Marwah Jamaluddin Puskesmas Pangkajene

BUKU LOGBOOK PRAKTIK PROFESI
STASE ASUHAN KEBIDANAN PRA NIKAH DAN PRA KONSEPSI
IDENTITAS MAHASISWA
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN

PROGRAM PROFESI
Nama Mahasiswa : Marwah Jamaluddin

NIM : 202210091
Tempat/ Tanggal Lahir : Pangkajene 22-09-1995
No. Hp : 085242591910
Email : Marwahjamaluddin133@Yahoo.Com
Alamat : Jl. Andi Haseng Pangkajene Sidrap
PROGRAM STUDI PENDIDIKAN PROFESI PROGRAM PROFESI

INSTITUT TEKNOLOGI KESEHATAN DAN SAINS (ITKES)
MUHAMMADIYAH SIDRAP
2022/2023
1
SAMBUTAN
REKTOR ITKES MUHAMMADIYAH SIDRAP
Dengan senantiasa memanjatkan puji dan syukur kepada Allah

SWT, karena atas rahmat dan karuniaNya jualah maka Logbook Praktik
Stase Asuhan Kebidanan Pra Nikah dan Pra Konsepsi Program studi
Pendidikan Profesi Bidan Program Profesi ITKES Muhammadiyah
Sidenreng Rappang tahun 2022/2023 dapat diselesaikan.
Kami haturkan terima kasih dan penghargaan yang tinggi atas
kerjasama dalam melaksanakan tugas – tugas ini dengan baik
Harapan kami dengan Kepada semua pihak yang telah berjasa
dalam penyusunan loogbook ini, sekali lagi diucapkan terima kasih. Dan
marilah kita berkomitmen untuk memajukan Pendidikan Tinggi ITKES
Muhammadiyah Sidrap dengan menjadi bagian penting dalam
Peningkatan Sumber Daya Manusia yang islami dan berkemajuan.
Pangkajene, 11 Zulhijjah 1443 H

20 Juli 2022 M
Rektor,
Ttd
DR.Muhammad Tahir, SKM.,M. Kes

NBM. 1069207
2
KATA PENGANTAR
Syukur Alhamdulillah kami panjatkan ke hadirat Allah SWT, karena

atas izin-Nya jualah maka Logbook Praktik Stase Asuhan Kebidanan
Pra Nikah dan Pra Konsepsi Program studi Pendidikan Profesi Bidan
Program Profesi ITIKES Muhammadiyah Sidenreng Rappang tahun 2022 -
2023 dapat diselesaikan.
Kami sadar bahwa apa yang terkandung dalam pedoman ini belum
tersaji dengan optimal, sehingga perlu kritik dan saran demi
tersempurnanya pedoman ini.
Jazakumullahu khairan katsiran.
Fastabiqulkhaerat.
Sidrap, 20 Oktober 2022

Ketua Prodi Pendidikan Profesi Bidan
ITKes Muhammadiyah Sidrap
TTD
Wilda Rezki Pratiwi, S.ST., M. Kes

NBM. 1259290
3
METODE BIMBINGAN EVALUASI
STASE Manaj
Laporan TOTAL
CBD BST TutorialK RefleksiK K JournalR OMP DOPS Mini C OSLER OSCE
(COC)
Keterampilan Dasar Praktik
Kebidanan 1 3 0 0 0 0 0 2 1 0 0 0 7
Asuhan Kebidanan pada Pra

1 2 0 1 0 2 1 0 1 0 0 2 10
Nikah dan Pra Konsepsi
Asuhan KebidananKehamilan
2 50 0 1 0 2 4 2 2 1 0 16 80
Asuhan KebidananPersalinan
1 23 1 1 0 1 5 2 2 1 0 2 39
Asuhan Kebidanan Bayi Baru
1 25 1 1 0 2 3 1 1 1 0 9 45
Lahir
Asuhan Kebidanan Nifas 1 60 1 1 0 2 5 2 2 1 0 20 95
Asuhan Kebidanan Pada Bayi,
1 61 0 1 0 2 5 2 2 1 0 20 95
Balita dan Anak Pra Sekolah
Asuhan Keluarga Berencana
1 10 0 1 0 2 1 1 1 1 0 2 20
dan Pelayanan Kontrasepsi
Asuhan Pada Remaja dan
1 2 0 1 0 0 0 1 2 0 0 1 8
Perimenopause
Asuhan Kebidanan
0 0 0 0 2 0 0 0 0 0 0 0 2
berkelanjutan
Asuhan Kebidanan Komunitas
0 0 0 0 0 0 0 0 0 0 0 2 2
Manajemen Pelayanan
0 0 0 0 0 0 0 0 0 0 0 2 2
Kebidanan
TOTAL 10 236 3 8 4 13 24 15 13 6 0 76 405
4
STASE II
LOGBOOK PRAKTIK STASE ASUHAN KEBIDANAN

PRA NIKAH DAN PRA KONSEPSI)
i
STASE II
ASUHAN PRANIKAH DAN PRAKONSEPSI
A. TUJUAN
1. Tujuan Umum
Memberikan pengalaman belajar klinik pada mahasiswa dalam
lingkup asuhan remaja yang meliputi kesehatan fisik, mental
pranikah, persiapan kehamilan sehat dan kesehatan reproduksi
2. Tujuan Khusus
a. Mampu melakukan asuhan kebidanan pada pranikah dan prakonsepsi
secara holiktis, komprehensif dan berkesinambungan yang didukung
kemampuan berpikir kritis, rasionalisasi klinis dan reflektif
b. Mampu melakukan deteksi dini, konsultasi, kolaborasi dan rujukan,
didukung kemampuan berpikir kritis dan rasionalissi klinis sesuai lingkup
asuhan reproduksi.
c. Mampu melakukan KIE, promosi kesehatan dan konseling tentang
kesehatan reproduksi
d. Mampu melakukan pendokumentasian asuhan dan pelaporan pelayanan
kebidanan sesuai kode etik profesi (pranikah dan prakonsepsi)
e. Mampu melakukan KIE, promosi kesehatan dan konseling tentang
kesehatan reproduksi, kehidupan berkeluarga sehat antara lain; perilaku
reproduksi sehat, perencaan keluarga, persiapan menjadi orang tua,
pemunahan hak asasi manusia, keadilan dan kesetaraan gender
f. Mampu melakukan upaya pemberdayaan perempuan sebagai mitra untuk
meningkatkan kesehatan perempuan
g. Mampu membuat keputusan secara tepat dalam pelayanan kebidanan
berdasarkan pemikiran logis, kritis, inovatif sesuai dengan kode etik
B. TEMPAT DAN WAKTU PELAKSANAAN

Waktu Praktik : 16 s/d 28 Januari 2023
Tempat : UPT Puskesmas Pangkajene Sidrap
Bagian : POLI KIA
C. KOMPETENSI YANG INGIN DICAPAI
1. Konseling pranikah
2. Konseling Kesehatan reproduksi pada wanita
ii
3. Melakukan skrining HIV pranikah / pre marital check up
4. Teknik pengambilan dan pengiriman sediaan pap smear
5. Melakukan deteksi dini dan kolaborasi interprofesional dalam

kasus : a) amenore primer dan sekunder b) benjolan pada
payudara c) disminore d) DUB e) infeksi saluran reproduksi dan
infeksi menular seksual (gonorhea, hepatitis, TORCH,
PMS/PHDD, PCO, PID, sifilis, trichomonas, vulvovaginalis,
candidiasis) f) Gejala fertilitas primer dan sekunder g) risiko
tinggi masa prakonsepsi
6. Imunisasi pranikah
7. Penyuluhan kesehatan mengenai kesehatan reproduksi,

penyakit menular seksual (PMS), HIV/AIDS, hepatitis
8. Identifikasi gangguan masalah dan kelainan-kelainan sistem

reproduksi
9. Kolaborasi dan atau rujukan secara tepat pada wanita atau ibu
dengan gangguan sistem reproduksi
10. Melakukan dokumentasi pada asuhan kebidanan pada

pranikah
11. Pemeriksaan dan konseling pranikah
12. asuhan dan konseling jenis-jenis kontrasepsi
13. persiapan menjadi orang tua
14. konseling persiapan kehamilan
15. Evidancebased terkait prakonsepsi
16. Melakukan dokumentasi pada asuhan kebidanan pada

prakonsepsi
D. TARGET
1. CBD 1
2. BST 2
3. Refleksi Kasus 1
4. Journal Reading 2
5. OMP 1
iii
iv
v
LAPORAN CASE BASED DISCUSSION (CBD)
STASE PRANIKAH PRAKONSEPSI
ASUHAN KEBIDANAN PADA NN N DENGAN AMENOREA SEKUNDER
TAHUN AKADEMIK 2022/2023
Preseptor Pembimbing Pendidikan : Nasrayanti SST.,M. Keb
Disusun Oleh :
MARWAH JAMALUDDIN
202210091
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM PROFESI

