speak about adolescent health twice a year in schools Now, I will be the first to admit that this is not easy. Every one of these ideas may well meet resistance from health administrators, from parents, from schools, but I am convinced that there are already many of these same stakeholders who are eager to try out innovative solutions to the challenges of adolescent health confronting us. The consequences of not doing anything are too dire.

Harshad Sanghvi Honorary Fellow of the Indian college of obstetrics and Gynecology

Meeting held on 3rd Sept. 2013 at FOGSI office Mumbai. Guidelines & forms are now made available on the FOGSI website for examination of victim of rape. Following are the Members of FOGSI Anti Violence against Women Cell: Dr. Hema Divakar, Bangaluru, Dr. Nozer Sheriar, Mumbai, Dr. Hrishikesh Pai, Mumbai, Dr. Jayam Kannan, Trichy, Dr. Sadhana Desai, Mumbai, Dr. Duru Shah, Mumbai, Dr. Ashwini Bhalerao Gandhi, Mumbai, Dr. Roza Olyai, Gwalior, Dr. Bhaskar Pal, Bengal.

See Dr Gupta's interview here: http://www.jhpiego.org/en/content/ government-india%E2%80%99s-new-strategy-interview-msanuradha-gupta

Photo: Young midwives serving adolescents What can and should a practicing obstetrician / gynecologist do: 1. Educate Ourselves: With so many adolescents in need, it is obvious that preservice medical education and residency must include relevant training in handling issues related to adolescent care. This requires those who teach students to have both knowledge and understanding of key interventions. More 6

Adolescent Health Committee FOGSI

ADOLESCENCE

FOGSI's Campaign for Value, Safety & Respect for Women Naari Samman 2013 Dr Hema Divakar President FOGSI 2013 With the increase in the number of incidents of atrocities against women in the nation, the Federation of Obstetric & Gynaecological Societies of India (FOGSI), the apex body for all Obstetricians & Gynaecologists in the country, launched a new CSR initiative – Social Innovation – to create Value, Safety & Respect (VSR) for women by ushering in synergy among all stakeholders concerned in an event titled Naari Samman 2013 .The FOGSI, as a socially-conscious organization, intends to tackle the issues of atrocities against women, be it domestic violence, rape, sexual harassment, dowry harassment, gender-based discrimination, and violence- through long-term plans with the support of stakeholders. The Social Innovation CSR initiative is an extension of FOGSI's 'Innovation to Implementation' theme for 2013 under which several path-breaking innovations aimed at improving the women's healthcare services were successfully implemented.

As part of the Social Innovation CSR initiative, a day-long conclave titled 'Naari Samman' was organized in Mumbai on 14th of November 2013.The conclave brought together policy-makers, legal fraternity, NGOs, key opinion leaders and bureaucrats to identify the way forward to create VSR for women . On the occasion, the Women's Health Forum (WHF) – India was launched. The WHF will ensure that this mission is completed successfully.

There are several issues affecting women today and they can be broadly classified into social and criminal, but both are interlinked. Be it female feticide, child trafficking, dowry deaths, domestic violence, sexual violence, rape or gender-based discrimination and missing girls, all need the active support of the legal fraternity, policy-makers, and medical communities.

For instance, Haryana has the worst male-female ratio in India and it is below the national average (943 female against 1000 males). In Haryana, it is 879 females followed by Jammu & Kashmir (889 females); Uttar Pradesh (912 females) and Bihar (918 females) and Rajasthan (926 females) for every 1000 males. Several cases of domestic violence, especially in rural areas are going unreported.

While in cities, including shanty towns, domestic violence is 40 per cent the same in rural areas is as high as 56 per cent. According to NCRB data, 244,270 cases of crime reported against women were reported in 2012. While 38,262 cases related to kidnapping and abduction of women / girls; 45,351 cases were related to assault on women with intent to outrage her modesty. A whopping 106,527 cases were on cruelty by husband or his relatives while there were 8,233 cases relating to dowry death.

According to the National Crime Records Bureau (NCRB), in India, a child goes missing every eight minutes. Almost 40% of them are

7

never found and incidentally a majority of them are girls. Similarly, violence against women continues to remain high. A survey conducted by Trust Law reveals that all kinds of violence against women are on the rise. A survey conducted by Oxfam India and Social & Rural Research Institute has revealed that 17 per cent of working women experienced sexual harassment. The maximum number of sexual harassment cases was reported among labourers (29 per cent); domestic helps (23 per cent) and small scale units (16 per cent), which reflect the vulnerability of the underprivileged sections of society. A report released by Ministry of Women & Child Development a few years ago has revealed that an estimated 150 million girls under the age of 18 years have been subjected to sexual harassment at home and at educational institutes.

These are disturbing facts. Sex-selective abortion and infanticide have led to lopsided sex ratios in several North Indian states; crimes against women continue to rise and of late awareness has led to increase in the number of incidents. However, we need a paradigm shift to change the attitude of society towards the girl child and women. Crimes are perpetrated against women from the womb to the tomb. The FOGSI is making concerted efforts to tackle them in a systematic manner by way of creating awareness and educating the people concerned. FOGSI has a strong network of obstetricians and gynaecologists across the country and we will leverage them to tackle these societal inconsistencies.

Helping Mothers Survive Dr. Jayamkannan Chairperson Adolescent Health Committee FOGSI (2013-15) Emeritus professor, Tamil Nadu MGR medical university 2013-FOGSI has taken up implementation of innovations at a fast track pace! Dr. Hema Divakar, FOGSI PRESIDENT IS CREDITED FOR THE SPEED AND EFFECIENCY.” Helping mothers survive” implementation was decided to be spearheaded in medical colleges.

Master trainers were spotted, trained at Bengaluru in 2012 OctoberNovember by the JHPIEGO team. South Zone was allotted to me and Dr. Sheela Mane. I started my first programme at Cuddalore district with doctors from Chidambaram Medical College and consultants. As we started moving around with the mamanatalie demos, we could train many master trainers, the number has raised to 20 in Tamil Nadu alone. By the end of 3 months we could finish 30 programmes of training.

Having realised the need of this programme to the nurses in labour ward, President Hema Divakar gladly permitted me to take this session to the nurses in all areas. My joy of demonstrations of the mamanatalie knew no bounds. We have done nearly 65 programmes.

Our hallmark programme was at FOGSI FIGO Conference at Hyderabad, with due credit to Dr. Shantha Kumari who could get us in a corporate venue. This has made us march towards the RCOG world conference in 2014.

