Website: www.bogs.org.in | Email: bogs1936@gmail.com Volume 3 | Issue 4

Page 2BOGS Activities

Page 6 & 7Face to Face with a Stalwart

Page 3From Team BOGS

Page 11Snippets

TimesTHE BENGAL OBSTETRIC AND GYNAECOLOGICAL SOCIETY

May 2012

Page 8 & 9Controversy

EDITORIAL

Hello friends,

We are yet to recover from the embracing memories of the

BOGSCON and the East Zone YUVA FOGSI is knocking at the door.

With that the BOGS times resurfaces with its basket of scientific

tribute and glimpses of the recent events.

Estrogen or no estrogen after menopause? the debate continues

and we have an informative juggling of ideas for and against the

issue crossing the minds of two eminent gynaecologists.

The presence of a stalwart has always glorified every issue of the

BOGS times and this time it is Prof Biman Chakraborty who

unravels the story of his sojourn in the realms of Gynaecology &

Obstetrics.

An interesting case study stimulates our brains and a bunch of

snippets are there as usual accumulating news from all nooks and

corners of the world of Obstetrics & Gynaecology.

Hope you enjoy leafing through this issue while basking in the

warmth of the East Zone YUVAFOGSI 2012.

Thank you

Long live BOGS

Jai Hind

Bulletin & Website Committee

EXECUTIVE COMMITTEE 2011-2012

BULLETIN & WEBSITE COMMITTEEAdvisors :

Chairperson :Convenors :

VP-in-charge :

Dr. Sudip ChakrabortyDr. Kalidas BakshiDr Bhaskar PalDr. Sebanti GoswamiDr. Susmita ChattopadhyayDr. Arup Kumar Majhi

President:

President Elect:

Vice-Presidents:

Hony. Secretary:

Hony. Joint Secretary:

Hony. Treasurer:

Hony. Clinical Secretary:

Dr. Pradip Kumar Mitra

Dr. Kalidas Bakshi

Dr. Sukanta MisraDr. Arup Kumar MajhiDr. Krishnendu Gupta

Dr. Subhash Chandra Biswas

Dr. Abinash Chandra Roy

Dr. Sudhir Adhikari

Dr. Dibyendu Banerjee

Dr. Sukumar BarikDr. Suranjan ChakrabortyDr. Pronab Dasgupta

Dr. Kusagradhi Ghosh

Special Invitees:

Immediate Past President:

Members:

Moffusil EC Members

Junior E.C. Members

Dr.Alok BasuDr. Saktirupa ChakrabortyDr. Jayita ChakrabartiDr. Mousumi De (Banerjee)Dr. Basab MukherjeeDr.Ashis Kumar MukhopadhyayDr. Bhaskar PalDr. Nirmala PiparaDr. Bulbul RaichaudhuriDr. Bibek Mohan RakshitDr. Joydeb RoychowdhuryDr. M.M. SamsuzzohaDr. Subrata Lal SealDr. Shyamal Sett

Dr. Ram Prasad DeyDr. Rabindra Nath Ray

Dr. Bhaskar PaulDr. Shiuli MukherjeeDr. Tridib Ranjan Khata

Platinum Jubilee Year

BOGS

BOGSTimes2

CME on “Medical Disorders inPregnancy”: CME on “Medical Disorders inPregnancy” was organized by MedicalDisorders in Pregnancy Committee ofBOGS on Saturday, March 10, 2012 at“Pratishruti”. More than 70 delegatesattended the programme. Speakersincluded Prof. Salil Pal (Dept of Medicine,Midnapur Medical College), Dr. DebasisBasu, Professor & Head, Dept. ofNeurology, Calcutta Medical College, Dr.L.N. Biswas, Consultant Oncologist,Radiotherapy Dept, Apollo GleneaglesHospital. Dr. Ranjan Kumar Sharma,Professor, Dept. of Cardiology, NRSMedical College and Dr. Dipankar Sarkar,Consultant Internist and Intensivist, ICU inCharge, Columbia Asia Hospital. Eminentfaculty from our society enriched theproceedings of this enlightening meeting.

CME on “Infertility”: CME on “Infertility”was organized by Infertility &Reproductive Endocrinology Committee,BOGS on Saturday, March 31, 2012 at“Pratishruti”. More than 70 delegatesattended the programme. Speakersincluded Prof. B.N. Chakraborty, Dr.Pramathes Das Mahapatra, and Dr.Siddhartha Chattopadhyay. The followingtopics were discussed - Endometrialreceptivity, Luteal phase defect,Seminopathy update, tips & tricks ofOvulation Induction, role of Endoscopy indiagnosis & treatment of Infertility.Infertility Management: present & future.

44th Dr. Subodh Mitra MemorialOration& Clinical Meeting: 44th Dr.Subodh Mitra Memorial Oration was heldon Saturday, February 11, 2012 atIPGME&R & SSKM Hospital, Kolkata. Theoration was delivered by Dr. Sujit Basu,M.D., Ph.D., Associate Professor, CancerCenter, Ohio State University, USA on“NEUROTRANSMITTER DOPAMINE MEDIATEDREGULATION OF ANGIOGENESIS: FROMBENCH TO THE CLINICS”. About 87delegates attended the oration. Theoration was followed by a clinical meetingwhere Dr. Sushma B of IPGME & R, Kolkatapresented “Term Pregnancy withColostomy in a case of megacolon afterCPT repair” and Dr. Mriganka Mouli Sahaof IPGME & R, Kolkata presented “Anabdominal fibromatous mass: Dilemma infinal diagnosis”.

