GYNECOLOGY

dr. Nashria
dr. Reagan Resadita
dr. Sekar Laras
 Siklus
Infeksi
Neoplasma Menstruasi Infertilitas
Kongenital
Abnormal
Vulva Menstruasi Toxoplasmosis
Analisis Sperma
Perdarahan
Vagina
Uterus Abnormal
Rubella
Tes Fertilitas
Serviks Endometriosis
Wanita
CMV
Korpus Uteri Amenorrhea
Policystic Ovarian
Ovarium Menopause Syndrome Varicella
 Neoplasma
Pertumbuhan jaringan yang berlebihan dan abnormal
Gejala Utama : Perdarahan abnormal, massa pelvis, gejala vulvovaginal
Benigna VS Maligna Lokasi Tersering
Benigna vs Maligna

Tidak invasif, terlokalisasi Sifat Invasif, destruktif,

lambat Pertumbuhan cepat

Gejala penekanan massa Gejala Sindrom Para neoplastik

(nyeri punggung, obstipasi, (endokrinopati), cachexia
retensi urin)
Perdarahan, ulserasi, Komplikasi Metastasis
infeksi sekunder

SOLID KISTIK
Massa padat Kantong tertutup berisi cairan, gas, atau substansi semisolid

Kista ovarium, kista dermoid, kista bartholini

 Neoplasma Vulva
Kista Bartholini Fibroma Vulva
Lokasi 1/3 posterior labium mayus, posisi jam 4 Lokasi Area vulva, labium mayus
dan 8 Asal Proliferasi fibroblast labium
Asal sumbatan pada ductus/ kelenjar mayus
bartholini (rekurensi 68-75%) S&S massa, penekanan urethra,
S&S massa, nyeri, dyspareunia, demam nyeri, dyspareunia

Tx - Word Catheter (kambuh 3-17%) Tx Eksisi

- Marsupialisasi (kambuh 10-24%)
- Insisi drainase
Jika infeksi -> abses (tersering N.gonorrhoeae)
 Treatment Kista Bartholini
word CATHETER MARSUPIALISASI
• Pembuatan 5 mm incisi pada kista atau abses • Membuka rongga tertutup menjadi kantong
terbuka.
• Masukkan kateter Word dan dikembangkan dengan
2-3 ml saline  selama 3-4 minggu • Pembuatan insisi vertikal elips 1,5-3 cm (sesuai
garis Langer)
• Pengeluaran isi kista dg sendok kuret kecil
sampai bersih
• Dinding kista dijahit ke kulit vertibular dengan
jahitan interupted
 Neoplasma vagina
Kista Gartner Endometriosis Vagina Fibroma Vagina

• Lokasi: dinding • Lokasi: Fornix posterior • Lokasi: tidak khas

anterolateral vagina
• Asal: sisa kanalis Wolfii
(duktus gartner)
• S&S: massa
• Tx: Insisi dan eksisi
• Asal: Endometrium
• S&S: nodul subepitel
dengan perdarahan
ireguler
• Tx: sesuai tx endometriosis
• Asal: proliferasi fibroblast
jaringan ikat dan otot
vagina
• S&S: massa, dyspareunia
• Tx: eksisi
 Neoplasma serviks uteri
Kista Nabothian (Retensi) Polip serviks Mioma Serviks

• Lokasi: Area endoserviks • Lokasi: Endo-ektoserviks • Lokasi: 1/3 inferior

• Asal: Retensi muara • Asal: Lapisan Stroma uterus
kelenjar endoserviks  endo-ektoserviks • Asal: proliferasi
retensi cairan musin • S&S: Massa bertangkai, fibroblast jaringan otot
• S&S: asimptomatik rapuh, merah/pucat, uterus
• Tx: tidak ada terapi bleeding, dyspareunia • S&S: massa, dyspareunia
• Tx: Ekstirpasi  • Tx: ekstirpasi, eksisi,
kuretase , kauterisasi histerektomi
 Tumor Maligna Serviks Uteri
Klasifikasi
A. Karsinoma serviks
 Squamous cell carcinoma 91 %
 Adenocarcinoma
 Adenosquamous carcinoma
 Adenoacanthoma
B. Sarcoma (sangat jarang)
Faktor Resiko
 Infeksi HPV tipe16, 18, 45 dan 56
 Status sosial ekonomi
 Menikah/ memulai aktivitas seksual pada usia muda (kurang 18
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)
 Zona
Transformasi

