November 2018 Dil Se Dil Tak Newsletter (FOGSI)

1. 1
remain the key to reducing the effect of cancer and improving outcomes
across communities worldwide. In fact, researchers estimate that 50%
of cancer cases and deaths in the United States could be prevented if
people adopted simple healthy lifestyle choices that include avoiding
smoking and alcohol, maintaining a healthy weight and exercising
regularly.
Along with this if we focus on two important preventive vaccines,
one human papillomavirus (HPV) and second Hepatitis B, it will
take care of two major malignancies. FOGSI this year took up project
“AkshayaJeevan”forcancercervixscreeningandvaccinationandalsois
working towards developing a module towards breast cancer screening
with I-Breast along with Lions club and hope to sensitize populations
towards universal screening. So dear friends, let us start a drive against
rising trends in cancer and this has to be multi-pronged approach and
work towards reducing incidence of cancer in our country.
“It’s about focusing on the fight and not the fright.”
~Robin Roberts
This month we have a YUVA conference dedicated towards
Preventive Oncology and I hope many of our members will benefit
from its deliberations.
Looking forward to seeing you all soon.
Warm regards
Lots of Love
Om Shanti
Jaideep Malhotra
President’s Message
Dear FOGSIans
Greetings!
Here comes November and our issue
dedicated to preventive oncology
is on your table. There is no doubt
that cancer as a whole has overtaken
Non-communicable diseases as far as
mortality is concerned and today cervical cancer and breast cancer are
the most common cause of cancer deaths among women in India, but
we also do understand that early detection and proper treatment can
improve this prognosis and can make cancer curable.
A study conducted by EY and FICCI has reported that in India,
2,000 women are newly diagnosed with cancer every day. About 1,200
of these cases are detected in late stages, which reduces the 5-year
survival rate by 3 to 17 times for breast and cervical cancer. This late
detection also raises the cost of treatment by 1.5 to 2 times that for
early-stage cancers.
So the major thrust in cancer control has to be on early detection
and prevention. Mass screening for cancers is not possible, but unless
we do that, how are we going to pick up cancers early and save lives.
This requires great determination and political will, along with creating
awareness. Also what is important is to spread information regarding
the risk factors include smoking, excess body weight, physical
inactivity and changes in reproductive patterns, such as a later age at
first childbirth and fewer childbirths and improving our environment.
Cancer prevention efforts—including cancer screening,
vaccination, tobacco control, healthy eating and physical activity—
“PREVENTIVE ONCOLOGY”
Warm regards

2. 2
An ounce of preven-
tion is worth a pound
of cure
Preventive oncology is the study
for preventing cancer to develop,
rather counteract the advancement
in progression. In many respects, it
isapreventablediseaseandonehalf
arises from modifiable risk factors
or can be detected as precursor
lesions. Prevention can be primary, addressing the cause or
secondary which identifies the disease, before the onset of
symptoms and keeps it from becoming more extensive. Risk
assessment of an individual is the key, to identify modifiable
and nonmodifiable risk factors.
Breast self examination (BSE) is recommended because of
lowcostandbenefitsofmakingthepatientanactiveparticipant
in her health. Beginning in the early 20’s women must be taught
the importance of prompt reporting of any new symptoms
and their technique need to be monitored. Clinical breast
examination(CBE)hasgreatersensitivitywithmammography,
low grade, atypical squamous or glandular lesions. Primary
HPV test is avoided before 30 years because of high false
positive rates. The Pap smear is needed to follow a positive
HPV test. Age-based screening after total hysterectomy with
bilateral salpingo-oophorectomy (BSO) for cervical or uterine
cancer must be continued for 20 years at least. Endometrial
and ovarian cancer screening for general population is not
recommended. Risk of malignancy index (RMI) is calculated
based on menopausal status, CA-125 and transvaginal
ultrasonography (TVS) findings.
Selective estrogen receptor modulators (SERMs) are
available for primary prevention of breast cancer, but risks
and benefits need to be assessed. HPV vaccines are available
in three doses over 6 months. Adolescents need two doses.
Catch-up vaccination can be given. Because of lack of study,
it is not recommended in immune compromised. Pap smear
must be continued even after vaccination. In individuals with
high risk of cancer (hereditary and genetic predisposition)
prophylactic surgical interventions provides another means of
risk reduction. Hence, on a positive note there is more hope
today then ever before.
Not only “Yuvraj” but lesser mortals have fought the
dreaded disease and are still fighting its aftermath. The journey
has been very traumatic for the so called “Survivors”. If you are
a health professional, it is all the more gruesome, because you
know all about it. It is not easy for any one of us to sit on the
other side of the table, to wait in the queue with other patients,
to lie on the OT table again and again, to wait for the results
of various investigations and biopsies. Above all if at the end
of the treatment people discuss it with you saying it was not
proper, it could be different, thinking you being a doctor are
brave enough to digest everything. You are shattered.
It is human nature to surround and flock the powerful
and discard, disown the needy and down under. Loneliness,
disrespect and depression slowly ignites courage within you
to stand up and face fear. Fear of death. Fear of uncertainities.
Life starts moving, being soul conscious helps and so does
focusing on your karma, without regrets.
Now most of the time I forget that I had cancer. Memory is
a beautiful thing, but not always, sometimes so is a fading one.
Preventive Oncology
“Stealing cancer’s thunder”
Dr Ragini Singh
but has higher false positive rates than mammography alone.
Studies show, since 1990, mammography accounts for 41%
reduction in mortality rate in breast cancer. Film or digital
mammograms are used. Digital is more accurate in dense
breasts and in premenopausal women. Most experts agree that
screening mammography is essential in women of 50–69 years
and beyond 70 years who have a life expectancy of 10 years
or more. Some express concern regarding radiation risk, but
direct data associated with this level of exposure are lacking.
Breast ultrasonography and magnetic resonance imaging are
not used for routine screening in general population.
Human papillomavirus testing may be used along with
conventional smear or liquid-based cytology (LBC) for
cervical cancer screening. LBC is superior in picking up

