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GYNECOLOGY

dr. Nashria
dr. Reagan Resadita

Keganasan
2

Serviks

Siklus
Menstruasi
Abnormal
Menstruasi

Infertilitas

Analisis Sperma

Perdarahan
Uterus Abnormal
Korpus Uteri

Endometriosis

Polycystic
ovarian
syndrome

Infeksi
Kongenital
Toxoplasmosis

Rubella

CMV

Amenorrhea
Ovarium

Menopause

Tes Fertilitas
Wanita

Varicella

Neoplasma

Pertumbuhan jaringan yang berlebihan dan abnormal

Benigna VS Maligna

Solid VS Cystic

Gejala Utama

Tumor Benigna

Perdarahan abnormal

Dapat menyebabkan penyakit


klinis yang signifikan

Massa pelvis

Gejala vulvovaginal

Peningkatan tekanan pada


mioma uteri menyebabkan
nyeri punggung belakang,
obstipasi dan retensi urin
Komplikasi: Perdarahan
abnormal, ulserasi, infeksi
sekunder
Perubahan menjadi maligna

Tumor Maligna
Menyebabkan penyakit klinis
yang lebih signifikan seperti
invasif, pertumbuhan cepat
mudah berdarah, ulserasi dan
infeksi
Sindrom Para neoplastic
(endocrinopathies)
cachexia

Lokasi Tersering

Tumor Serviks Uteri


lokasi: Berada di 1/3 bawah uterus, dibawah os cervicalis interna
Klasifikasi
Faktor Resiko
Tumor Benigna
Leiomyoma (myoma)
Tumor Maligna
A. Karsinoma serviks
1. Squamous cell
carcinoma 91 %
2. Adenocarcinoma
3. Adenosquamous
carcinoma
4. Adenoacanthoma
B. Sarcoma ( sangat
jarang)

Infeksi HPV tipe16, 18, 45 dan 56


Status sosial ekonomi
Menikah/ memulai aktivitas seksual
pada usia muda (kurang 20 tahun)
Berganti ganti pasangan seksual.
Berhubungan seks dengan laki laki
yang berganti ganti pasangan
Riwayat infeksi di daerah kelamin
atau radang panggul
Perempuan yang melahirkan banyak
anak
Perempuan perkokok(2,5x lebih
tinggi)
Perokok pasif (1,4x lebih tinggi)

Patogenesis
5

Infeksi terjadi melalui kontak kulit ke kulit


Lesi biasanya belum timbul hingga 3-5
tahun setelah terpapar

Zona Transformasi

6
Displasia
adalah
hilangnya
diferensiasi normal dari epitel serviks
Tempat paling sering terjadinya
displasia dan SCC adalah junctio
epitelium
skuamosum
dan
kolumnar (zona transformasi)
Daerah ini paling rentan terhadap
infeksi virus, perubahan pH vagina
dan fluktuasi level estrogen
Peningkatan estrogen menstimulus
epitel kolumnar bergerak keluar
menuju
vagina
(kehamilan,
konsumsi pil kontrasepsi, bayi baru
lahir).
Penurunan estrogen menstimulus
epitel kolumnar untuk masuk
kembali ke kanalis endoserviks

Tanda Klinis & Gejala


8

Tanda Klinis
Nodul, ulkus, erosi serviks
Advanced: crater-shaped
ulcer with high or friable
warty mass
Perdarahan
Mobilitas serviks tergantung
derajat ca

Gejala

Perdarahan vagina, rektal,


urethra
Penekanan:obstipasi, anuria
hidronefrosis gagal ginjal
uremia
Infeksi:discar vagina yang bau

Pencegahan
Primer: Gaya hidup sehat
dan vaksinasi HPV
(kuadrivalen- genotipe 6,

11, 16 &18 ; bivalen- genotipe 16


&18)

Sekunder: Skrining untuk lesi


pra kanker & diagnosis awal
diikuti dengan terapi

Tersier: Diagnosis dan

terapi dari kanker yang


terbukti. Terapi: operasi,
radiotherapy dan
terkadang chemotherapy.
Dianjurkan paliatif jika tidak
dapt disembuhkan

Screening for cervical cancer Visual Inspection Test


9

Perempuan berusia 30-50


tahun
Pasien klinik IMS dengan
discharge dan nyeri abdomen
bawah (semua usia)
Perempuan yang tidak hamil
Perempuan yang mendatangi
puskesmas, klinik IMS< dan
klinik KB yang meminta
screening
Jika hasl tes IVA negatif,
skrining dilakukan minimal 5
tahun sekali. Jika hasil tes IVA
positif harus melakukan tes IVA
6 bulan kemudian
Pedoman teknis Ca Payudara dan Ca
Serviks, kemenkes

Screening for Cervical Cancer


10

The United States Preventive Services Task Force


stated screening may stop at age 65 if :
11
recent normal smears
not at high risk for cervical cancer.
The American Cancer Society guideline stated that
women age 70 or older may elect to stop cervical
cancer screening if :
had three consecutive satisfactory,
normal/negative test results and no abnormal
test results within the prior 10 years.
Not recommended in women who have had total
hysterectomies for benign indications (presence of
CIN II or III excludes benign categorization).
Screening of women with CIN II/III who undergo
hysterectomy may be discontinued after three
consecutive negative results have been obtained.
However, screening should be performed if the
woman acquires risk factors for intraepithelial
neoplasia, such as new sexual partners or
immunosuppression.

Kecuali...
Women at increased risk
of CIN :
1. in utero DES
(diethylstilbestrol)
exposure,
2. immunocompromise,
3. a history of CIN II/III or
4. Cancer

should continue to be
screened at least
annually.