FAKULTAS KEPERAWATAN DAN KEBIDANAN
ITKES MUHAMMADIYAH SIDRAP
vi
HALAMAN PENGESAHAN LAPORAN CASE BASED DISCUSSION (CBD)
STASE PRANIKAH DAN PRANKONSEPSI
JUDUL KASUS AMENOREA SEKUNDER PADA NN N
TAHUN AKADEMIK 2023
pangkajene, 19 januari 2023
Preseptor Pendidikan Preceptor Lahan Mahasiswa
Nasrayanti, S,ST.,M.Keb Herlina, S.ST Marwah Jamaluddin

NIDN :0915019105 NIP:19841231201704 2 014 NIM: 202210091
vii
DAFTAR ISI
DAFTAR ISI............................................................................................. i
PENDAHULUAN...................................................................................... 2
1. Latar Belakang .............................................................................................. 2
2. Tujuan ........................................................................................................... 3
TINJAUAN TEORI........ 5
A. KONSEP DASAR TENTANG KESEHATAN REPRODUKSI .................... 5
B. KONSEP DASAR AMENOREA SEKUNDER ............................................ 6
DOKUMENTASI SOAP DAN RENCANA TINDAK LANJUT ..........11
PEMBAHASAN ......................................................................................15
KESIMPULAN....................................................................................... 16
REFERENSI......................................................................................... 17
i
PENDAHULUAN
1. Latar Belakang
Kesehatan reproduksi merupakan aspek yang menjadi perhatian
setelah upaya kesehatan pada umumnya tercapai. Kesehatan reproduksi
menurut WHO adalah kesejahteraan fisik, mental dan sosial yang utuh
bukan hanya bebas dari penyakit atau kecacatan dalam segala aspek
yang berhubungan dengan sistem reproduksi, fungsi serta prosesnya
(Manuaba, I.B.G. 2013)
Wanita rentan terhadap penyakit yang menyerang organ reproduksinya.
Kebanyakan wanita, sangat malu dan tertutup untuk berkonsultasi
secara langsung mengenai kesehatan pribadinya. Faktor lain pun
dikarenakan biaya untuk pemeriksaan ke dokter spesialis cenderung
mahal. Ada juga yang tidak mempedulikan gejala yang muncul, dan
ketika kondisi sudah memburuk dan memerlukan penanganan yang
ekstra, dokter spesialis menjadi tujuan akhir (Merin, 2013)
Wanita dalam kehidupannya tidak luput dari adanya siklus
menstruasi normal yang terjadi secara periodik. wanita akan merasa
terganggu bila hidupnya mengalami perubahan, terutama bila
menstruasi menjadi lebih lama dan atau banyak, tidak teratur, lebih
sering atau tidak menstruasi sama sekali, bahkan bisa disertai nyeri.
Diharapkan semua wanita mengalami siklus menstruasi yang teratur,
namun hampir semua wanita pernah mengalami gangguan menstruasi
selama masa hidupnya. Gangguan ini dapat berupa kelainan siklus atau
perdarahan. Masalah ini dihadapi oleh wanita remaja, reproduksi dan
2
klimakterium (Kumalasari dan Andhyantoro, 2013)
Amenore sekunder lebih menunjuk kepada sebab yang timbul
kemudian dalam kehidupan wanita, seperti gangguan metabolisme,
tumor, penyakit infeksi, stres (di rumah, sekolah, atau tempat kerja),
latihan fisik yang melelahkan, dan gangguan gizi dimana berat badan
rendah untuk tinggi badan (IMT kurang) (Merin, 2013)
Peran Bidan dalam upaya meningkatkan kesehatan reproduksi yaitu
melakukan penyuluhan mengenai cara untuk mengurangi keluhan
tersebut pada remaja, dengan berperilaku hidup sehat, memperbaiki
keadaan kesehatan seperti perbaikan gizi, kehidupan dalam lingkungan
yang sehat dan tenang, mengurangi berat badan pada wanita dengan
obesitas, olah raga, dan konsumsi nutrisi yang seimbang. Selain itu
khususnya sebagai remaja juga harus dapat menerapkan perilaku hidup
sehat untuk menjaga kesehatan reproduksi, karena wanita sebagai
tonggak kehidupan yang akan melahirkan generasi kehidupan
(Kumalasari dan Andhyantoro, 2013)
Beberapapenyebabmenstruasi mengalami penyimpangan yang
akibatnya perempuan bisa menderita anemia hingga kurang subur.
Gangguan menstruasi dapat berdampak serius, menstruasi yang tidak
teratur menjadi pertanda bahwa seseorang kurang subur (infertil)
(Merin, 2013)
2. Tujuan
a. Tujuan Khusus
Untuk melaksanakan manajemen asuhan kebidanan dalam
pranikah sesuai dengan Evidance Based Midwifery
3
b. Tujuan Umum
1) Untuk melakukan pengkajian lengkap mengenai asuhan
kebidanan dalam pranikah dengan amenorea sekunder
2) Untuk menganalisa kasus yang berkaitan dengan asuhan
kebidanan dalam pranikah dengan amenorea sekunder
4
TINJAUAN TEORI
A. KONSEP DASAR TENTANG KESEHATAN REPRODUKSI
1. Defenisi
Istilah reproduksi berasal dari re yang artinya kembali dan kata
produksi yang artinya membuat atau menghasilkan. Jadi istilah
reproduksi mempunyai arti suatu proses kehidupan manusia dalam
menghasilkan keturunan demi kelestarian hidupnya (Yanti, 2011).
Menurut International Conference on Population and
Development (ICPD) (1994), kesehatan reproduksi adalah sebagai
hasil akhir keadaan sehat sejahtera secara fisik, mental dan sosial dan
tidak hanya bebars dari penyakit atau kecacatan dalam segala hal
yang terkait dengan sistem fungsi serta proses reproduksi
2. Gangguan dan Masalah Kesehatan Reproduksi
Wanita dalam kehidupannya tidak luput dari adanya siklus haid
normal yang terjadi secara periodik. Masalah gangguan pada
gangguan reproduksi, yaitu:
a. Infertilitas : Infertilitas adalah suatu keadaan dimana
seseorang wanita tidak mempunyai kemampuan untuk
mengandung sampai melahirkan bayi hidup setelah
setahun melakukan hubungan seksual yang teratur dan
tidak menggunakan alat kontrasepsi apapun setelah
memutuskan untuk mempuyai anak (Noviana dan
Wilujeng, 2014).
b. Gangguan menstruasi : menurut Varney (2007),
gangguan menstruasi terdiri dari :
5
1) Amenore merupakan perubahan umum yang
terjadi pada beberapa titik dalam sebagian besar
siklus menstruasi wanita dewasa.
2) Dismenorhoe menstruasi yang sangat
menyakitkan, terutama terjadi pada perut bagian
bawah dan punggung serta biasanya terasa seperti
kram.
3) Menoragia merupakan salah satu dari beberapa
keadaan menstruasi yang pada awalnya berada
dibawah label perdarahan uterus difungsional.
4) Metroragia , apabila menstruasi terjadi dengan
interval tidak teratur, atau jika terdapat insiden
bercak darah atau perdarahan diantara
menstruasi.
5) Oligomenore : aliran menstruasi yang tidak
sering atau hanya sedikit. f)Sindrom
pramenstruasi
6) Perubahan siklik fisik, fisiologi, dan perilaku
yang mencerminkan saat siklus menstruasi terjadi
hampir pada semua wanita beberapa waktu antara
menarche dan menopause
B. KONSEP DASAR AMENOREA SEKUNDER
1. Defenisi
Amenorea sekunder yaitu pernah mengalami menstruasi dan
selanjutnya berhenti lebih dari tiga bulan . Amenore sekunder
6
atau Jing-Bi adalah keadaan tidak haid untuk sedikitnya 3 bulan
berturut-turut. Amenore sekunder ( SA ) secara klinis
didefinisikan sebagai tidak adanya menstruasi selama lebih dari 3
interval siklus atau 6 bulan berturut-turut pada wanita yang
sebelumnya mengalami menstruasi (Merin dkk, 2012)
2. Etiologi
Menurut Fansia (2013), penyebab amenore dapat
fisiologik, endokrinologik, atau organik, atau akibat
gangguan perkembangan. Amenore dalam ilmu TCM
(Traditional Chinese Medicine) disebut sebagai Jing-Bi
disebabkan karena malnutrisi, keadaan emosional (stress),
perubahan lingkungan, dan beberapa penyakit organ
reproduksi lainnya
Sedangkan menurut Manuaba (2013), penyebabnya
kemungkinan gangguan gizi dan metabolisme, gangguan
hormonal, terdapat tumor alat kelamin atau terdapat penyakit
menahun. Penyebab amenore diakibatkan oleh beberapa
keadaan seperti hipotensi, anemia, infeksi, atau kelemahan
kondisi tubuh secara umum. Selain itu bisa juga disebabkan
oleh stres psikologis.
3. Gejala
Menurut Nugroho dan Utama (2014), gejala amenore bervariasi
tergantung kepada penyebabnya. Jika penyebabnya adalah kegagalan
mengalami pubertas, maka tidak akan ditemukan tanda-tanda
pubertas seperti pembesaran payudara, pertumbuhan rambut ketiak
7
serta perubahan bentuk tubuh. Jika penyebabnya adalah kehamilan
akan ditemukan morning sickness dan pembesaran perut. Jika