3. 3

4. 4
Cancer and Fertility
Dr Keshav Malhotra
Cancer therapy has advanced
and with this it has increased
the number of long-term
cancer survivor worldwide.
It had been suggested that by
2010, 1 in 250 adult would be
a childhood cancer survivor.
In India alone the number of
patients who would develop
cancer in their lifetime is set to go up from 9.79 lacs
in 2010 to 11.4 lacs by 2020, out of these more than
140,000 would be diagnosed in their reproductive age.
Effect of cancer therapies on fertility
Chemotherapeutic agents produce a varied effect on
fertility and it involves different pathophysiological
pathways, which makes it difficult to predict the effect,
alsomakesitdifficulttounderstandandthuscounsel.We
have a basic understanding that the chemotherapeutic
agents target proliferating cells like bone marrow and
ovarian follicles etc. The reported rates of premature
ovarian failure in such patients differs considerably. It
is a known dilemma for oncologist that women are born
with their full complement of eggs which decreases with
timetilltheyachievemenopauseandbothchemotherapy
and radiotherapy accelerate that decline, if the eggs
survive they might lose their functional competence as
the DNA in such eggs might have been compromised
due to the therapy and though this response varied in
women, ovarian dysfunction post chemotherapy is quite
common specially when using alkylating agents. Cancer
survivors post chemotherapy can conceive naturally
as there have been reports in literature regarding the
same but we know that chemotherapeutic agents can
be mutagenic and teratogenic and thus conception in
such women should be delayed otherwise there is a
risk of congenital malformations specially if conception
happens within 3 months post treatment as suggested
by animal models. However in humans the live birth
rates in survivors are similar to their siblings, there has
been no reports of significant increase in malformations,
abortions, genetic defects when conception has taken
place long after finishing therapy. Risk has been pro-
posed to be maximum during oocyte maturation and
not when they’re dormant, therefore it is suggested that
a woman should wait about 6 months after finishing
treatment in order to conceive and even if preservation
isn’t done before treatment it should be done 6 months
post treatment and not in between, the safety guidelines
for this are yet to be established.
In men the chemotherapeutic agents have a
profound effect on the seminiferous tissues, which is
the crux of spermatogenesis but leydig cells tend to
tolerate chemotherapy better and thus, post treatment,
even though these men might be rendered as oligo-
asthenozoospermic they still produce testosterone.
There have been various studies which have stated
that gonads might be highly sensitive to irradiation

5. 5
and the damage induced by radiotherapy depends
on the field of exposure, the dosage and also the age
of the patient at time of exposure. The human egg is
highly susceptible to damage due to irradiation and
the LD 50 which is the lethal dosage to kill half of the
pool of oocytes has been shown to be <2 Gy (Wallace
et al., 2003). Wallace (2005) also studied the sterilizing
dosage which is when 97.5% of the oocytes are lost and
this varies with age which is shown in the chart. It is
not just the ovaries that are susceptible to damage, the
uterus also undergoes changes post irradiation, and
radiation can cause reduction in blood flow, fibrosis
and even endometrial insufficiency and atrophy. A
dosage of about 12 Gy can cause significant effects on
the uterus, there have been studies which have reported
an increase in miscarriage rate, intrauterine growth
restriction (IUGR), preterm deliveries and even low
weight at birth apart from an increase in the incidence
of infertility within a year of irradiation. A radiation
dosage of 25 Gy and above can cause permanent and
irreversible uterine damage in childhood cases.
In men a radiation dosage of 0.1-1.2 Gy could
result in detectable damage but a dosage of 4 Gy
causes permanent damage. As far as pediatric
oncology is concerned, post radiation testicular
dysfunction is one of the commonest issues specially
in common cancers like leukemia. Treatment for it
includes irradiation with doses going as high as 24 Gy
which can render the child as azoospermic. A total
body irradiation dose for bone marrow conditioning
before transplant is also 14.4 Gy and can cause
permanent damage but leydig cell function might get
spared. The various chemo and radiotherapy options
and their effect on fertility both male and female are
mentioned in the tables.

