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2.1. Pap Smear 2.1.1.

Definisi Pap Smear Tes Pap Smear adalah pemeriksaan sitologi dari serviks dan porsio untuk melihat adanya perubahan atau keganasan pada epitel serviks atau porsio (displasia) sebagai tanda awal keganasan serviks atau prakanker (Rasjidi, Irwanto, Sulistyanto, 2008). Pap Smear merupakan suatu metode pemeriksaan sel-sel yang diambil dari leher rahim dan kemudian diperiksa di bawah mikroskop. Pap Smear merupakan tes yang aman dan murah dan telah dipakai bertahun-tahun lamanya untuk mendeteksi kelainan-kelainan yang terjadi pada selsel leher rahim (Diananda, 2009). Pemeriksaan ini mudah dikerjakan, cepat, dan tidak sakit, serta bisa dilakukan setiap saat, kecuali pada saat haid (Dalimartha, 2004). Pap Smear pertama kali diperkenalkan tahun 1928 oleh Dr. George Papanicolou dan Dr. Aurel Babel, namun mulai populer sejak tahun 1943 (Purwoto & Nuranna, 2002). 2.1.2. Manfaat Pap Smear Pemeriksaan Pap Smear berguna sebagai pemeriksaan penyaring (skrining) dan pelacak adanya perubahan sel ke arah keganasan secara dini sehingga kelainan prakanker dapat terdeteksi serta pengobatannya menjadi lebih murah dan mudah (Dalimartha, 2004). Pap Smear mampu mendeteksi lesi prekursor pada stadium awal sehingga lesi dapat ditemukan saat terapi masih mungkin bersifat kuratif (Crum, Lester, & Cotran, 2007). Manfaat Pap Smear secara rinci dapat dijabarkan sebagai berikut (Manuaba, 2005): a. Diagnosis dini keganasan Pap Smear berguna dalam mendeteksi dini kanker serviks, kanker korpus endometrium, keganasan tuba fallopi, dan mungkin keganasan ovarium. b. Perawatan ikutan dari keganasan Pap Smear berguna sebagai perawatan ikutan setelah operasi dan setelah mendapat kemoterapi dan radiasai. c. Interpretasi hormonal wanita Pap Smear bertujuan untuk mengikuti siklus menstruasi dengan ovulasi atau tanpa ovulasi, menentukan maturitas kehamilan, dan menentukan kemungkunan keguguran pada hamil muda. d. Menentukan proses peradangan

Pap Smear berguna untuk menentukan proses peradangan pada berbagai infeksi bakteri dan jamur. 2.1.3. Petunjuk Pemeriksaan Pap Smear American Cancer Society (2009) merekomendasikan semua wanita sebaiknya memulai skrining 3 tahun setelah pertama kali aktif secara seksual. Pap Smear dilakukan setiap tahun. Wanita yang berusia 30 tahun atau lebih dengan hasil tes Pap Smear normal sebanyak tiga kali, melakukan tes kembali setiap 2-3 tahun, kecuali wanita dengan risiko tinggi harus melakukan tes setiap tahun. Selain itu wanita yang telah mendapat histerektomi total tidak dianjurkan melakukan tes Pap Smear lagi. Namun pada wanita yang telah menjalani histerektomi tanpa pengangkatan serviks tetap perlu melakukan tes Pap atau skrining lainnya sesuai rekomendasi di atas. Menurut American College of Obstetricians and Gynecologists (1989) dalam Feig (2001), merekomendasikan setiap wanita menjalani Pap Smear setelah usia 18 yahun atau setelah aktif secara seksual. Bila tiga hasil Pap Smear dan satu pemeriksaan fisik pelvik normal, interval skrining dapat diperpanjang, kecuali pada wanita yang memiliki partner seksual lebih dari satu. Pap Smear tidak dilakukan pada saat menstruasi. Waktu yang paling tepat melakukan Pap Smear adalah 10-20 hari setelah hari pertama haid terakhir. Pada pasien yang menderita peradangan berat pemeriksaan ditunda sampai pengobatan tuntas. Dua hari sebelum dilakukan tes, pasien dilarang mencuci atau menggunakan pengobatan melalui vagina. Hal ini dikarenakan obat tersebut dapat mempengaruhi hasil pemeriksaan. Wanita tersebut juga dilarang melakukan hubungan seksual selama 1-2 hari sebelum pemeriksaan Pap Smear (Bhambhani, 1996). 2.1.4. Prosedur Pemeriksaan Pap Smear Menurut Soepardiman (2002), Manuaba (2005), dan Rasjidi (2008), prosedur pemeriksaan Pap Smear adalah: 1. Persiapan alat-alat yang akan digunakan, meliputi spekulum bivalve (cocor bebek), spatula Ayre, kaca objek yang telah diberi label atau tanda, dan alkohol 95%. 2. Pasien berbaring dengan posisi litotomi. 3. Pasang spekulum sehingga tampak jelas vagina bagian atas, forniks posterior, serviks uterus, dan kanalis servikalis. 4. Periksa serviks apakah normal atau tidak. 5. Spatula dengan ujung pendek dimasukkan ke dalam endoserviks, dimulai dari arah jam 12 dan diputar 360 searah jarum jam.