BOGS Activities and Events

A public awareness programme: A publicawareness programme was held on“Adolescent Health & Sexual Medicine” onFriday, 20th January, 2012 at Brahma GirlsBalika Bidyalaya, Kolkata. More than 200girls with their parents attended thisprogramme. The programme was attendedby Dr. Kalidas Bakshi, Dr. Arati BasuSengupta, Dr. Jayita Chakrabarti, Dr.Basab Mukherjee, and Dr. DibyenduBanerjee.

Rural Camp: A Camp was held on 12thFebruary at Tribeni, Hooghly nearly 60 kmfrom Kolkata .The camp was organized inthe premises of Agragami Club atBaikunthapur, Tribeni. 160 patients wereexamined at the camp. Free testing forhemoglobin, sugar, BMD test and Papsmears was done The camp was attendedby Past President Dr. Arati Basu Sengupta,Dr. Basudeb Mukherjee, President electDr. Kalidas Bakshi and three EC members-Dr. Bulbul Raichaudhuri, Dr. BasabMukherjee, Dr. Saktirupa Chakraborty. Thecamp was appreciated by one and all.

24th Dr. Chunilal Mukherjee MemorialOration: 24th Dr. Chunilal MukherjeeMemorial Oration was held on Friday, April13, 2012 at IPGME&R & SSKM Hospital,Kolkata. The oration was delivered by Dr.N. R. Biswas, Former Govt. of IndiaAdvisor to BPKIHS Hony. Prof. of ClinicalPharmacology, BPKIHS on “RECENTADVANCES IN NANOTECHNOLOGY INOBSTETRICS AND GYNAECOLOGY”. About65 delegates attended the oration. Theoration was followed by a clinical meetingwhere Dr. Sushma B of IPGME & R, Kolkatapresented “Diagnostic dilemma of cervicalmass in an adolescent girl”.

FOGSI Usha Krishna QUIZ: Society levelrounds: The society level rounds of theFOGSI Usha Krishna Quiz were held on18th April at SSKM Kolkata. Several teamsparticipated from all the medicalcolleges. Dr. Urmi Sanyal and Dr. MariumKhanam were the winners from MedicalCollege Kolkata. They will be representingthe Bengal society in the Zonal quiz whichis scheduled to be held on 6th of May atthe YUVA FOGSI, Kolkata.

CME on “PracticalObstetrics & Oncology”:CME on “PracticalObstetrics & Oncology”was organized by Practical

Obstetrics & Oncology Committee, BOGSon Friday, April 27, 2012 at “Pratishruti”.More than 60 delegates attended theprogramme. Eminent faculty from oursociety enriched the proceedings of thisenlightening meeting. The followingtopics were discussed - The art of assistedbreech delivery – is it forgotten?,Caesarian section – in placenta praevia,surgical management of PPH, preventionand fertility preserving surgeries inCarcinoma of Cervix and management ofpersistent G.T.T.

Health Check up Camp: A Health Checkup Camp was organized by Dr. SudhirAdhikari and Dr. Sk. Easin Ali incollaboration with BOGS and Sitala Sangha& Library at Joychandrapur, on 5th April,2012 at Budge Budge. There was a “BabyShow” where 50 children participated.More than 100 mothers attended theHealth Camp.

MESSAGE FROM TEAM BOGS 2011-12

I am too fortunate to serve as editor of the first edition of BOGS Times with two budding brilliances few yearsback – nurtured it from infancy to adolescence and now while penning my last Presidential Message in thePlatinum Jubilee year of BOGS I just get amazed to see its proficiency ,its magnitude and its supremacy.

Our’ face book’ was born in a place where every academician belongs, hearts dance there together and sorrowfades, silver falls from linings of fleeting clouds, and turns to gold as it kisses the sun's rays. This place is ourhome – Pratishruti

Inheritance of heritage brings with it new tasks for new generations. Our predecessors did super excellent job.My soul believes that when the baton is passed on, the next-gen will do even better in the upcoming 25 years andbeyond by furthering the fraternity’s glorious tradition while keeping up with the eternal changes. Present BOGSTimes is poised at crossroads waiting to create a landmark in its journey in global scenario as signaled by itsintercontinental ballistic scientific potentiality with art–which everyone including you and me will visualize –but probably from different unknown points of universe.

‘Manifest the divinity within you , be it minimal and everything will be harmoniously arranged around it’ – myhumble confession what BOGS taught me.

And how to define BOGS Times on my last day? None else but…….

“Afinite movement of the InfiniteCame winging its way through a wider air of TimeAmarch of knowledge moved in NescienceAnd guarded in the form a separate soul” – SriAurobindo

With regards

Pradip Kr MitraPresident , BOGSPlatinum Jubilee Year (2011-12)

PresidentSpeaks ...

Hony. SecretarySpeaks ...

Dear Members,

Subho Nababarsho !!

As the Bengali New Year dawns, my tenure as the Hony. Secretary of BOGS comes to an end. I wish everyone myheartiest congratulations and I express my gratitude for constantly supporting me throughout the year.

This year despite holding the Platinum Jubilee Celebrations of BOGSCON at ECO-HUB, which is situated at thefar end of East Kolkata and is rather a desolate area, many attended the conference from far-off places.

I, personally, am indebted to each one of you for making the event such a grand success. It is unbelievable thatthis year, we had a record number of registrations, in the history of BOGSCON.