6. 6
What is the current
scenario of Ca Cx in
India?
It is the commonest cancer in
women in India.
India accounts for 25% of global
burden of cervical cancer
Ca cervix is the most common
cancer in India followed by breast cancer. According to a
data in 2012, the crude incidence rate of Ca cervix 26.2 per
100,000 women per year to 16.5 per 100,000 women for
breast cancer.
What causes cervical cancer?
There are multiple HPV genotypes, a subset of which infects
the anogenital tract and cause cervical cancer. One group is
responsible for most genital warts and are known as “low
risk”, contains closely related species HPV 6 and HPV 11.
There is another group of 30 oncogenic or “high risk”
HPV which causes cervical cancer. Of these, HPV 16 and
HPV 18 are responsible for 70% cases and along with HPV
31, 33 and 45 for more than 80% of cases.
What is the role of HPV in cervical cancer?
Human papillomavirus infects the transformation zone. In
the cervix, persistent infection causes dysplastic changes,
LSIL or HSIL on cytology and CIN 1 and CIN II and III
on histopathology. These lesions may take 2 to 5 years to
progress. Cervical cancer is a late consequence of ‘persistent
HPV infection’ and may take 10-20 years to develop. Almost
80-90% of genital HPV infections resolve with time and the
remaining 10-20% develop persistent infection.
What are the co factors responsible for persistent
infection?
Early age at first intercourse, multiple sexual partner,
multiple pregnancies, smoking, oral contraceptive use and
male partner not circumcised.
How does HPV get transmitted?
Oncogenic HPV can spread via close skin to skin and
sexual contact and does not necessarily require penetrative
sex. Thus condoms cannot prevent HPV infection, unlike
other STDs.
Non sexual routes
Vertical transmission (mother to baby), fomites (surgical
gloves, undergarments, surgical instruments). These are
hypothesized but not well documented.
Update on Primary Prevention of Cancer Cervix
Dr Vaidehi Marathe
What are the important serotypes responsible for
cancer?
Human papillomavirus 16 and 18 are responsible for 70%
of squamous cell carcinoma and high grade invasive cancer
worldwide. Six other most common high risk serotypes are
31, 33, 35, 45, 52 and 58.
These eight serotypes together account for 90% of
cervical cancers.
If cervical cancer a disease of middle-age, why
catch them young?
The lag period of infection and cancer is 15-20 years. Since
the protection is seen only when the vaccine is given before
infection, the vaccine should be given prior to beginning of
sexual activity.
Why natural infection doesn’t give immunity?
How does the vaccine provide protection?
Natural HPV infection induces weak immune response.
So, the antibody response is quite poor after natural
infection.However, HPV vaccine is immunologically a
potent antigen hence immune response is robust, thereby
providing protection.
Which vaccines are currently available?
Bivalent, quadrivalent and 9-valent vaccines are available
and approved for girls aged 9–26 years. The 9-valent vaccine
which covers five additional serotypes will soon replace the
quadrivalent vaccine in India.
What is the recommended dose schedule?
The Advisory Committee on Immunization Practices
(ACIP) recommends.
Quadrivalent vaccine (16, 18, 6, 11)
The administration schedule consists of a dose of 0.5 mL
at 0, 2 and 6 months, administered intramuscularly in the
deltoid muscle.
The 2-dose schedule recommendations—Advised for
girls aged 9-14 years at ‘0 and 6-12 months’; for girls 15
years and older, current 3-dose schedule will continue. The
interval between the first and second dose may be extended
up to12 months.
However, for immunocompromised individuals,
including HIV-infected, the 3-dose schedule is
recommended, irrespective of age.
Bivalent vaccine (16, 18)
The 2-dose schedule remains the same for girls between
9–14 years.
Girls 15 years and above—3-dose schedule of 0, 1 and
6 months.

7. 7
The vaccine is currently licensed for use between 9 years
and 26 years of age, however bivalent vaccine can be given
up to 45 years of age.
What are the adverse effects of the vaccine?
• Minor: Local area pain, swelling and erythema, fever on
the day of vaccination
• Major: Anaphylaxis in subjects sensitive to yeast—S.
cerevisiae, bronchospasm, gastroenteritis, and vaginal
bleeding have been reported in isolated patients, their
association with the vaccine is unclear. No vaccine-
related deaths have been reported.
Is there anyone who should not get HPV vaccine?
Some people should not get HPV vaccine or should wait:
• Anyone who has ever had a life-threatening allergic
reaction to any component of HPV vaccine, or to a
previous dose of HPV vaccine, with severe allergies,
including an allergy to yeast
• HPV vaccine is not recommended for pregnant women.
Can be given during breastfeeding
• People with a moderate or severe illness should wait
until they are better.
Are HPV vaccines safe?
Yes. The HPV vaccine was well studied in clinical trials and
the vaccine safety monitoring studies showed that it was
safe and effective.
Do HPV vaccines cause serious side effects?
Serious side effects to all vaccines, including HPV vaccines,
are extremely rare.
The benefits of getting the HPV vaccine greatly outweigh
the very small risks.
Do women still need Pap tests if they get the HPV
vaccine?
Yes. Sexually active women of all ages will still need to get
Pap tests after they’ve been vaccinated. This is important
because HPV vaccines protects against most but not all
cancers of the cervix.
Should women get the HPV vaccine if they are
already sexually active?
A person should still get the vaccine even if they are already
sexually active as they are unlikely to have been exposed to
all of the types of HPV contained in the vaccine.
Can HPV vaccines cause premature menopause
in young women, leading to infertility?
There is no current evidence that HPV vaccines cause
reproductive problems in women.
Have HPV vaccines been linked to Guillain-Barré
syndrome?
The studies provide evidence that the risk of getting
Guillain-Barré syndrome following HPV vaccination is
extremely rare.
Can HPV vaccines cause postural orthostatic
tachycardia syndrome (POTS)?
Ongoing safety monitoring through VAERS (the Vaccine
Adverse Event Reporting System) has not detected any
safetyconcernsrelatedtoPOTSfollowingHPVvaccination.
Do HPV vaccines cause chronic regional pain
syndrome (CRPS)?
The VAERS review concluded that CRPS following HPV
vaccination is rare.
DoHPVvaccinescausechronicfatiguesyndrome?
Centers for Disease Control and Prevention (CDC) is
aware of reports of chronic fatigue syndrome following
HPV vaccines and continues to monitor for any unusual or
unexpected patterns among reported cases.
Has anyone died after receiving HPV vaccines?
After careful review of every reported case of death that
has happened after HPV vaccination, CDC concluded , the
evidence did not suggest a causal link.
Finally, what are the recommendations for males?
Human papillomavirus is responsible for genital warts and
penile/anal cancers in males. Males can transmit HPV to
their sexual partners. Therefore, 3-dose schedule from 9–26
years of age is recommended (CDC guidelines)
References
1. ACIP- advisory committee on Immunization Practices, US.
2. CDC guidelines.
3. ACVIP - advisory committee on vaccines and Immunization
practices, India (IAP).
4. ACOG commitee opinion Number 704, june 2017.
5. IAP guidebook on vaccines and Immunization practices.
Humour of The Month