6. Sediaan yang telah didapat, dioleskan di atas kaca objek pada sisi yang telah diberi tanda dengan membentuk sudut 45 satu kali usapan. 7. Celupkan kaca objek ke dalam larutan alkohol 95% selama 10 menit. 8. Kemudian sediaan dimasukkan ke dalam wadah transpor dan dikirim ke ahli patologi anatomi. 2.1.5. Interpretasi Hasil Pap Smear Terdapat banyak sistem dalam menginterpretasikan hasil pemeriksaan Pap Smear, sistem Papanicolaou, sistem Cervical Intraepithelial Neoplasma (CIN), dan sistem Bethesda. Klasifikasi Papanicolaou membagi hasil pemeriksaan menjadi 5 kelas (Saviano, 1993), yaitu: a. Kelas I : tidak ada sel abnormal. b. Kelas II : terdapat gambaran sitologi atipik, namun tidak ada indikasi adanya keganasan. c. Kelas III : gambaran sitologi yang dicurigai keganasan, displasia ringan sampai sedang. d. Kelas IV : gambaran sitologi dijumpai displasia berat. e. Kelas V : keganasan.

Sistem CIN pertama kali dipublikasikan oleh Richart RM tahun 1973 di Amerika Serikat (Tierner & Whooley, 2002). Pada sistem ini, pengelompokan hasil uji Pap Semar terdiri dari (Feig, 2001): a. CIN I merupakan displasia ringan dimana ditemukan sel neoplasma pada kurang dari sepertiga lapisan epitelium. b. CIN II merupakan displasia sedang dimana melibatkan dua pertiga epitelium. c. CIN III merupakan displasia berat atau karsinoma in situ yang dimana telah melibatkan sampai ke basement membrane dari epitelium. Klasifikasi Bethesda pertama kali diperkenalkan pada tahun 1988. Setelah melalui beberapa kali pembaharuan, maka saat ini digunakan klasifikasi Bethesda 2001. Klasifikasi Bethesda 2001 adalah sebagai berikut (Marquardt, 2002): 1. Sel skuamosa

a. Atypical Squamous Cells Undetermined Significance (ASC-US) b. Low Grade Squamous Intraepithelial Lesion (LSIL) c. High Grade Squamous Intraepithelial Lesion (HSIL) d. Squamous Cells Carcinoma 2. Sel glandular a. Atypical Endocervical Cells b. Atypical Endometrial Cells c. Atypical Glandular Cells d. Adenokarsinoma Endoservikal In situ e. Adenokarsinoma Endoserviks f. Adenokarsinoma Endometrium g. Adenokarsinoma Ekstrauterin h. Adenokarsinoma yang tidak dapat ditentukan asalnya (NOS).

About Pap smears The Pap smear checks for changes in the cells of the cervix (neck of the womb) at the top of the vagina. It is a screening test to find early warning signs that cancer might develop in the future. If abnormal changes are found at screening, further tests may be done to see if treatment is needed.

Key facts: HPV is a virus. Almost all abnormal Pap smear results are caused by HPV. Anyone who has ever had sex can have HPV - its so common that four out of five people will have had HPV at some time in their lives. In most cases, it clears up by itself in one to two years. In rare cases, if left undetected, it can lead to cervical cancer this usually takes about 10 years.

A Pap smear every two years can detect the presence of HPV, which can then be monitored and/or treated to prevent cancer.

The pap smear test is essential in detecting atypia early. It is named after the doctor who made it popular, Dr. Papanicolaou. The aim of a pap smear test is to obtain a specimen from the cervix using a swab, or smear. The specimen is sent to a lab to be analyzed.