penyebabnya adalah kadar hormon tiroid yang tinggi maka gejalanya
adalah denyut jantung yang cepat, kecemasan, kulit yang hangat dan
lembab. Sindroma cushing menyebabkan wajah bulat (moon face),
perut buncit dan lengan serta tungkai yang kurus. Gejala lain yang
mungkin ditemukan, yaitu:
a. Sakit kepala
b. Galaktore (pembekuan air susu pada wanita yang tidak hamil
dan tidak sedang menyusui.
c. Gangguan penglihatan (pada tumor hipofisa)
d. Penurunan atau penambahan berat badan yang berarti
e. Vagina yang kering
f. Hirsutisme (pertumbuhan rambut yang berlebihan yang
mengikuti pola pria), perubahan suara dan perubahan
ukuran payuarabenar.
4. Diagnosa
Menurut Nugroho dan Utama (2014), diagnosis ditegakkan
berdasarkan gejala, hasil pemeriksaan fisik dan usia penderita.
Pemeriksaan yang biasa dilakukan yaitu:
a. Biopsi endometrium
b. Progestin withdrawal
c. Kadar prolaktin
d. Kadar hormon
e. Tes fungsi tiroid
8
f. Tes kehamilan
g. Kadar FSH (Folicle Stimulatin Hormon), LH (Luteinzing
Hormone) dan TSH (Thyroid Stimulating Hormone).
h. Kariotipe untuk mengetahui adanya kelainan kromosom.
i. CT Scan kepala (jika diduga ada tumor hipofisa)
5. Penatalaksanaan
Menurut Nugroho dan Utama (2014), pengobatan tergantung
kepada penyebabnya. Jika penyebabnya adalah penurunan berat
badan yang drastis atau obesitas, penderita dianjurkan untuk
menjalani diet yang tepat. Jika penyebannya adalah olah raga yang
berlebihan, penderita dianjurkan untuk menguranginya. Jika seorang
anak perempuan belum pernah mengalami menstruasi dan semua
hasil pemeriksaan normal, maka dilakukan pemeriksaan setiap 3 – 6
bulan untuk memantau perkembangan pubertasnya. Untuk
merangsang menstruasi bisa diberikan progesteron. Untuk
merangsan perubahan pubertas pada anak perempuan yang
payudaranya belum membesar atau rambut kemaluan dan ketiaknya
belum tumbuh bisa diberikan estrogen.
Jika penyebabnya adalah tumor, maka dilakukan pembedahan
untuk mengangkat tumor tersebut. Tumor hipofisa yang terletak di
dalam otak biasanya diobati dengan bromokriptin untuk mencegah
pelepasan prolaktin yang berlebihan oleh tumor. Bila perlu bisa
dilakukan pengangkatan tumor. Terapi penyinaran biasanya baru
dilakukan jika pemberian obat ataupun pembedahan tidak berhasil.
Menurut Fansia (2011), amenore sekunder tersebut dapat
9
ditangani dengan Kombinasi terapi akupunktur dengan prinsip
meningkatkan sirkulasi Qi, menghilangkan stasis darah, dan
memulihkan siklus menstruasi. Terapi akupunktur dilakukan dalam 5
kali perawatan dengan merangsang titik-titik akupunktur yaitu
Zhongji (CV 3), Diji (SP 8), Hegu (LI 4), Sanyinjiao (SP 6),
Taichong (LV 3), Fenglong (ST 40), dan Guanyuan (CV 4). Selain
itu, pasien juga mendapat terapi herbal yaitu kunyit yang memiliki
efek estrogenik. Dalam pemberian herbal kunyit ditambahkan asam
kawak yang kemungkinan dapat memperkuat efek peluruh haid, dan
madu yang memiliki kandungan vitamin dan mineral. Pemberian
herbal kunyit diberikan dalam bentuk dekokta (rebusan) kunyit asam
dengan dosis kunyit sebanyak 21 gr, asam kawak 5 gr, madu 3 sdm,
dan garam secukupnya, kemudian direbus dalam 750 mL air, lalu
dijadikan 600 mL. Rebusan tersebut diminum 3 kali sehari @ 200
mL
Pada pasien juga dilakukan upaya perbaikan gizi dengan
pemberian susu kedelai sebanyak 30 gr yang dicampur dengan air
hangat sebanyak 240 mL dan pemberian rebusan air kacang hijau
dengan dosis kacang hijau sebanyak 30 gr dalam 300 mL air, lalu
dijadikan 240 mL. Kedelai dan kacang hijau memiliki efek
estrogenik.
Menurut Proverawati dan Misaroh (2019), meliputi : observasi
keadaan umum, perbaikan asupan gizi, pengurangan berat badan
pada wanita obesitas, pemberian tiroid pada wanita dengan
hipotiroid, pemberian kortikosteroid pada gangguan glandula
10
DOKUMENTASI SOAP DAN RENCANA TINDAK LANJUT
No. RM : 2X XX XX
Nama Pengkaji : Marwah jamaluddin
Tanggal MRS : 19-1-2023 Jam 10.00 Wita
Tanggal Pengkajian : 19-1-2023 Jam 11.00 Wita
Tempat Pengkajian : POLI KIA
IDENTITAS ISTRI/ SUAMI
1. Nama Istri : NN N
2. Umur : 21 Tahun
3. Suku : Bugis
4. Agama : Islam
5. Pendidikan: SMA
6. Pekerjaan : Wiraswasta
7. Alamat : Pangkajene
8. No. HP : 0812 90 XXX XXX
a. Subjecktif ( S )
- Nn. N mengatakan sudah 3 bulan lebih belum mendapatkan
menstruasi
- Nn N mengeluh cemas dengan keadaannya
- Nn. N mengatakan haid pertama menstruasi umur 13 tahun
- Nn. N mengatakan siklus menstruasinya ± 30 hari.
- Nn. N mengatakan menstruasinya teratur
11
- Nn. N mengatakan menstruasinya 5 – 6 hari
- Nn. N mengatakan ganti pembalut 2 -3/hari
- Nn. N mengatakan sifat darahnya merah segar dan ada gumpalan
- Nn. N mengatakan tidak pernah nyeri perut bagian bawah saat
menstruasi
- Nn. N mengatakan belum pernah menikah
b. Objecktif ( O)
- Keadaan umum : Baik
- Kesadaran :Composmentis
- TTV :
- TD : 110/70 mmHg
- R: 20x/menit
- N : 78 x/menit
- S : 36,40 C
- TB : 157 cm
- BB sebelum : 62 kg BB sekarang :59 kg.
- Pemeriksaan fisik head to toe :
- Wajah : simetris kiri dan kanan,
tidak ada edema dan nyeri tekan.
- Mata : simetris kiri dan kanan, konjungtiva merah muda,
sklera
putih.
- Mulut : bibir tidak pucat, tidak ada sariawan, gigi tidak
tanggal
12
dan tidak ada caries gigi.
- Leher : tidak ada pembesaran kelenjar limfe, tidak ada
pembesaran kelenjar tiroid dan vena jugularis.
- Payudara : simetris kiri dan kanan, hiperpigmentasi pada
areola mammae, puting susu menonjol, tidak ada
benjolan dan nyeri tekan.
- Abdomen : tidak ada nyeri tekan
- Genitalia : tidak ada kelainan, tidak ada pembengkakan
dan nyeri tekan.
- Anus : tidak ada hemoroid pada anus.
- Ekstremitas : simetris kiri dan kanan, tidak ada varises,
tidak edema
- refleks patella kiri (+) kanan (+).
c. Analisa( A )
Nn N usia 21 tahun amenorea sekunder
d. Penatalaksanaan ( P )
- Jelaskan pada pasien tentang hasil pemeriksaan
Nn N telah mengetahui kondisi kesehatannya saat ini
- Berikan KIE pada pasien mengenai amenore sekunder
Nn N sudah mendapatkan konseling dan edukasi mengenai
amenorea sekunder
- Anjurkan pasien untuk istirahat yang cukup dan mengkonsumsi
makanan bergizi
Nn N sudah dianjurkan untuk istrirahat yang cukup dan
mengkonsumsi makanan yang bergizi
13
- Berikan support mental pada pasien untuk mengurangi kecemasan
Nn N telah diberikan support mental untuk mengurangi
kecemasannya
- Anjurkan pasien untuk kunjungan ulang 10 hari lagi atau jika ada
keluhan.
Nn N mengatakan akan melakukan kunjungan ulang 10 hari lagi
14
PEMBAHASAN
Amenorea sekunder yaitu pernah mengalami menstruasi dan
selanjutnya berhenti lebih dari tiga bulan . Amenore sekunder atau Jing-
Bi adalah keadaan tidak haid untuk sedikitnya 3 bulan berturut-turut.
Amenore sekunder ( SA ) secara klinis didefinisikan sebagai tidak
adanya menstruasi selama lebih dari 3 interval siklus atau 6 bulan
berturut-turut pada wanita yang sebelumnya mengalami menstruasi
(Merin dkk, 2012)
Dari tinjaun pustaka dapat disimpulkan bawah tidak ada kesenjangan
anatara asuhan kebidanan dengan amenore sakunder dengan teori
evidance based yang ada
15
KESIMPULAN
Amenore sekunder lebih menunjuk kepada sebab yang timbul
kemudian dalam kehidupan wanita, seperti gangguan metabolisme, tumor,
penyakit infeksi, stres (di rumah, sekolah, atau tempat kerja), latihan fisik
yang melelahkan, dan gangguan gizi dimana berat badan rendah untuk
tinggi badan (IMT kurang) Peran Bidan dalam upaya meningkatkan
kesehatan reproduksi yaitu melakukan penyuluhan mengenai cara untuk
mengurangi keluhan tersebut pada remaja, dengan berperilaku hidup sehat,
memperbaiki keadaan kesehatan seperti perbaikan gizi, kehidupan dalam
lingkungan yang sehat dan tenang, mengurangi berat badan pada wanita
dengan obesitas, olah raga, dan konsumsi nutrisi yang seimbang. Selain itu
khususnya sebagai remaja juga harus dapat menerapkan perilaku hidup
sehat untuk menjaga kesehatan reproduksi, karena wanita sebagai tonggak
kehidupan yang akan melahirkan generasi kehidupan
16
REFERENSI
Bartini. (2019). Buku Ajar Asuhan Kebidanan Kehamilan. EGC.
Kumalasari dan Andhyantoro, 2013. Kesehatan Reproduksi untuk