HMS Programme to nurses includes: 1. Short explanation of third stage of labour, as a serious preventable cause of maternal mortality 2. Demonstration of AMSTYL, active management of third stage of labour in all deliveries 3. Demonstration of management of atonic PPH, Blood loss assessment 4. Demonstration of management of retained placenta/placental bits management 5. Demonstration of management of tissue tears 6. Short explanation about PET and eclampsia 7. How to administer magnesium sulphate.

Training evaluation includes pre-test and post-test questionnaire.

Implementation of the programme is almost a process of unlearning our expectant management of third stage of labour and relearning the active management of third stage of labour. Gone are the days of watchful expectancy and masterly inactivity in labour. We have been getting good response in all these programmes. I have done 6 review programmes with great satisfaction.

I immensely thank the entire Fogseans who cooperated in this work, President Hema Divakar in particular.

We sincerely hope to show betterment in our maternal death rates.

FOGSI's Vision 2022, which is aimed at changing the way society and people perceive women in the next one decade in the country. Vision 2022 aims at: (a) Saving the Girl child should become a non-issue by the year 2022. (b) Education and empowerment of women is a continuous effort, and (c) Ensure that adolescent healthcare is in place as 360 million youth in India journey towards wellness with through anaemia eradication, sex education, vaccinations, contraception, and HIV/AIDS care (d) Tackling the tsunami of gestational diabetes and cancer cervix and reduce the burden of non-communicable diseases The meet helped to create a consensus in favour of long-term solutions with in depth discussions on root causes and collective efforts that ought to be made by all stake holders.Through this platform, it will be our endeavour to convert our FOGSI innovations into implementation. As a society we have already spent adequate time on the need for upholding the rights and dignity of women.

What we now need is action that can deliver results. We hope that Naari Samman is the first stepping stone towards achieving a fair and equitable society, which is devoid of any bias against women

The Critical Care Conference Pune – A Great Conference to Remember !

8

Adolescent Health Committee FOGSI

ADOLESCENCE

Contraception in Adolescents

1. Barrier Contraceptives: • Correct and consistant use is the most important requirement • Include male and female condoms, cervical caps, diaphragm, spermicides, sponges etc. failure rate is 2-20%.

• Relatively inexpensive, readily available • Bought over the counter • Protects against STI & HIV 2. Natural & Behavioural methods: Two major approaches: (a) FAM – Practising periodic abstinence or using barrier methods on fertile days. (b) LAM – Relying on recognition of the tested parameters of the lactational infertility. Exclusive breast feeding with amenorrhea are essential. (c) Withdrawal method - (may be difficult for young) 3. IUD: These are small flexible devices made of metal/plastic; they may be inert, or may release copper or hormone. Copper bearing devices include the copper T380A, Copper T220C, Multiload Cu 375 and Nova T. Levonorgestrel releasing IUD is also available.

This particular method may not be very suitable for adolescents specially unmarried females, although there are no specific contraindication for its use. The method may be very useful after an abortion and can be more effective as emergency contraception as compared to pills.

Frameless IUD -Young nulliparous/nulligravid and parous women may significantly benefit from the advantages of the frameless IUS. Furthermore, the frameless IUS has been shown to be highly effective for emergency contraception and for immediate postabortal insertion.

The long life span of the IUS could constitute a cost effective, reversible method for the young.

amount of estrogen (≤ 20mcg) and a third generation progestin which has got anti androgenic properties and is lipid friendly to minimize the risk of thromboembolism , dislipidemia and androgenic effect. A high content of estrogen OCP should be used to treat spotting or breakthrough bleeding.

WHO Recommendations- Bone Metabolism (Geneva Convention 2005) • Among Adolescents (Menarche to <18). The advantages of using hormonal contraception generally out way the theoretical safety concerns regarding fracture risk. Since data are insufficient to determine if this is the case with long term use among these age groups , the overall risk and benefits for continuing use of the method should be reconsidered overtime with the individual user.

6. Effect on bone mineral density. Unlike the common belief, the recent researchers believe that DMPA interferes with BMD by lowering estrogen levels. Lower bone density appears to recover inadolescent females once they stop using DMPA, according to a study funded by the "National Institute of Child Health and Human Development" in US. It showed that their bone density can increase to levels comparable to those of other women in their age group.

Effect on Breast feeding: Studies have shown that there are no adverse effects on• Quantity and quality of breast milk.

• Health and development of the infant.

• Recommended to be started six weeks postpartum, the time given to infants liver to be sufficiently mature.

Newer Pills- Pills with CPA :

Risk of Breast Cancer:

1. PCOS- Cyproterone acetate, a progestin with good anti androgenic properties and strong progestational activity, has also proved its contraceptive properties in combination with estradiol. Long term use of these pills (>36 months) has shown significant improvement in endocrine and clinical parameters.

WHO study shows no overall increase in breast cancer risk.

2. Hirsutism – Pill with CPA is effective in Hirsutism as there is a significant improvement in Ferriman-Gallwey score and rise in SHBG levels. This pill with CPA induces quickest response to treatment of adrenal and ovarian hirsutism in sexually active women.

3. Acne: EE-CPA combinations are widely accepted as effective treatment of acne with 90% success rate., showing significant progressive reduction in severity of comedones and pustules.

Pills with Drospirenone – DRSP Drospirenone ,a novel progestin combining potent progestogenic, antimineralocorticoid and antiandrogenic activity.

A new lower dose formulation depo-subQ-provera (DMPA-SC) injected subcutaneously is available which contains 104 mg of DMPA, the dosage schedule remaining the same. It can also be used as self injection. Approved in US & UK. Combined injectable contraception: Cyclofem Mesigyna - have completed the clinical trial and are introduced in number of countries.

Amenorrhea and late return of fertility may be disturbing to young couples especially in Indian scenario. DMPA can safely be used in youth to postpone first pregnancy for a few years, but couple must be counseled regarding its efficacy, other health effects. It can be used for longer periods i.e. >3-5 years as lost BMD does not have impact in later life after discontinuation.

6. Emergency Contraception

Pills with less than 20mcg Estrogen

Emergency contraception is designed to prevent pregnancy after unprotected intercourse being indicated in –

"Minesse", the 15 mcg pill is undertrial, but has very high incidence of break through bleeding.

1. Contraceptive accidents.

Continuous use pills One formulation "Seasonale" is packaged for continuous use and is FDA approved (150mcg of Levonorgestrel + 30 mcg of EE). It is taken for 84 days(12 weeks) with a pill free interval of seven days.

b. Causes endometrial atrophy thereby hindering implantation. c. Makes cervical mucus scanty,thick and sticky affecting sperm penetration.