Every Committee has helped me earnestly. The bulletin & website & publication committee has done a remark-able job by portraying our academic activities through the newsletter, “BOGS Times” and I hope they continuewith this wonderful work and make it all the more attractive and memorable.

I sincerely hope that the next Executive Committee too achieves success through constant endeavor anddetermination -‘LABORE ET CONSTANTIA’.

Long live ‘BOGS’.

My best wishes to all.

Dr. Subhash Chandra BiswasHony. Secretary, BOGS

3BOGSTimes

BOGSTimes4

BOGSCON Platinum Jubilee Year

The BOGSCON was preceded by a live Pre-Congress Workshop on “Minimally invasivesurgery- A new cutting edge technology with achievable skills”, held on January 06,2012 at ILS Hospital, Salt Lake, Kolkata with live transmissionto CII Suresh Neotia Centre, Salt Lake. Nine cases ofendoscopic surgery were demonstrated whichwas attended by 144 delegates. Dr. PrakashTrivedi and his team along with eminent localfaculties operated in the workshop.

37th Annual Conference, “BOGSCON–Platinum Jubilee Year 2011-12” was held onSaturday & Sunday, 07 & 08 January, 2012 atECOHUB-Conclave, New Town. The response in thetwo day scientific programme was overwhelming with520 members participating. The conference wasinaugurated by the Sri Sudip Bandyopadhyay, Hon'bleMinister of State, Dept of Health & Family Welfare, GOI,and Dr. Malabika Sarkar, Vice Chancellor, PresidencyUniversity, Kolkata was the guest of honor. On thisOccasion, past presidents of the society were felicitatedfor their outstanding service that has lifted our Society toits present heights.

Dr. P.K. Shah, Secretary General & President Elect, FOGSI, delivered the 14th Dr.D.C. Dutta Memorial Conference Oration on “Decision Making in IUGR”

Like previous years the highly prestigious Dr. Subodh Sur RoyMemorial Conference CME was held on January 08, 2012. Apublic awareness programme was held on “Cancer inWomen” on January 07, 2012. Lay people from differentfields of societies were invited and actively participatedin this programme.

Cultural programme included a rendition by LopamudraMitra with Surasandhani Band at “Rang Manch”,Swabhumi on 6th January. On January 7, Bangla Band“Dohar” performed at ECHO HUB.

Our junior members participated in large numbers and presented oral papersand posters. The prizes were announced during the valedictory session. Dr.Lahori Roy (PGT, R.G. Kar Medical College, Kolkata), Dr. Ushashree Das (CNCI) &Dr. Broti Basu (CNCI) won the first, second & third prize respectively in the Oral

37th

Annual Conference of BOGS

BOGSTimes 5

Free Paper Competition. Dr. Sujoy Dasgupta (PGT, MedicalCollege, Kolkata) won the First Prize in case presentation. Inthe Poster Competition, the First & the Second Prize wentto Dr. Sujata Kumari (PGT, R.G. Kar Medical College,Kolkata) & Dr. Soni Sohanee (PGT, R.G. Kar Medical College,Kolkata) respectively.

A Live Post-congress workshop on “Non Decent VaginalHysterectomy (NDVH)” was held on January 13, 2012 at

Ramakrishna Mission Seva Pratishthan, Kolkata, inassociation with FOGSI. Nine cases of vaginal hysterectomywere demonstrated and 131 delegates participated. Dr.Shirish Sheth, Dr. P.C. Mahapatra, Dr. H.P. Pattanaik andeminent local faculties operated in the workshop.

Overall, the annual conference of the society in the PlatinumJubilee year set a new standard of scientific and culturalextravaganza.

Attentive audience Engrossed in scientific atmosphere

Pampering the palate Release of BOGS Times The house Full

In a light mood Presenting memento to the Orator FOGSI President in full form

Letting the hair down

BOGSCON Platinum Jubilee Year

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Sir please tell us about yourchildhood.

I was born in Bardhaman but grewup in Dinajpur in undivided Bengal.I passed matriculation at the ageof 14 years form Dinajpur JillaSchool in 1946. In the same year Iarrived in Calcutta and gotadmission in Presidency College on12th of August for ISC and had towitness ‘The great CalcuttaKilling’ on 15th of August sameyear.

I was the eldest of three brothers and was their localguardian in Calcutta. My father was a doctor and continuedhis practice in erstwhile East Pakistan throughout his life.

I was a very keen sports person since my school days andwas actively involved in football and hockey.

We are interested to know the milestones in your medicalcareer.

I joined R.G Kar Medical College in 1948 and by the time Iwas 21 in the year 1953, I had passed MBBS. As we hadrecently migrated from East Pakistan, I qualified for therefugee scholarship for my MBBS. But my father, who paidfor my studies, said, ‘Why deprive another boy whose needmight be more than yours?’ In 1956 I did my DGO from RGKar and went to the UK in 1957 for MRCOG.

Sir why did you take up Gynaecology as your specialty?

Now that you ask, I had all plans to become anophthalmologist; but as I could not stand first in Eye exam(in MBBS) and therefore could not be in Dr Nihar RanjanMunshi’s (the revered eye surgeon) team, I opted forgynaecology and trained under Prof JajneshwarChakraborty.

Besides studies, please tell us something about yourcollege days.

I was the literary secretary during my college daysand was actively associated with the college soccer

team. I have very vivid memories of great matchesbetween RG Kar and Ashutosh College both of which hadvery high quality players at that time. I was also activelyinvolved in politics and participated in the joint doctor andengineers’ strike which went on for 42 days.