 Displasia adalah hilangnya diferensiasi normal dari epitel serviks

 Tempat paling sering terjadinya displasia 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
 Patogenesis
Carcinoma Serviks
Spektrum klinis ca. serviks
 GEJALA & TANDA KLINIS
Gejala
• Pre invasive stage: asimtomatik
• Early invasive stage: perdarahan vagina abnormal, nyeri (dispareunia) dan perdarahan post
coitus, vaginal discharge
• Advanced stage: nyeri panggul (pelvic pain), weight loss, anorexia, anemia

Tanda Klinis
• Nodul, ulkus, erosi serviks (tahap lanjut: crater-shaped ulcer dengan massa rapuh), massa
eksofitik
• Perdarahan
• Mobilitas serviks tergantung derajat keganasan (lunak  keras)

MANAJEMEN PREVENTIF
Primer:
• Gaya hidup sehat
• Vaksinasi HPV (kuadrivalen- genotipe 6, 11, 16 &18 ; bivalen- genotipe 16
&18)  usia > 10 th
Sekunder:
• Skrining untuk lesi pra kanker & diagnosis awal diikuti dengan terapi
Tersier:
• Diagnosis Dini dan terapi dari kanker yang terbukti
 Screening Kanker Serviks
IVA PAP’S SMEAR
 Inspeksi Visual dengan Asam Asetat (IVA)

• 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 hasil tes IVA negatif,  ulangi
3-5 tahun sekali.
• Jika hasil tes IVA positif 
rekomendasi krioterapi  ulangi 1
bulan post krioterapi  ulangi 6
bulan post krioterapi
Pedoman teknis Ca Payudara dan Ca Serviks,
kemenkes 2015
 PAP SMEAR

PAP’S SMEAR
•Mendeteksi perubahan
pada morfologi sel
(dysplasia) yang merupakan
prekursors dari keganasan
Syarat:
•Lakukan Paps smear pada
fase proliferasi (1 minggu
setealah mens berakhir)
•Tidak melakukan hubungan
sexual 24-48 jam sebelum
paps smear
•Tidak menggunakan Exception: ACOG
Women at increased risk of CIN :
lubrikan vagina. 1. in utero DES (diethylstilbestrol) exposure  annually guideline
2. Immunocompromise  2x in first year then annually 2012
3. History of cervical cancer
should continue to be screened at least annually (2008)  More frequent screening (2012)
 HASIL PAP SMEAR

ACOG guideline 2012

 Recommendation for screening
Keluhan Lesi anatomis Rekomendasi
skrining
- - IVA
+ - PAP SMEAR

+ + Biopsi

Cervical Cancer, Am Fam
Physician. 2000 Mar 1;61(5):
1369-1376.
Kolposkopi adalah pemeriksaan visual bertenaga
tinggi (pembesaran) untuk melihat leher rahim,
bagian luar dan kanal bagian dalam leher rahim.
Biasanya disertai biopsi jaringan.
Digunakan terutama untuk DIAGNOSIS
 Squamous Cell Carcinoma
Cervical dysplasia:
Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope

©2015
UpToDate®
Terapi Penjelasan
Krioterapi 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 Excision Pengambilan jaringan yang
Procedure (LEEP) mengandung sel prakanker
dengan menggunakan alat
LEEP
Konikasi Pengangkatan jaringan yang
megandung sel prakanker
dengan operasi
Histerektomi Pengangkatan seluruh rahim
termasuk leher rahim
 NEOPLASMA UTERI
Tumor Benigna
• Leiomyoma (myoma)
• Etiological factors: estrogen,
negroid, nullipara
Type of Leiomyoma
1. Submucous : beneath
endometrium, if
pedunculated  geburt
myoma
2. Intramural/interstitial: within
uterine wall
3. Subserous/subperitoneal: at
the serosal surface or bulge
outward from myometrium; if
pedunculated  satelite
myoma
S&S:
• Menorrhagia – heavy & prolonged
menstruation (common)
• Pelvic pressure：urinary frequency,
constipation
• Spontaneous abortion, Infertility
A palpable abdominal tumor :
arising from pelvis, well defined margins
, firm consistency, smooth
surface, mobile from side to side.
• Pelvic examination：Uterus —
enlarged and irregular, hard
• Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
Management
• Observation: for small myoma,
premenopause
• Operation : myomectomy or
hysterectomy Whorl like pattern / Pusaran air
1 Uterine
fibroid
therapy
2