• Dysmenorrhea • Menorrhagia • Endometriosis

5. Other effects. Eg. headache, sore breasts, nausea, abdominal discomfort, dizziness, depression,skin rashes, hair loss etc.

• There should be no restriction on the use of combined hormonal contraceptive methods among women who are otherwise eligible to use these methods , including no restrictions on duration of use.

4. OCP:

The young girls are concerned about the issues of weight gain and hence must be counseled accordingly and the OCP chosen appropriately. The ideal OCP will be a product which contains least 9

4. Irregular bleeding specially in first few months.

The largest target population of 35,00,000 youth in developing country needs to be addressed for issues related to contraception and reproductive health and options available to them.

Contraception Acne PCOS Severe PMS

Services designed for the adults may not be truly accessible to the youth due to lack of privacy, social stigma and other factors. Therefore, there is a need to design and implement programs that have a holistic approach and meet the requirements of the youth.

3. Amenorrhea - >50% experience amenorrhea within one year

a. Reduces release of GnRH causing suppression of ovulation.

• • • •

Non hazardous health effects: 2. Change in menstrual bleeding pattern.

Thus, IUD can and should be considered for an older teenager who is in a stable monogamous relationship, for a nulligravid young woman and also for young woman who has a child and who wants reversible spacing method.

Indications for OCP use in the young:

EC due to ignorance, carelessness and casual attitude should totally be forbidden.

1. Weight gain comparable to OCs.

Dr. Ragini Mehrotra B.Sc, MBBS, MS, FICMCH Prof. & Head of the Dept of Obs. & Gyn., AIIMS Bhopal, MP The period of adolescence is vital in a female life, as sexual relationship, marriage and child bearing are likely to begin. Even if not married, the young girls may become pregnant. Such unwanted pregnancy is associated with misconceptions, fear and apprehensions. Adolescents are the largest population targeted for unmet needs of contraception. It is pertinent to redefine contraceptive options ans safe sexual practices for adolescents to reduce lifelong morbidity and mortality .

expect a wait of some months after stopping injectables to become pregnant.

5. Progesterone injectables: It acts at various levels:

Following a single 150 mg DMPA I/m injection peak plasma concentration of 1-7 mg/ml is reached in three weeks, decreasing thereafter.

Effectiveness & Reversibility: DMPA combines complete effectiveness with reliability to the extent of <1 pregnancy per100 W.Y. comparable to Norplant and TCu 280 A81UD. It may take a little longer (4-6 months) for return of fertility but it is same as IUD or OC users at the end of 2 years. The women should

2. Sex against will.

3. Sexual assault.

4. Recent use of teratogenic drugs.

Type of EC: 1. Levonorgestrel –Current recommendation is two doses of LNG 0.75mg to be taken at 12hr. internal within 72hrs. of unprotected intercourse,or 1.5mg of LNG- i.pill-(Cipla ltd.)-single tablet is in use with good efficacy, if taken within 72 hrs.

2. Mifepristone (antiprogestin) 600mg single dose to be taken within 72 hrs. has been very effective and with no significant side effects.

3. Insertion of a Cu releasing IUD as an EC within five days of unprotected sex is highly effective. It may be used for ongoing contraception as well. Not recommended for nulliparous women or for those at risk of PID. Termination of pregnancy is recommended in case of method failure.

Young adolescents with increased access to EC, should use the method more frequently when needed because using EC is any day better than undergoing abortion. But at the same time they should not compromise their useof routine contraception nor increase their sexual risk behaviour. Irresponsible, unethical and rampant usage of

REFERENCES 1. Committee on Adolescence, Contraception and Adolescent, Policy statement PEDIATRICS Vol. 120 No.5 November 2007; 1135-1148.

2. International Planned Parenthood Federation Statement on Statement on Barrier Methods of Contraception; Tokyo May 2001.

4. World Health Organization (WHO) Depatment of Reproductive Health and Research. Selected Practice Recommendation for Contraceptive Use. 2nd ed.

Geneva, WHO, 2004.

5. Hui-QinL,Zhuan-Chong F, Yu-Bao W, Yiao-Lin H, Van Kets H, Wildemeerch D; Performance of the frameless IUD (Flexigard prototype inserter) and the TCu380A after six years as part of a WHO multicenter randomized comparative clinical trial in parous women; Advances in Contraception, 1999;15(3):20109(9).

6. Alan Guttmacher Institute(AGI). Into a New World: Young Women's Sexual and Reproductive Lives,1998.

7. Gage A. Sexual activity and contraceptive use: The components of the decisionmaking process. Studies in Family Planning 29(2) (June 1998).

8. Rapkin AJ, Mikacich JA. Premenstrual syndrome in adolescents: diagnosis and treatment. Pediatr Endocrinol Rev 2006; Jan 3(Suppl 1): 132-7.

9. Van Volten WA, van Haselen CW van Zuuren EJ Gerlinger C, Heithecker R. The effect of 2 combined oral contraceptives containing either drospirenone or cyproterone acetate on acne and seboorrhea. Cutis. 2002 Apr; 69(4 Suppl):215.

10. Breitkopf DM, Rosen MP, Young SL, Nagamani contraceptives in the treatment of hirsutism.Contraception 2003 May ; 67(5):53.

11. Batukan C, Muderris II, Ozcelik B, Ozturk A. Comparison of two oral contraceptives containing either drospirenone or cyproterone acetate in the treatment of hirsutism. Gynecol Endocrinol. 2007 Jan;23(1):38-44 12. Borges LE, Andrade RP, Aldrighi JM,Guazelli C, Yazlle ME, Isaia CF,Petracco A Peixoto FC,Camargos AF.Effect of a combination of ethinylestradiol 30 microg and drospirenone 3 mg on tolerance , cycle control, general well being and fluidrelated symptoms in women with premenstrual disorders requesting contraception. Contraception. 2006 Dec; 74(6):446-50. Epub 2006 Oct 19.

13. Dollery C (Ed). Therapeutic Drugs Vol.1, Edinburg Churchill Liningstone, 1999;C381-384.

14. Satoskar SS,Bhandarkar SD and Ainapure SS,Pharmacology and Pharmacotherpeutics, Revised 16th Edition, Mumbai. Popular Prakashan.1999; 975.

15. BLOCH B. Depot medroxyprogesterone acetate (Depo-Provera) as a contraceptive preparation. South African Medical Journal 1971;45(28):777780.

16. BRAT TM.Acceptability of Depo-Provera as a reliable contraceptive method.

[Abstract] In:Kleinman R, Pickles VR (EDS). 7th World Congress, Fertility and Sterility, Oct. 1971. Amsterdam, Exerpta Medica Foundation, 1971. (International Congress Series No.234a)p 85.