ACOG guideline 2008

Screening for Cervical Cancer Pap Smear


12

Keluhan

Lesi anatomis

Rekomendasi
skrining

IVA

Syarat:

PAP SMEAR

Lakukan
Paps
smear
pada fase proliferasi (1
minggu setealah mens
berakhir)

Biopsi

Mendeteksi perubahan
pada morphology
sel(dysplasia) yang
merupakan precursors
dari carcinoma.

Tidak
melakukan
hubungan sexual 24-48
jam sebelum paps smear
Tidak
menggunakan
lubrikan vagina.

Unreliable Pap smear due to inflammation:


First, diangose and treat inflammation

Repeat pap smear after the condition resolves to diminish


the false positive result.
Source: Emedicine

Squamous Cell Carcinoma


Cervical dysplasia:

Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope

2015 UpToDate

Tanda dan Gejala


Perubahan prekanker serviks sering tidak disertai tanda
dan gejala

14

Diagnosis
Tests may include:
another Pap test if mild changes found
HPV test, which may be done on a sample of
cervical cells taken during a Pap test
colposcopy and biopsy
endocervical curettage during colposcopy
Treatment

Often, milder changes (such as CIN I or low-grade SIL)


return to normal without any treatment& the doctor
may do repeat testing later.
More severe abnormalities (such as CIN III or highgrade SIL) are more likely to develop into invasive
cervical cancer, especially if they are not treated.
Treatment options : cryosurgery, laser surgery, cone
biopsy, hysterectomy

15

Terapi

Penjelasan

Krioterapi
16

Perusakan
sel
sel
prakanker dengan cara
dibekukan
(dengan
membentuk bola es pada
permukaan serviks)

elektrokauter

Perusakan
sel
sel
prakanker dengan cara
dibakar
dengan
alat
kauter,
dilakukan
leh
SpOG dengan anestesi

Loop
ElectroSutgican Pengambilan
jaringan
Excision Procedure (LEEP)
yang mengandung sel
prakanker
dengan
menggunakan alat LEEP

Konikasi

Pengangkatan
jaringan
yang
megandung
sel
prakanker dengan operasi

Histerektomi

Pengangkatan
seluruh
rahim termasuk leher rahim

Clinical staging of Cervical Cancer


17

Tumor Korpus Uteri


Tumor Benigna
18
Leiomyoma
(myoma):
Paling sering (sel otot halus)
Etiological factors:
estrogen, ras kulit hitam,
nullipara

Tanda dan Gejala


Menorrhagia heavy &
prolonged menstruation
(common)
Pelvic pressureurinary
frequency, constipation
Spontaneous abortion, Infertility

Type of Leiomyoma
1. Submucous : beneath
endometrium, if
pedunculated
geburt myoma
2. Intramural/interstitial:
within uterine wall
3. Subserous/subperitone
al: at the serosal
surface or bulge
outward from
myometriuml ; if
pedunculated : satelite
myoma

A palpable abdominal tumor :


arising from pelvis, well defined
margins , firm consistency, smooth
surface, mobile from side to side.
Pelvic examinationUterus
enlarged and irregular, hard
Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
Terapi
Observation: for small myoma,
premenopause
Operation : myomectomy or
hysterectomy
Whorl like pattern / Pusaran air

19

Influencing factors of Myoma Uterine

20

Specific Signs of Uterine Fibroid

Perubahan Sekunder Myoma


21

Jenis Degenerasi Ganas


Myoma uteri yang menjadi
leiomyosarkoma hanya 0,32
0,6% dari seluruh myoma
Leiomyosarkoma
merupakan 50-75% dari
semua jenis sarkoma uteri
Kecurigaan malignansi:
apabila myoma uteri cepat
membesar dan terjadi
pembesaran myoma pada
menopause.

Tumor Korpus Uteri


A. Karsinoma
endometrium
22
75% terjadi pada periode pos
menopause
Etiologi: paparan estrogen terlalu
banyak, obesitas, manopause
terlambat, PCOS, estrogen
secreting ovarian tumor, konsumsi
estrogen dari luar, diabetes dan
hipertensi
Adenokarsinoma endometrium
Adenoacanthoma
Karsinoma adenoskuamos
B. Sarkoma uteri
1. Leiomiosarkoma
2. Tumor mesodermal campuran
3. Sarkoma stromal endometrium
Kejadiannya sangat jarang
Diagnosis
Perdarahan post menopause
Siklus menstruasi iregular
Curretage

Tumor Ovarium
Mortalitas tinggi dari semua tumor gyn (silent
lady killer)
Gejala
Low abdominal discomfort (fullness,
bowel symptom)
Loss of weight, malaise, anorexia
Pain due to torsion, hemorage or
rupture
Pressure symptom
Benign Tumor
Small can be felt by bimanual
Medium may have long pedicle and
rise out of pelvis

Benign mucinous cyst may be vary in


size
Benign teratoma cyst the commonest
undergo torsion
Benign solid tumor are less common
Meig syndrome : solid tumor, ascites,
pleural effusion

Malignant Tumor
Early detection would improve
prognosis, bimanual, USG or tumor
marker

Ovarian teratoma
Bizarre
tumor,
biasanya
benigna, rata2 mengenai wanita
di usia 30 tahun
Kista dermoid berkembang dari
sel germinal totipotensial (oosit
primer) yang tetap berada di
ovarium, sehingga berkembang
menjadi semua bentuk sel matur
seperti rambut, gigi, tulang,
jaringan saraf.