3
 Uterine
fibroid
therapy

4
 Tipe maligna neoplasma uteri
Sarkoma Uteri
• Myoma uteri yang menjadi
leiomyosarkoma hanya 0,32 – 0,6%
dari seluruh myoma
• Leiomyosarkoma merupakan 50-75%
dari semua jenis sarkoma uteri
• Kecurigaan malignansi:
• Perdarahan pascamenopause
• Myoma uteri cepat membesar
• Pembesaran myoma pada
menopause
• Muncul jaringan nekrotik
Kanker endometrium
• Insidensi keganasan ini 4,8% (ke-4
terbanyak) pada organ ginekologik
• Faktor risiko: obesitas, rangsangan
estrogen, menopause terlambat,
nulipara, siklus anovulasi, hiperplasi
endometrium, HRT
• Kecurigaan malignansi:
• Perdarahan uterus abnormal
• Perdarahan pascamenopause
• Diagnosis: kuretase diagnostic, biopsy
endometrium
 NEOPLASMA OVARIUM
Functional Malignant( or
- Follicle cyst malignant potential)
- Corpus Luteum cyst - Malignant teratoma
- Theca lutein cyst - Endometrioid
Inflammatory carcinoma
- Tubo-ovarian abcess - Dygerminoma
- Secondary ovarian
Benign tumor/cyst tumor
- Endometriotic cyst - Cystadenoma,
- Brenner tumor cystadenocarcinoma
- Benign teratoma - Granulosa cell tumor
- Fibroma - Arrhenoblastoma
- Theca cell tumor

Robins Basic Pathology 9th edition

 Overview of Ovarian Tumor
No Type Frequency Age Group Subtype Note
1. Epithelium 65-70% Adult (20+ Serous Most common
years) 60% benign
-Benign
Can be bilateral
-Malignant
(25%)
-Borderline (low
Malignant type
malignant
highly associated
potential)
with BRCA gene
mutation

Mucinous
Endometrioid
Clear-cell
Brenner
Cystadenofibroma
2. 15-20% 0-25+ years Teratoma Most common in
Germ Cell young women
Dysgerminoma
Endodermal sinus Majority are benign.
tumor
Choriocarcinoma
3. 5-10% All ages Fibroma May produce
Sex-Cord Granulosa-theca cell estrogen or
Stroma Sertolli Leydig androgen
 KANKER OVARIUM
Etiology
• inactivation of tumor suppressor genes (PTEN, p16, p53)
• activation of oncogenes (HER-2, c-myc, K-ras, Akt)
• mutations in BRCA1, BRCA2

• Age  mostly found in older age;
>50% cases found >63 y.o patients
• Family history of ovarian cancer,
breast cancer, or colorectal cancer
• Obesity
• Reproductive history
• Fertility drugs
• Estrogen therapy and hormone
therapy
• Personal history of breast cancer
Known as silent lady killer  high mortality
S&S
• Low abdominal discomfort (fullness, bowel
symptom)  Pressure symptom
• Loss of weight, malaise, anorexia
• Pain due to torsion, hemorage or rupture
Risk Factor:
• Increasing menstrual cycle
• Induction clomiphene citrate

Diagnosis:
• USG
• Tumor marker Ca-125
 Clinical Work-up
Laboratory Testing
No tumor marker (eg, CA125, beta-human chorionic gonadotropin, alpha-fetoprotein,
lactate dehydrogenase) is completely specific; therefore, use diagnostic
immunohistochemistry testing in conjunction with morphologic and clinical findings.
Also, obtain a urinalysis to exclude other possible causes of abdominal/pelvic pain,
such as urinary tract infections or kidney stones.
CA 125 –. CA 125 is abnormally elevated in about 80 percent of women with
advanced ovarian cancer.
non-cancerous conditions can cause CA 125 to be elevated e.g endometriosis,
uterine fibroids, pelvic infections, heart failure, and liver and kidney disease.
 Teratoma ovarian (Dermoid cyst of ovary)
• Bizzare Tumour

