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GYNECOLOGY

dr. Nashria
dr. Reagan Resadita
Siklus
Infeksi
Keganasan
2 Menstruasi Infertilitas
Kongenital
Abnormal
Menstruasi Toxoplasmosis
Serviks Analisis Sperma
Perdarahan
Uterus Abnormal
Rubella
Polycystic
Korpus Uteri Endometriosis ovarian
syndrome
CMV
Amenorrhea
Tes Fertilitas
Ovarium
Wanita Varicella
Menopause
Neoplasma
3 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
Peningkatan tekanan pada
mioma uteri menyebabkan
nyeri punggung belakang, Gejala vulvovaginal
obstipasi dan retensi urin Lokasi Tersering
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
Tumor Serviks Uteri
lokasi: Berada di 1/3 bawah uterus, dibawah os cervicalis interna
4
Klasifikasi Faktor Resiko
Tumor Benigna Infeksi HPV tipe16, 18, 45 dan 56
Leiomyoma (myoma) Status sosial ekonomi
Menikah/ memulai aktivitas seksual
Tumor Maligna pada usia muda (kurang 20 tahun)
A. Karsinoma serviks Berganti ganti pasangan seksual.
1. Squamous cell Berhubungan seks dengan laki laki
carcinoma 91 % yang berganti ganti pasangan
2. Adenocarcinoma Riwayat infeksi di daerah kelamin
3. Adenosquamous atau radang panggul
carcinoma Perempuan yang melahirkan banyak
4. Adenoacanthoma anak
Perempuan perkokok(2,5x lebih
B. Sarcoma ( sangat tinggi)
jarang)
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
7
Tanda Klinis & Gejala Pencegahan
8 Tanda Klinis Primer: Gaya hidup sehat
Nodul, ulkus, erosi serviks dan vaksinasi HPV
(kuadrivalen- genotipe 6,
Advanced: crater-shaped 11, 16 &18 ; bivalen- genotipe 16
ulcer with high or friable &18)
warty mass
Perdarahan Sekunder: Skrining untuk lesi
pra kanker & diagnosis awal
Mobilitas serviks tergantung diikuti dengan terapi
derajat ca
Gejala Tersier: Diagnosis dan
Perdarahan vagina, rektal, terapi dari kanker yang
urethra terbukti. Terapi: operasi,
Penekanan:obstipasi, anuria radiotherapy dan
hidronefrosis gagal ginjal terkadang chemotherapy.
uremia
Dianjurkan paliatif jika tidak
Infeksi:discar vagina yang bau
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 Kecuali...
stated screening may stop at age 65 if : Women at increased risk
11
recent normal smears
not at high risk for cervical cancer. of CIN :
The American Cancer Society guideline stated that 1. in utero DES
women age 70 or older may elect to stop cervical (diethylstilbestrol)
cancer screening if : exposure,
had three consecutive satisfactory, 2. immunocompromise,
normal/negative test results and no abnormal 3. a history of CIN II/III or
test results within the prior 10 years. 4. Cancer
Not recommended in women who have had total should continue to be
hysterectomies for benign indications (presence of screened at least
CIN II or III excludes benign categorization). annually.
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
ACOG guideline 2008
woman acquires risk factors for intraepithelial
neoplasia, such as new sexual partners or
immunosuppression.
Screening for Cervical Cancer Pap Smear
12
Mendeteksi perubahan Keluhan Lesi anatomis Rekomendasi
pada morphology skrining
sel(dysplasia) yang
merupakan precursors
dari carcinoma.
- - IVA
Syarat: + - PAP SMEAR
Lakukan Paps smear
pada fase proliferasi (1 + + Biopsi
minggu setealah mens
berakhir) Unreliable Pap smear due to inflammation:
Tidak melakukan First, diangose and treat inflammation
hubungan sexual 24-48
jam sebelum paps smear Repeat pap smear after the condition resolves to diminish
the false positive result.
Tidak menggunakan
lubrikan vagina.
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 high-
grade 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 Perusakan sel sel
16
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 Tanda dan Gejala
18
Leiomyoma (myoma): Menorrhagia heavy &
Paling sering (sel otot halus) prolonged menstruation
Etiological factors: (common)
estrogen, ras kulit hitam, Pelvic pressureurinary
nullipara frequency, constipation
Spontaneous abortion, Infertility
Type of Leiomyoma
1. Submucous : beneath A palpable abdominal tumor :
endometrium, if arising from pelvis, well defined
pedunculated margins , firm consistency, smooth
geburt myoma surface, mobile from side to side.
2. Intramural/interstitial: Pelvic examinationUterus
within uterine wall enlarged and irregular, hard
3. Subserous/subperitone Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
al: at the serosal
Terapi
surface or bulge Observation: for small myoma,
outward from premenopause
myometriuml ; if Operation : myomectomy or
pedunculated : satelite hysterectomy
myoma Whorl like pattern / Pusaran air
19
Influencing factors of Myoma Uterine
Specific Signs of Uterine Fibroid
20
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 Tumor Ovarium Ovarian teratoma
Mortalitas tinggi dari semua tumor gyn (silent
22
A. Karsinoma endometrium lady killer) Bizarre tumor, biasanya
75% terjadi pada periode pos Gejala benigna, rata2 mengenai wanita
menopause Low abdominal discomfort (fullness, di usia 30 tahun
bowel symptom)
Etiologi: paparan estrogen terlalu
Loss of weight, malaise, anorexia
banyak, obesitas, manopause Kista dermoid berkembang dari
Pain due to torsion, hemorage or
terlambat, PCOS, estrogen rupture sel germinal totipotensial (oosit
secreting ovarian tumor, konsumsi Pressure symptom primer) yang tetap berada di
estrogen dari luar, diabetes dan Benign Tumor ovarium, sehingga berkembang
hipertensi Small can be felt by bimanual menjadi semua bentuk sel matur
Adenokarsinoma endometrium Medium may have long pedicle and seperti rambut, gigi, tulang,
rise out of pelvis
Adenoacanthoma jaringan saraf.
Benign mucinous cyst may be vary in
Karsinoma adenoskuamos size
B. Sarkoma uteri Benign teratoma cyst the commonest
1. Leiomiosarkoma undergo torsion