8. 8
Malaria infection in pregnant
women is associated with high risks
of both maternal and perinatal
morbidity and mortality. Malaria
infection during pregnancy can
lead to maternal anemia and
adverse pregnancy outcomes like
spontaneous abortion, premature
delivery, growth restriction/low
birth weight, stillbirth, congenital
infection and neonatal mortality.
Pregnant women are three times more likely to develop
severe disease than nonpregnant women from the same
geographical area. The mechanism behind this is poorly
understood, one of the reasons being that pregnant women
have a reduced immune response and therefore less effectively
clear malaria infections. In addition, malaria parasites
sequester and replicate in the placenta. This also disrupts
nutritional exchange between mother and fetus and can lead
to intrauterine growth retardation.
In early stages of the disease, it can present similar to
any viral or flu-like illness. There are no specific symptoms
and signs; if there is any suspicion of malaria, it should be
confirmed by a blood film.
Microscopy and rapid diagnostic tests are the standard
tools available. Rapid detection tests may miss low parasi-
temia, which is more likely in pregnant women and rapid
detections tests are relatively insensitive in P. vivax malaria.
Microscopic diagnosis allows species identification and
estimation of parasitemia, so that appropriate antimalarials
can be prescribed.
Women with malaria in pregnancy should have the
severity of their condition assessed and documented as an aid
to management. Severe/complicated malaria can present with
impaired consciousness, respiratory distress, convulsions,
circulatory collapse, abnormal bleeding or jaundice. The
clinical condition is the most important indicator of severity
and should be assessed promptly.
The severity of malaria determines the treatment and
predicts the case fatality rate. In uncomplicated malaria,
fatality rates are low–approximately 0.1% for P. falciparum.
In severe malaria, particularly in pregnancy, fatality rates are
high (15–20% in nonpregnant women compared with 50% in
pregnancy).
For pregnant women diagnosed with uncomplicated
malaria caused by P. malariae, P. vivax, P. ovale, or chloroquine-
sensitive P. falciparum infection, prompt treatment with
chloroquine (treatment schedule as with nonpregnant adult
patients) is recommended. Alternatively, hydroxychloroquine,
may be given instead.
For women in their second or third trimesters, artemether/
lumefantrine is an additional option.
For pregnant women diagnosed with uncomplicated
malaria caused by chloroquine-resistant P. falciparum
infection, women in the second and third trimesters can be
Malaria in Pregnancy
Dr Gunjan Bhola
treated with artemether/lumefantrine, and for all trimesters,
mefloquine or a combination of quinine sulfate and
clindamycin is recommended.
Quinine treatment should continue for 7 days for infections
acquired in Southeast Asia and for 3 days for infections
acquired elsewhere; clindamycin treatment should continue
for 7 days regardless of where the infection was acquired.
For pregnant women diagnosed with uncomplicated malaria
caused by chloroquine-resistant P. vivax infection, prompt
treatment with artemether/lumefantrine (second and third
trimesters) or mefloquine (all trimesters) is recommended.
Doxycycline and tetracycline are generally not indicated
for use in pregnant women.
Pregnant women with complicated/severe malaria should
be started with artesunate IV 2.4 mg/kg at 0, 12 and 24 hours,
then daily thereafter. When the patient is well enough to
take oral medication she can be switched to oral artesunate
2 mg/kg (or IM artesunate 2.4 mg/kg) once daily, plus
clindamycin. If oral artesunate is not available, use a 3-day
course of atovaquone-proguanil or a 7-day course of quinine
and clindamycin at 450 mg three times a day 7 days.
Vertical transmission to the fetus can occur when there is
infection at the time of birth and the placenta and the cord
are blood film malaria positive. All neonates whose mother
developed malaria in pregnancy should be screened for
malaria with standard microscopy of thick and thin blood
films at birth and weekly thereafter for 28 days.

9. 9
Few Important Links to Read
• https://www.memorialcare.org/events-education/live-healthy/
gynecologic-cancers-signs-symptoms
• http://www.uchospitals.edu/specialties/cancer/gynecologic/
prevention/index.html
• https://www.cdc.gov/cancer/gynecologic/basic_info/prevention.htm
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891179/
• http://www.nccc-online.org/hpvcervical-cancer/gynecological-
cancers/
• https://www.foundationforwomenscancer.org/about-gynecologic-
cancers/
• https://journals.lww.com/ijgc/pages/default.aspx
• https://cancer.coloradowomenshealth.com/cancer-symptoms/index.
html
• https://igcs.org/gynecologic-oncology-
news-updates/
• https://www.ncbi.nlm.nih.gov/
pubmed/29468855
• https://www.esmo.org/Guidelines/
Gynaecological-Cancers
• https://www.webmd.com/children/
vaccines/hpv-vaccine-what-you-need-
know#1
• https://www.cdc.gov/hpv/parents/
vaccine.html
• https://en.wikipedia.org/wiki/HPV_
vaccine
Professor Dr S Sampathkumari
“Cancer Changes us, there’s no doubt about that. But it’s up to us to decide what that change
will mean in our lives, and who we will become as a result”
Britta Aragon
President of India endorses FOGSI’s initiative of H.E.R. (Health; Empowerment & Respect)
Special Appreciation to Dr Meera Agnihotri for
organizing WWWCON