17. Change in Bone Mineral Density Among Adolescent Women Using and Discontinuing Depot Medroxyprogesterone Acetate Contraception Delia Schooles, PhD; Andrea Z. LaCroix, PhD;Laura E. Ichikawa, MS; William E.Barlow, PhD; Susan M.Ott, MD Arch Pediatr Adolesc Med. 2005;159:139-44 18. Fortheby K,SHI YE Howard G Elder MG, Muggeridge J. Return of ovulation and fertility in women using norethisterone oenanthate.

Contraception 1984;29(5):447-55.

19. World Health Organization. A multicentred Phase III comparative clinical trial of depotmedroxyprogesterone acetate given three monthly at doses of 100 mg or 150mg: 1.Contraceptive efficacy and side effects. Contraception 1986;34(3): 223-35.

20. Wynn, RM. Obstetrics and gynecology: The clinical core. 5th ed. Philadelphia, Lea and Febiger 1992;373.

21. Zimmerman, AW, Holden KR, Reiter EO, Dekaban AS. Medroxyprogesterone acetate in the treatment of seizures associated with menstru-action. Journal of Pediatrics 1973;83(6):959-63.

22. Glasier A Thing K. Dewar Mackzie M, Baird D.Mifepristone(RU 486)compared with high dose estrogen and progestogen for Emergency Post Coital Contraception, 1992.

23. Webb. AMC, Russell J,and Elstein M: Comparison of Yuzpe Regimen, Danazol and Mifeprostone (RU 486) in Oral Postcoital Contraception. Br. Med. Jr.,1992;305:927-31.

24. WHO Scientific Group: Mechanism of Action, Safety and Efficacy of Intrauterine Devices. Report of a WHO Scientific Group,Geneva,WHO Tech Report Series 1983;753.

25. Wildemeesch D,Batar I,Webb A, et al. Gyne Fix: The frameless Intrauterine Contraceptive Implant An Update for Interval, Emergency and Postabortal Contraception, Br Jr Fam. Plann 24,1999;149-59.

26. Harper Cynthia C, Cheong Monica et al. The Effect of increased access to Emergency Contraception among Young Adolescents. ObstetGynecol Sept 2005;106(3):483-91

10

Adolescent Health Committee FOGSI

ADOLESCENCE

Thyroid Disorders in Adolescent Girls Effect on Fertility Hypothyroidism & Hyperthyroidism both cause ovulatory failure and lead to infertility.7 Dr. Kiran Pandey MD.(Obst & Gynae), FICOG, FICMCH, FIMSA, MAMS Professor & Head Department of Obstetrics & Gynaecology G.S.V.M. Medical College, Kanpur Disorders of thyroid gland is one of the most common endocrine problems of adolescence.

Due to the rising incidence of thyroid disorders in adolescence in recent years, it has become important to recognize it and take steps for the prevention by educating the adolescents and their parents. However more studies are needed in the Indian set-up for assessment of exact magnitude of the problem.

While the disease process is similar to adults, the incidences, presentations, and clinical consequences can differ.

DefinitionHypothyroidism is a disease of thyroid characterised by low serum T4 and high serum TSH (above reference values); decreased production and secretion of thyroid hormones.

Hyperthyroidism is a condition characterised by high serum T4 and low serum TSH (below reference values).

The condition is often referred to as an "overactive thyroid."

Causes of Hypothyroidism 1. Primary Hypothyroidism- (occurs when there is a problem with the thyroid gland itself).

↑T4→↑TRH→ Thyroid can't→↑↑ TRH & TSH→↑prolactin→ ovulatory failure & TSH respond Effect on Pregnancy

Teenagers who are at Risk HYPOTHYROIDISM

HYPERTHYROIDISM

Strong predilection for females as compared to males (6:1)

Females > males (2-10 times more)

Close family member with autoimmune disease

Having any past history of thyroid problems, autoimmune disease, or endocrine disease

Received past radiation therapy to chest & neck

Overtreatment of hypothyroidism

Smoking -

Smoking -

Having thyroid surgically removed

Any trauma to the thyroid surgery or biopsy of thyroid gland.

Obesity (risk factors: Calorie dense junk foods & sugar laden soft drinks)3

Stress (increases severity of clinical symptoms of Grave's disease)

Intake of goitrogenic foods-

Intake of excessive I2 containing supplements bladderwrack, kelp (a variety of sea weeds) etc.

Symptoms HYPOTHYROIDISM

HYPERTHYROIDISM Miscarriage Intrauterine growth restriction (IUGR) Premature labour Higher risk of perinatal mortality.

Complications

an increase in serum thiocyanate May exacerbate Grave's concentration from smoking may ophthalmopathy.1,2 contribute to the development of hypothyroidism in patients with Hashimoto's thyroiditis.

Cabbage, broccolis etc.

HYPOTHYROIDISM Habitual abortion Intrauterine growth restriction (IUGR) Preterm delivery Intrauterine death Anaemia, Postpartumdepression, Cardiac dysfunction Congenital hypothyroidism

HYPERTHYROIDISM

• Hashimoto's thyroiditis. (most common cause of adolescent hypothyroidism)

Hair loss, thinning of hair

Hair loss

HYPOTHYROIDISM • bradycardia, • hypertension • cardiac enlargement

HYPERTHYROIDISM • tachycardia CVS • palpitations • abnormal heart rhythms • heart failure • Diarrhoea • chronic constipation GIT • Increased ventilatory drive • Hypoventilation RESP • respiratory muscle • sleep apnea weakness • muscle and joint fatigue • peripheral neuropathy CNS & NEUROMUSCUL-AR• Carpal tunnel syndrome • Insomnia • depression • Dementia • mood swings • Delirium • Thyroid psychosis • Grave's Dermopathy • Dry, patchy skin SKIN • Pretibial Myxedema • Hyponatremia METABOLIC • hyperlipidemia, • Hypercholesterolemia • Hypertriglyceridemia • Grave's ophthalmopathy • Refractory anemia OTHERS • Myxedema

• Titrate dose every 6wks acc.to S.TSH • Initial 12.5-25 mcg/day. Adjust dose by 25mcg/day as appropriate .

Hyperthyroidism Investigations• S.T3, T4 and TSH • Iodine thyroid scan.

• As an initial single test, a sensitive TSH assay may be most costeffective and specific. TSH should be 0 – .1 µU/ml in significant thyrotoxicosis, although values of .1 – .3 are seen in patients with mild illness.

Treatment 1. Antithyroid drugs- methimazole , propylthiouracil and carbimazole.

• Overtreatment of Hyperthyroidism.