Having a Pap smear every two years offers the best chance of preventing cervical cancer. In 2009, 771 Australian women were diagnosed with cervical cancer. The Pap smear is a quick and simple test used to check for changes to the cells of the cervix that may lead to cervical cancer. A doctor or nurse takes a sample of cells from the surface of the cervix and smears them on to a glass slide. The slide is sent to a laboratory for analysis and the results are usually available within a week. Most Pap smear results are normal. A small number show changes in the cells of the cervix, mostly minor infections that usually clear up naturally or are easily treated. In a very small number of cases the abnormality persists and if left untreated, may develop into cervical cancer. When detected early, changes to the cells of the cervix can be treated. Why have a Pap smear? The Pap smear is currently the best test available for the prevention of most cases of cervical cancer. All women between the ages of 18 and 70 should have a Pap smear every two years. Women should start having Pap smears between 18 and 20 years of age or one to two years after becoming sexually active. It is important to know that no screening test is 100 per cent accurate. What about the vaccine for cervical cancer? Cervical cancer mostly occurs as a consequence of a human papillomavirus (HPV) infection. HPV is a common viral infection, affecting at least 75 per cent of sexually active adults at some time in their life. There are more than 200 different types of HPV, but only a few that affect the cervix. Vaccines are now available that prevent the types of HPV infection that cause most cervical cancers. Currently the available vaccines do not protect against all the types of HPV that can cause cervical cancers. All vaccinated and unvaccinated women still need regular Pap smears. What is an unsatisfactory Pap smear? An unsatisfactory Pap smear means that the laboratory staff could not see the cells well enough to give a report. In this case, you may be asked to have a repeat Pap smear. This is not a cause for alarm. What does an abnormal Pap smear result mean? An abnormal Pap smear result means that some cells from your cervix looked different from normal cells. This occurs in around 1 in 10 Pap smears.

It is natural to feel anxious or worried if you have just found out that your Pap smear result is abnormal, however less than one per cent of abnormalities are cancer.

Low grade abnormalities result from slight changes in the cells of the cervix, which may be the result of a mild infection such as thrush or HPV. HPV is present in 99.7 per cent of cervical cancer cases. However, not all HPV infections lead to cervical cancer. Most women dont know they have HPV until they receive an abnormal Pap smear result. For most women the virus clears naturally in one to two years. However, in some cases HPV may take longer to clear from the body, increasing the risk of developing cervical cancer. If you have a low grade abnormality and your previous Pap smears were normal, your doctor will ask you to come back for a repeat Pap smear in one year. This allows time for the body to naturally clear the HPV infection. If the repeat Pap smear result is abnormal you will be referred to a specialist for further investigation, called a colposcopy. The specialist uses a colposcope toget a magnified view of the cervix, to check the extent and nature of any abnormalities. High grade abnormalities can result from more severe changes to the surface layers of the cervix. If leftuntreated they have a greater chance of developing into cervical cancer. It usually takes at least 10 years before high grade abnormalities develop into cervical cancer. If you have a high grade abnormality your doctor will refer you to a specialist for further investigations and treatment. How will I know when to have my next Pap smear? Most doctors have an established recall system to notify you when your next Pap smear is due. Most state health departments have established Pap smear registries that provide a safety net recall system although you can opt out. Remember, if you have any concerns or questions, please contact your doctor. Where can I get reliable information? Cancer Council Helpline 13 11 20 Information and support for you and your family for the cost of a local call anywhere in Australia. National Cervical Screening Program 13 15 56 www.cervicalscreen.health.gov.au

HPV vaccine

Question Pap smear: Do I need one if I'm a virgin? Do virgins need Pap smears? Does a Pap smear cause you to lose your virginity? Answer from Sandhya Pruthi, M.D. If you're a virgin meaning you haven't had sexual (vaginal) intercourse you probably don't need a Pap smear. And even if you do have a Pap smear, it will not cause you to lose your virginity. Although the instruments used to collect the cervical cells may stretch or even tear your hymen the thin tissue covering the vaginal opening, which is present in some women who've never had sex you will only lose your virginity when you have sexual intercourse. The purpose of a Pap smear is to collect cells from your cervix, which is the lower end of your uterus. The cells collected in a Pap smear can detect if you have cervical cancer or suspicious cells that indicate you may develop cervical cancer. In most cases, cervical cancer is caused by a sexually transmitted infection called human papillomavirus (HPV). If you've never had any type of sexual intercourse, you're unlikely to have HPV. However, there are other risk factors for developing cervical cancer, such as family history and smoking, so talk to your doctor if you have concerns. For effective cervical cancer screening, the American Cancer Society recommends that all women have an initial Pap smear by the age of 21, regardless of whether or not they've had sexual intercourse, or after they've been sexually active for three years, whichever comes first. The American College of Obstetricians and Gynecologists recommends that women begin having Pap smears at age 21, regardless of when they become sexually active.