• Insidensi: 15-20% tumor ovarium

• Sering terjadi pada wanita usia decade 2

 semakin muda, semakin maligna

• Asal: totipotential germ cell (ektodem,

mesoderm, endoderm)  membentuk
rambut, kelenjar keringat, tulang, gigi,
sel saraf
Robins Basic Pathology 9th edition
• Gejala: infertilitas, torsio (10-15%
kejadian)  operasi emergensi

• Terapi: Laparotomi, kistektomi

SIKLUS MENSTRUASI
Menstrual cycle

Image
source:https://embryology.med.unsw.edu.au/
 •GnRH merupakan hormon yang diproduksi oleh
GnRH hipotalamus di otak.
• GnRH akan merangsang pelepasan FSH (Folicle
Estrogen
Stimulating Hormon) di hipofisis. •Estrogen dihasilkan oleh ovarium.
• Bila kadar estrogen tinggi, maka estrogen akan •Estrogen berguna untuk pembentukan ciri-ciri
memberikan umpan balik ke hipotalamus sehingga perkembangan seksual pada wanita yaitu
kadar GnRH akan menjadi rendah, begitupun pembentukan payudara, lekuk tubuh, rambut
sebaliknya.. kemaluan.
•LH mempertahankan korpus luteum untuk tetap • Estrogen juga berguna pada siklus menstruasi
LH menghasilkan ovarium. dengan membentuk ketebalan endometrium,
menjaga kualitas dan kuantitas cairan cerviks dan
•Dibawah pengaruh LH, korpus luteum
mengeluarkan estrogen dan progesteron, dengan vagina sehingga sesuai untuk penetrasi sperma.
jumlah progesteron jauh lebih besar.
•Kadar progesteron meningkat dan mendominasi
dalam fase luteal, sedangkan estrogen mendominasi
Progesteron
fase folikel. •Hormon ini diproduksi oleh korpus luteum.
•Walaupun estrogen kadar tinggi merangsang sekresi •Progesteron mempertahankan ketebalan
LH, progesteron dengan kuat akan menghambat endometrium sehingga dapat menerima implantasi
sekresi LH dan FSH. zygot.
•Kadar progesteron terus dipertahankan selama
•Hormon yang diproduksi oleh hipofisis akibat
FSH rangsangan dari GnRH.
trimester awal kehamilan sampai plasenta dapat
membentuk hormon HCG.
•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
 Normal Menstrual Bleeding

• Occurs approximately once a month

(every 21 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
 Ovulasi
• >> kadar progesterone
• Terjadi 14 hari sebelum mens
2ng/ml
berikutnya
• 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
 Abnormal Uterine Bleeding
Term (Previous) Definition Pattern
Amenorrhea No uterine bleeding for moments
Menorrhagia Excessive amount (>8omL/cycle) or Occurs at irregular interval
prolonged duration > 7 days, also
called “hypermenorrhea”
Metrorrhagia Uterine bleeding occurring at Irregular
irregular but frequent interval,
amount varies
Menometrorrhagia Irregular, heavy, and prolonged Irregular
menstrual bleeding
Oligomenorrhea Decreased, scanty flow, the term Interval >36-40 days
“hypomenorrhea” is used for regular
timing with scanty amount
Polymenorrhea Regular, frequent menstruation Interval < 21 days
Intermenstrual Bleeding or spotting between Between periods (usually light flow)
normal periode
 NEW RECOMMENDED TERMINOLOGY, DEFINITIONS, AND
CLASSIFICATIONS OF SYMPTOMS OF ABNORMAL UTERINE BLEEDING
Terminology Definition
Prolonged menstrual bleeding Menstrual period exceeding 8 days in duration on regular basis

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 No bleeding in a 90 days period

(amenorhea)
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 (>80mL)

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

Light Menstrual Bleeding Based on patient complaint, rarely related to pathology (<5mL)
 Terminology
Acute Abnormal Uterine Bleeding
Chronic Abnormal uterine bleeding
Irregular Non Menstrual Bleeding
Post menopausal bleeding
Precocious menstruation
Definition
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
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 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
Bleeding occurring >1 year after the acknowledge menopause
Usually associated with other sign of precocious puberty, occur before 9 years of
age
Polip Coagulopathy
• Endocervical polip - Von Willebrand
• Endometrial polip disease
- Gangguan agregasi
platelet