What sets apart the students of today from those in the50s?

We had all stayed in the hostel during our college days; wenever had any problems with drugs etc, which is a concernamong the young people today. We also did not have anylady students in RG Kar in our batch.

Your experience in the UK?

We had financial problems when I went for MRCOG but Iearned my passage to England by teaching final yearmedical students. One way ticket to England by ship at thattime had cost me Rs 1200. I knew I could not survivewithout a job so after I did my MRCOG course inHammersmith, I went for an interview in Windsor. To mysurprise I was selected for the job in spite of being theyoungest applicant. I was in fact the first Indian registrar inWest Middlesex University Hospital and trained under Mr.Barnet.

I used to teach MRCOG students regularly, when to mysurprise Dr Bhabesh Lahiri came to attend one of theclasses. Needless to say I told Mr. Barnet that I could notteach Bhabeshda, so he took the class himself and alsocommented on how remarkable and bright he was.

I was going to be a consultant but I got a letter from myfather that my youngest brother was not doing well inschool in Kolkata. I had to come back home.

And after returning home?

I had to have a job to sustain my family. I joined the healthservice in 1960 and my first posting was in Malda town. One

FACE TO FACE WITH A STALWART

PROF BIMAN CHAKRABORTY

Prof Biman Chakraborty has been a revered teacher and continues to be a very active member of BOGS. Dr Kushagradhi Ghosh, Dr PushanKundu and Dr Susmita Chattopadhay met him recently to reminiscence about life, time and BOGS.

BOGSTimes6

Try to be a complete man, not just a doctor

big problem was that there was no place to stay, the livingquarters were in very poor condition. Almost everyalternate weekend I used to drive down to Calcutta myselfin my ‘Standard Herald’. It was while on duty at Malda thatI helped to save the life of a patient with ruptured uterusby doing a timely hysterectomy. After this the publicthemselves put pressure on the authorities and assignedthe SDO quarter to me.

How did you get involved with BOGS?

I have been regularly attending meetings from 1960. In factI used to drive down from Malda.

Sir what is the secret of your punctuality?

It was inculcated in me from my early days byProf Jajneshwar Chakraborty.

We all know that you love to teach, whoinspired you?

My first experience was when I was postedin Bankura Medical College. I alwayswanted to teach. The faculty in Bankuraat that time was awe inspiring. Itincluded personalities like Dr BhabeshLahiri, Dr U S Arora and Dr SubhashMukherjee. In 1979 I used to stay there inthe same flat with Dr Subhash Mukherjee.

I went to John Hopkins for post doctoralfellow-ship, in 1977 (this was allowed by WBgovt). Since then I have visited the US manytimes for uplifting of academic activities.

As a teacher, I am proud of all my students whohave done well nationally & internationally.

Any memorable event while teaching at Calcutta MedicalCollege?

I worked for 9 years (1980-89), in Medical College andworked with many stalwarts of our specialty. One incidentof which I am proud of is when, during the house staffstrike in 1986-87, the students chose me to represent themand speak to the Government on their behalf.

Sir please tell us about Prof Biman Chakraborty, the familyman?

My brothers and I grew up together, very much dependanton one another in the formative years. One of my brothersis an orthopaedic consultant in London and the other is aconsultant engineer in California.

I got married while I was working in Malda, in 1962. It wasan arranged marriage. My wife Chandan considers herself a‘pucca Bihari’ because she was brought up in Patna. She isvery actively involved in her social work with the ‘RotaryInner Wheel’. Our marriage has lasted 50 years, we haveone son who lives and works in the US.

How has retirement affected you?

I am actually enjoying my retired life as I joinedThakurpukur Cancer Hospital immediately afterretirement. I am still working there for last 22 years. I nowpractice not out of necessity, but out of passion. Besides, Ihad always maintained a very active social life apart fromwork. I had always been an active Rotarian and in 1989,

after retirement, I took up the Presidency of Rotary Club ofCalcutta Mid -town.

Any comments on BOGS now and BOGS then?

BOGS is my second home, in fact my wife calls ‘Pratishruti’as my second wife as I spend so much time there. Thestandard of academics is now very good. A lot of youngpeople are taking part and are getting scope to getinvolved. The current BOGS is very affluent. In fact itamazes me that so many regular CME and teaching sessionsare for free.

You were involved with FOGSI as well, so why didn’t youspend more time there?

I was FOGSI, MTP committee chairperson. I hadimmense problem maintaining my private

practice and also maintaining the FOGSIactivities which I believe is the sameproblem with many of you today.

Sir, what are your hobbies,interests and passion?

Driving is my passion. Ever since Ibought my first car, which was aStandard Herald, I have always drivenmyself. I still do. Theatre is anextracurricular activity which both my

wife and I share. We perform at theCalcutta Club, Rotary Club theatres. I also

like to cook exotic dishes.

Any regrets?

I would have loved to become the president ofFOGSI. I did compete against RP Soonawala but

unfortunately could not take time off my private practiceto devote enough time to have a national presence.

Sir, what guides you in life?

I have not aimed to be successful, I have tried to excel atmy job and the rest followed. I had always wanted to be acomplete man, not only a doctor. I have tried to contributein all spheres of life, sports, theatre, and social work.

Any message for the juniors?

Love your subject, success will follow.