Definition By Mayo Clinic staff Pap test

A Pap smear, also called a Pap test, is a procedure to test for cervical cancer in women. A Pap smear involves collecting cells from your cervix the lower, narrow end of your uterus that's at the top of your vagina. Detecting cervical cancer early with a Pap smear gives you a greater chance at a cure. A Pap smear can also detect changes in your cervical cells that suggest cancer may develop in the future. Detecting these abnormal cells early with a Pap smear is your first step in halting the possible development of cervical cancer. Why it's done By Mayo Clinic staff A Pap smear is used to screen for cervical cancer. The Pap smear is usually done in conjunction with a pelvic exam. In women older than age 30, the Pap smear may be combined with a test for human papillomavirus (HPV) a common sexually transmitted infection that can cause cervical cancer in some women. Who should have a Pap smear? You and your doctor can decide when it's time for you to begin Pap smear testing and how often you should have the test. In general, doctors recommend beginning Pap smear testing at age 21 and then every two or three years. After age 30, Pap smears are generally recommended every three years, or every five years when the Pap smear is combined with an HPV test. If you have certain risk factors, your doctor may recommend more-frequent Pap smears, regardless of your age. These risk factors include: A diagnosis of cervical cancer or a Pap smear that showed precancerous cells Exposure to diethylstilbestrol (DES) before birth HIV infection Weakened immune system due to organ transplant, chemotherapy or chronic corticosteroid use

You and your doctor can discuss the benefits and risks of Pap smears and decide what's best for you based on your risk factors.

What do medical organizations recommend? A number of organizations have recommendations regarding when and how frequently a woman should have Pap smears. These guidelines differ slightly because each organization takes different factors into consideration. The guidelines are recommendations for you and your doctor to consider and discuss. In general, groups agree that you should have your first Pap smear at age 21: The American Cancer Society (ACS) recommends having your first Pap smear at age 21. The American Congress of Obstetricians and Gynecologists (ACOG) recommends having your first Pap smear at age 21. The U.S. Preventive Services Task Force (USPSTF) recommends that women begin Pap smear testing at age 21. The Institute for Clinical Systems Improvement (ICSI) recommends that women begin Pap smear testing at age 21.

Groups' guidelines differ for how often the tests should be done. Age 21 29 30 and older ACS Every 3 years Every 3 years, or every 5 years when Pap smear is combined with an HPV test women at high risk may need to be screened more often ACOG Every 3 years Every 3 years, or every 5 years when Pap smear is combined with an HPV test women at high risk may need to be screened more often USPSTF Every 3 years Every 3 years, or every 5 years when Pap smear is combined with an HPV test ICSI Every 2 years Every 3 years if you've had 3 negative tests in a row

Who can consider stopping Pap smears? Discuss your screening options with your doctor. In certain situations a woman and her doctor may decide to end Pap testing, such as: After total hysterectomy. After a total hysterectomy surgical removal of the uterus including the cervix ask your doctor if you need to continue having Pap smears. If your hysterectomy was performed for a noncancerous condition, such as uterine fibroids, you may be able to discontinue routine Pap smears. But if your hysterectomy was for a precancerous or cancerous condition of the cervix, your doctor may recommend continuing routine Pap smears.

Older age. Groups agree that older women may consider stopping routine Pap tests. ACS guidelines suggest a woman older than age 65 can stop having tests if she's had regular screenings with normal results. USPSTF guidelines recommend against Pap testing for women older than age 65 who have had routine Pap testing in the past and are not at high risk of cervical cancer. ICSI guidelines recommend women ages 65 to 70 may consider stopping Pap testing if their last three tests have been negative and they've had no abnormal tests in 10 years. ACOG guidelines say that women older than age 65 can stop Pap tests if they've had three consecutive negative Pap tests in the last 10 years, or two consecutive negative Pap tests combined with negative HPV tests in the last 10 years, with the most recent test performed within the past 5 years. Discuss your options with your doctor and together you can decide what's best for you based on your risk factors. If you are sexually active with multiple partners, your doctor may recommend continuing Pap smear testing. Risks By Mayo Clinic staff A Pap smear is a safe way to screen for cervical cancer. However, a Pap smear isn't foolproof. It's possible to receive false-negative results meaning that the test indicates no abnormality, even though you do have abnormal cells. A false-negative result doesn't mean that a mistake was made. Factors that can cause a falsenegative result include: An inadequate collection of cells A small number of abnormal cells Blood or inflammatory cells obscuring the abnormal cells

Although it's possible for abnormal cells to go undetected, time is on your side. Cervical cancer takes several years to develop. And if one test doesn't detect the abnormal cells, the next test most likely will. How you prepare By Mayo Clinic staff To ensure that your Pap smear is most effective, follow these tips prior to your test: Avoid intercourse, douching or using any vaginal medicines or spermicidal foams, creams or jellies for two days before having a Pap smear, as these may wash away or obscure abnormal cells. Try not to schedule a Pap smear during your menstrual period. Although the test can be done, it's best to avoid this time of your cycle, if possible.