Ovulatory disturbance
Adenomyosis
- Endocrinopatie
• Part of endometrial (PCOS, Hypotiroid,
that penetrate to obesity, anorexia)
myometrium -Extreme exercise,
stress

Leiomyoma Endometrial
• Submucosal -Endometrial
inflammation infection
• Subserosal -Defisiensi endothelin-1,
• intramural Prostaglandin F2-alpha

Iatrogenic
Malignancy and
Drugs : rifampicin,
hyperplasia defined as bleeding from the uterine corpus that is abnormal in griseofulvin, trisiklik,
- Endometrial cancer regularity, volume, frequency, or duration and occurs in the absence of phenothiazine,
anticoagulant, antiplatelet,
pregnancy
 Medical Management for Acute AUB
Hormonal management is considered the first line of medical therapy for patients with
acute AUB without known or suspected bleeding disorders.
Drug Dosage Schedule Contraindication

Conjugated 25 mg IV Every 4-6 hours Breast canver.

equine estrogen for 24 hour PAD, Venous
thrombosis, liver
dysfunction
Combined oral Combined oral 3x/day for 7 days Cigeratte smoking
contraceptive contraceptive (aged > 35 years),
contain 35 hypertension,
microgram ethinyl DVT, CVD,
estradiol migraine, breast
cancer, liver
dysfunction
Medroxyprogeste 20 mg PO 3x/day for 7 days DT, breast cancer,
rone acetate liver dysfunction
Tranexamic acid 1,3 gram PO or 10 3x/day for 5 days Trombosis,
mg/kg IV (max. impaired color
600 mg/dose) vision,
thromboembolic
ACOG 2013, COMMITTEE OPINION, Management of disease
Acute AUB in nonpregnant Reproductive Aged For longterm therapy: Levonorgestrel intrauterine, Oral contraceptive,progestin therapy,
Women tranexamic acid,NSAID
 PELVIC INFLAMMATORY DISEASE (PID)

Infeksi polimikrobial yang melibatkan traktus genital atas

Terutama menyerang wanita usia muda yang aktif secara seksual
Chlamydia trachomatis dan Neisseria gonorrhoeae adalah patogen tersering

Kriteria minimum Kriteria tambahan Pemeriksaan Penunjang

(satu atau lebih harus - Temperatur oral > 38.3 C - Biopsi endometrial
ada untuk PID) - Discharge serviks atau vagina yang - Transvaginal sonografi
- Cervical motion mukopurulen dan abnormal atau MRI
tenderness/nyeri - Terdapat sel darah putih pada - Laparoskopi
goyang serviks pemeriksaan mikroskopis cairan vagina
- Uterine tenderness - Peningkatan laju sedimentasi eritrosit
- Adnexal tenderness - Peningkatan CRP
- Bukti lab adanya gonorrhea atau
klamidia
Suggested Criteria for Hospitalization of Patients with Pelvic Inflammatory Disease
• Inability to follow or tolerate an outpatient oral medication regimen
• No clinical response to oral antimicrobial therapy
• Pregnancy
• Severe illness, nausea and vomiting, or high fever
• Surgical emergencies (e.g., appendicitis) cannot be excluded
• Tubo-ovarian abscess

DRUG DOSAGE
ORAL Option 1
Ceftriaxone (Rocephin) 250 mg IM in a single dose
plus
Doxycycline 100 mg orally twice per day for 14 days
with or without
Metronidazole (Flagyl) 500 mg orally twice per day for 14 days

DRUG DOSAGE
PARENTERAL Regimen A
Cefotetan (Cefotan) 2 g IV every 12 hours
or
Cefoxitin 2 g IV every six hours
plus
Doxycycline 100 mg orally or IV every 12 hours
 Dysmenorrhea
Dysmenorrhea: painful cramp during menstruation. Divided into 2 broad categories: primary (occurring in
the absence of pelvic pathology) and secondary (resulting from identifiable organic diseases).
Primary
• Onset 6-12 months after menarche
• 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 F2α
(PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium.
Treatment:
NSAID  celecoxib, Ibuprofen, Naproxen, mefenamic acid
Hormonal  COC, Levonorgestrel-releasing intrauterine system Medroxyprogesterone injection
Secondary
• Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles
• Heavy menstrual flow or irregular bleeding
• Most ethiologies: Endometriosis, adenomyosis, PID, infection
• Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives (OCs)
• Often with Infertility, Dyspareunia, Vaginal discharge
Diagnosis and Initial Management of Dysmenorrhea, Am Fam Physician. 2014;89(5):341-346.
 Endometriosis
Kondisi ditemukannya jaringan endometrium diluar korpus uteri merespon
estrogen  perdarahhan  inflamasi