Mahasiswa Kebidanan dan Keperawatan. Jakarta: Salemba Medika
Manuaba, I.B.G. 2013 Memahami Kesehatan Reproduksi Wanita. Jakarta :

EGC
Merin,2013. Amenorrhea: Cytogenetic Studies and Beyond.
core.ac.uk/download/pdf/12348799.pdf. diakses 24 November 2015
17
18
19
20
21
22
23
REFLEKSI KASUS
1. DESKRIPSI KASUS
Pada tanggal 19 januari 2023, Nona N datang Ke puskesmas di antar oleh
ibunya. Nn. N mengatakan bahwa sampai saat ini dirinya belum pernah
menstruasi. Nn N mengeluh cemas dengan keadaannya Nn. N mengatakan
belum pernah menikah . Dari hasil pemeriksaan didapatkan keadaan umum :
baik kesadaran :composmentis TTV TD : 100/70 mmHg R: 20x/menit N
: 80 x/menit S : 36,40 C TB: 157 cm BB :42 kg LILA :22 cm dan
Pemeriksaan head to toe dalam batas normal
2. EMOSI PRIBADI
Pada saat saya melihat nonaN, saya menydari nona N terlihat cemas dan
bingug dengan kondisi kesehatan reproduksinya saat ini. Perasaan pertama
setelah melihat nona N adalah kasian dan berempati dan mendoakan
kesehatan reproduksi nona K dapat normal
3. EVALUASI
Apa yang menyebabkan terjadinya amenorea primer ? Bagaimana asuhan
kebidanan dalam kasus amenorea primer ?
4. ANALISA KASUS
Sama halnya dengan amenorea sekunder, pada amenorea primer ada
banyak faktor penyebab terjadinya amenorea sekunder diantaranya
penyebabnya kemungkinan gangguan gizi dan metabolisme, gangguan
hormonal, terdapat tumor alat kelamin atau terdapat penyakit menahun.
Penyebab amenore diakibatkan oleh beberapa keadaan seperti hipotensi,
anemia, infeksi, atau kelemahan kondisi tubuh secara umum. Selain itu bisa
juga disebabkan oleh stres psikologis.
Pada kasus amenorea primer , asuhan kebidanan yang dapat dilakukan
ialah pemeberian konseling mengenai mengenai amenore primer, anjurkan
pasien untuk istirahat yang cukup dan mengkonsumsi makanan bergizi,
berikan support mental pada pasien untuk mengurangi kecemasan. Terapi
selanjutnya merupakan wewenang dokter spesialis obgyn
24
5. KESIMPULAN
Dalam masa kanak-kanak ovarium boleh dikatakan masih dalam keadaan
istirahat, belum menunaikan faalnya dengan baik. Baru jika terjadi pubertas (
akil balig), maka terjadilah perubahan-perubahan dalam ovarium yang
mengakibatkan pula perubahan-perubahan besar pada seluruh badan wanita
tersebut. Pubertas tercapai pada umur 12-16 tahun dan dipengaruhi oleh
keturunan, bangsa, iklim, dan lingkungan. Kejadian yang terpenting dalam
pubertas ialah timbulnya haid yang pertama kali (menarche ). Walaupun
begitu menarche merupakan gejala pubertas yang lambat. Paling awal terjadi
pertumbuhan payudara ( thelarche ), kemudian tumbuh rambut kemaluan (
pubarche ), disusul dengan tumbuhnya rambut di ketiak. Setelah tu barulah
terjadi menarche, dan sesudah itu haid datang secara siklik.
Haid ( menstruasi ) adalah perdarahan yang siklik dari uterus sebagai
tanda bahwa alat kandungan menunaikan faalnya. Secara fisiologis
menstruasi adalah proses hormonal dalam tubuh wanita sebagai hasil dari
pelepasan ovum. Pelepasan itu terjadi ketika ovum yang ada di ovarium tidak
dibuahi. Amenore adalah absennya perdarahan menstruasi. Amenore normal
terjadi pada wanita prepubertal, kehamilan, dan postmenopause. Pada wanita
usia reproduktif, yang harus diperhatikan pertama kali dalam mendiagnosa
etiologi dari amenore adalah kehamilan. Apabila tidak ada kehamilan, barulah
kita harus mencari alternatif lain untuk mencari etiologi dari amenore itu
sendiri kehidupan
Menurut Nugroho dan Utama (2014), pengobatan tergantung kepada
penyebabnya. Jika penyebabnya adalah penurunan berat badan yang drastis
atau obesitas, penderita dianjurkan untuk menjalani diet yang tepat. Jika
penyebannya adalah olah raga yang berlebihan, penderita dianjurkan untuk
menguranginya. Jika seorang anak perempuan belum pernah mengalami
menstruasi dan semua hasil pemeriksaan normal, maka dilakukan
pemeriksaan setiap 3 – 6 bulan untuk memantau perkembangan pubertasnya.
Untuk merangsang menstruasi bisa diberikan progesteron. Untuk merangsan
perubahan pubertas pada anak perempuan yang payudaranya belum
membesar atau rambut kemaluan dan ketiaknya belum tumbuh bisa diberikan
25
estrogen
6. TINDAK LANJUT
Pada kasus Nona K , tindakan yang dilaksanakan ialah jelaskan pada pasien
tentang hasil pemeriksaan, berikan kie pada pasien mengenai amenore primer
, anjurkan pasien untuk istirahat yang cukup dan mengkonsumsi makanan
bergizi , berikan support mental pada pasien untuk mengurangi kecemasan
dan anjurkan nona K untuk langsung berkonsultasi dengan dokter spesialis
obgyn
26
LAPORAN PRAKTIK PROFESI READING JURNAL
TENTANG HUBUNGAN KONSELING NUTRISI DENGAN
KECEMASAN PASIEN AMENOREA PRIMER
TAHUN AKADEMIK 2023
Disusun Oleh :
MARWAH JAMALUDDIN
202210091
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM

PROFESI FAKULTAS KEPERAWATAN DAN KEBIDANAN
27
HALAMAN PENGESAHAN READING JURNAL
TENTANG HUBUNGAN KONSELING NUTRISI DENGAN
KECEMASAN PASIEN AMENOREA PRIMER
TAHUN AKADEMIK 2023
Preseptor Institusi Preceptor Lahan Mahasiswa

NIDN :0915019105 NIP:19841231201704 2 014 NIM: 202210091
KATA PENGANTAR
Assalamualaikum Warahmatulahi Wabarakatuh