Results

By Mayo Clinic staff Bottom of Form The Pap smear can alert your doctor to the presence of suspicious cells that need further testing. Normal results If only normal cervical cells were discovered during your Pap smear, you're said to have a negative result. You won't need any further treatment or testing until you're due for your next Pap smear and pelvic exam. Abnormal results If abnormal or unusual cells were discovered during your Pap smear, you're said to have a positive result. A positive result doesn't mean you have cervical cancer. What a positive result means depends on the type of cells discovered in your Pap smear. Here are some terms your doctor might use and what your next course of action might be: Atypical squamous cells of undetermined significance (ASCUS).Squamous cells are thin and flat and grow on the surface of a healthy cervix. In the case of ASCUS, the Pap smear reveals slightly abnormal squamous cells, but the changes don't clearly suggest that precancerous cells are present. With the liquid-based test, your doctor can reanalyze the sample to check for the presence of viruses known to promote the development of cancer, such as some types of human papillomavirus (HPV). If no high-risk viruses are present, the abnormal cells found as a result of the test aren't of great concern. If worrisome viruses are present, you'll need further testing. Squamous intraepithelial lesion. This term is used to indicate that the cells collected from the Pap smear may be precancerous. If the changes are low grade, it means the size, shape and other characteristics of the cells suggest that if a precancerous lesion is present, it's likely to be years away from becoming a cancer. If the changes are high grade, there's a greater chance that the lesion may develop into cancer much sooner. Additional diagnostic testing is necessary. Atypical glandular cells. Glandular cells produce mucus and grow in the opening of your cervix and within your uterus. Atypical glandular cells may appear to be slightly abnormal, but it's unclear whether they're cancerous. Further testing is needed to determine the source of the abnormal cells and their significance. Squamous cell cancer or adenocarcinoma cells. This result means the cells collected for the Pap smear appear so abnormal that the pathologist is almost certain a cancer is present. "Squamous cell cancer" refers to cancers arising in the flat surface cells of the vagina or cervix. "Adenocarcinoma" refers to cancers arising in glandular cells. If such cells are found, your doctor will recommend prompt evaluation.

If your Pap smear is abnormal, your doctor may perform a procedure called colposcopy using a special magnifying instrument (colposcope) to examine the tissues of the cervix, vagina and vulva. Your doctor also may take a tissue sample (biopsy) from any areas that appear abnormal. The tissue sample is then sent to a laboratory for analysis and a definitive diagnosis.

CERVICAL CANCER SCREENING, TREATMENT & PREVENTION

PAP SMEAR

Cervical cancer screening involves routine Pap smears aimed at women with no symptoms. It is a simple painless test in which cells from the cervix and vagina are examined for any abnormalities that could lead to cancer. Fortunately, some early changes in the cervix can be seen long before cancer develops (pre-cancer stage). Once these changes are treated, cancer can be prevented. It is recommended that all women who have ever had sexual intercourse should have regular Pap smears so that problems can be detected early and thus treated before they become serious.

COLPOSCOPY

Colposcopy is a way of looking at the cervix through a special magnifying device. This allows us to find problems that cannot be seen by the eye alone. It is a relatively painless procedure in which the cervix is examined under magnification after a mild vinegar-like solution (acetic acid) is applied to the cervix. Biopsies of abnormal areas are taken for further evaluation and treatment can be performed based on these results. The methods of treating pre-cancerous changes of the cervix include laser vaporization, LEEP and cone biopsy with laser, diathermy or knife.

LEEP (LOOP ELECTROSURGICAL EXCISION PROCEDURE) AND CONE BIOPSY

LEEP or cone biopsy are minor surgical procedures that involve removal of a cylindrical or cone-shaped piece of cervix in which abnormal cells are located by using a heated electrical loop wire or with a laser, diathermy or knife respectively. For your comfort, a local anaesthetic is administered prior to the LEEP procedure which takes about 15 minutes. An anaesthetist will discuss the types of pain-relief available to you during your cone biopsy which lasts approximately 20 minutes.