Bradycardia

Racing heartbeat, tachycardia

• Drugs -Iodine deficiency/ excess, e.g. methimazole, propylthiouracil, lithium, amiodarone, interferon alpha

Cold intolerance

Patients feel warm or hot

2. Radioactive iodine (RAI) is the most commonly recommended permanent treatment for teens with Grave's disease today. It is usually given at a hospital, but doesn't require a hospital stay. RAI is considered safe for teens when given in the standard amount.

Weight gain

Weight loss

3. Thyroidectomy

• Infiltrative diseases- rare (TB, leukemia, hemochromatosis, amyloid etc.)

Diarrhoea

Chronic constipation

Hypothyroidism & Hyperthyroidism both cause a delay in puberty and onset of menstruation. Hypothyroidism, in addition causes –

Absolute Indications Failed medical therapy Severe reaction to antithyroidal drugs and not a candidate for radioablation therapy.

Persistent thyrotoxicosis despite maximum antithyroidal drug therapy or repeated radioablation treatment Underlying thyroid cancer Suspicious or malignant nodules on FNA

• Deceleration of linear growth with or without short stature.

Prevention

• Incomplete isosexual precocious development of breast and internal genitalia in girls.

1. Exercise & Yoga improve blood circulation & balance thyroid hormone production.

2. Secondary hypothyroidism- (when there is a problem with the pituitary, not the thyroid).e.g.pituitary tumors, Sheehan's syndrome, surgery, radiotherapy.

Menstrual symptomsoligomenorrhea(3 times common)4

Hypomenorrhoea

3. Tertiary hypothyroidism- hypothalamic damage from tumors, radiation.

Amenorrhoea, Menorrhagia, Dysmenorrheoa

Amenorrhoea

4. Subclinical hypothyroidism-

Effect on Puberty & Growth

• Continuum between euthyroidism and hypothyroidism • Asymptomatic state with normal serum & free T4 & elevated TSH (prevalence 4-8.5%).

Causes of Hyperthyroidism 1. Graves' disease- most common cause.(an autoimmune condition)

Management HypothyroidismDiagnosis

2. Thyroiditis.

3. Thyroid nodule.

5. Excess iodine. Kelp or seaweed supplements and the medications. e.g. amiodarone .

6. Over treatment of Hypothyroidism.

• The generally accepted reference range for normal serum TSH is 0.40-4.2 mIU/L. Patients with elevated TSH levels (usually 4.510.0 mIU/L) but normal free hormone levels or estimates are considered to have mild or subclinical hypothyroidism.

• Children born to mothers with hypothyroidism during pregnancy had lower IQ and impaired psychomotor (mental and motor) development. If properly controlled, often by increasing the amount of thyroid hormone, women with hypothyroidism can have healthy, unaffected babies.

11

Levothyroxine-synthetic T4 or 3,5,3',5' tetraiodo L -thyroxine is a synthetic form of thyroxine (1.7 mcg /kg/day (tab/cap),empty stomach).

Relative Indications Symptomatic goiters Pregnancy Severe Graves' ophthalmopathy Toxic adenoma Amiodarone related

2. A diet rich in protein, calcium, magnesium, and iodine supports thyroid function. You want to be sure you are receiving enough of all the B vitamins, vitamin A, vitamin C, and selenium, which, in high doses, may cause thyroid problems.

References 1. Nikolaos P, Gerassimos E:Influence of cigarette smoking on thyroid function, goiter formation and autoimmune thyroid disorders .HORMONES. 2002, 1(2):91-98.

2. James et al 2005, Int J Obs 29 suppl2; 354:7.

3. Krasses GE et al 1999, disturbances of menstruation in hypothyroidism. Clin Endocrinol (Oxf) 50; 655-659.

4. Usha R.et al Indian Medical Gazette.2001(1) 12

Adolescent Health Committee FOGSI

ADOLESCENCE

Examination of a Rape Victim

Dr. Alka Kuthe LLM (Criminology), PG Dip. Human Rights Consultant Gynecologist, Medico-legal Counselor, Amravati The term “Rape” is used to describe sexual criminal assault on woman, although literally it means taking anything by force. It is in existence since ancient times, but the magnitude of this crime has increased tremendously in recent years. No age is immune from rape as a child of one year or less and an old woman of 85 years and above have been reported raped. The incidence of rape on adolescent girls below 16 years of age accounts for more than 75% of total rape cases in last few years This shows the gravity of the offence and an urgent need to tackle this problem. Section 375 IPC defines rape as “Any girl under 16 years of age cannot give valid consent for sexual intercourse. Sexual intercourse with her amounts to rape.” A woman of 16 years and above can give valid consent for sexual intercourse.

The consent must be free and voluntary and should be given while she is of sound mind and not intoxicated and must be given prior to act.

Exception to this is sexual intercourse by a man with his own wife even against her will if she is above 15 years of age (marital right of the couple). Drug facilitated sexual assault is a growing menace especially in metropolitan cities. In about 25% of rape cases ' drug' is involved.

Adolescent girls (16-19 years) and young adult women (20-24years) are 4 times more likely to be sexually assaulted than women in other age group. Adolescents need safety tips to help them to have a safe time when at a party, bar, picnic or just hanging out with friends. The rape is a cognizable offence and as a citizen of the country, the medical practitioner is duty bound to inform it to the police when he is aware of this grave offence.

The medical examination of rape victim and the accused person soon after the incident often yields a wealth of corroborative evidence. The proper interpretation of the physical findings in a complainant of rape is one of the most difficult and controversial aspect of the medical examination. However the rape in adolescents where the age of victim is below 16 years, the interpretation is relatively easy as the plea of consensual rape is not valid in these cases and presence of any feature of sexual intercourse will amount to rape. The features of sexual intercourse are easily evident in these girls.

There are mainly three objectives while examining a case of rape victim, 1) To search for physical signs that will correlate with the history given by the victim.

2) To search for and collect & preserve all traces of evidence for laboratory examination.

3) To counsel, prevent & treat sexually transmitted diseases, pregnancy and psychological damage.

Written consent from the parents/guardians should be taken before examining adolescent with the purpose to prepare a medico-legal report. e.g. in case of rape . The parents can refuse the examination but they must be given prior idea that the report may or may not go in their favor.

Consent while examining Rape cases: While examining the victim of a criminal case (victim of rape, assault, etc.) consent must be taken from girl if she is above 16 years and from the guardian/ parents if she is below 16 years. In India, a woman above the age of 16 years has a capacity to consent for sexual intercourse. Thus a woman below the age of 16 years, even if willfully allows an intercourse, it will be considered as rape. In marriage, however, as said before ,the cut off age is 15 years.