Dengan mengucapkan puji syukur kehadirat Allah, penulis dapat
menyelesaikan jurnal reading yang berjudul asuhan kebidanan pada kasus
hubungan konseling nutrisi dengan kecemasan amenorhea primer pada nona k ”.
Penulis sadar bahwa penulisan laporan jurnal reading ini masih jauh dari
sempurna . Untuk itu penulis memohon kritik dan saran yang dapat membangun
agar penulisan laporan reading jurnal ini menjadi lebih baik lagi. Akhir kata,
penulis mengucapkan terimakasih dan memohn maaf jika ada kesalahan dalam
penulisan laporan jurnal reading ini
Wassalamualaikum Warahmatullahi Wabarakatuh
Sidrap, 19 januari 2023

Penulis
BAB I
PENDAHULUAN
A. Masalah
Dalam masa kanak-kanak ovarium boleh dikatakan masih dalam keadaan
istirahat, belum menunaikan faalnya dengan baik. Baru jika terjadi pubertas ( akil
balig), maka terjadilah perubahan-perubahan dalam ovarium yang mengakibatkan
pula perubahan-perubahan besar pada seluruh badan wanita tersebut. Pubertas
tercapai pada umur 12-16 tahun dan dipengaruhi oleh keturunan, bangsa, iklim, dan
lingkungan. Kejadian yang terpenting dalam pubertas ialah timbulnya haid yang
pertama kali (menarche ). Walaupun begitu menarche merupakan gejala pubertas
yang lambat. Paling awal terjadi pertumbuhan payudara ( thelarche ), kemudian
tumbuh rambut kemaluan ( pubarche ), disusul dengan tumbuhnya rambut di ketiak.
Setelah tu barulah terjadi menarche, dan sesudah itu haid datang secara siklik.
(Nugroho dan utama, 2014)
Haid ( menstruasi ) adalah perdarahan yang siklik dari uterus sebagai tanda
bahwa alat kandungan menunaikan faalnya. Secara fisiologis menstruasi adalah
proses hormonal dalam tubuh wanita sebagai hasil dari pelepasan ovum. Pelepasan
itu terjadi ketika ovum yang ada di ovarium tidak dibuahi. Amenore adalah absennya
perdarahan menstruasi. Amenore normal terjadi pada wanita prepubertal, kehamilan,
dan postmenopause. Pada wanita usia reproduktif, yang harus diperhatikan pertama
kali dalam mendiagnosa etiologi dari amenore adalah kehamilan. Apabila tidak ada
kehamilan, barulah kita harus mencari alternatif lain untuk mencari etiologi dari
amenore itu sendiri (Nugroho dan utama, 2014)
Kesehatan reproduksi merupakan aspek yang menjadi perhatian setelah
upaya kesehatan pada umumnya tercapai. Kesehatan reproduksi menurut WHO
adalah kesejahteraan fisik, mental dan sosial yang utuh bukan hanya bebas dari
penyakit atau kecacatan dalam segala aspek yang berhubungan dengan sistem
reproduksi, fungsi serta prosesnya (Manuaba, I.B.G. 2013)
Kebanyakan wanita, sangat malu dan tertutup untuk berkonsultasi secara langsung
mengenai kesehatan pribadinya. Faktor lain pun dikarenakan biaya untuk
pemeriksaan ke dokter spesialis cenderung mahal. Ada juga yang tidak
mempedulikan gejala yang muncul, dan ketika kondisi sudah memburuk dan
memerlukan penanganan yang ekstra, dokter spesialis menjadi tujuan akhir (Merin,
2013)
Amenore primer juga dapat diakibatkan oleh kelainan pada aksis hipotalamus-
hipofisis-ovarium. Hypogonadotropic amenorrhoea menunjukkan keadaan dimana
terdapat sedikit sekali kadar FSH dan SH dalam serum. Akibatnya, ketidakadekuatan
hormon ini menyebabkan kegagalan stimulus terhadap ovarium untuk melepaskan
estrogen dan progesteron. Kegagalan pembentukan estrogen dan progesteron akan
menyebabkan tidak menebalnya endometrium karena tidak ada yang merasang.
Terjadilah amenore. Hal ini adalah tipe keterlambatan pubertas karena disfungsi
hipotalamus atau hipofosis anterior, seperti adenoma pitiutari (Nugroho dan utama,
2014)
B. Skala
Amenorea primer pada remaja yang tidak ditangani dengan tepat akan
menimbulkan berbagai masalah kesehatan reproduksi diantaranya ialah
infertilitas.
C. Kronologi
Penyebab Amenorea primer merupakan suatu kejadian yang tidak
pernah mengalami menstruasi samasekali, Amenore primer juga dapat
diakibatkan oleh kelainan pada aksis hipotalamus-hipofisis-ovarium.
Hypogonadotropic amenorrhoea menunjukkan keadaan dimana terdapat
sedikit sekali kadar FSH dan SH dalam serum. Akibatnya, ketidakadekuatan
hormon ini menyebabkan kegagalan stimulus terhadap ovarium untuk
melepaskan estrogen dan progesteron. Kegagalan pembentukan estrogen dan
progesteron akan menyebabkan tidak menebalnya endometrium karena tidak
ada yang merasang. Terjadilah amenore. Hal ini adalah tipe keterlambatan
pubertas karena disfungsi hipotalamus atau hipofosis anterior, seperti
adenoma pitiutari (Merin dkk, 2012).
Menurut Manuaba (2013), penyebabnya kemungkinan gangguan gizi
dan metabolisme, gangguan hormonal, terdapat tumor alat kelamin atau
terdapat penyakit menahun. Penyebab amenore diakibatkan oleh beberapa
keadaan seperti hipotensi, anemia, infeksi, atau kelemahan kondisi tubuh
secara umum. Selain itu bisa juga disebabkan oleh stres psikologis
Pada pasien yang mengalami amenorea akan muncul berbagai
masalah gangguan psikologi salah satunya ialah kecemasan, kecemasan yang
berlebihan akan menambah masalah pada kelenjar hipofisis dan membuat
amenorea primer makin sulit untuk diidentifikasi.
D. Solusi
Penangan yang dapat dilakukan bidan sesuai evidance based midwifery
dalam mengatasi masalah amenorhea primer ialah pemberian konseling
informasi dan edukasi mengenai amenorea primer terutama pada faktor
pemicu terjadinya amenorea primer, Amenorhea primer pada umumnya
dipicu oleh masalah nutrisi pada remaja seperti anemia, gaya hidup tidak
sehat hingga kekurangan energi kronik. Pengenalan dan identifikasi masalah
yang terjadi pada diri remaja perlu untuk disosialisasikan agar remaja yang
mengalami amenorea primer dapat mengetahui apa pemicu terjadinya
masalah ini (Manuaba, 2013)
BAB II
TINJAUAN PUSTAKA
A. Asuhan Kebidanan
Judul/Waktu Deskriptif Resposisi TTD