23

24

Siklus Menstruasi Abnormal

Menstrual cycle
25

Image source:https://embryology.med.unsw.edu.au/

FSH
26

Hormon yang diproduksi oleh


hipofisis akibat rangsangan
dari GnRH.
FSH
akan
menyebabkan
pematangan dari folikel.
Dari folikel yang matang akan
dikeluarkan ovum. Kemudian
folikel ini akan menjadi korpus
luteum dan dipertahankan
untuk waktu tertentu oleh LH

LH
LH mempertahankan korpus luteum
untuk tetap menghasilkan ovarium.
Dibawah pengaruh LH, korpus luteum
mengeluarkan
estrogen
dan
progesteron,
dengan
jumlah
progesteron jauh lebih besar.
Kadar progesteron meningkat dan
mendominasi dalam fase luteal,
sedangkan estrogen mendominasi
fase folikel.
Walaupun estrogen kadar tinggi
merangsang sekresi LH, progesteron
dengan kuat akan menghambat
sekresi LH dan FSH.

27

Estrogen
Estrogen
dihasilkan
oleh
ovarium.
Estrogen
berguna
untuk
pembentukan
ciri-ciri
perkembangan seksual pada
wanita yaitu pembentukan
payudara,
lekuk
tubuh,
rambut kemaluan.
Estrogen juga berguna pada
siklus
menstruasi
dengan
membentuk
ketebalan
endometrium,
menjaga
kualitas dan kuantitas cairan
cerviks dan vagina sehingga
sesuai untuk penetrasi sperma.

Progesteron
Hormon ini diproduksi oleh korpus
luteum.
Progesteron
mempertahankan
ketebalan
endometrium
sehingga
dapat menerima implantasi zygot.
Kadar
progesteron
terus
dipertahankan selama trimester awal
kehamilan sampai plasenta dapat
membentuk hormon HCG.

GnRH
GnRH merupakan hormon yang diproduksi oleh
hipotalamus di otak.
GnRH akan merangsang pelepasan FSH (Folicle
Stimulating Hormon) di hipofisis.
Bila kadar estrogen tinggi, maka estrogen akan
memberikan umpan balik ke hipotalamus
sehingga kadar GnRH akan menjadi rendah,
begitupun sebaliknya..

28

Normal Menstrual Bleeding


29

Occurs approximately once a


month (every 26 to 35 days).
Lasts a limited period of time (3 to
7 days).
May be heavy for part of the
period, but usually does not
involve passage of clots.
Often is preceded by menstrual
cramps, bloating and breast
tenderness, although not all
women experience these
premenstrual symptoms.
Average : 35-50 cc

Lect. By dr. Hasto Wardoyo, Sp. OG

30

Ovulasi

Terjadi 14 hari sebelum mens


berikutnya

>> kadar
progesterone 2ng/ml
LH surge (dg
Tanda dan tes :
Radioimunoassay)
Rasa sakit di perut bawah (mid cycle
pain/mittleschmerz)
USG folikel >1,7 cm
Perubahan temperatur basal efek
termogenik progesteron
Perubahan lendir serviks
Uji membenang (spinnbarkeit): Fase
folikular : lendir kental, opak,
menjelang ovulasi encer, jernih,
mulur
Fern test : gambaran daun pakis

Fertility Test
31

LH-FSH Ratio : the relative value of 2 gonadotropin hormone


produce by the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone
(FSH) stimulate ovulation by working in different ways.
in premenopusal women, the normal LH-FSH ration is 1:1 as
measured on day three of the menstrual cycle
Variation from this ratio used to diagnose PCOS or other
disorders, explain infertility or verify that woman has entered
menopause
FSH stimulates the ovarian follicle to mature. Then a large
surge of LH stimulates the follicle to release an egg to
fertilization
On day 3 of the cycle, LH should be low. If LH is elevated on
this day, possible even as high as FSH, then it suggest problem
with ovulation. Ovulation requires an LH surge, and if LH is
already elevated, it may not surge and ovulated

32

33

Abnormal Uterine Bleeding

34

Polyp

Coagulopathy

Adenomyosis

Ovulatory disorder

Malignancy and
hyperplasia

leiomyoma

Endometrial

iatrogenic

Not Yet Classified

Polip
35

Endocervical polip
Endometrial polip

Adenomyosis
Part of endometrial that penetrate to myometrium

Leiomyoma
Submucosal
SUbserosal
intramural

Malignancy and hyperplasia


- Endometrial cancer

Coagulopathy
36

Von Willebrand disease


Gangguan agregasi platelet

Ovulatory disurbance
Endocrinopatie (PCOS, Hypotiroid, obesity, anorexia)
Extreme exercise, stress

Endometrial
Endometrial inflammation
Endometrial infecton
Defisiensi endothelin-1, defisiensi Prostaglandin F2-alpha

Iatrogenic
Drugs : rifampicin, griseofulvin, trisiklik,
phenothiazine, anticoagulant, antiplatelet,

Treatment of uterine bleeding


37

Infrequent bleeding
1. Therapy should be directed at the underlying cause
when possible.
2. If the CBC and other initial laboratory tests & history
and physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid