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BOGSTimes 7

FACE TO FACE WITH A STALWART

“A personwho never

made amistake

never triedanything

new”

—Albert

Einstein

BOGSTimes8

Controversy: ESTROGEN THERAPY FOR MENOPAUSE

SHOULD BE AVOIDED

Joydeb RoychowdhuryProfessor & Head, Dept of G&O, ESI-PGIMSR, Joka

India has 71 million people over 60 years of age out of whichnumber of menopausal women is about 43 million. Projectedpopulation in India by 2026 will be 1.4 billion; people over 60years will become 173 million, and the menopausal populationas 103 million. Average age of menopause is 47.5 years inIndian women with an average life expectancy of 71 years.Menopausal symptoms are different in rural and urban areas.Urogenital symptoms, fatigue and weakness, body aches, andpains are the predominant symptoms in both rural and urbanmenopausal women. Hot flushes, psychological symptoms,mood swings, and sexual dysfunctions are seen more in urbanwomen. Not all women require routine hormone therapy aswell as HT does not suit everyone. Each woman needs to beaware of the benefits and potential risks of HT so that she canmake an informed decision. HT should be given at the lowesteffective dose for the shortest length of time necessary toachieve the desired clinical effect.

In 2002, the initial results of a long-term randomised con-trolled trial (Level II) of HRT (Women’s Health Initiative [WHI])showed that, after 5 years of combined oestrogen andprogestogen therapy in a relatively asymptomatic, olderpopulation, commencing therapy on average about 13 yearsafter menopause, there was a significant reduction in frac-tures, but no overall cardiovascular benefit, and an increased

occurrence of breast cancer and thromboembolism.

Recent analyses of the WHI data, other randomized controlledtrials, and observational and animal studies have now unifiedmuch of the data on HT and greatly changed the risk–benefitratio for most women who commence HT for symptom controlaround menopause. There are now strong data in support ofthe “critical therapeutic window” hypothesis that estrogen iscardioprotective only if initiated around menopause whenthere are still vascular estrogen receptors responsive to

exogenous ET. ET administered near menopause appears toreduce the progression of atherosclerotic plaque, but ifadministered many years after menopause it is not beneficialand may sometimes disrupt established plaque with adverseoutcomes.

Estrogen is known to stimulate breast tissue with an increasedrisk of breast cancer after long term therapy. Conventionalhormone therapy is usually not prescribed to breast cancersurvivors because of a fear of recurrence. The Million WomenStudy concluded that current use of HT is associated with anincreased risk of incident and fatal breast cancer; the effect issubstantially greater for estrogen- progestogen combinationsthan for other types of HT.

Low dose topical estrogen is an effective treatment forgenitor-urinary atrophy. But Estriol is a weak estrogen and CEErequires either the addition of progestogen or close monitor-ing of the endometrium if used for more than 3 months(Grade A)

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Estrogen is not an effective treatment in elderly women withestablished Alzheimer's disease (Grade A). Similarly, Estrogentherapy is not an effective treatment for loss of libido inpostmenopausal women.

HERS II trial results confirm the initial findings of HERS I thatthere is increased risk of coronary events in the early years oftreatment as well as increase in thromboembolic events in theET group compared with placebo mainly seen in the first yearof use.

ET is contraindicated for secondary prevention of furthercoronary disease because of lack of documented efficacy anda possible early excess mortality.

The need for an ideal drug which proves beneficial in someorgans and avoids the undesirable effects on other organs hasresulted in the development of Selective Estrogen ReceptorModulators (SERMs) that could confer all the benefits ofestrogen without any of its risks. These compounds exhibitselective agonistic or stimulatory effects (i.e. estrogenic) onone organ system and neutral or antagonistic (i.e.antiestrogenic) effects on other organ systems. Raloxifene hasbeen approved for the prevention of postmenopausal osteopo-rosis in 1997 and the treatment of postmenopausal osteoporo-sis in 1999. But Raloxifene may induce hot flushes and legcramps. It is not beneficial for vaginal atrophy. Raloxifene alsoincreases the risk of Deep Vein Thrombosis (DVT) to a degreesimilar to that observed with estrogen. Venous thrombo-embolic events occurred in 1.0% of women who receivedRaloxifene, compared with 0.3% of women who receivedplacebo.

All the current available reports advocate againstroutine use of Hormone therapy to all postmenopausalwomen. Hormone therapy is indicated for benefit of someindividuals if started near menopause with minimum effectivedose for required period of time. Estrogen Therapy in generalis not favored nowadays because of its potential adverseeffects particularly if the woman needs to use for long termbeneficial effect when there are other options available

Conclusion:

References

1. Writing Group for the Women’s Health InitiativeInvestigators. Risks and benefits of estrogen plus progestin inhealthy postmenopausal women. Principal results from theWomen’s Health Initiative randomised controlled trial. JAMA2002; 288: 321-333.

2. Salpeter SR, Walsh JME, Greyber E, Salpeter EE. Coronaryheart disease events associated with hormone therapy inyounger and older women. J Gen Intern Med 2006; 21: 363-366.