Asuhan S
Kebidanan pra - Nn. K mengatakan
nikah pada bahwa sampai saat ini Mahasiswa
remaja yang dirinya belum pernah
mengalami menstruasi.
amenorea primer - Nn K mengeluh cemas
dengan keadaannya
- Nn. K mengatakan belum pernah
Marwah jamaluddin
Tanggal 8 menikah
/1/2023 - O:
Jam :19.56 - Keadaan umum : Baik
- Kesadaran
:Composmentis
- TTV :
- TD : 100/70 mmHg
- R: 20x/menit CI Institusi:
- N : 80 x/menit
- S : 36,40 C
- TB : 157 cm
- BB :42 kg
- LILA :21 cm
A:
Nn K usia 16 tahun dengan Nasrayanti,S.ST.,M.Keb
amenorea primer
P:
- Jelaskan pada pasien
tentang hasil pemeriksaan
Hasil : Nn K telah
mengetahui kondisi
kesehatannya saat ini Preseptor lahan
- Berikan KIE pada pasien
mengenai amenore primer
Hasil : Nn K sudah
mendapatkan konseling dan
edukasi mengenai
amenorea primer
- Anjurkan pasien untuk
istirahat yang cukup Herlina, S.ST
- Hasil : Nn K sudah
dianjurkan untuk istrirahat
yang cukup
- Berikan konseling
mengenai pemenuhan
nutrisi agar klien tidak
cemas berlebihan
Hasil : Nn K sudah
mengetahui pemenuhan
nutrisi yang baik
- Berikan support mental
pada pasien untuk
mengurangi kecemasan
Hasil : Nn K telah
diberikan support mental
untuk mengurangi
kecemasannya
- Anjurkan pada pasien
untuk berkonsultasi dan
memeriksakan kedokter
spesialis obgyn
Hasil : Nn K mengatakan
akan melakukan
memeriksakan dirinya ke
dokter sepesialis Obgyn
B. Telaah Jurnal
Jurnal Judul Populasi Intervensi Comparasio Outcome Time
J. Endocrinol.
Konseling Remaja - Pemberian Pada asuhan kebidanan - Kecemasa 1 hari
Invest. 36: 343-Nutrisi yang konseling mengenai yang telah saya lakukan n remaja
346, 2013 terhadap mengalami nutrisi dalam dengan kasus amenorea menghilang
kecemasan amenorea penanganan amenorea primer tidak ada - Adanya
pada remaja primer primer kesenjangan antara perbaikan gizi
yang berjumlah - Faktor asuhan kebidanan yang
mengalami 293 orang prognostik dalam telah diberikan dengan
amenorea penelitian ini ialah intervensi yang
primer kelainan genetika tercantum pada jurnal ini
Pak J Med Sci Hubungan Remaja - Pemberian Pada asuhan kebidanan - Kecemasa 1 hari
2014;30(1):140- Konseling yang konseling mengenai yang telah saya lakukan n remaja mengenai
144. nutrisi pada mengalami nutrisi dalam dengan kasus amenorea amenorea primer
remaja yang amenorea penanganan primer tidak ada berkurang
mengalami primer amenorea primer kesenjangan antara
kecemasan berjumlah - Faktor asuhan kebidanan yang
amenorea 100 orang prognostik dalam telah diberikan dengan
primer penelitian ini ialah intervensi yang
kelainan genetika tercantum pada jurnal ini
Sri lanka Journal Hubungan Remaja - Pemberian Pada asuhan kebidanan - Kecemasa 1 hari
Vol 1 No 2 2022 konseling yang konseling mengenai yang telah saya lakukan n remaja mengenai
nutrisi mengalami nutrisi dalam dengan kasus amenorea amenorea primer
terhadap amenorea penanganan primer tidak ada berkurang
kecemasan primer amenorea primer kesenjangan antara
remaja yang berjumlah - Faktor asuhan kebidanan yang
mengalami 30 orang prognostik dalam telah diberikan dengan
amenorea penelitian ini ialah intervensi yang
primer di Sri kelainan genetika tercantum pada jurnal ini
Lanka
C. Deskripsi Asuhan Kebidanan dengan Reading Jurnal
Hasil asuhan kebidanan yang saya lakukan kepada pada Nn K usia 16 tahun dengan
amenorea primer sejalan dengan hasil reading jurnal pertama yang oleh (E. Bacchi, 2013)
dalam jurnal J. Endocrinol. Invest. 36: 343-346, 2013 dengan hasil bahwa ada hubungan
signifikan antara konseling nutrisi dengan tingkat kecemasan remaja yang mengalami amenorea
primer dengan tingkat signifikasi sebesar < 0.005. kemudian didukung oleh jurnal kedua yang
diteliti oleh (Saira Dars, 2014 ) dengan judul Hubungan Konseling nutrisi pada remaja yang
mengalami kecemasan amenorea primer dalam jurnal Pak J Med Sci 2014;30(1):140-144, hasil
penelitian menyatakan ada hubungan antara konseling nutrisi dengan kecemasan remaja yang
mengalami amenorea primer dengan tingkat signifikansi sebesar P =0.001 Kemudian disertai
oleh jurnal ketiga yang diteliti oleh DA Jayakody dengan judul Hubungan konseling nutrisi
terhadap kecemasan remaja yang mengalami amenorea primer di Sri Lanka dalam jurnal Sri
lanka Journal Vol 1 No 2 2022 dengan hasil bahwa ada hubungan antara konseling nutrisi
dengan tingkat kecemasan remaja yang mengalami amenorea primer di Sri Lanka dengan tingkat
signifikasi sebesar P=<0.005
D. Teori dari pokok bahasan asuhan kebidanan dengan reading jurnal
Teori dari pokok bahasan asuhan kebidanan dengan reading jurnal ialah konseling
mengenai nutrisi dapat membuat pengetahuan remaja meningkat, Pada umumnya amenorea
primer terjadi disebabkan oleh masalah nutrisi pada remaja seperti anemia, gaya hidup tidak
sehat hingga kekurangan energi kronik. Pengenalan dan identifikasi masalah yang terjadi pada
diri remaja perlu untuk disosialisasikan agar remaja yang mengalami amenorea primer dapat
mengetahui apa pemicu terjadinya masalah ini (Manuaba, 2013) Dan pada jurnal 1,2,3 terkait
dengan kasus menjelaskan tidak ada perbedaan secara signifikan statistik dalam pemberian
asuhan kebidanan pada kasus amenorea pada remaja
Penelitian ini sejalan dengan penelitian terdahulu yang dilakukan oleh (veronika, 2018)
bahwa konseling atau pun penyuluhan kesehatan yang berkaitan dengan suatu penyakit akan
menurunkan tingkat kecemasan pasien. Pada remaja yang mengalami amenorea primer pada
umumnya akan terjadi kecemasan dan menganggap bahwa dirinya mengalami ketidak normalan
yang tidak dapat untuk disembuhkan. Hasil penelitian ini menyatakan bahwa terdapat hubungan
yang signifikan antara konseling kesehatan dengan penurunan tingkat kecemasan pasien
amenorea primer
BAB III
KESIMPULAN DAN SARAN
A. KESIMPULAN
Amenore sekunder lebih menunjuk kepada sebab yang timbul kemudian dalam kehidupan
wanita, seperti gangguan metabolisme, tumor, penyakit infeksi, stres (di rumah, sekolah, atau
tempat kerja), latihan fisik yang melelahkan, dan gangguan gizi dimana berat badan rendah
untuk tinggi badan (IMT kurang) Peran Bidan dalam upaya meningkatkan kesehatan
reproduksi yaitu melakukan penyuluhan mengenai cara untuk mengurangi keluhan tersebut
pada remaja, dengan berperilaku hidup sehat, memperbaiki keadaan kesehatan seperti
perbaikan gizi, kehidupan dalam lingkungan yang sehat dan tenang, mengurangi berat badan
pada wanita dengan obesitas, olah raga, dan konsumsi nutrisi yang seimbang. Selain itu
khususnya sebagai remaja juga harus dapat menerapkan perilaku hidup sehat untuk menjaga
kesehatan reproduksi, karena wanita sebagai tonggak kehidupan yang akan melahirkan
generasi kehidupan
Pada umumnya amenorea primer terjadi disebabkan oleh masalah nutrisi pada remaja
seperti anemia, gaya hidup tidak sehat hingga kekurangan energi kronik. Pengenalan dan
identifikasi masalah yang terjadi pada diri remaja perlu untuk disosialisasikan agar remaja yang
mengalami amenorea primer dapat mengetahui apa pemicu terjadinya masalah ini
Dari pembuatan jurnal reading ini dapat disimpulkan bahwa tidak ada kesenjangan antara
asuhan kebidanan yang saya berikan kepada Nn K usia 16 tahun dengan amenorea primer
dengan jurnal 1,2,3 dan dengan teori evidance based yang ada.
B. SARAN
1. Hasil penelitian ini diharapkan dapat menjadi referensi dalam pemberian asuhan kebidanan
dengan kasus amenorea primer di RSUD Ponek
2. Hasil penelitian ini diharapkan dapat menjadi kebutuhan untuk penelitian lebih lanjut
mengenai amenorea primer
DAFTAR PUSTAKA

Manuaba, I.B.G. 2013 Memahami Kesehatan Reproduksi Wanita. Jakarta : EGC
core.ac.uk/download/pdf/12348799.pdf.
Nugroho dan utama, 2014. Masalah Kesehatan Reproduksi Wanita. Yogyakarta:Medical Book
LAPORAN PRAKTIK PROFESI READING JURNAL
TENTANG MANAJEMEN STRESS TERHADAP KECEMASAN
PASIEN AMENOREA SEKUNDER
TAHUN AKADEMIK 2023
Disusun Oleh :
MARWAH JAMALUDDIN
202210091
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM PROFESI FAKULTAS

KEPERAWATAN DAN KEBIDANAN
HALAMAN PENGESAHAN READING JURNAL
TENTANG MANAJEMEN STRESS TERHADAP KECEMASAN
PASIEN AMENOREA SEKUNDER
TAHUN AKADEMIK 2023
Preseptor Pendidikan Preceptor Lahan Mahasiswa

NIDN :0915019105 NIP:19841231201704 2 014 NIM: 202210091
i
KATA PENGANTAR
Assalamualaikum Warahmatulahi Wabarakatuh

Dengan mengucapkan puji syukur kehadirat Allah, penulis dapat
menyelesaikan jurnal reading yang berjudul asuhan kebidanan pada kasus
hiperemesis gravidarum”. Penulis sadar bahwa penulisan laporan jurnal reading
ini masih jauh dari sempurna . Untuk itu penulis memohon kritik dan saran yang
dapat membangun agar penulisan laporan reading jurnal ini menjadi lebih baik
lagi. Akhir kata, penulis mengucapkan terimakasih dan memohn maaf jika ada
kesalahan dalam penulisan laporan jurnal reading ini
Wassalamualaikum Warahmatullahi Wabarakatuh
Sidrap, -19 Januari 2023