ACOG 2008

Frequent or heavy bleeding


38
1. NSAID
Inhibisi sintesis prostaglandin
Increases uterine vasoconstriction.
NSAIDs are the first choice in the treatment of menorrhagia because they are well
tolerated and do not have the hormonal effects of oral contraceptives.
a. Mefenamic acid (Ponstel) 500 mg tid during the menstrual period.
b. Naproxen (Anaprox, Naprosyn) 500 mg loading dose, then 250 mg tid during the
menstrual period.
c. Ibuprofen (Motrin, Nuprin) 400 mg tid during the menstrual period.
2. Ferrous gluconate 325 mg tid.
3. Patients with hypovolemia or a hemoglobin level below 7 g/dL should be hospitalized for
hormonal therapy and iron replacement.
Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops.
Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper slowly to
one pill qd.
If bleeding continues, IV vasopressin (DDAVP) should be administered.
ACOG 2008

39

Hysteroscopy may be necessary, and dilation and curettage is


a last resort.
Transfusion may be indicated in severe hemorrhage.
Ferrous gluconate 325 mg tid.
4. Primary childbearing years ages 16 to early 40s
A. Contraceptive complications and pregnancy are the most
common causes of abnormal bleeding in this age group.
Anovulation accounts for 20% of
cases.
B. Adenomyosis, endometriosis, and fibroids increase in
frequency as a woman ages, as do endometrial hyperplasia
and endometrial polyps. Pelvic inflammatory
disease and endocrine dysfunction may also occur.

ACOG 2008

40

Dysmenorrhea
Dysmenorrhea refers to the symptom of painful menstruation. It can be
divided into 2 broad categories: primary (occurring in the absence of
pelvic pathology) and secondary (resulting from identifiable organic
diseases).

Primary

Usual duration of 48-72 hours (often starting several hours before or just after
the menstrual flow)
Cramping or laborlike pain
Background of constant lower abdominal pain, radiating to the back or thigh
Often unremarkable pelvic examination findings (including rectal)
Current evidence suggests that the pathogenesis of primary dysmenorrhea is
due to prostaglandin F2 (PGF2), a potent myometrial stimulant and
vasoconstrictor, in the secretory endometrium.

Secondary
41

Dysmenorrhea beginning in the 20s or 30s, after previous


relatively painless cycles
Heavy menstrual flow or irregular bleeding
Dysmenorrhea occurring during the first or second cycles
after menarche
Pelvic abnormality with physical examination
Poor response to nonsteroidal anti-inflammatory drugs
(NSAIDs) or oral contraceptives (OCs)
Infertility
Dyspareunia
Vaginal discharge

Drug Therapy
Dysmenorrhoea can be effectively treated by drugs that inhibit
prostaglandin synthesis and hence uterine contractility.
These drugs include aspirin, mefenamic acid, naproxen or
ibuprofen.

Endometriosis

42

Penyakit estrogen dependen yang sering menyebabkan morbiditas, nyeri pelvis yang berat,
operasi berulang dan infertilitas.
Secara klinis ditemukan jaringan endometrial-like diluar uterus, yang menyebabkan reaksi
inflamasi

Lokasi paling sering: GI tract

Lokasi lain: urinary tract, soft tissues & diaphragm

Pathophysiology
43 In situ from wolffian or mullerian duct remnants (metaplastic theory)

Coelemic metaplasia
Sampsons theory
Iron-induced oxidative stress
Stem cells

Sign Symptom
Classic signs:
severe dysmenorrhea, dyspareunia,
chronic pelvic pain,
infertility

Dysmenorrhea
Heavy or irregular bleeding
Cylical/noncylical pelvic pain
Lower abdominal or back pain
Dyschezia, often with cycles of
diarrhea/constipation
Bloating, nausea, and vomiting
Inguinal pain
Dysuria
Dyspareunia with or without penetration
Nodules may be felt upon pelvic exam
Imaging may indicate pelvic mass/endometriomas

44

Physical exam and imaging

Physical examination has poor


sensitivity, specificity, and
Predictive value in diagnosis
endometriosis.
Combination of History, Physical
exam and laboratory and
diagnostic studies is indicated to
determine cause of pelvic pain
and rule out non endometriosis
concerns
Pain mapping may help isolate
location spesific disease such as
nodulas masses in posterior
rectovaginal septum
Absence of evidence during exam
is not evidence of disease absence

Imaging studies
Transvaginal or endorectal USG may reveal US
feature varying from cyst with internal echoes to
solid masses, usually devoid of vascularity
CT may reveal endometrioma appearing as cystic
masses; however, apperance are non specific and
imaging modalities should not be relied upon on for
diagnosis
MRI : may detect even smallest lesion and
distinguish hemorragic signal of endometrial
implant
MRI demonstrated to accurately detect
rectovaginal disease and obliteration in more than
90% of cases when USG gel was inserted in the
vaginal and rectum

45

Endometriosis therapy

Medical Therapies

Gonadotropin-releasing
hormone agonists (GnRH),
oral contraceptives,
Danazol,
aromatase inhibitors,
Progestins

Surgical Intervention
Laparoscopy
Hysterectomy/Oophorect
omy/Salpingooophorectomy
Nonsurgical Therapies
Medical Therapies
Alternative Therapies

Indications for surgical management:


Diagnosis of unresolved pelvic
pain
Severe, incapacitating pain with
significant functional impairment
and reduced quality of life
Advanced disease with
anatomic impairment
(distortion of pelvic organs,
endometriomas, bowel or
bladder dysfunction)
Failure of expectant/medical
management
Endometriosis-related
emergencies, ie, rupture or
torsion of endometrioma, bowel
obstruction, or obstructive
uropathy

Endometriosis therapy

46

Mild Moderate Pain

Moderate-Severe Pain

NSAID

GnRH agonis

Oral contraceptive

Danazole

progestin

Aromatase inhibitor

47

Endometriosis therapy

Oral contraceptive
Generally well tolerated,
fewer metabolic and
hormonal side effect than
similar therapies
Relieve dismenorrhea throuh
ovarian supresion and
continous progestin
administration
Often simple, effective
choice to manage
endometriosis through
avoidance or delay menses
for upwards of 2 years