10. 10

11. 11
Aries: Good month for this sun sign, good phase to
continue. Some celebrations in the family indicated.
You will enjoy good health and mental peace.
Taurus: Gear up for hard work, you will face stiff
competition this month, work related issues might
stress you out and your health might be a cause for
concern.
Gemini: Try not to take major decisions this month,
take advise from your elders, be careful while driving.
If wanting to start a family this is the right time. Fruitful
for women wanting to get pregnant.
Cancer: Very good month for Cancerians, time
for fulfilment of desires. Promotion on the cards, if
planning to buy a new car this is the best time, you
might be going on a holiday. All good things coming
your way.
Leo: Money will go as soon as it comes, so try to be
cautious with your expenses. You are likely to benefit in
work and get accolades. Travel on the cards.
Virgo: Work will keep you on your toes, travel and lots
happening around, try to stay focussed look after your
health and try to relax.
Libra: Travel on the cards, work is likely to be
demanding. Good month, fun with family and friends.
Try not to overdo things and look after your health.
Scorpio: New relationships will be formed, work will
be exciting and rewarding. Friends and colleagues will
be supportive. Try to keep an eye on the expenses.
Stressful and exciting month.
Sagittarius: Time to reap the fruits of your hard work,
this month will be rewarding. Increase in income,
promotion, financial gains indicated. Good family life,
a happy and satisfying month.
Capricorn: Try not to hold on to the past, move ahead,
forgive and forget. A month for self-cleansing and
realisation. Try to relax yourself.
Aquarius: Changes in your attitude and thoughts for
the better, a good month. You will get lots of attention
from friends and colleagues. Good health is indicated.
Pisces: Travel on the cards. Work will be demanding.
You might be confused and stressed out this month, do
not make impulsive decisions. Think carefully before
you speak.
Rest is in the hands of God, have a blessed November.
—Deepa Kochhar (Noida)
kochhar.deepa@gmail.com
Tarot for November 2018
Dear FOGSIans,
October has been a great
travelling month for many of
us and we are all back now
refresh and recharged.
November is our month of
festivities and I wish all of you
a very Happy Diwali.
“May every Lamp which is lit
bring in Happiness”
This month our focus is
on preventive oncology
and we hope to see you all
in our last Yuva of year at
Gangtok.
“Our Support to all Cancer Fighters
Our Admiration to all Cancer Survivors
Our Honor to all Cancer Lost.”
Let us all help our women understand preventive
oncology and screen them regularly.
We also must focus on working in improving the
environment as endocrine disruptors are a huge
underlying cause.
“Nothing ever goes away until it teaches us what we
need to know”
Dr Neharika Malhotra Bora
Joint Secretary
FOGSI
Dr Neharika Malhotra Bora
Disclaimer: This is private Newsletter Published by Jaypee Brothers Medical Publishers for circulation among FOGSI Members

13. 22, 23 & 24 November 2018
Organized by Gangtok Obstetrics & Gynaecological Society, Sikkim
Venue: Sikkim Manipal Institute of Medical Sciences (SMIMS) Gangtok, Sikkim, India
22, 23 & 24 November 2018
Venue: Sikkim Manipal Institute of Medical Sciences (SMIMS) Gangtok, Sikkim, India
22nd November Pre congress workshop
•Gynecological endoscopy
•Imaging/Ultrasound
•Preventive Oncology/Colposcopy
23-24 November -Congress
•Dr Kamini Rao YUVA oration
•Senior Orations
•Keynote addresses & Symposiums
•Oral and poster presentations (award)
•Intercollege postgraduate Quiz (award)
23-24 November –Congress highlights
•Gynecologic malignancies : Indian Scenario
•Guide lines in Gynecologic malignancies
•Imaging in diagnosis and management of
Gynecologic malignancies
•Gynecologic malignancies in Young women
•Fertility sparing management in
Gynecological malignancies
•Updates on rare Gynecological malignancies
•Immunotherapy in Gynecologic oncology
Important dates
Abstract submission last date-31st Oct 2018
Author notification by -31st Octo 2018
Author registration deadline-1st Nov 2018
Regular registration by-1st November 2018
Online registration closes 15h Nov 2018
Getting to Gangtok
•By Air-Nearest airport Pakyong
(20KM) / Bagdogra (120KM)
•By Train-Nearest station NJP
•By road-Bagdogra/ NJP/ Siliguri well
connected by NH31 A to Gangtok and
about 3 hour drive by taxi/bus.
Category Regular up to 31st October 2018 1 November 2018 onward
Delegate/Faculty (INR) 6000 7000
*P.G Students (INR) 4000 5000
Accompanying Person (INR) 3500 4000
Banquet (INR) 2000 2500
Workshops (INR) 1500 2000
Registration Details [For detailed information or online registration log on to www.gangtokogs.in or mail at ezyf2018@gmail.com
•Payment by cheque or DD to be issued in favour of “East Zone Yuva FOGSI 2018” payable at Gangtok.
•For NEFT or online transfer A/C name-East Zone Yuva FOGSI 2018, A/C no-8676101009259, Canara Bank, Tadong branch, IFSC
code-CNRB0008676, MICR code-737015003. Please send scanned copy of payment slip and registration form by e-mail or post.
*PG students need certificate from HOD. Registration form/Cheque/DD or all communication should be addressed to: Dr Hafizur
Rahman, Organizing Secretary-East Zone Yuva FOGSI 2018, Professor of Obstetrics and Gynaecology,Sikkim Manipal
Institute of Medical Sciences,5th Mile, Tadong, Gangtok-737102,Sikkim, India.(M)+919733400336.Email: ezyf2018@gmail.com
For detailed information and registration form log on to Gangtok OBGYN Society website at www.gangtokogs.in or conference website
Institute of Medical Sciences,5th Mile, Tadong,
Dr R.N Deokota
Organizing Chairman
Dr GS Joneja
Organizing Co-Chairman
For detailed information and registration form log on to Gangtok OBGYN Society website at www.gangtokogs.in or conference we
India.(M)+919733400336.Email: ezyf2018@gmail.com
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Places to visit
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Gangtok
: Sikkim Manipal Institute of Medical Sciences (SMIMS)
•Imaging in diagnosis and management of
Gynecologic malignancies
•Gynecologic malignancies in Young women
•Fertility sparing management in
Gynecological malignancies
•Updates on rare Gynecological malignancies
•Immunotherapy in Gynecologic oncology
•Theme- Gynecologic Oncology
Dr Hafizur Rahman
Organizing Secretary
Dr Rajat Kr Ray
Organizing Chairman
Dr Jaideep Malhotra
FOGSI President 2018