CERVARIX AND GARDASIL HUMAN PAPILLOMA VIRUS (HPV) VACCINATION

Cervical cancer is the 2nd most common cancer worldwide in women over 15 years of age. Worldwide every 2 minutes a woman dies of cervical cancer. About 500,000 women globally are diagnosed with cervical cancer with an average of 270,000 deaths a year. Sexually active women may be at risk of being affected by cervical cancer or the early stages of the disease irrespective of age and lifestyle. Cervical cancer is the 2nd most common female cancer in Asia and the 7th most common cause of cancer deaths among Singaporean women. There are over 100 identified types of Human Papilloma Virus (HPV), most of which are harmless and asymptomatic. HPV is spread through sexual contact targeting the genitals. There are 15 cancer-causing types which can lead to cervical cancer; HPV 16 and 18 together cause more than 70% of all cervical cancers in Asia Pacific and worldwide.

Cancer-causing HPV types 16, 18, 45 and 31 together account for over 80% of cervical cancer cases in Asia Pacific.

Cervarix

Cervarix cervical cancer vaccine provides protection against HPV types 16 and 18 associated pre-cancerous lesions and cancer. Cervarix uses the ASO4 adjuvant system technology which induces a stronger and more sustained immune response. Cervarix with AS04 provides cross protection against infection of HPV 45 & 31, which are the 3rd and 4th most common types found in cervical cancer globally. Cervarix vaccine is indicated in females for prevention of cervical cancer by protecting against incident and persistent infections as well as lesions caused by cancer-causing HPV types 16 and 18. The primary vaccination course consists of three doses, given at 0, 1 and 6 months. It is not a substitute for routine Pap smears for cervical cancer screening.

Gardasil

Gardasil is a vaccine that helps protect against HPV types 6, 11, 16 and 18 which are associated with cervical, vaginal, vulva and anal cancer, precancerous changes of the cervix and vulva, and genital warts. It is estimated that in the absence of vaccination, the majority of sexually active people will be infected by HPV during their lifetime. Many people who have HPV may not show any signs or symptoms, hence they may transmit the virus unknowingly. Both men and women can receive Gardasil. The vaccine works best when given to persons with no prior HPV contact although possible benefits can be derived in persons who may have had previous HPV exposure. It is given as an injection and a complete course consists of 3 doses where the 2nd and 3rd doses are administered 2 months and 6 months after the 1st dose respectively. This vaccine helps prevent but does not treat these diseases. It is not a substitute for routine Pap smears for cervical cancer screening.

2.1 Deteksi Dini Kanker Leher Rahim 2.1.1 Tes PAP Pap smear (juga dikenal sebagai tes Pap) adalah suatu tindakan medis yang mana mengambil sampel sel dari serviks (leher rahim) seorang wanita (serviks merupakan bagian ujung dari uterus yang masuk ke dalam vagina), kemudian dioleskan pada slide. Sel tersebut diperiksa dengan mikroskop untuk mencari lesi prakanker atau perubahan keganasan. Tindakan pap smear sangat mudah, cepat dan tidak atau relatif kurang rasa nyerinya. Pemeriksaan ini spesifitas dan sensitifitasnya tidak terlalu tinggi, sehingga ada beberapa wanita berkembang menjadi kanker leher rahim meskipun secara teratur melakukan pemeriksaan test Pap. Tes ini memerlukan prasarana yang lengkap dan kompleks yaitu : Materi (slide, spatula), Reagents, Mikroskop, tehnisi sitologi / ahli patologi terlatih, Pengiriman slide yang handal ke lokasi pengujian dan pembacaan slide. Jika salah satu komponen tidak ada, seluruh program tidak berjalan. Program skala kecil akan mengalami biaya yang lebih besar. (FK.UI.,dll., 2007) Telah diakui bahwa pemeriksaan tes Pap mampu menurunkan kematian akibat kanker serviks di beberapa negara, walaupun tentu ada kekurangan. Sensitivitas dan Spesifisitas Tes Pap bervariasi dari 50-98%. ( Nuranna, 2001) 2.1.2 Kajian Terhadap Berbagai Metode Pemeriksaan Alternatif Kanker Leher Rahim Beberapa metode pemeriksaan kanker leher rahim selain Tes Pap telah dikenal, antara lain: Kolposkopi, Servikologi, Pap Net (dengan komputerisasi), Tes molekul DNA- HPV. Dan hingga metode skrining yang lebih sederhana, yaitu : Inspeksi visual dengan asam asetat (IVA) dan Inspeksi visual dengan asam asetat dan pembesaran gineskopi (IVAB) Kolposkopi Pemeriksaan melihat porsio (juga vagina dan vulva) dengan pembesaran 10-15x; untuk menampilkan porsio, dipulas terlebih dahulu dengan asam asetat 3-5%. Pada porsio dengan kelainan (infeksi Human Papilloma Virus atau Neoplasia Intraepitel Serviks) terlebih bercak putih atau perubahan corakan pembuluh darah. Kolposkopi dapat berperan sebagai alat skrining awal, namun ketersediaan alat ini terbatas karena mahal. Oleh karena itu alat ini lebih sering digunakan dalam prosedur pemeriksaan lanjut dari hasil tes pap abnormal. Servikografi Pemeriksaan kelainan di porsio dengan membuat foto pembesaran porsio setelah dipulas dengan asam asetat 3-5% yang dapat dilakukan oleh bidan. Hasil foto serviks dikirim ke ahli genokologi (yang bersertifikat untuk menilai) Pap Net (dengan komputerisasi)