Non Steroidal Anti


Inflamatory
Proven efficacy fot
treatment of primary
dismenorhea
Acceptable side
effects

Reasonable cost
Ready availability

Progestins
Inhibit growth of lesion by infucing
ecidualization followed by
athropy uterine type tissue

Compared to GnRH therapy,


both modalities show
comparable effectiveness
Medroxyprogesterone acetat
proven for pain suppresion both
oral and injectable
Adverse effect : weight gain, fluid
retention, depresion, breakhrough
bleeding

48

Endometriosis therapy

Aromatase Inhibitor

GnRH agonist

Danazol

Endometriotic implan express


aromatase and consequently
generate esterogen, maintaining
own viability

Produced hypogonadic state


through down regulation of
pituitary gland

Among oldest of medical


therapy for endometriosis

Inhibit local esterogen production


in endometrioticimplant
Significantly reduce pain,
compared with GnRH agonit
alone.

Efective as other therapies in


relieving pain and reduce
progression
No fertility improvement
High cost, bone density loss,
intolerable hypoesterogeninc
side effect
Preoperative therapy reported
to reduce pelvic vascularity
and size of lesion, reduce
intraoperative blood loss

Inhibit midcycle FSH and


LH surge and prevent
steroidogenesis in corpus
luteum
Higher incidence of
adverse effect more
recent therapy
Androgenic manifestation
(oily skin, ane, weight gain,
deepening voice,
hirsutism) maybe
intolerable

Amenorrhea
49
Amenorrhea is
menstruation.

the

absence

of

Primary

Absence of menses by age 14


without
secondary
sexual
development
Absence of menses by age 16
with normal secondary sexual
characteristic
Secondary
Absence of menses for 6 month
in a previous menstruating
female
Lect. By dr. Hasto Wardoyo, Sp. OG

50

Terminology

51

Definition

Menstrual period
exceeding 8 days inbleeding
duration on regular basis
Definisi heavy
menstrual
dkk

Prolonged menstrual
bleeding
Shortened menstrual
bleeding

Uncommon, define as bleeding of no longer than 2 days

Irregular menstrual bleeding

Bleeding of 20 days In individual cycle length over period of one year

Absent menstrual bleeding


(amenorhea)

No bleeding in a 90 days period

Infrequent menstrual
bleeding

One or two episode in a 90 day period

Frequent menstrual bleeding

More than four time episode in a 90 day period

Heavy menstrual bleeding

Excessive menstrual blood loss that interferences with the woman


physical, emotional, social, and material quality of life and can occur
alone or in combination with other symptom

Heavy and prolonged


menstrual bleeding

Less common than HMB, its important to make a distinction from HMB
given they may have different etiologies and respond to different
therapies

Light Menstrual Bleeding

Based on patient complaint, rarely related to pathology

52
Terminology

Definition

Acute Abnormal Uterine


Bleeding

Episode of bleeding in a woman of reproductive age, who is not


pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss

Chronic Abnormal uterine


bleeding

Bleeding from the uterine corpus that is abnormal in duration,


volume, and/or frequency and has been present for the majority of
the last 6 month

Irregular Non Menstrual


Bleeding

Irregular episode of bleeding, often light and short, occurring


between normal menstrual period. Mostly associated with benign
or malignant structure lesion, may occur during or following sexual
intercourse

Post menopausal bleeding

Bleeding occurring >1 year after the acknowledge menopause

Precocious menstruation

Usually associated with other sign of precocious puberty, occur


before 9 years of age

Amenorrhea primer
53

I. GADIS USIA 14 TH TANDA SEKS SEKUNDER (-) & BLM


MENARKE
II. GADIS USIA 16 TH TANDA SEKS SEKUNDER (+) TETAPI
BELUM MENARKE

54

Diagnosis of
primary
amenorrhea

55

Diagnosis of
secondary
amenorrhea

56

Functional hypothalamic amenorrhea:


57
the hypothalamic-pituitary-ovarian axis is
suppressed due to an energy deficit
stemming from stress, weight loss
(independent of original weight), excessive
exercise, or disordered eating.
It is characterized by a low estrogen state
without other organic or structural disease
Menses typically return after correction of
the underlying nutritional deficit.

58

Menopause

Definisi: Berhentinya siklus menstruasi untuk selamanya bagi wanita

yang sebelumnya mengalami menstruasi setiap bulan, yang


disebabkan oleh jumlah folikel yang mengalami atresia terus meningkat,
sampai tidak tersedia lagi folikel, serta dalam 12 bulan terakhir
mengalami amenorea, dan bukan disebabkan oleh keadaan patologis,
rata-rata usia 50 tahun

Perimenopause
It is 3-5 years period before menopause with increase frequent
irregular anovulatory bleeding followed by episodes of
ammenorrhea and intermittent menopausal symptoms.
Menopause:
- The point in time at which menstrual cycles permanently cease. It is
a retrospective diagnosis after 12 months of ammenorrhea women
classified as being menopause.
- Mean age 51 years.