Penulis
ii
DAFTAR ISI
HALAMAN PENGESAHAN READING JURNAL 28

KATA PENGANTAR 29
DAFTAR ISI iii
BAB I 30
A. Masalah ............................................................................................................. 30
B. Skala ................................................................................................................. 31
C. Kronologi .......................................................................................................... 31
D. Solusi ................................................................................................................ 32
BAB II 32
A.Asuhan Kebidanan 33
B.Telaah Jurnal 35
C.Deskripsi Asuhan Kebidanan dengan Reading Jurnal 36
D.Teori dari pokok bahasan asuhan kebidanan dengan reading
jurnal 36
BAB III 37
A.KESIMPULAN 37
B.SARAN 37
DAFTAR PUSTAKA 38
LAMPIRAN
iii
BAB I
PENDAHULUAN
E. Masalah
Amenore sekunder lebih menunjuk kepada sebab yang timbul kemudian dalam
kehidupan wanita, salah satunya ialah stres (di rumah, sekolah, atau tempat kerja
Wanita dalam kehidupannya tidak luput dari adanya siklus menstruasi normal yang
terjadi secara periodik. wanita akan merasa terganggu bila hidupnya mengalami
perubahan, terutama bila menstruasi menjadi lebih lama dan atau banyak, tidak
teratur, lebih sering atau tidak menstruasi sama sekali, bahkan bisa disertai nyeri.
Diharapkan semua wanita mengalami siklus menstruasi yang teratur, namun hampir
semua wanita pernah mengalami gangguan menstruasi selama masa hidupnya.
Gangguan ini dapat berupa kelainan siklus atau perdarahan. Masalah ini dihadapi
oleh wanita remaja, reproduksi dan klimakterium (Merin, 2013)
Kesehatan reproduksi merupakan aspek yang menjadi perhatian setelah upaya
kesehatan pada umumnya tercapai. Kesehatan reproduksi menurut WHO adalah
kesejahteraan fisik, mental dan sosial yang utuh bukan hanya bebas dari penyakit
atau kecacatan dalam segala aspek yang berhubungan dengan sistem reproduksi,
fungsi serta prosesnya (Manuaba, I.B.G. 2013)
Kebanyakan wanita, sangat malu dan tertutup untuk berkonsultasi secara langsung
mengenai kesehatan pribadinya. Faktor lain pun dikarenakan biaya untuk
pemeriksaan ke dokter spesialis cenderung mahal. Ada juga yang tidak
mempedulikan gejala yang muncul, dan ketika kondisi sudah memburuk dan
memerlukan penanganan yang ekstra, dokter spesialis menjadi tujuan akhir (Merin,
2013)
F. Skala
Gangguan amenorea sekunder dapat dialami oleh remaja hingga dewasa.
Namun pada usia remaj hingga pranikah pada umumnya amenorea sekunder terjadi
sebabkan oleh stress yang mempengaruhi hipotalamus untuk tidak mematangkan
sel ovum. Kondisi ini menyebabkan komplikasi terparah jika kasus amenorea
sekunder tidak segera diatasi ialah infertilitas.(Merin, 2013)
G. Kronologi
Menurut Fansia (2013), penyebab amenore sekunder dapat fisiologik,
endokrinologik, atau organik, atau akibat gangguan perkembangan. Amenore dalam
ilmu TCM (Traditional Chinese Medicine) disebut sebagai Jing-Bi disebabkan
karena keadaan emosional (stress), hormonal, perubahan lingkungan, dan beberapa
penyakit organ reproduksi lainnya
Sedangkan menurut Manuaba (2013), penyebabnya kemungkinan gangguan
hormonal, terdapat tumor alat kelamin atau terdapat penyakit menahun. Penyebab
amenore diakibatkan oleh beberapa keadaan seperti hipotensi, anemia, infeksi, atau
kelemahan kondisi tubuh secara umum. Selain itu bisa juga disebabkan oleh stres
psikologishiperemesis gravidarum belum diketahui secara pasti. Resiko
kemandulan dan komplikasi kesehatan reproduksi merupakan resiko masalah
kesehatan yang akan terjadi jika tidak mendapatkan penanganan yang cepat dan
tepat.
H. Solusi
Penangan yang dapat dilakukan bidan sesuai evidance based midwifery dalam
mengatasi masalah amenorea sekunder adalah pemberian konseling edukasi dan
informasi mengenai amenorea sekunder dan manajemen stress agar pasien tidak
mengalami kecemasan yang berlebihan.
BAB II
TINJAUAN PUSTAKA
E. Asuhan Kebidanan
Judul/Waktu Deskriptif Resposisi TTD