Pada dasarnya pemeriksaan Pap Net berdasarkan pemeriksaan slide Tes Pap. Bedanya untuk mengidentifikasi sel abnormal dilakukan secara komputerisasi. Slide hasil Tes Pap yang mengandung sel abnormal dievaluasi ulang oleh ahli patologi/sitologi. Saat ini dijaringan Pap net yang ada di Indonesia slidenya dikirim ke Hongkong. Tes DNA-HPV Telah dibuktikan bahwa lebih 90% kondiloma serviks, NIS (Neoplasia Intraepitel Serviks) dan kanker leher rahim mengandung DNA-HPV. Hubungannya dinilai kuat dan tipe HPV mempunyai hubungan patologi yang berbeda Tipe 6 dan 11 termasuk tipe HPV resiko rendah jarang ditemukan pada karsinoma infasif kecuali karsinoma verukosa. Sementara itu tipe 16, 18, 31, dan 45 tergolong tipe risiko tinggi. ( Nuranna, 2001) Inspeksi Visual dengan Asam Asetat (IVA) Pemeriksaan visual exocervix, SCJ (squamocolumnar junction), dan kanal endocervix dengan mata telanjang (tanpa pembesaran) dengan asam asetat. Hanya digunakan sebagai tes penapisan. Laporan hasil : Tes-positif, Tes-negatif, Dicurigai kanker. (FK.UI.,dll., 2001) Inspeksi Visual dengan Asam Asetat dan pembesaran gineskopi (IVAB) Gineskopi menggunakan teleskop monokuler, ringan dengan pembesaran 2.5 x dapat digunakan untuk meningkatkan deteksi dini dengan sitologi. Biopsi atau pemeriksaan kolposkopi dapat segera disarankan bila tampak daerah berwarna putih dengan pulasan asam asetat. ( Azis, 2001) 2.1.3 IVA (Inspeksi Visual dengan Asam Asetat) Sebagai Metode Pemeriksaan Alternatif Yang Sesuai Untuk Indonesia Pemikiran perlunya metode pemeriksaan alternatif dilandasi oleh fakta, bahwa temuan sensitifitas dan spesitifitas tes Pap bervariasi dari 50-98%. Selain itu juga kenyataannya skrining massal dengan tes Pap belum mampu dilaksanakanantara lain karena keterbatasan ahli patologi/sitologi dan teknisi sitologi. Manfaat dari IVA antara lain : memenuhi kriteria tes penapisan yang baik, penilaian ganda untuk sensitivitas dan spesifitas menunjukkan bahwa tes ini sebanding dengan Pap smear dan HPV atau kolposkopi. (FK.UI.,dll., 2007) Mengkaji masalah penanggulangan kanker leher rahim yang ada di Indonesia dan adanya pilihan metode yang mudah diujikan diberbagai negara , agaknya metode IVA (Inspeksi Visual dengan Asam Asetat) layak dipilih sebagai metode pemeriksaan alternatif untuk kanker leher rahim. Pertimbangan tersebut didasarkan oleh pemikiran, bahwa metode pemeriksaan iva itu . - Mudah, praktis dan sangat mampu dilaksanakan.