14. NON HORMONAL THERAPY FOR MANAGEMENT
OF PREMENSTRUAL SYNDROME (PMS)
Dr.A.A.Faruqui, Clinical pharmacologist, Bandra (W), Mumbai-400050
INTRODUCTION
Today, research on women’s health has greatly improved.
Premenstrual syndrome (PMS) is a common health problem in
women in reproductive age and defined as a collection of emotional
symptoms, with or without physical symptoms, related to a woman’s
menstruation cycle. PMS occurs during the luteal phase of menses,
however, it disappears with menstrual flow.1
PMS can be clinically recognized as chronic disorder that impairs
relationships, work productivity, and social activities.2
Pre-Menstrual Syndrome (PMS) & Pre-Menstrual Dysphoric
Disorder (PMDD)
A) Pre-Menstrual Syndrome (PMS)
PMS is a psycho-neuroendocrine disorder of unknown etiology, often
noticed just prior to menstruation. There is cyclic appearance of large
number of symptoms during the last 7-10 days of the menstrual cycle.3
Pathophysiology: The exact cause is not known but following
hypothesis is postulated:3
a) Alteration in the level of estrogen and progesterone starting from
the midluteal phase. Either there is altered estrogen: progesterone
ratio or diminished progesterone level.3
b) Neuroendocrine factors:3
• Serotonin is an important neurotransmitter in the CNS. During the
luteal phase, decreased synthesis of serotonin is observed in
women suffering from PMS.
• Endorphins: The symptom complex of PMS is thought to
be due to the withdrawal of endorphins (neurotransmitters) from
CNS.
• GABA suppresses the anxiety level in the brain. Medications that are
GABA agonist are effective.
c) Psychological and psychosocial factors may be involved to produce
behavioral changes.3
d) Others: Thryotrophin releasing hormone (TRH) prolactin, renin,
aldosterone & prostaglandins.3
Clinical features: The prevalence of PMS has been reported in 20 to
32 % of premenopausal and 30-40% of the reproductive female
population.1
The symptoms of PMS are depicted below
Symptoms of Pre-menstrual syndrome
B) Premenstrual dysphoric disorder (PMDD)3
It is a severe form of PMS that includes physical and behavioral
symptoms that usually resolve with the onset of menstruation.
PMDD causes extreme mood shifts that can disrupt work and damage
relationships. Symptoms include extreme sadness, hopelessness,
irritability or anger, plus common PMS symptoms such as breast
tenderness and bloating. Difference between PMS and PMDD is
tabulated below
Incidence of PMS in India
Cyclic symptoms in women of reproductive age has been recognized
for thousands of years. Premenstrual syndrome (PMS) is one of the
most common disorders of women of reproductive age. The incidence
of PMS peaks among women age 30 to 40, but studies have shown
that adolescents frequently suffer from PMS as well.4
85% of women in their reproductive age suffer from PMS.4
In a population based study 91% of the participants reported at least
one symptom, 10.3% had PMS and 3.1% fulfilled the criteria for
premenstrual dysphoric disorder (PMDD). Both PMS and PMDD
were strongly associated with poor physical health and psychological
distress.
The most commonly reported symptom is “fatigue/lack of energy”
(68.3%), followed by “decrease interest in work” (60.1%) and
“anger/irritability” (59.9%).2
In a cross sectional survey conducted by Raval et al in 5 colleges of
Bhavnagar (Gujarat), it was found that the prevalence of PMS was
18.4%. Moderate to severe PMS was 14.7% and PMDD was 3.7%.
The symptoms commonly reported were “fatigue/lack of energy,”
“decrease interest in work,” and “anger/irritability.” The most
common functional impairment item was “school/work efficiency and
productivity.”5
Available therapy in management of AUB
If symptoms are so intense that interfere with the routine life, drugs
may be recommended that include-
(a) Hormonal contraceptives: These are the drugs that prevent
ovulation and may be effective in relieving physical symptoms.2
• Disadvantages: Possibility of unwanted ‘premenstrual symptoms’
including: bloating, oedema, headache, depression and reduced
libido;
PMS
Symptoms
Anger
Anxiety
Bloating
Brain fog
Craving for
sweet
and/or
salty food
Fatigued
Depressed
Tired
Lethargy
Irritable
Tense
Mood
swings
Joint pain
Muscle
pain
Nausea
Decreased
libido
Headaches
Indecission
Insomnia
Weight gain
Swollen
hands/feet
PMS
Mild to severe physical and/or
emotional symptoms that typically
occur about 5-11 days before a
woman starts her monthly
menstrual cycle, and these
symptoms stop shortly after
menstruation begins.
Less severe
Treatments include lifestyle
modifications and medical therapy
PMDD
Acondition in which a woman has
severe depression symptoms not
otherwise specified and emotion and
cognitive behavioral symptoms before
menstruation
PMDD is a severe form of PMS
Treatments include lifestyle
modifications, medical therapy, stress
management, anger control and
relaxation techniques