Examination of victim: In the case of adolescence abuse and domestic violence, the role of a comprehensive forensic medico-legal examination of the victim is of utmost importance in the full 13

investigation of the case and the building of an effective prosecution in the court. The protection of the sexually abused child from any additional emotional trauma during physical examination is also of great importance. A brief assessment of the developmental, behavioral, mental and emotional status should also be obtained.

Medico-legal examination is one of the star evidences in the judicial proceeding that cannot be ignored. The children who are subjected to sexual assaults, may not be able to give proper history. So the examiner must have high degree of suspicion. Many times a child might have been brought to a gynecologist, only with the history of trauma and bleeding per vagina or inability to pass the urine or loss of appetite or for MTP. She may be brought by police as a victim of the alleged rape. Therefore medical history must be obtained by a highly skilled professional without leading questions. When taking a history, the doctor must use language that is appropriate, supportive and demonstrative of a friendly and caring attitude. What they state should be recorded in their own words .Hence, a medical practitioner is not only morally but also legally bound to examine, document and collect all relevant and feasible material from a victim of abuse. It is advisable to examine the victim at the earliest after the incident to achieve the above goal The physical examination includes inspection of the whole body with special attention to the mouth, breasts, genitals, perineal region, buttocks and anus. Each examination should include a complete physical examination in appropriate position with careful photographic recording of any trauma away from the genital area. Bite marks are common in sexual assaults and it is important to measure and photograph them carefully to allow matching or exclusion of the teeth of the alleged assailant. At times, the physical examination may reveal normal findings in sexually abused child. There are several reasons for this paucity of diagnostic findings. Children are naturally reluctant about reporting such conduct, so the opportunity to see and record acute changes is lost. In the differential diagnosis of anal sexual abuse the practitioner must be aware of non-abuse related conditions for example, Crohn's disease, child with significant constipation, etc.

Forensic studies should be performed, when the examination is carried within 72 hours of alleged sexual assault or sexual abuse.

Forensic science techniques provide corroborative evidence. When relevant swabs from mouth, anus or vagina are taken, they should be allowed to dry in the atmosphere before they are sealed. It is important to note that though the documented presence of an ejaculate is the most positive identifying element for the expert, its absence by no means refutes complaint of sexual assault. Evidence should be preserved carefully and a written record kept establishing the chain of evidence, every person-to person transfer, to document that no tampering or mix-up occurred during the process. Cultures and serological tests for sexually transmitted infections are decided by the forensic expert according to the special circumstances of the case.

Pregnancy test should be performed in each case of sexually abused girl in a reproductive age if she misses the next menstrual cycle. At times, with proper informed consent, pregnancy can be prevented by giving EC pills. A full clinical inspection, including a skeletal radiological survey, must be undertaken. Usually, such examinations involve a forensic medical examiner and a pediatrician. However, it may be necessary to involve another medical professional, such as genitourinary physician, psychiatrist or family planning doctor. For the identification of assailant apart from exploration of different characteristics of head and pubic hair, Identification of generic markers in the blood saliva and serum (ABO typing and other blood enzyme systems) should be performed within 72 hours of alleged sexual assault or sexual abuse. DNA finger printing can nowadays, establish the identity of a perpetrator with a high degree of certainty.

Premarital Counseling Dr. Krishna Kavita Ramavath MD FICOG 7522 Hampton Ln Shakopee, MN 55379, USA Premarital counseling is practical advice given to a couple in preparation for marriage. It aims to assess the strengths and challenges of the couple's relationship. Specific needs of the partners are taken into account and the interventions are provided according to the need. Communication skills and conflict resolution techniques are frequently used tools in the process of counseling.

Many couples choose their partners quickly, end up in a hasty marriage and then regret. We as individuals are not only differently physically, but there are differences in the social backgrounds, outlook on life and the way to approach a challenging situation. The more a couple learns to understand those differences, the stronger a marriage will become.

Premarital counseling can be given by therapists or the doctors. The phases of premarital counseling can be broadly framed into 3 phases: an initial assessment phase, the working phase and the final termination phase.

The assessment phase: The couple and the therapist as a team get to know each other with a number of questions, which are going to help to get a sense of who you are and what the nature of your relationship is. This can greatly benefit couples to help them prepare for the stress of adapting to a shared life. It also gives an opportunity to explore the dynamics of the partnership for a fulfilling future together.

The working phase: This phase is specifically tailored to each couple and relationship needs. There is an educational aspect to this phase of counseling, which focuses on better communication skills to negotiate conflict and resolve differences to strengthen the relation.

The inbuilt coaching aspect helps the couples to practice, with the therapist's help, the new perspectives and new skills that they are learning. This application helps to develop a strong and healthy relationship. By the end of this phase couples usually feel more secure in the relationship.

The termination phase: In this is the last phase of pre-marital counseling, new learning, skills and understandings are consolidated and put to practice. It is at this time that a plan for building of the relationship is put together.

Role of doctor's as therapists: We sometimes may have to switch roles as therapists. We must be also sensitive to cultural practices of different states or different countries like Asia, Middle East, South Africa and USA. One may have to take a closer look at some common issues in all types of marriages and premarital counselling.

Couples may come with a wide variety of values, and we as therapists should investigate their core beliefs early in the process. Some couples may value gender equality which is common with the younger generation. While others might see separate roles for men and women as a fair approach that promotes marital harmony which is common in many cultures.

Consequently, we should consider meeting with each partner individually in different sessions and educate both partners. A written questionnaire provided separately would give an insight into their conflict areas, fears and strengths. This will help us to communicate better.

We also should be well aware of the fact that families often play a central role in the relationship. Establishing proper boundaries with in-laws may seem to be a struggle for some. We as therapists should determine each partner's comfort level with family involvement before making recommendations.

Dear readers, you who have come thus far with me reading this article, I think will also agree with me if I say, life always is full of changes and challenges. So we should let the couples understand that the hard days may be self, work, situation or life-induced. One can never be fully prepared for what might come, but can prepare themselves that when something comes, whatever it is and no matter how hard it is, that they can handle it. That confidence comes with togetherness and a single vision.

It is needless to say that the strength in the marriage comes with commitment, dedication and love towards the partner.

And finally when the couple is leaving the office definitely add these points. These are good tips for couples who come for premarital counseling.

Things to remember: • Invite God into your lives first, meditate together by reading Holy writings. Let Him sustain and strengthen your marriage.

• Establish the understanding early in the relationship.

• Be more connected to each other and be less demanding.

• Consult a Gynecologists for queries regarding use of contraception & spacing the first child, blood group & vaccination.