2. Tumor mesodermal campuran Benign solid tumor are less common

3. Sarkoma stromal endometrium Meig syndrome : solid tumor, ascites,


pleural effusion
Kejadiannya sangat jarang Malignant Tumor
Diagnosis Early detection would improve
Perdarahan post menopause prognosis, bimanual, USG or tumor
marker
Siklus menstruasi iregular
Curretage
23
24
Siklus Menstruasi Abnormal
Menstrual cycle
25

Image source:https://embryology.med.unsw.edu.au/
FSH LH
26 LH mempertahankan korpus luteum
Hormon yang diproduksi oleh
hipofisis akibat rangsangan untuk tetap menghasilkan ovarium.
dari GnRH. Dibawah pengaruh LH, korpus luteum
FSH akan menyebabkan mengeluarkan estrogen dan
pematangan dari folikel. progesteron, dengan jumlah
Dari folikel yang matang akan progesteron jauh lebih besar.
dikeluarkan ovum. Kemudian Kadar progesteron meningkat dan
folikel ini akan menjadi korpus mendominasi dalam fase luteal,
luteum dan dipertahankan sedangkan estrogen mendominasi
untuk waktu tertentu oleh LH fase folikel.
Walaupun estrogen kadar tinggi
merangsang sekresi LH, progesteron
dengan kuat akan menghambat
sekresi LH dan FSH.
Progesteron
27
Estrogen
Hormon ini diproduksi oleh korpus
Estrogen dihasilkan oleh luteum.
ovarium. Progesteron mempertahankan
Estrogen berguna untuk ketebalan endometrium sehingga
pembentukan ciri-ciri dapat menerima implantasi zygot.
perkembangan seksual pada Kadar progesteron terus
wanita yaitu pembentukan dipertahankan selama trimester awal
payudara, lekuk tubuh, kehamilan sampai plasenta dapat
rambut kemaluan. membentuk hormon HCG.
Estrogen juga berguna pada
siklus
membentuk
menstruasi dengan
ketebalan
GnRH
endometrium, menjaga GnRH merupakan hormon yang diproduksi oleh
kualitas dan kuantitas cairan hipotalamus di otak.
cerviks dan vagina sehingga GnRH akan merangsang pelepasan FSH (Folicle
sesuai untuk penetrasi sperma. 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 >> kadar
berikutnya progesterone 2ng/ml
Tanda dan tes : LH surge (dg
Rasa sakit di perut bawah (mid cycle
Radioimunoassay)
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