BOGSTimes 9

Controversy: ESTROGEN THERAPY FOR MENOPAUSE

HAS A PLACE

Dr Ratnabali ChakravortyProf., Obs & Gynae, MGM Medical College, KishanganjConsultant :Institute of Laparoscopic Surgery, Columbia Asia Hospital, Fortis Hospital, KolkataPast Secretary General of Indian Menopause Society

The menopausal hormone replacement therapy has under-gone a total change in its concept as an after math of WHI trialwhich was prematurely stopped due to some unpredicted highincidence of side effects of HRT. It seemed that the result ofWHI trial was speaking in a completely different and unknownlanguage. It seemed that globally the physicians who wereprescribing HRT and following up their patients for consider-able period of time, have done so blindly and the women whowere using it were so ignorant that they never correlated andcame back to their caregivers even if they suffered from life-threatening diseases due to HRT. However during last ten yearsthe relook into the WHI trial showed that the trial has beendesigned in a wrong way. For example, it included women of ahigher age group who had some pre existing age relateddisease and HRT was started much late after menopause whenalready her vascular changes due to age and metabolic factorshave set in.

As caregivers for women now we have to change our mind setand consider HRT in its new light. It is no more HRT. It is MHT-menopausal hormone therapy which comprises of: HT –Hormone Therapy (when hormones are prescribed to meno-pausal women over and above their existing endogenoushormonal milieu). HRT – Hormone Replacement Therapy(when hormones are prescribed after surgical and naturalmenopause when the woman has no or very little hormone inher circulation).

WHI trial has clearly shown thatprogestogen rather than estrogen component of HRT isresponsible for the side effects like increased incidence ofbreast cancer and cardiovascular accidents. In fact the womenwho were only on ER(estrogen therapy), like thehysterectomised women, showed decreased incidence ofbreast cancer. When HT was started late in menopausespecially in women who never been exposed to HT in her earlymenopause will not only not be benefited from HT, will alsohave increased chances of cardiovascular events. Therefore ascare-givers we must prescribe HT, during the window ofopportunity i.e. as soon as the women faces hormone depriva-tion naturally or surgically. It takes healthy tissue to respondto the hormone therapy and provide benefit to the woman inmaintenance of health. The endothelial cells become involvedwith atherosclerosis and neurons become affected with thedegenerative changes of Alzheimer's with passage of timeafter menopause. Thus beneficial effect to estrogen dimin-

ishes.

Though the duration of treatment should be as minimal asrequired, some women may ask for long term treatment toimprove their 'QOL' (Quality Of Life ). The long term HT/HRT isnot precluded by the results of WHI. It is still believed thatapart from relief of vasomotor symptoms the QOL improvesdue to maximal protection against osteoporotic fractures, areduction in colorectal cancers, maintenance of skin turgor

Estrogen or Progestogen:

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and elasticity, and the possibility of primary prevention ofcoronary heart disease andAlzheimer's disease.

Almost all health organizations like International MenopauseSociety, North American Menopause Society, AustralianMenopause Society, Preventive Services Task Force revisedtheir recommendations regarding hormone therapy inresponse to the findings from the WHI. Although hormonetherapy should not be used for prevention of Cardiovasculardiseases, Alzheimer's, Osteoporosis (unless all other regimensare contraindicated or ill tolerated) it is still appropriate as atreatment to relieve menopausal symptoms. The US Food andDrug Administration (FDA) required labeling information toinclude the following statement: "Estrogens with or withoutprogestins should be prescribed at the lowest effective dosesand for the shortest duration consistent with treatment goalsand risks for the individual woman." ACOG, NAMS, and the USPreventive Services Task Force echoed the same recommenda-tions.

Hormone therapy should be part of an overall strategyincluding lifestyle recommendations regarding diet, exercise,smoking and alcohol for maintaining the health ofpostmenopausal women.

In the absence of new, relevant information onhormonally treated women undergoing menopause, the

Executive Committee of International Menopause Societyrecommends the continuation of presently acceptedglobal practice, including the use of estrogen + progestin,or estrogen alone in the case of women who have under-gone hysterectomy, for the relief of menopausal andurogenital symptoms, avoidance of bone-wasting andfractures, and atrophy of connective tissue and epithelia.The initiation of hormones during the menopausaltransition appears to provide protection against compli-cations of the climacteric such as fractures and heartdisease.Dosage should be titrated to the lowest effective dose.Prevention, not treatment, is the most feasible goalThe initiation of hormones during the menopausaltransition appears to provide protection against compli-cations of the climacteric such as fractures and heartdisease.Progesterone/progestins are only required for protectionof the endometrium.

Current Recommendations for Hormone Therapy

The Governing Principles of HT:

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1. Leon Speroff and MARC A. FRITZ; Clinical GynaecologicEndocrinology and Infertility (seventh Edition) 2005; 489-777.

2. Wright J.Naftolin F. Schneider HP.et al: Executive Committee ofthe International Menopause Society. Maturitas.2004:48(1):27-31.

BOGSTimes10

Case Report

Episiotomy scar endometriosis is one of the rarest types ofendometriosis. In our institute we have successfully treatedsuch a case.

A 29 year old multiparous lady came to us withcomplaints of awareness of a pea-sized nodular mass over theepisiotomy scar area. She had a normal delivery withepisiotomy a year ago. The nodule was not associated withpain but it was tender to touch. She noticed that the mass usedto increase in size during her menstrual periods. On examina-tion we could palpate bimanually a 3×2 cm nodule around theepisiotomy site, though the episiotomy site looked healthy.We re-examined the patient during her next period was able toappreciate that the mass has increased in size. We did an FNACand the report revealed endometriosis. Subsequently wecompletely excised the nodular mass. The fat plane wasdissected to enucleate the endometriotic tissue from the rightischiorectal fossa. The empty space was obliterated toprevent recurrence. The histopathology report confirmedendometriosis consisting of both endometrial glandular andstromal elements. On follow up, the patient has been doingwell. Oral contraceptive pills were prescribed as contracep-tive during post operative period.