• Keep a role model couple whom you admire and listen to their stories. Meet with them often and also when in need.

• Have space for each other.

“Challenges for Youth Today & Tomorrow" Report by : Dr. S. Sampathkumari Associate Professor & Head of Department (OG) at Government Medical College & Hospital at Thiruvannamalai.

School & college Health Program, Chennai TN

Legal definitions of abuse and neglect vary from state to state. Sexual abuse is a criminal offence and is investigated by the police. However physicians and care providers in all states are required by law to report all suspected cases of child abuse and neglect. These laws offer protection from lawsuits to mandatory reporters who report in good faith. Failure to report suspected child abuse may result in a penalty.

14

Adolescent Health Committee FOGSI

ADOLESCENCE

Dysmenorrhea interventions, and dietary/herbal supplements are commonly utilized by women in an effort to relieve dysmenorrhea.

Dr Rishma Pai Consultant Gynaecologist Lilavati and Jaslok Hospitals Mumbai, Hon. Sec. of the Indian Society of Assisted Reproduction, Jt. Clinical Sec. Mumbai Obs. & Gyn. Society.

Definition and Pathophysiology “Dysmenorrhea” is derived from a Greek word which means' difficult menstrual flow'.

Primary dysmenorrhea is defined as recurrent, crampy pain occurring with menses in the absence of identifiable pelvic pathology. It usually begins in adolescence after the establishment of ovulatory cycles, and is caused by myometrial activity resulting in uterine ischemia causing pain. Secondary dysmenorrhea is menstrual pain associated with underlying pelvic pathology such as endometriosis or fibroids etc.

Risk Factors Ninety percent of women presenting for primary care suffer from some menstrual pain. Age is a determinant of menstrual pain with symptoms being more pronounced in adolescents than in older women. Associated factors for more severe episodes of dysmenorrhea may include early menarche, heavy and increased duration of menstrual flow and family history. There is some evidence that parous women have less severe dysmenorrhea.

Smoking worsens primary menstrual pain. There is some suggestion that more frequent life changes, fewer social supports, and stressful close relationships maybe associated with increased dysmenorrhea.

There may bean increased prevalence of dysmenorrhea in lower socioeconomic groups. There is controversy about the association of obesity, physical activity, and alcohol with primary dysmenorrhea.

Diagnosis of Primary Dysmenorrhea Typically, primary dysmenorrhea is characterized by a crampy suprapubic pain that begins somewhere between several hours before and a few hours after the onset of the menstrual bleeding. Symptoms peak with maximum blood flow and usually last less than one day, but the pain may persist up to 2 to 3 days. The pain is characteristically colicky and located in the midline of the lower abdomen but may also be described as dull and may extend to both lower quadrants, the lumbar area, and the thighs. Frequently associated symptoms include diarrhea, nausea and vomiting, fatigue, light-headedness, headache, dizziness and, rarely, syncope and fever. These associated symptoms have been attributed to prostaglandin release.

The differential diagnosis of primary dysmenorrhea is summarizedin Table 1.

Table 1. Differential diagnosis of dysmenorrhea • Primary dysmenorrhea • Secondary dysmenorrhea - Endometriosis - Adenomyosis - Uterine myomas - Endometrial polyps - Cervical stenosis - Obstructive malformations of the genital tract • Other causes of pain - Chronic pelvic inflammatory disease - Pelvic adhesions - Irritable bowel syndrome - Inflammatory bowel disease - Interstitial cystitis • Sudden onset of dysmenorrhea - Pelvic inflammatory disease - Unrecognized ectopic pregnancy or spontaneous abortion 15

Dr Nandan Roongta Consultant Gynecologist, Bloom IVF Centre, Lilavati Hospital, Mumbai.

Clinical Approach History An attempt should be made to differentiate between primary and secondary dysmenorrhea. The history should focus on menstrual history, including age at menarche, length and regularity of cycles, dates of last two menses, and duration and amount of the bleeding.

The length of time elapsed between menarche and the beginning of dysmenorrhea should be established. The pain should be clearly defined in terms of type, location, radiation, and associated symptoms, as well as the chronology of the onset of pain in relation to onset of menstrual bleeding. The severity and duration of symptoms, the progression overtime, and the degree of the patient's disability should be established. Significant gastrointestinal or urinary symptoms or the presence of pelvic pain not related to the menstrual cycle may suggest other causes of pelvic pain.

In obtaining a thorough history, it is important to inquire about sexual activity, dyspareunia, and contraception. Past obstetric and gynaecologic history, in particular, sexually transmitted infections, pelvic infection, infertility, and pelvic surgery, as well as other medical problems should be recorded. A family history of endometriosis should also be sought. The patient should also be asked about all types of therapy tried in the past.

Physical Examination Women suffering from primary dysmenorrhea are expected to have a normal pelvic examination. However, a normal pelvic examination does not systematically rule out the presence of a pelvic pathology. An abdominal examination should be done in every patient to rule out palpable pathology. In an adolescent who has never been sexually active and presents with a typical history of mild to moderate primary dysmenorrhea, pelvic examination is not necessary. However, some authors recommend inspecting the external genitalia of all patients to exclude an abnormality of the hymen. On the other hand, when history is suggestive of organic disease or congenital malformation of the genital tract, or when the patient does not respond to the conventional therapy of primary dysmenorrhea, a complete pelvic examination is indicated.

Investigations Laboratory testing or imaging is not required to make a diagnosis of primary dysmenorrhea. Complementary investigations may be ordered when secondary dysmenorrhea is suspected.

Ultrasonography: For women who suffer from dysmenorrhea refractory to first-line therapy, or in women who have a clinical abnormality on pelvic examination, and in adolescents in whom a pelvic examination is impossible or unsatisfactory, ultrasound may identify causes of secondary dysmenorrhea.

Magnetic resonance imaging: This expensive test has limited clinical usefulness.

• Transcutaneous Electrical Nerve Stimulation (Tens) / Acupuncture: TENS involves use of electrodes to stimulate the skin at various frequencies and intensities in an attempt to diminish pain perception.

• Spinal Manipulation: Overall results provided no evidence that spinal manipulation relieves dysmenorrhea.

• Behavioural Interventions: Procedures such as biofeedback, desensitization, Lamaze exercise, hypnotherapy, and relaxation training.

• Topical Heat

Surgical Options For a small number of women, the dysmenorrhea will persist despite medical management, and in this group of women it is appropriate to consider surgical options. Surgery therefore constitutes the final diagnostic and therapeutic option in the management of dysmenorrhea.