II. Pathophysiology
pada usia sekitar 50 tahun fungsi ovarium menjadi sangat menurun.
59
Folikel mencapai jumlah yang kritis, maka akan terjadi gangguan
sistem pengaturan hormon
insufisiensi korpus luteum, siklus haid anovulatorik dan pada akhirnya
terjadi oligomenore
Masa perimenopause aktivitas folikel dalam ovarium mulai
berkurang.
Ketika ovarium tidak menghasilkan ovum dan berhenti
memproduksi estradiol, kelenjar hipofise berusaha merangsang
ovarium untuk menghasilkan estrogen, sehingga terjadi
peningkatan produksi FSH.
Pada pascamenopause kadar LH dan FSH akan meningkat, FSH
biasanya akan lebih tinggi dari LH sehingga rasio FSH/ LH menjadi
lebih besar dari satu.
Hal ini disebabkan oleh hilangnya mekanisme umpan balik negatif
dari steroid ovarium dan inhibin terhadap pelepasan gonadotropin.
Diagnosis menopause dapat ditegakkan bila kadar FSH lebih dari 30
mIU/ml

60

61

62

63

III. Symptoms of Menopause:


1. Hot flushes - cutaneous
vasodilation
- occurs in 75% of
women
- more severe after
surgical menopause
- continue for 1 year
- 25% continue more
than 5 years
2. Urinary Symptoms
- urgency
- frequency
- nocturia

3. Psychological changes
decreased level of
central
neurotransmitters
- Depression
- Irritability
- Anxiety
- Insomia
- lose of concentration

64

4. Atrophic Changes

Vagina
*vaginitis due to thinning of epithelium, PH and lubrication.
*dysparnuedue to decrease vascularity and dryness

Decrease size of cervix and mucus with retract of segumocolumnar (SC)


junction into the endocervical canal.

Decrease size of the uterus, shrinking of myoma & adenomyosis.

Decrease size of ovaries, become non palpable.

Pelvic floor - relaxation prolapse.

Urinary tract atrophy lose of urethral tone caruncle


Hypertonic Bladder - detrusor instability

Decrease size of breast and benign cysts.


5.
Skin Collagen collagen & thickness elasticity of the skin.
6.
Reversal of premenstrual syndrome

65

Diagnosis
Diagnosis menopause dibuat setelah terdapat
amenorea sekurang-kurangnya 12 bulan terakhir, kadar
FSH > 30 mIU/ml dan kadar E2 < 30pg/ml (Rogerio, 2000;
Baziad, 2003).

Terapi
Estrogen a minimum of 2mg of oestradiol is needed to
mantain bone mass and relief symptoms of menopause.
Women with uterus add progestin at last 10 days to
prevent endometrial Hyperplastic
Sequential Regimens - used in patient close to
menopause.
Oestrogen in the first of 28 day per pack
& Oestrogen & Progetin in 2nd 1/12 of 28 day pack..

66

Benefits of HRT:

Vagina- vaginal thickness of epithelium


dyspareunia & vaginitis.
Urinary tract enhancing normal bladder
function.
Osteoporosis decrease fractures by
more than 50%
CVS decrease by 30% by observation
studies but recent studies shows no
benefits.
Colon Cancer decrease up to 50%

Post Menopausal Bleeding:


67

Vaginal bleeding occurs after 12 months of Amenorrhea in middle


age women who are not receiving replacement therapy.

Etiologi:
Endometrial Ca:
The most common Gynecological malignancy.
-Endometrial neoplasia can progress from simple hyperplasia to investive Ca
caused by unopposed oestrogen.
The mechanism of many End. Ca. is prolonged oestrogen stimulation of the
endometrium unopposed by progesterone. The source may be:
a. Exogenous Estrogen (E2) (ERT)
b. Peripheral Aromatization of Androstendione to estrone obesety or PCO
c. Estrogen (E2) producing tumor (like granuloza cell ovarian tumour)
d. Tamoxifen Stimulation of Endometrium

PMS (Pre Menstrual Syndrome)


68
the cyclic recurrence in the luteal phase of
the menstrual cycle of a combination of
distressing physical, psychological, and/or
behavioral changes of sufficient severity to
result in deterioration of interpersonal
relationships and/or interference with
normal activities..

PMM
Many patients with psychiatric disorders
also complain of worsening of their
symptoms around the premenstrual phase,
called premenstrual magnification.

Lect. By dr. Hasto Wardoyo, Sp. OG

ACOG 2008

69

INFERTILITAS

70

Infertility

71

Infertilitas
failure of a couple to conceive after 12 months of regular intercourse
without use of contraception in women less than 35 years of age; and
after six months of regular intercourse without use of contraception in
women 35 years and older
40% faktor istri
40% faktor suami
20% pada keduanya
wanita: 35-60% faktor tuba & peritonium
10-25% kasus: Unexplained infertility

Faktor Suami
a. 35% : faktor sperma
-b. Gangguan transportasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan
kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome,
Myotonic distrophy), kelainan hipotalamus-hipofisa
-c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.

72

Faktor Istri:
73

Infeksi

Gangguan ovulasi
Gangguan anatomi
Gangguan Ovulasi
Penuaan (usia)
POF
Polikistik Ovarii (PCOS)

Kelainan pada hipotalamushipofisis


Hiperprolaktin
Kelainan kongenital

74

75

Analisa Sperma

ANALISA SPERMA

76

Fertilitas seorang pria ditentukan


oleh jumlah dan kualitas
spermanya
Normozoospermia
Jumlah sperma 20 juta/ml
Oligozoospermia

Jumlah sperma < 20 juta/ml

A: bergerak cepat dan lurus


B: Bergerak lambat dan tidak lurus

C : bergerak ditempat
D : tidak bergerak
Teratozoospermia
Morfologi sperma normal < <30%