Endometriosis is classically defined as thepresence of functional endometrial glands and stromal tissueoutside the uterine cavity. It may even be present at differentsurgical scar sites particularly following gynaecologicalsurgeries. Scar endometriosis was first reported in 1885.

The majority of scar endometriosis which has beenreported was following caesarean deliveries, hysterectomy,hysterotomy, tubal ligation and episiotomy. A few number ofcases had been reported the development of endometriotictissue along the laparoscopic trocar sites and amniocentesisneedle tract sites.

The incidence following hysterotomy is 1.08 to 2%; aftercaesarean delivery, it is 0.03 to o.4% and following episiotomy,it is only about 0.03 to 0.1%.

The time interval between the operative procedure andthe development of scar endometriosis varies widely from3months to 10 years. The average being 5 years.

Amongst the various theories about the pathogenesis ofendometriosis, the implantation theory better explains theoccurrence of scar endometriosis. According to this theory theendometrial tissue is transported to the incision or wound siteduring surgical procedure (as during episiotomy), stimulatedlatter on by oestrogen to produce endometriosis.

Scar endometriosis has often been misdiagnosed as stitchgranuloma, lipoma, abscess, incisional hernia, dermoid,sarcoma, primary or even as metastatic tumours.

So a high index of suspicion is required to diagnose thiscondition. The majority of the patients complain of cyclicalpain around the scar site. The pain and size of the mass usually

Case report:

Discussion:

EPISIOTOMY SCAR ENDOMETRIOSIS-A CASE REPORT

Dr Sandip Kumar Sengupta , Dr Shalini Gainder1 2

1 2IPGMER, Kolkata, Assistant Professor (G&O) PGIMER, Chandigarh

increase during menstrua-tion. So the patient should bere-examined during hermenstrual cycle.

Among the diagnosticprocedures, Color Dopplerultrasonography may revealpresence of hypoechoic, vascularsolid or cystic lesions; CT scan may showa well circumscribed solid mass.MRI is considered betterdiagnostic modality than CT scan for detection of fat planesbetween tissues. FNAC often reveals the presence ofendometriotic tissue. But the diagnostic test is excisionbiopsy.

Once the provisional diagnosis is made, the treatment ofchoice is wide, complete excision of the mass with clearmargin. The closure of the dead space is to be done in order toprevent recurrence. The commonly used other treatmentmodalities like GnRH agonist, progestogens, oral contracep-tive pills, danazol may only give symptomatic relief but theydo not cause reduction in the lesion size.

Malignancy may complicate episiotomy scarendometriosis. The rate of malignancy is 0.3 to1%. Thecommonest type of malignancy is clear cell carcinoma,followed by endometrial carcinoma, adenocarcinoma andsquamous cell carcinoma.

In order to reduce the incidence of episiotomy scarendometriosis we should avoid unnecessary episiotomy duringvaginal delivery; we may put a sterile gauge inside in order toprevent direct implantation of endometrial tissue from theuterine cavity to the episiotomy wound site while repairingthe episiotomy wound. We should avoid excessive curetting ofthe uterine cavity in order to prevent shedding of endometrialtissue to the wound site.

BOGSTimes 11

ANTENATAL CARE OF MULTIPLEPREGNANCIES

ANTI-INFLAMMATORY DRUGS ANDMISCARRIAGE

EXTREME PREMATURITY & LEARNING

FOLIC ACID & LONG-TERM NEURO-DEVELOPMENT

COMPARISON BETWEEN THE PERI- ANDPOSTOPERATIVE COMPLICATION RATESOF TWO CESAREAN DELIVERYTECHNIQUES

T h e i n c i d e n c e o fmultiple pregnancies hasincreased because ofassisted reproductiontechniques and accountfor 3% of births in

developed countries. They are majorcontributors to preterm delivery ratesand the cost of neonatal services. Theemotional and financial costs of weeks ina neonatal intensive care unit (almostalways state funded) are seldom factoredinto the ART calculations. The drive forfertility is never an entirely left-brainactivity.

The UK’s National Institute for Health andClinical Excellence (NICE) is respectedworldwide as a source of data on which tobase clinical practice so theirpronouncement on the antenatal care oftwin and triplet pregnancies is welcome(www.n i ce .o rg .uk/CG129 ) . Theinformation offered is valuable to thosemanaging multiple pregnancies, as is thesummary by Visintin et al (BMJ 2011;343:d5714)

• Between 11 and 14 weeks expertultrasound should be offered todetermine ges ta t iona l age,chorionicity and the risk for Down’sSyndrome by nuchal translucency

• Decisions for team care should bemade early with appropriate referralbased on co-morbidity, chorionicityand the subsequent growth. NICEconsiders a multidisciplinary teamapproach to be “crucial”

• Ultrasound at least 4 weekly withmonitoring of fetal growth

• As far as preterm delivery isconcerned, NICE recommendationsare:

1. D O N O T g i v esteroids unlesss p e c i f i c a l l yi n d i c a t e dclinically

2. DO NOT use testsfor predictingpreterm laboursuch as fetal fibronectin,cervical length or measurementsof uterine-activity

3. DO NOT offer prophylacticmeasures such as bed rest,

hospitalisation, progesterone,cervical cerclage or tocolytics asthey do not work

• Elective deliveryof uncomplicateddichorionic twinsat 37 weeks

• Elective deliveryof uncomplicatedmonocho r i on i ctwins at 36 weeksafter steroids

A large study of women who miscarry hasshown that anti-inflammatory drugs maybe a risk factor. Observational evidencefrom nearly 50 000 pregnancies indicatesthat those exposed to non-aspirin, non-steroidal anti-inflammatories had a 7.5%chance of a spontaneous end to theirpregnancy compared with 2.5% ofcontrols (Nakhai-Pour et al CMAJ2011;183:1713-20).