Laparoscopy In women who do not obtain adequate pain relief with NSAIDs and oral contraceptives, the likelihood of pelvic pathology such as endometriosis is high. The lesions of endometriosis may be cauterized or resected at the time of laparoscopy followed by medical suppressive therapy.

Non-Hormonal Medical Treatment

In women who experience relief of their dysmenorrhea with NSAIDs or oral contraceptives, there is a possibility of underlying endometriosis, but the risks of laparoscopic documentation of the disease must be weighed against the predicted advantages of having a diagnosis of endometriosis when the symptoms are controlled without surgery.

NSAIDs

Presacral Neurectomy

Medicinal Therapeutic Options Many drugs are commercially available and approved for the use in treatment of primary dysmenorrhea.

Examples of NSAIDs Class of NSAIDs

Medications

Acetic acid derivatives (including indole derivatives)

Diclofenac potassium (Voltaren Rapide) Indomethacin (Indocid)

Cyclooxygenase-2 (COX-2) inhibitors

Celecoxib (Celebrex) Meloxicam (Mobicox)

Presacral Neurectomy (PSN) involves the total transaction of the presacral nerves lying within the boundaries of the interiliac triangle.

PSN seems to be the method of pelvic denervation that is associated with major long-termeffectiveness in pain relief. Some of the complications of this procedure may include constipation as well as urinary urgency which is unlikely to respond to medical treatment.

Fenamates

Mefenamic acid (Ponstan, Mefenamic)

Laparoscopic Uterosacralnerve Ablation (LUNA)

Oxicams

Meloxicam (Mobicox)

Propionic acid derivatives

Ibuprofen (Advil, Motrin) Naproxen (Naprosyn) Naproxen sodium (Anaprox)

Resection of the uterosacral ligaments achieves in theory a more complete uterine denervation than presacral neurectomy. The intervention carries the risk for complications such as bleeding, ureteral lesions, and pelvic support disorders.

Salicylic acid derivatives

Acetylsalicylic acid (Aspirin)

Hysterectomy

Hormonal Medical Treatment Combined oral contraceptive (COC)

Pelvic pain should be carefully investigated prior to considering a hysterectomy. There is a case for hysterectomy when an underlying disease, amenable to hysterectomy, is demonstrated and the patient has completed her family. Hysterectomy may offer permanent relief for the woman who has pain confined to her menses, and therefore there is good evidence for excellent patient satisfaction following hysterectomy in this context

Research suggests that the COC suppresses ovulation and endometrial tissue growth, thereby decreasing menstrual fluid volume and prostaglandin secretion with subsequent decrease in intrauterine pressure and uterine cramping.COCs are considered an effective treatment for primary dysmenorrhea. When given in a continuous fashion, the COC may have anumber of advantages, including a decreased incidence of dysmenorrhea.

• Vitamin B1

Progestin regimens

• Vitamin E

Depot medroxyprogesterone acetate (DMPA) works primarily by suppressing ovulation. It also can induce endometrial atrophy. One of its non-contraceptivebenefits is amenorrhea with a resultant reduction in the incidence of dysmenorrhea.

• Fish oil / Vitamin B12 combination

Levonorgestrel intrauterine system (LN-IUS) LN-IUS (Mirena) is an intrauterine device that release sprogestin locally inside the uterine cavity. Although ovulation is not suppressed, the LN-IUS has a local effect on the endometrium, which becomes atrophic and inactive. Menstrual blood loss is reduced by 74% to 97%and 16% to 35% of LN-IUS users will become amenorrheic after 1 year of use. Dysmenorrhea has been shown to improve in LN-IUS users.

Complementary and Alternative Medicines (CAM)

• Magnesium • Vitamin B6 • Toki-shakuyaku-san • Fish oil • Neptune krill oil • Vitamin B6/magnesium combination • Vitamin E (daily) in addition to ibuprofen(during menses) • Fennel

Hysteroscopy and saline sonohysterography are helpful in the diagnosis of endometrial polyps and submucosalleiomyomas.

Laparoscopy is the only procedure that will establish a definite diagnosis of endometriosis, pelvic inflammatory disease, or pelvic adhesions. It should be performed when these pathologies are strongly suspected or when first-linetherapy has failed. Biopsies of visible lesions, especially when atypical, are recommended in order to have histological confirmation of the diagnosis.

Non-Medicinal Therapeutic Options Non-medicinal approaches such as exercise, heat, behavioural

We do not get unlimited chances to have the things we want.

Nothing is worse than missing an opportunity that could have changed our life.

16

Adolescent Health Committee FOGSI

“Challenges for Youth Today & Tomorrow"

ADOLESCENCE

Natrampalli, Tamil Nadu Report By: Dr. Jayamkannan,Chairperson Adolescent Health Committee FOGSI

YUVA FOGSI West Zone.

The conference was a grand success with the theme based on the Adolescent girl child.

World Population Day 2013 Theme of 2013 - Adolescent Pregnancy World Population Day was celebrated focusing on the theme of 2013 “Adolescent Pregnancy” On 11th July 2013. Lectures & talks was focused on ASRH. Dr. Roza Olyai, Vice President FOGSI 2014 was invited as expert on a Doordarshan show episode based on Adolescence issues. She also was invited for a workshop to give a talk on unmet need of Adolescents & contraception organized by FPAI Gwalior branch.

Trichy, Tamil Nadu Report By: Dr. Jayamkannan,Chairperson Adolescent Health Committee FOGSI South Zone YUVA FOGSI was a unique programme of 4 days event in which day one was totally earmarked for Adolescent Health.

2013,being the 150th birth centenary year of Swami Vivekananda, the YUVA FOGSI programme was a combination of Healthcare for doctors in the morning, followed by a rally skating by students and others carrying banners of Vivekananda's quotes for teens in the afternoon.

Evening programme was graced by FIGO President Sir Prof Arul Kumaran, FOGSI President Dr. Hema Divakar and a religious celebrity Swamiji from Ramakrishna Ashram.

Further, in the month of June 2013 itself 150 colleges were requested to participate in the oratorical and essay competition on the following themes.

1. Service is vedantam 2. Vivekananda's vision on youth

17

3. Women in the vision of Vivekananda.

There was a huge response; the oratorical contest went through one full day.

Students who bagged the first 3 prizes were asked to present their views again during the CMEs. The program was also broadcast in Doordharshan DTH throughout India.

Same can be viewed in the following website • YUGA FOGSI- PUYAL VEESUM VAYASU! PART -1 • http://youtu.be/hnltH5eJA3s • YUGA FOGSI- PUYAL VEESUM VAYASU! PART - 2 • http://youtu.be/zvkWwxtrxXs

18