15. • Androgenic effects, such as acne and hirsutism;
• Irregular breakthrough bleeding and a change in carbohydrate
tolerance and lipid balance.
(b) Antidepressants- These drugs can help lessen mood symptoms.2
(c) Anti-anxiety drugs- If anxiety is a major PMS symptom, these
drugs may be used.2
• Disadvantages: Common side effects of SSRIs include insomnia,
drowsiness, fatigue, nausea, nervousness, headache, mild tremor,
and sexual dysfunction.
• Treatment using anxiolytic agents is not recommended because of
addictive potential, tolerance.6
(d) Non-steroidal anti-inflammatory drugs (NSAIDs) can help
reduce pain. Long term use of NSAIDs is not recommended.2
Disadvantages: Bloating, GI disturbances, nausea, vomiting,
headaches
(e) Diuretics are drugs that help the body to lose excess water through
the kidneys. These medicines have been used to reduce weight
gain, breast swelling, and bloating associated with PMS.2
Disadvantages: Nausea and headache, body might retain more water
than it did before using them.
Alternative therapy in management of PMS
Premenstrual syndrome (PMS) is one of the most frequent complaints
noted in gynecology practices.7
Pre-menstrual syndrome (PMS) is a complex of symptoms
characterised not only by psychological changes including irritability,
aggression, tension, anxiety, and depression but also by somatic
changes attributed to fluid retention such as feeling bloated, weight
increase, oedema, breast tenderness, and headache before menses.7
The extract of Vitex agnus castus L. fruits is used traditionally to
relieve the complaints related to PMS.7
How vitex agnus castus works?
Vitex agnus castus
1. Normalizes shortened luteal phases
2. Corrects luteal phase progesterone deficiencies
3. Reduces PMS symptoms in women with luteal phase defects
caused by latent hyperprolactinemia
Thus VAC shows a beneficial effect in reducing symptoms of PMS.
Clinical evidences of use of vitex agnus castus (VAC) in PMS
Study 1: In a 3 month study conducted in 1634 patients, 857
gynecologists presented their data suggesting the use of vitex agnus
castus in treating PMS. It was seen that, after a treatment period of
three menstrual cycles 93% of patients reported a decrease in the
number of symptoms or even cessation of PMS complaints. 85% of
physicians rated it as good or very good and 94% of patients assessed
the tolerance of Vitex treatment as good or very good.8
Study 2:Aprospective observational study was conducted to evaluate
the efficacy of vitex agnus castus in 50 women suffering from PMS.
Duration of study was of 8menstrual cycles (2 baseline, 3 treatment
and 3 post-treatment). Global efficacy was considered excellent by
76% patients. Incidence of adverse events was low and the severity
was mild. The VAS score during the luteal phase was reduced
progressively by treatment over the 3-cycle treatment period (47.2%;
p < 0.001) and at the end of the post-treatment observation period the
score was still 21.7% below baseline values (p < 0.001).7
Study 3: A comparative double blind study was conducted in 175
patients with PMS complaints to evaluate the efficacy of VAC against
pyridoxine. For 3 months, patients were randomised either to VAC
(3.5-4.2 mg dried extract corresponding to 40 mg drug; once a day) or
Pyridoxine (100 mg twice daily). Overall, 77.1% and 60.6 % of
patients showed an improvement in the VAC and pyridoxine groups,
respectively. VAC treatment extended the luteal phase from 5.4 to 11.4
days, thus leading to a biphasic cycle (p =0.05).9
Changes in premenstrual tension syndrome scale (PMTS) total
score- mean values9
Study 4: In a double blind study conducted in 41 patients with
premenstrual dysphoric disorder (PMDD), VAC was compared
against Fluoxetine. Rate of responders to Vitex agnus (57.9%) and
Fluoxetine (68.4%). Patients with PMDD respond well to treatment
with both Vitex agnus and fluoxetine. However, Vitex agnus
diminished the physical symptoms and Fluoxetine was more effective
for psychological symptoms.10
Study 5: In another multi-center, prospective, open-label, single-arm,
phase 3 study conducted in 69 Japanese women with PMS and aged
18-44 years, it was seen that, after the first menstrual cycle, a
statistically significant decrease in total VAS score was observed
(P<0.001). VAS score continued to diminish for the following two
cycles. Rate at the third menstrual cycle was 91.0% and almost all of
the patients were without symptoms.11
Safety Studies of VAC
Metanalysis including 33 studies advocates that:
• In a 3 month randomized study conducted by Turner and Mills in 217
participants, no adverse events were reported.
• Non-randomised study conducted by Bautze in 200 participants, no
adverse events were reported
• In a study conducted for 3 months by Mohr et al on 817 participants,
15 patients (1.83%) reported itching/exanthema, some women
reported earlier menstrual period.12
0
2
4
6
8
10
12
14
16
Vitex agnus castus Pyridoxine
Trial entry
Last visit values
Absolute changes
15.2
11.9
6.8
5.1
10.1
5.1
Vitex agnus castus
Stimulates Dopamine
release1
Decrease prolactin
Stimulate corpus luteum
development
Normalizes progesterone
deficiency in luteal phase
Correction of estrogen/progesterone
Up regulates Progesterone
receptor expression2,3
Modulates anterior
pituitary hormone1
1) Increase LH
2) Mildly sippresses FSH
Enhances binding of
Progesterone
Normalization of menstrual cycle