- Dapat dilaksanakan oleh Tenaga Kesehatan bukan Dokter Ginekologi, dapat dilakukan oleh bidan disetiap tempat pemeriksaan kesehatan ibu. - Alat-alat yang dibutuhkan sangat sederhana. - Metode skrining IVA sesuai untuk pelayanan sederhana. 2.1.4 Prosedur Diagnosis IVA A. Siapa Yang Harus Menjalani Tes IVA Menjalani tes kanker atau pra-kanker dianjurkan bagi semua wanita berusia 30 dan 45 tahun. Kanker leher rahim menempati angka tertinggi diantara wanita berusia antara 40 dan 50 tahun, sehingga tes harus dilakukan pada usia dimana lesi pra-kanker lebih mungkin terdeteksi, biasanya 10 sampai 20 tahun lebih awal. Sejumlah faktor resiko yang berhubungan dengan perkembangan kanker leher rahim, diantaranya sebagai berikut: - Usia muda saat pertama kali melakukan hubungan seksual (usia<20) - Memiliki banyak pasangan seksual (wanita atau pasangannya) - Riwayat pernah mengalami IMS (Infeksi Menular Seksual), seperti Chlamydia atau gonorrhea, dan khususnya HIV/AIDS - Ibu atau saudara perempuan yang memiliki kanker leher rahim - Hasil Pap Smear sebelumnya yang tak normal - Merokok Selain itu, ibu yang mengalami masalah penurunan kekebalan tubuh (mis., HIV/AIDS) atau mengunakan costicosteroid secara kronis (mis.,pengobatan asma atau lupus) berisiko lebih tinggi terjadinya kanker leher rahim jika mereka memiliki HPV. (FK.UI.,dll., 2007) B. Kapan Harus Menjalani Tes IVA Tes IVA dapat dilakukan kapan saja dalam siklus menstruasi, termasuk saat menstruasi, pada masa kehamilan dan saat asuhan nifas atau paska keguguran. Tes tersebut dapat dilakukan pada wanita yang dicurigai atau diketahui memiliki IMS atau HIV/AIDS. Bimbingan diberikan untuk tiap hasil tes, termasuk ketika konseling dibutuhkan. Untuk masing-masing hasil akan diberikan beberapa instruksi baik yang sederhana untuk ibu tersebut (mis., kunjungan ulang untuk tes IVA setiap 1 tahun secara berkala atau 3/5 tahun paling lama) atau isu-isu khusus yang harus dibahas seperti kapan dan dimana pengobatan

dapat diberikan, risiko potensial dan manfaat pengobatan, dan kapan perlu merujuk untuk tes tambahan atau pengobatan yang lebih lanjut. C. Penilaian Klien Tanyakan riwayat singkat kesehatan reproduksinya, antara lain: - Riwayat menstruasi - Pola pendarahan (mis.; paska coitus atau mens tak teratur) - Paritas - Usia pertama kali berhubungan seksual - Penggunaan alat kontrasepsi D. Peralatan dan Bahan Lain IVA dapat dilakukan di klinik manapun yang mempunyai sarana sebagai berikut ini: - Meja periksa - Sumber cahaya/lampu - Spekulum Bivalved (Cusco or Graves) - Rak atau wadah peralatan Bahan-bahan yang diperlukan untuk melakukan tes IVA harus tersedia di tempat: - Kapas swab digunakan untuk menghilangkan mukosa dan cairan keputihan dari serviks (leher rahim) dan untuk mengoleskan asam asetat ke leher rahim. - Sarung tangan periksa harus baru - Spatula kayu; digunakan untuk mendorong dinding lateral dari vagina jika menonjol melalui bilah spekulum. - Asam asetat; adalah bahan utama cuka. Larutan asam asetat (3-5%) Untuk melakukan IVA, petugas mengoleskan larutan asam asetat pada leher rahim. Larutan tersebut menunjukkan perubahan pada sel-sel yang menutupi leher rahim (sel-sel epithel) dengan menghasilkan reaksi acetowhite. Pertama-tama petugas melakukan menggunakan spekulum untuk memeriksa leher rahim, lalu dibersihkan untuk menghilangkan keputihan, kemudian asam asetat dioleskan secara merata pada serviks. Setelah minimal 1 menit, serviks dan seluruh SSK (sambungan

skuamokolumner), sebagai sambungan antara epitel skuamous dan epitel glanduler diperiksa untuk melihat apakah terjadi perubahan acetowhite. hasil tes (positif atau negatif) harus dibahas bersama ibu, dan pengobatan harus diberikan setelah konseling, jika diperlukan dan tersedia. Tabel 1. Klasifikasi IVA Sesuai Temuan Klinis KLASIFIKASI IVA TEMUAN KLINIS Hasil Tes-postif Hasil Tes-Negatif Kanker Plak putih yang tebal atau epitel acetowhite, biasanya dekat SSK (sambungan skuamokolumner) Permukaan polos dan halus, berwarna merah jambu; ectropion, polyp, cervicitis, imflammation, nabothian cysts Massa mirip kembang kol atau bisul.

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