Astenozoospermia

OligoAstenoTeratozoospermia sindroma
OAT

Motilitas sperma a<25% atau


a+b <50%

Azoopermia 0 sperma + plasma semen


Aspermia 0 sperma + 0 plasma semen

77

Motilitas spermatozoa dan viabilitas


Digunakan untuk kriteria D tidak bergerak uji viabilitas
Pewarnaan supravital menggunakan Eosin Y dengan prinsip sperma hidup
tidak dapat menyerap zat warna dan sebaliknya denan sperma mati
(disintegrasi membran sel)
Dilihat dibawah mikroskop
Sperma hidup kepala bening

Sperma mati kepala ungu


Dari 100 sperma yang dihitung
80 sperma kepala bening
20 sperma kepala ungu

Uji Viabilitas 80%

Sindroma Ovarium Polikistik


78

Kelainan endokrin

wanita usia reproduktif

Definisi klinis

Terdapatnya
hiperandrogenemia yang
berhubungan dengan
anovulasi kronik pada wanita
tanpa adanya kelainan dasar
spesifik pada adrenal atau
kelenjar hipofisa

Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia

79

Source: http://www.pathophys.org/pcos/

Therapy
Lifestyle modification: may help
80 all symptoms of PCOS
attenuate
and reduce the long-term risk of
infertility, CVD and T2DM.

Estrogen and progestin oral


contraceptive (OCP)
therapy: treatment of acne,
hirsutism and irregular menstrual
cycles.

Can be used to normalize androgen levels and attenuate the signs of


hyperandrogenism as well as to regulate menstrual cycles. This also helps to
reduce the risk of heavy and irregular menstrual bleeding associated with the loss
of normal estrogen and progestrone levels.

Anti-androgens (e.g.
spironolactone,finasteride,
flutamide): treatment of acne and
hirsutism.

Spironolactone and flutamide competitively inhibits DHT and testosterone by


binding to their receptors in peripheral cells (e.g. hair follicles).
Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the
more potent DHT in peripheral cells.
Anti-androgens can be used synergistically with OCPs, which act centrally to
suppress androgen release.

First line of PCOS management.


Increased exercise, improved diet, and weight loss can help to reduce the
metabolic abnormalities associated with PCOS.
Weight loss 5-10% correct oligoanovulation & improve conception.

Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin


Metformin: treatment of glucose
intolerance, hyperinsulinemia, and sensitivity and decreasing hepatic gluconeogenesis and lipogenesis; it can
anovulation. Reducing circulating therefore be used to help prevent and treat T2DM. Treating these factors can also
insulin levels may secondarily
induce ovulation.
reduce ovarian androgen synthesis. Combined treatment with metformin and clomiphene citrate (see below) more
effective than either agent alone in inducing ovulation.
Source: http://www.pathophys.org/pcos/

Clomiphene

81

Clomiphene citrate is a selective estrogen receptor modulator (SERM). It


induces ovulation by interfering with estrogen feedback to the brain and
thus increasing FSH release. There is increased risk of multigestational
pregnancy (e.g. twins or triplets) because of the large number of antral
follicles in polycystic ovaries. Clomiphene citrate treatment should be
limited to 12 cycles because longer-term treatment is associated with
increased risk of ovarian cancer due to ovarian hyperstimulation.

Gonadotropin therapy: recombinant FSH and


hCG can be used to induce ovulation in
cases where treatment with clomiphene
citrate and metformin has been unsuccessful.

Exogenous gonadoptropins can be administered to mimic physiological


mechanisms of follicle development. FSH is given to promote growth of a
dominant follicle to a particular size, and then human chorionic
gonadotropin is used to induce ovulation.

Ovarian drilling: a laparoscopic surgical


procedure that may be used to treat
clomiphene citrate-resistant anovulation.

Ovarian drilling involves the creation of ~10 perforations in the ovary using
either cautery or laser. The ablation of some of the ovarian theca is thought
to help induce ovulation by decreasing androgen production.

IVF: used for the treatment of infertility in


women who have not responded to other
therapies to induce ovulation.

IVF involves the retrieval of oocytes from the ovaries and in vitro
combination with sperm to produce embryos. Viable embryos are then
transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.

82

Fertility Test
LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.

in premenopusal women, the normal LH-FSH ration is 1:1 as measured on


day three of the menstrual cycle
Variation from this ratio used to diagnose PCOS or other disorders, explain
infertility or verify that woman has entered menopause
FSH stimulates the ovarian follicle to mature. Then a large surge of LH
stimulates the follicle to release an egg to fertilization
On day 3 of the cycle, LH should be low. If LH is elevated on this day,
possible even as high as FSH, then it suggest problem with ovulation.
Ovulation requires an LH surge, and if LH is already elevated, it may not
surge and ovulated

83

Kista Gartner
Kista yang terdapat didinding
lateral vagina
Berkembang dari sisa duktus
mesonephric atau duktus
gartner
Biasanya asimtomatis

85

Kista dan Abses Bartholini


Kista bartholini adalah kista yang
terbentuk akibat sumbatan pada
ductus/ kelenjar bartolini & retensi
sekret
Umum pada wanita umur
reproduksi
Lokasi pada labia mayora.
apabila terinfeksi abses

Abses 3 kali lebih umum dari pada


kista

86

Patologi
Abses Bartholini merupakan
polymikrobal infeksi
Neisseria gonorrhoeaea
yang paling umum
Jika tidak inflamasi
asimtomatik
Simtom: nyeri vulva,
dispareunia, kesulitan
berjalan/olah raga

Isolates from Bartholin's Gland


Abscesses
Aerobic organisms
Neisseria gonorrhoeae
Staphylococcus aureus
Streptococcus faecalis
Escherichia coli
Pseudomonas aeruginos
Chlamydia trachomatis
Anaerobic organisms
Bacteroides fragilis
Clostridium perfringens
Peptostreptococcus
species
Fusobacterium species