Patofisiologi: mullerian duct remnants theory, menstruasi retrograde,

coelomic metaplasia, Sampson’s theory, Iron-induced oxidative stress

Lokasi tersering: peritoneum, ovarium, tuba falopi

Lokasi lain: vesical urinaria, ureter, usus halus, fornix posterior, SIGN and SYMPTOM
rectum, diafragma
• Dismenorea
• Menorhagia
TRIAS klasik: dismenorhea berat, dyspareunia/ nyeri panggul kronis, • Nyeri goyang panggul
infertil • Nyeri perut bawah
• Dyschezia
• Dysuria
Penunjang: Transvaginal/endorectal USG, MRI (deteksi implantasi • Dyspareunia
endometrial) • Mual, muntah, rasa penuh perut
 Endometriosis therapy
Medical Therapies Surgical Intervention
• Laparoscopy
Mild-Moderate Pain Moderate –Severe Pain • Hysterectomy/Oophorectomy/Salpingo-
oophorectomy
1. Combined Oral 1. GnRH Agonist
Contraceptive 2. Danazol
Indications for surgical management:
2. NSAID 3. Aromatase Inhibitor
3. Progestin • 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

• ESHRE guideline: management of women with endometriosis

• Journal of Obstetrics and Gynaecology Canada: Endometriosis diagnosis and
management
 Amenorrhea
Amenorrhea is the absence of menstruation.
• Primary
– Absence of menses by age 13 without or age 15 with secondary sexual development
• Secondary
– Absence of menses for 3 month in regular or 6 month in iregular cycle menstruation

Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788
Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788
Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788
Functional hypothalamic amenorrhea:

•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

Perimenopause
• Periode 3-5 tahun sebelum menopause yang ditandai dengan peningkatan frekuensi
irregular anovulatory bleeding yang selanjutnya diikuti periode amenorrhea dan
gejala-gejala menopause lainnya
Menopause
• Periode dimana siklus menstruasi secara permanen berhenti. Diagnosis secara
retrospektif sejak 12 bulan paska amenorrhea. (Rerata usia 51 tahun).
PATOFISIOLOGIS MENOPAUSE
• pada usia sekitar 50 tahun fungsi ovarium menjadi sangat menurun. 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
S S
I Y
G M
N P
T
A O
N M
D P
Symptoms of Menopause:
1. Hot flushes - cutaneous vasodilation 5. Atrophic Changes
• occurs in 75% of women • Vagina
• more severe after surgical menopause *vaginitis due to thinning of epithelium, ↓ PH
• continue for 1 year and lubrication.
• 25% continue more than 5 years *dysparnue→due to decrease vascularity and
dryness
2. Urinary Symptoms • size of breDecrease size of cervix and mucus
• Urgency with retract of segumocolumnar (SC) junction
• Frequency into the endocervical canal.
• nocturia • Decrease size of the uterus, shrinking of
myoma & adenomyosis.
3. Psychological changes decreased level of central • Decrease size of ovaries, become non
neurotransmitters palpable.
• Depression • Pelvic floor - relaxation →prolapse.
• Irritability • Urinary tract →atrophy →lose of urethral
• Anxiety tone →caruncle
• Insomia • Hypertonic Bladder - detrusor instability
• lose of concentration • Decrease ast and benign cysts.
4. Skin Collagen – ↓ collagen & thickness →
↓ elasticity of the skin. 6. Reversal of premenstrual syndrome
Diagnose
• Retrospective diagnose, FSH > 30 mIU/ml and E2 < 30pg/ml (Rogerio, 2000; Baziad, 2003).