The data reinforce the advice that anyunnecessary drug should be avoided inpregnancy.

Extreme preterm delivery is defined asbirth at less than 28 weeks gestation or aweight of less than 1000g. Thesechildren are at risk of substandardachievement in terms of spelling,counting and teacher assessment inpreschool and their first year at regularschool compared with matched childrenborn at term (Taylor et al Arch PediatrAdol Med 2011; 165:819-25).

Mean lower scores were present even inchildren with apparently no neurosensorydeficits or low cognitive ability so thedeficiencies are subtle and prompt therecommendation of more extensivemonitoring and interventions in thiscohort before formal schoolingcommences.

It is established that folic acidsupplementation reduces the risk ofneural tube defects in situations ofdietary insufficiency. Folate taken 4

weeks prior to conception and during thefirst 8 weeks of gestation markedlydecreases the incidence of spina bifida,meningomyelocele and other structuralanomalies. Now it seems that its use alsoprotects against functional developmentdelays in later life.

In Norway, wherethe fortification offoodstuffs withfolic acid is notcarried out, asurvey has shownthat the childrenof mothers who did not take folatepericonceptually are at a higher risk oflanguage delay problems than thosewhose mother did take folate (Roth et alJAMA 2011; 306:1566-73). Nearly 40 000children were tested for severe languagedifficulty (only 1 word or unintelligibleutterances) at 3 years of age and theirmaternal intake of folate compared tothe norm. In the general populationsevere language delay was present in0.5% of children but when mothers didnot supplement theirdiets with folic acid,the incidence was0.9%.

Clearly food forthought.

Medical records from 1,087 patients whohad a Caesarean delivery with regionalanaesthesia between 2008 and 2010 werereviewed retrospectively.

No clinically significant differences werefound between the exteriorization and insitu uterine repair groups for meanhaematocrit differences, intra-operativeblood loss, peri-operative nausea,t a chy ca rd i a , h ypo ten s i o n andpostoperative analgesic doses. However,the mean operative time, time to thefirst recognized bowel movement,surgical site infection rate and length ofhospital stay were significantly lower inthe in situ repair group.

Snippets

BOGSTimes12

Published by Dr Subhash Chandra Biswas, Hony Secretary, The Bengal Obstetric Gynaecological Society, "Pratishruti", AQ-10/3, Sector-V, Salt Lake City, Kolkata 700091Printed by M/s Phildon, 3 Dr. Suresh Sarkar Road, Kolkata 700014, Phone: 98365 64291, Email: phildon@rediffmail.com

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Annual Members:

Life Members:

Dr. Rahul Deb Mondal, Dr. Gourab Misra, Dr. Rajit Bhattacharyya, Dr. Marian Khanam, Dr. Chandrima Ray,Dr. Dipa Banerjee, Dr. Ranjan Basu, Dr. Goutam Dutta Sharma, Dr. Chitra Ray, Dr. Jasmin Reza Susarla, Dr. TandraMukhopadhyay, Dr. Sandipan Chowdhuri, Dr. Archana Singh, Dr. Soham Chowdhuri, Dr. Ranjeeta Khati, Dr. Ayesha Khan,Dr. Radha Kanta Pal, Dr. Abhijit Mukhopadhyay, Dr. Suchitra Mitra (Mukiherjee), Dr. Snigdha Kumari, Dr. Piya Ray, Dr.Nandini Kar, Dr. Chandranil Saha, Dr. Sukhendu Bhaumik, Dr. Pradipta Banu, Dr. Indrani Das, Dr. Nikita, Dr. Rajiv Sarkar,Dr. Teesta Banerjee, Dr.Amrita Saxena, Dr. Swati Chatterjee, Dr. Mau Mitra, Dr. Beauti Sarkar.

Dr. Dipa Banerjee, Dr. Suparna Raval (Samanta).

New Members

Date Programme Venue

May 4-6, 2012 East zone YUVA FOGSI Hotel Hindusthan International

May 13, 2012 Dr. Sreemanta Banerjee Memorial Oration Medical College Kolkata

May 22, 2012 Annual General Body Meeting “Pratishruti”, Salt Lake, KolkataFort

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Organised by

The Bengal Obstetric &Gynaecological Society

Under the aegis of FOGSI

EAST ZONE

YUVA FOGSI

KOLKATA

EAST ZONE

YUVA FOGSI

KOLKATA

THEME: Investing in Youth for Women s Health’

4 - 6 May 2012Hotel Hindusthan International

Kolkata

V VEAST ZONE

YUVA FOGSI

KOLKATAEAST ZONE

YUVA FOGSI

KOLKATA

THEME: Investing in Youth for Women s Health’

4 - 6 May 2012

Venue: Hotel Hindusthan International, Kolkata

4 - 6 May 2012

Venue: Hotel Hindusthan International, Kolkata

Organised by

The Bengal Obstetric &

Gynaecological Society

Under the aegis of FOGSI IN

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