16. DISCUSSION
VAC fruit extract has been used in the treatment of many female
conditions, including menstrual disorders, premenstrual syndrome
(PMS), corpus luteum insufficiency, hyperprolactinaemia, infertility,
acne, menopause and disrupted lactation.13
When compared with analgesics, hormones, or SSRi (selective
serotonin reuptake inhibitors), which help only in symptom
alleviation, VAC is an effective treatment for relieving not only the
physical but also the mental symptoms of PMS treatment.
Data from clinical trials, post-marketing surveillance studies, surveys,
spontaneous reporting schemes, manufacturers and herbalist
organisations indicate that the adverse events following VAC
treatment are mild and reversible.12
A positive risk/benefit ratio exists for VAC in the treatment of PMS.
Trials have proved Vitex to be effective with respect to all psychic and
somatic symptoms of the heterogeneous and multifaceted PMS.8
It Fulfills the European Medicine Agency’s (EMA) requirements for
well-established use in the treatment of the premenstrual syndrome
with a response rate of 93%.
CONCLUSION
Vitex agnus castus is an effective treatment for women with
premenstrual syndrome. Although the condition tends to be mild to
moderate, the effects on women can be debilitating. Patient
acceptance is crucial in the treatment of this condition. Researchers
have shown that though the effects of treatment gradually decrease
over time, they are still felt for as long as three cycles after treatment.
Although many modern medicine drugs are available, VAC is an
addition to the existing armamentarium with an excellent safety
profile which can alleviate both physical & mental symptoms of PMS.
REFERENCES
1. Moghadam A.D, Sayehmiri K, Delpisheh A, and Kaikhavand S. Epidemiology of
Premenstrual Syndrome (PMS)-A Systematic Review and Meta-Analysis Study. J Clin
Diagn Res. 2014 Feb; 8(2): 106–109.
2. NHP India (National health portal); “Premenstrual syndrome”’, updated on Oct
2016,https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/premenstrual-syndro
me
3. Howkins & Bourne Shaw’s. Disorders of Menstruation. Textbook of gynecology, 13th
edition, 2004; page number: 277-290
4. Joseph L. Mayo. A Natural Approach to Management. Applied Nutritional Science
Reports. Volume 5, (6)1999:1-8
5. Raval C.M, Panchal B.N, Tiwari D.S,Ashok Ukabhai Vala, and Bhatt R.B. Prevalence
of premenstrual syndrome and premenstrual dysphoric disorder among college students
of Bhavnagar, Gujarat. Indian J Psychiatry. 2016 Apr-Jun; 58(2): 164–170.
6. Lori M. Dickerson, Pamela J. Mazyck and Melissa H. Hunter. Premenstrual
Syndrome. Am Fam Physician. 2003 Apr 15; 67(8):1743-1752.
7. Berger D, Schaffner W, Schrader E, Meier B, Brattström A. Efficacy of Vitex agnus
castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Arch Gynecol
Obstet 2000, 264: 150-153
8. EG Loch, H Selle, N Boblitz. Treatment of premenstrual syndrome with a
phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend
Based Med. 2000 Apr; 9(3): 315–320.
9. Lauritzen C, Reuter HD, Repges R, Böhnert KJ, Schmidt U. Treatment of
premenstrual tension syndrome with Vitex agnus castus. Controlled, double-blind study
versus pyridoxine. Phytomedicine 1997, 4(3): 183-189
10. Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the
treatment of premenstrual dysphoric disorder. Hum Psychopharmacol. 2003 Apr;
18(3):191-5.
11. Momoeda M, Sasaki H, Tagashira E, Ogishima M, Takano Y, Ochiai K. Efficacy and
safety of Vitex agnus-castus extract for treatment of premenstrual syndrome in Japanese
patients: a prospective, open-label study. Adv Ther. 2014 Mar; 31(3):362-73.
12. Daniele C, Thompson J.C., Pittler M.H. and Ernst E. Vitex agnus castusASystematic
Review of Adverse Events. Drug Safety 2005; 28 (4): 319-332.
13. Committee on herbal medicinal products (HMPC). EMEA. Draft assessment report
on Vitex agnus-castus L., Fructus. September 2009
Rx
Menorrhagia, Oligomenorrhoea, Polymenorrhoea, Pre Menstrual Syndrome,
Dysmenorrhoea, Hyperprolactinemia and Mastalgia
In