Malignancy and
Polyp Adenomyosis leiomyoma
hyperplasia

Coagulopathy Ovulatory disorder 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
Von Willebrand disease
36
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
Dysmenorrhea
40
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
Dysmenorrhea beginning in the 20s or 30s, after previous
41
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.
42 Endometriosis
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: Dysmenorrhea
severe dysmenorrhea, dyspareunia, Heavy or irregular bleeding
chronic pelvic pain, Cylical/noncylical pelvic pain
infertility 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 Imaging studies
sensitivity, specificity, and
Transvaginal or endorectal USG may reveal US
Predictive value in diagnosis
feature varying from cyst with internal echoes to
endometriosis.
solid masses, usually devoid of vascularity
Combination of History, Physical
CT may reveal endometrioma appearing as cystic
exam and laboratory and
masses; however, apperance are non specific and
diagnostic studies is indicated to
imaging modalities should not be relied upon on for
determine cause of pelvic pain
diagnosis
and rule out non endometriosis
concerns MRI : may detect even smallest lesion and
distinguish hemorragic signal of endometrial
Pain mapping may help isolate
implant
location spesific disease such as
nodulas masses in posterior MRI demonstrated to accurately detect
rectovaginal septum rectovaginal disease and obliteration in more than
90% of cases when USG gel was inserted in the
Absence of evidence during exam
vaginal and rectum
is not evidence of disease absence
Endometriosis therapy
45
Medical Therapies Indications for surgical management:
Gonadotropin-releasing
hormone agonists (GnRH), Diagnosis of unresolved pelvic
oral contraceptives, pain
Danazol, Severe, incapacitating pain with
aromatase inhibitors, significant functional impairment
Progestins and reduced quality of life
Advanced disease with
anatomic impairment
Surgical Intervention (distortion of pelvic organs,
Laparoscopy endometriomas, bowel or
Hysterectomy/Oophorect bladder dysfunction)
omy/Salpingo- Failure of expectant/medical
management
oophorectomy Endometriosis-related
emergencies, ie, rupture or
Nonsurgical Therapies torsion of endometrioma, bowel
Medical Therapies obstruction, or obstructive
Alternative Therapies uropathy
46 Endometriosis therapy

Mild Moderate Pain Moderate-Severe Pain


NSAID GnRH agonis
Oral contraceptive Danazole
progestin Aromatase inhibitor
47 Endometriosis therapy
Oral contraceptive Non Steroidal Anti Progestins
Inflamatory
Generally well tolerated, Inhibit growth of lesion by infucing
fewer metabolic and Proven efficacy fot ecidualization followed by
treatment of primary athropy uterine type tissue
hormonal side effect than
similar therapies dismenorhea Compared to GnRH therapy,
both modalities show
Relieve dismenorrhea throuh Acceptable side
comparable effectiveness
ovarian supresion and effects
continous progestin Medroxyprogesterone acetat
Reasonable cost proven for pain suppresion both
administration
Ready availability oral and injectable
Often simple, effective Adverse effect : weight gain, fluid
choice to manage retention, depresion, breakhrough
endometriosis through bleeding
avoidance or delay menses
for upwards of 2 years
48 Endometriosis therapy
Aromatase Inhibitor GnRH agonist Danazol
Endometriotic implan express Produced hypogonadic state Among oldest of medical
aromatase and consequently through down regulation of therapy for endometriosis
generate esterogen, maintaining pituitary gland
own viability Inhibit midcycle FSH and
Efective as other therapies in LH surge and prevent
Inhibit local esterogen production relieving pain and reduce steroidogenesis in corpus
in endometrioticimplant progression luteum
Significantly reduce pain, No fertility improvement Higher incidence of
compared with GnRH agonit adverse effect more
High cost, bone density loss,
alone. recent therapy
intolerable hypoesterogeninc
side effect Androgenic manifestation
Preoperative therapy reported (oily skin, ane, weight gain,
to reduce pelvic vascularity deepening voice,
and size of lesion, reduce hirsutism) maybe
intraoperative blood loss intolerable
Amenorrhea
49
Amenorrhea is the absence of
menstruation.
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 Definition
51 Definisi heavy
Prolonged menstrual
bleeding
menstrual
Menstrual period exceeding 8 days inbleeding dkk
duration on regular basis

Shortened menstrual Uncommon, define as bleeding of no longer than 2 days


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

Absent menstrual bleeding No bleeding in a 90 days period


(amenorhea)
Infrequent menstrual One or two episode in a 90 day period
bleeding
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 Less common than HMB, its important to make a distinction from HMB
menstrual bleeding 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 Episode of bleeding in a woman of reproductive age, who is not
Bleeding pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss

Chronic Abnormal uterine Bleeding from the uterine corpus that is abnormal in duration,
bleeding volume, and/or frequency and has been present for the majority of
the last 6 month
Irregular Non Menstrual Irregular episode of bleeding, often light and short, occurring
Bleeding 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.
Menopause
58
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
III. Symptoms of Menopause:
63

1. Hot flushes - cutaneous 3. Psychological changes


vasodilation decreased level of
- occurs in 75% of central
women neurotransmitters
- more severe after - Depression
surgical menopause - Irritability
- continue for 1 year - Anxiety
- 25% continue more - Insomia
than 5 years - lose of concentration

2. Urinary Symptoms
- urgency
- frequency
- nocturia
4. Atrophic Changes
64 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
Diagnosis
65
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
Infertilitas
71

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 hipotalamus-
hipofisis
Hiperprolaktin
Kelainan kongenital
74
75

Analisa Sperma
76 ANALISA SPERMA
Fertilitas seorang pria ditentukan A: bergerak cepat dan lurus
oleh jumlah dan kualitas B: Bergerak lambat dan tidak lurus
spermanya
C : bergerak ditempat
Normozoospermia
D : tidak bergerak
Jumlah sperma 20 juta/ml
Teratozoospermia
Oligozoospermia
Morfologi sperma normal < <30%
Jumlah sperma < 20 juta/ml
OligoAstenoTeratozoospermia sindroma
Astenozoospermia OAT
Motilitas sperma a<25% atau Azoopermia 0 sperma + plasma semen
a+b <50%
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 First line of PCOS management.
attenuate 80 all symptoms of PCOS Increased exercise, improved diet, and weight loss can help to reduce the
and reduce the long-term risk of metabolic abnormalities associated with PCOS.
infertility, CVD and T2DM. Weight loss 5-10% correct oligoanovulation & improve conception.

Estrogen and progestin oral Can be used to normalize androgen levels and attenuate the signs of
contraceptive (OCP) hyperandrogenism as well as to regulate menstrual cycles. This also helps to
therapy: treatment of acne, reduce the risk of heavy and irregular menstrual bleeding associated with the loss
hirsutism and irregular menstrual of normal estrogen and progestrone levels.
cycles.
Anti-androgens (e.g. Spironolactone and flutamide competitively inhibits DHT and testosterone by
spironolactone,finasteride, binding to their receptors in peripheral cells (e.g. hair follicles).
flutamide): treatment of acne and Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the
hirsutism. more potent DHT in peripheral cells.
Anti-androgens can be used synergistically with OCPs, which act centrally to
suppress androgen release.

Metformin: treatment of glucose Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin
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 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
81 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 Exogenous gonadoptropins can be administered to mimic physiological
hCG can be used to induce ovulation in mechanisms of follicle development. FSH is given to promote growth of a
cases where treatment with clomiphene dominant follicle to a particular size, and then human chorionic
citrate and metformin has been unsuccessful. gonadotropin is used to induce ovulation.

Ovarian drilling: a laparoscopic surgical Ovarian drilling involves the creation of ~10 perforations in the ovary using
procedure that may be used to treat either cautery or laser. The ablation of some of the ovarian theca is thought
clomiphene citrate-resistant anovulation. to help induce ovulation by decreasing androgen production.

IVF: used for the treatment of infertility in IVF involves the retrieval of oocytes from the ovaries and in vitro
women who have not responded to other combination with sperm to produce embryos. Viable embryos are then
therapies to induce ovulation. 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
Kista dan Abses Bartholini
85
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 Isolates from Bartholin's Gland
polymikrobal infeksi Abscesses
Neisseria gonorrhoeaea Aerobic organisms
yang paling umum Neisseria gonorrhoeae
Jika tidak inflamasi Staphylococcus aureus
asimtomatik Streptococcus faecalis
Simtom: nyeri vulva, Escherichia coli
dispareunia, kesulitan Pseudomonas aeruginos
berjalan/olah raga 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
Amniocentesis should not
be offered at less than 18
weeks gestation
102 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
Treatment
116

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.
The most promising therapy for congenital CMV
Source;
infection appears to be hyperimmune globulin.
http://www.peri
natology.com/e
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
DXMOTHER
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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