THERAPY
• 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.
o Oestrogen – in the first ½ of 28 day per pack
o Oestrogen & Progetin in 2nd 1/12 of 28 day pack

• Benefit for HRT:

o Vagina-↑ vaginal thickness of epithelium →↓ dyspareunia & vaginitis.
o Urinary tract – enhancing normal bladder function.
o Osteoporosis – decrease fractures by more than 50%
o CVS – decrease by 30% by observation studies but recent studies shows no benefits.
o Colon Cancer decrease up to 50%
 Post Menopausal Bleeding:
• Vaginal bleeding occurs after 12 months of Amenorrhea in middle age women who are not receiving
replacement therapy.

• Endometrial Ca:
• Endometrial neoplasia can progress from simple hyperplasia to investive Ca caused by unopposed
oestrogen.
• Mechanism: 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 aStimulation of Endometrium
• Risk Factor
o No pregnancy
o Prolonged Reproductive Life – late menopause
o Unopposed estrogen
o Triad of diabetes, hypertension & obesity
 PMS PMM
PMS Diagnostic
criteria
Tenth Revision of the
International
Diagnostic and
Statistical Manual of
the cyclic recurrence in the luteal Classification of Mental Disorders, 4th
phase of the menstrual cycle of a Disease (ICD-10) ed. (DSM-IV)

combination of distressing Providers using Obstetrician/gynec Psychiatrists, other

physical, psychological, and/or these criteria ologists, primary mental health care
care physicians providers
behavioral changes of sufficient
Number of One 5 of 11 symptoms
severity to result in deterioration symptoms
of interpersonal relationships required
and/or interference with normal
activities.. Functional Not required Interference
impairment with social or
role functioning

PMM Prospective Not required

required

Prospective daily
Many patients with psychiatric charting of charting of
disorders also complain of symptoms symptoms
required for two
worsening of their symptoms cycles
around the premenstrual phase,
called “premenstrual
magnification”. ACOG
2008
ACOG
 Infertilitas
Kegagalan dalam konsepsi, mempertahankan kehamilan, atau melahirkan bayi hidup bagi pasangan suami-istri yang
telah melakukan hubungan seksual secara regular tanpa kontrasepsi setelah:
1. Usia wanita < 35 tahun  melewati durasi 12 bulan
2. Usia wanita > 35 tahun  melewati durasi 6 bulan

Prevalensi:
a. 40% faktor istri
a. Infeksi: Servisitis  Inflamasi uterus  salfingitis  perituba adesi  stenosis tuba  oklusi tuba
b. Gangguan ovulasi: Penuaan (usia), Polikistik Ovarii (PCOS), Kelainan pada hipotalamus-hipofisis,
Hiperprolaktin
c. Gangguan anatomi: Kelainan kongenital

b. 40% faktor suami

a. Kelainan sperma
b. Gangguan transportasi: Varikokel, Prostatitis, Epididimitis, Orkhitis,
c. Kelainan kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome),
d. Kelainan hipotalamus-hipofisis
e. Autoimunitas, Impotensi

c. 20% pada keduanya

Primary infertility
When a woman is unable to ever bear a child, either due to the inability to become
pregnant or the inability to carry a pregnancy to a live birth she would be classified as
having primary infertility. Thus women whose pregnancy spontaneously miscarries, or
whose pregnancy results in a still born child, without ever having had a live birth
would present with primarily infertility.

Secondary infertility
When a woman is unable to bear a child, either due to the inability to become
pregnant or the inability to carry a pregnancy to a live birth following either a
previous pregnancy or a previous ability to carry a pregnancy to a live birth, she
would be classified as having secondary infertility. Thus those who repeatedly
spontaneously miscarry or whose pregnancy results in a stillbirth, or following a
previous pregnancy or a previous ability to do so, are then not unable to carry a
pregnancy to a live birth would present with secondarily infertile.
WHO - National, regional, and global trends in infertility: a systematic analysis of 277
health surveys
WHO 2010 sperm analysis
 Terminologi analisa sperma
Normozoospermia Jumlah sperma ≥ 15 juta/ml
Oligozoospermia Jumlah sperma < 15 juta/ml
Astenozoospermia Motilitas sperma A < 32 % atau a+b <40%
A : bergerak cepat dan lurus
B : Bergerak lambat dan tidak lurus
C : bergerak ditempat
D : tidak bergerak