87

Patofisiologi
Infeksi bakteri cepat menjadi abses keluar
lewat duktus tersumbat: abses membesar
Radang bisa berulang (68-75%)
Jika menahun terbentuk kista

88

Penatalaksanaan
Asimtomatik tidak perlu terapi

Incisi dan drainase tx cepat & mudah


kemungkinan rekuren
WORD CATHETER

MARSUPIALIZATION
INCISI & DRAINASE

WORD CATHETER
Pembuatan 5 mm incisi pada
kista atau abses
Masukkan kateter Word dan
dikembangkan dengan 2-3 ml
saline selama 3-4 minggu
Jika tidak ada bukti infeksi
tidak perlu antibiotik

89

Marsupialisasi
Membuka rongga tertutup mjd kantong
terbuka.
Untuk cegah kista berulang
Dengan lokal anestesi
Pembuatan insisi vertikal elips 1,5-3 cm
(sesuai garis Langer)
Cukup dalam sampai kulit vestibular
dinding kista
Pengeluaran isi kista dg sendok kuret
kecil sampai bersih
Dinding kista dijahit ke kulit vertibular
dengan jahitan interupted

91

Incisi dan drainase


Dilakukan pada pasien yang tidak respon pada
terapi konservatif tidak ada infeksi aktif

Kekambuhan
Pemasangan balon kateter Word (Kambuh 3-17%)
Marsupialisasi (Kambuh 10-24%)
Eksisi risiko perdarahan

92

Kista Nabothian
Kista nabothian merupakan benjolan kecil di leher
rahim yang berisi cairan.
Benjolan ini terjadi karena adanya penyumbatan
dari kelenjar.
Tidak didapatkan tanda dan gejala apapun, kista
nabothian biasanya di temukan pada saat
pemerikasaan spekulum.
Kista nabothian tidak berbahaya, sehingga tidak
diperlukan pengobatan apapun.

93

INFEKSI KONGENITAL

94

Teratogen: TORCH

95

96

97

TOXOPLASMOSIS

In pregnancy, the most


common mechanisms of
acquiring infection:
1. consuming raw or very
undercooked meats or
contaminated water,
2. exposure to soil
(gardening without
gloves) or
3. Exposure to cat litter

98

99

100

101

102

Amniocentesis should not


be offered at less than 18
weeks gestation
because of the high rate of
false-positive results.

Spiramycin: fetal
prophylaxis
Pyrimethamine folic
acid antagonist. Should
not be used in the first
trimester because it is
potentially teratogenic.
Folinic acid: to
counteract bone
marrow depression by
pyrimethamine

103

Congenital Toxoplasmosis

maternal infection 3 month before conception or during pregnancy

<18 minggu (hingga terbukti tidak ada infeksi pada janin):


Spiramicin: 1g per 8 jam bersama makan

>18 minggu (diberikan sampai lahir):


Pirimetamin 50 mg 2x sehari, selama 2 hari, dilanjutkan 50 mg/hari

Sulfadiazine loading 75 mg/kg, dilanjutkan 50 mg/kg 2x sehari


Asam folat : 10-20 mg/hari hingga 1 minggu bebas pirimetamin

Uptodate.com, medscape

104

105

Rubella

106

After infecting the


placenta, the
rubella virus
spreads to the fetal
vascular system
cytopathic
damage to blood
vessels ischemia

107

Risk of congenital defects:


Before 11 weeks of gestation 90%
13 -14 weeks 11%
15-16 weeks 24%
After 16 weeks 0%

108

109

110

111

CMV

112

Symptomatic CMV infection


113

Petechiae (54 to 76 percent)


Jaundice at birth (38 to 67 percent)
Hepatosplenomegaly (39 to 60 percent)
Small size for gestational age (39 to 50
percent)
Microcephaly (36 to 53 percent)

Sensorineural hearing loss (SNHL, present


at birth in 34 percent)
Lethargy and/or hypotonia (27 percent)
Poor suck (19 percent)
Chorioretinitis (11 to 14 percent)
Seizures (4 to 11 percent)
Hemolytic anemia (11 percent)
Pneumonia (8 percent)

114

115

116

Treatment
Once the diagnosis of congenital CMV infection is
confirmed, one option is pregnancy termination.
A second proposed option: treatment of the mother with
antiviral agents (ganciclovir, foscarnet, and cidofovir.)
These drugs are of moderate effectiveness in treating CMV
infection in the adult
No proven value in preventing or treating congenital CMV
infection.

Source;
http://www.peri
natology.com/e
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
DXMOTHER

The most promising therapy for congenital CMV


infection appears to be hyperimmune globulin.

117

Varicella Syndrome : USG findings


Calcification
o intrahepatic
o Intracranial : may also see liver, heart, and renal

Poly hydramnion : due to neurologic impairment of


swallowing
Limb Hipoplasia
Microcephaly

Varicella Infection

118

Hepatic calcification

Zooster Lesion

Radioulnar hipoplasia and


missing hand

119

Management
Fetal Infection
Amniocentesis (culture or PCR of virus)
Fetal MRI : CNS

Maternal infection symptomatic


Hospitalization in severe case, esp in varicella pneumonia
(emergency case)
Acyclovir 800 mg P.O 5 times a day, for 7 days

Maternal zooster outbreak in pregnancy is not associated with risk


of fetal malformation

120

Gynecology is done.... For now!

Alhamdulillah

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