Teratozoospermia Morfologi sperma normal < 4%

OligoAstenoTeratozoospermia (sindroma OAT)
Azoopermia 0 sperma + plasma semen
Aspermia 0 sperma + 0 plasma semen
 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
• Contoh: Dari 100 sperma yang dihitung, 80
sperma kepala bening, 20 sperma kepala
ungu  Uji Viabilitas 80%
• Laki-laki dinyatakan fertill jika uji viabilitas
>60%
 Fertility Test for women
• 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
 POLYCYSTIC OVARIAN SYNDROME (PCOS)
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

Syarat PCOS menurut Rotterdam Consensus (2003) yaitu 2 dari berikut:

1. Hiperandrogenisme klinis dan/atau hiperandrogenemia: hirsutisme, jerawat, alopesia
2. Oligoanovulasi: oligomenorhea dan/atau amenorhea
3. USG: polikistik ovari
Pathophysiology of
pcos
Lifestyle modification as
First line of PCOS
management

Source: http://www.pathophys.org/pcos/
 OVULATION INDUCTION. Approach to
ovulation induction in women with
polycystic ovarian syndrome. IVF: In
vitro fertilization
Guzick. Polycystic Ovary Syndrome. Obstet Gynecol. 2004
TORCH
Toxoplasmosis
Other (sifilis, varicella-zoster, parvovirus B19)
Rubella
Cytomegalovirus (CMV)
Herpes Infection

INFEKSI KONGENITAL
IgM is too large to cross placenta
and does not confer maternal
immunity

IgG crosses placenta and confers

passive immunity on the fetus
 Table 1: Clinical Features Associated with TORCH Infections

Infection Clinical Features

•Intracranial calcifications in a diffuse pattern
•Hydrocephalus
Toxoplasmosis
•Chorioretinitis
•Mononuclear CSF pleocytosis or elevated CSF protein
CLINICAL
•Cataracts, glaucoma, pigmented retinopathy FEATURES
•Congenital heart disease (patent ductusarteriosus and peripheral
pulmonary artery stenosis) ASSOCIATED
Rubella
•Radiolucent bone disease
•Sensorineural hearing loss
WITH
TORCH
•Periventricular intracranial calcifications
INFECTIONS
•Microcephaly
Cytomegalovirus (CMV)
•Thrombocytopenia

•Mucocutaneous vesicles or scarring

•CSFpleocytosis
Herpes Simplex Virus (HSV) •Thrombocytopenia
•Elevated liver transaminases
•Conjunctivitis or keratoconjunctivitis

•Skeletal abnormalities such as osteochondritis and periostitis

•Pseudoparalysis
Syphilis •Persistent rhinitis
•Maculopapular rash (most notably on palms and soles or in diaper
area)
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
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
 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
Ultrasonographic
findings
- Fetal
hydrocephalus
- Fetal intracranial
calcification

Classic triad
(affected in ~80%)
of congenital
toxoplasmosis:
- Hydrocephalus
- Chorioretinitis
- Intracranial
calcification
Rubella (German Measles)

Congenital rubella syndrome

 Algorithm for serologic evaluation of pregnant women
exposed to rubella

www.cdc.gov
Diagnosis of congenital
rubella
Congenital rubella syndrome

Risk of congenital defects:

• Before 11 weeks of gestation  90%
• 13 -14 weeks  11%
• 15-16 weeks  24%
• After 16 weeks  0%
CITOMEGALOVIRUS (CMV)
 CMV
Identification of Primary CMV in Pregnancy
Mother
Serologic testing:
•CMV – IgG positive with low IgG avidity
•CMV-IgM positive
Fetus
Amniocentesis:
•Viral/antigen detection CMV-PCR
•Viral load = severe infection
Ultrasound
Newborn
•CMV-IgM positive
•Virus/PCR positive in body fluid
•CMV IgG positive at 1 year
CMV: Ultrasonographic findings
Diagnostic clue:
Calcification
- Intracranial
- Hepatic
-- Hepatosplenomegaly
-- Amnniotic fluid volume disorder
 Symptomatic CMV infection
• 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)
 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.
• The most promising therapy for congenital CMV infection
appears to be hyperimmune globulin.

Source;
http://www.perinatology.com/exposures/I
nfection/CMV/Cytomegalovirus.htm#DXM
OTHER
VARICELLA
 Radioulnar hipoplasia
Hepatic calcification and missing hand
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
 Management
• Fetal Infection  Amniocentesis (culture or PCR of virus) or 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
Zooster Lesion fetal malformation