Asuhan S:
Kebidanan - Nn. J mengatakan
pranikah pada sudah 3 bulan lebih
kasus amenorea belum mendapatkan Mahasiswa
sekunder menstruasi
- Nn J mengeluh cemas
Marwah jamaluddin
dengan keadaannya
Tanggal 19 - Nn. J mengatakan haid
/1/2023 pertama menstruasi
Jam :11.56 umur 13 tahun
- Nn. J mengatakan siklus
menstruasinya ± 30 hari.
- Nn. J mengatakan
menstruasinya teratur
- Nn. J mengatakan
menstruasinya 5 – 6 hari
CI Institusi:
- Nn. J mengatakan ganti
pembalut 2 -3/hari
- Nn. J mengatakan sifat
darahnya merah segar Nasrayanti,S.ST.,M.Keb
dan ada gumpalan
- Nn. J mengatakan tidak
pernah nyeri perut
bagian bawah saat
menstruasi
- Nn. J mengatakan belum
pernah menikah
O:
- Keadaan umum : Baik
- Kesadaran Preseptor lahan
:Composmentis
- TTV :
TD : 110/70 mmHg
R: 20x/menit Herlina, S.ST
N : 78 x/menit
S : 36,40 C
- TB : 157 cm
- BB : 62 kg
A: Nn J 21 Tahun dengan
amenorea sekunder
P:
- Jelaskan pada pasien
tentang hasil
pemeriksaan
Hasil : Nn J telah mengetahui
kondisi kesehatannya saat ini
- Berikan KIE pada
pasien mengenai
amenore sekunder
Hasil : Nn J sudah mendapatkan
konseling dan edukasi
mengenai amenorea sekunder
istirahat yang cukup dan
mengkonsumsi makanan
bergizi
Hasil : Nn J sudah dianjurkan
untuk istrirahat yang cukup dan
mengkonsumsi makanan yang
bergizi
- Berikan support mental
berupa management
stress pada pasien untuk
mengurangi kecemasan
Hasil : Nn J telah diberikan
support mental untuk
mengurangi kecemasannya
memeriksakan dirinya
ke Dokter Spesialis
Obgyn
Hasil : Nn J mengatakan akan
berkonsultasi dengan dokter
spesialis obgyn
F. Telaah Jurnal
Jurnal Judul Populasi Intervensi Comparasio Outcome Time
Sports Med Manajemen stress Wanita usia - Pemberian Pada asuhan kebidanan - Kecemasa 1 hari
2021; 31 dengan 18-21 konseling informasi yang telah saya lakukan n pasien amenorea
(15): 1025- kecemasan pasien tahun yang edukasi mengenai dengan kasus amenorea sekunder menurun
1031 amenorea belum manajemen stress agar sekunder tidak ada
sekunder pernah tidak mempengaruhi kesenjangan antara
menikah kinerja hipotalamus asuhan kebidanan yang
sebanyak dalam merangsang telah diberikan dengan
45 orang pematangan ovum intervensi yang
- Faktor tercantum pada jurnal ini
prognostik dalam
penelitian ini ialah :
penyakit infeksi dan
gangguan metabolisme
Current Manajemen stress Wanita usia - Pemberian Pada asuhan kebidanan - Amenorea 1 hari
Opinion in dengan amenorea 18-21 konseling informasi yang telah saya lakukan sekunder teratasi
Psycofarm sekunder pada tahun yang edukasi mengenai dengan kasus amenorea dengan manajemen
2022Vol 6 gadis muda belum manajemen stress agar sekunder tidak ada stress
No 7 pernah tidak mempengaruhi kesenjangan antara
menikah kinerja hipotalamus asuhan kebidanan yang
sebanyak dalam merangsang telah diberikan dengan
28 orang pematangan ovum intervensi yang
- Faktor tercantum pada jurnal ini
prognostik dalam
penelitian ini ialah :
penyakit infeksi
Clin Res Pengaruh Wanita usia - mempengaruhi Pada asuhan kebidanan - Kecemasa 2 hari
Pediatr manajemen stress 18-21 kinerja hipotalamus yang telah saya lakukan n pasien amenorea
Endocrinol terhadap tahun yang dalam merangsang dengan kasus amenorea sekunder menurun
2020;12(Su kecemasan pasien belum pematangan ovum sekunder tidak ada
ppl 1):18-27 amenorea pernah - Faktor kesenjangan antara
sekunder menikah prognostik dalam asuhan kebidanan yang
sebanyak penelitian ini ialah : telah diberikan dengan
45 orang penyakit infeksi intervensi yang
tercantum pada jurnal ini
G. Deskripsi Asuhan Kebidanan dengan Reading Jurnal
Hasil asuhan kebidanan yang saya lakukan kepada pada Nn J usia 21 tahun dengan
amenorea sekunder sejalan dengan hasil reading jurnal pertama yang diteliti oleh (David C.
Cumming, 2021) dalam jurnal Sports Med 2021; 31 (15): 1025-1031 dengan judul Manajemen
stress dengan kecemasan pasien amenorea sekunder, dimana hasil penelitian ini manajemen
stress mempengaruhi kecemasan pasien amenorea sekunder dengan tingkat signifikasi P
<0.005 kemudian didukung oleh jurnal kedua yang diteliti oleh ( Blazej Meczekalski, 2022)
dalam jurnal Current Opinion in Psycofarm 2022 Vol 6 No 7 dengan judul Manajemen stress
dengan amenorea sekunder pada gadis muda hasil penelitian menyatakan manajemen stress
mempengaruhi kecemasan pasien amenorea sekunder dengan tingkat signifikasi P = 0.001
Kemudian disertai oleh jurnal ketiga yang diteliti oleh (Marie Eve Sophie Gibson, 2020) dalam
jurnal Clin Res Pediatr Endocrinol 2020;12(Suppl 1):18-27 dengan judul Pengaruh manajemen
stress terhadap kecemasan pasien amenorea sekunder hasil penelitian menyatakan manajemen
stress mempengaruhi kecemasan pasien amenorea sekunder dengan tingkat signifikasi P
<0.005
H. Teori dari pokok bahasan asuhan kebidanan dengan reading jurnal
Teori dari pokok bahasan asuhan kebidanan dengan reading jurnal ialah manajemen stress
yang dapat mempengaruhi kerja hipotalamus dalam merangsang pematang sel telur pada
wanita. Dalam asuhan kebidanan pranikah ini dukungan mental dan spiritual merupakan salah
satu bagian dari manajemen stress dimana individu menyerahkan dirinya kepada sang pencipta.
Stress manajemen dapat berupa dukungan menta dan spiritual dimana pada setiap
pemberian konseling informasi dan edukasi peran tenaga kesehatan diantaranya ialah
memberikan dukungan mental dan spiritual agar pasien tidak mengalami kecemasan yang
berlebihan terhadap penyakitnya
Hal ini sejalan dengan penelitian terdahulu yang dilakukan oleh (Septia, 2014) bahwa
manajemen stress dapat mengurangi tingkat kecemasan pasien serta dapat membuat pasien
lebih nyaman sehingga penyakit dapat segera teratasi. penelitian ini menunjukan bahwa ada
hubungan yang signifikan antara stress manajemen dengan tingkat kecemasan pasien. Semakin
pasien mengetahui tentang stress manajemen maka tingkat kecemasan terhadap suatu penyakit
akan menurun
Teori ini juga didukung oleh ( Alexandre, 2013) bahwa psikologis seorang individu akan
mempengaruhi status kesehatannya, seperti amenorea sekunder yang dapat terjadi karena stress
yang berlebihan hingga mempengaruhi hipotalamus dalam merangsang pematangan sel telur
1
0
Dan pada jurnal 1,2,3 terkait dengan kasus menjelaskan tidak ada perbedaan secara signifikan
dalam pemberian asuhan kebidanan pada kasus amenorea sekunder
1
1
BAB III
KESIMPULAN DAN SARAN
C. KESIMPULAN
Dari pembuatan jurnal reading ini dapat disimpulkan bahwa tidak ada kesenjangan antara
asuhan kebidanan yang saya berikan kepada Nn J Usia 21 Tahun dengan Amenorea Sekunder
dengan jurnal 1,2,3 dan dengan teori evidance based yang ada
Stress manajemen dapat berupa dukungan menta dan spiritual dimana pada setiap
pemberian konseling informasi dan edukasi peran tenaga kesehatan diantaranya ialah
memberikan dukungan mental dan spiritual agar pasien tidak mengalami kecemasan yang
berlebihan terhadap penyakitnya
Kesehatan reproduksi merupakan aspek yang menjadi perhatian setelah upaya kesehatan
pada umumnya tercapai. Kesehatan reproduksi menurut WHO adalah kesejahteraan fisik,
mental dan sosial yang utuh bukan hanya bebas dari penyakit atau kecacatan dalam segala
aspek yang berhubungan dengan sistem reproduksi, fungsi serta prosesnya. Wanita rentan
terhadap penyakit yang menyerang organ reproduksinya. Kebanyakan wanita, sangat malu dan
tertutup untuk berkonsultasi secara langsung mengenai kesehatan pribadinya. Faktor lain pun
dikarenakan biaya untuk pemeriksaan ke dokter spesialis cenderung mahal. Ada juga yang
tidak mempedulikan gejala yang muncul, dan ketika kondisi sudah memburuk dan memerlukan
penanganan yang ekstra, dokter spesialis menjadi tujuan akhir
D. SARAN
3. Hasil penelitian ini diharapkan dapat menjadi referensi dalam pemberian asuhan kebidanan
dengan kasus amenorea sekunder di RSUD Ponek
4. Hasil penelitian ini diharapkan dapat menjadi kebutuhan untuk penelitian lebih lanjut
mengenai amenorea sekunder
1
2
DAFTAR PUSTAKA
Kumalasari dan Andhyantoro, 2013. Kesehatan Reproduksi untuk Mahasiswa Kebidanan dan
Keperawatan. Jakarta: Salemba Medika
Manuaba, I.B.G. 2013 Memahami Kesehatan Reproduksi Wanita. Jakarta : EGC
core.ac.uk/download/pdf/12348799.pdf. diakses 14 februari 2023
1
3
Format OMP ( One Minute Preceptor)
Langkah Pelaksanaan OMP
No Langkah Hasil Catatan

Pembimbing
Lahan
1 Patient Encounter Identitas pasien
Interaksi dengan Pasien Nama : Nurlina
Umur : 25 Tahun
(Pemeriksaan dilakukan oleh
Pembimbing dan Mahasiswa S: terlihat cemas
dalam konsep BST)
O: TTV
TD : 100/70mmhg
N: 80 X/M
S : 36
R : 20 X/M
2 Get a Commitment
Diagnosis : amenore
Tanyakan komitmen mahasiswa
terkait dengan hasil pemeriksaan
Diagosis Banding:
pada Kasus
Pemeriksaan penunjang :
Terapi :
Dll:
3 Problem For Underlying

Hasil Analisis :
Reasoning
Menggalih bukti-bukti yang
mendukung
4 Reinforce what was done well Hasil Tanggapan

Pembimbing
1
4
Katakana apa yang dilakukan
mahasiswa sudah benar
5 Help Learner identify and give Evaluasi
1. Meminta
guidance about emissions and
mahasiswa
errors mengevaluasi
kesalahan/kekuran
gan yang telah
Perbaiki kesalahan mahasiswa dilakukan)
Hasil mahasiswa sudah
yang berulang
mampu melakukan
tindakan sesuai daftar
tilik
2. Saran Perbaikan
keterampilan oleh
pembimbing untuk
Mahasiswa
Hasil tetap di
pertahankan dan
tingkatkan
6 Tech general principles (Pembimbing

Menjelaskan konsep
Mengajarkan konsep umum
secara umum)
1
5
Format Laporan Target Kompetensi (LogBook ASKEB)
Nama Mahasiswa: Marwah Jamaluddin
Asuhan Kebidanan Pra Konsepsi pada Nn N dengan Amenore sakunder di UPT Puskesmas Pangkajene
Deskripsi Kegiatan Responsi Pembimbing CI TTD
Tanggal: Subjektif
19/01/23 1. Ibu mengatakan Mahasiswa
ingin
memeriksakan
No RM: 1x Xx keadaannya
Xx 2. Mengatakan tidak
menstruasi
selama 3 bulan Marwah jamaluddin
Identitas Pasien:
Nama Nn
Nurlina
Objektif
TTV
Umur 19 THN
TD100/70mmhg
N: 80 X/M
Agama Islam S : 36
R : 20 X/M CI Institusi:
Suku Bugis
Pendidikan
SMP Analisa Amenore
Primer
Pekerjaan -
Nasrayanti,S.ST.,M.Keb
Alamat Penatalaksanaan
pangkajene 1. Beritahu
hasil
pemeriksaan
pada pasien
No.Hp Pembimbing lahan
2. Kie tentang
085 XXX XXX amenore
XX primer
Herlina, S.ST
1
6
Format Laporan Target Kompetensi (LogBook ASKEB)
Nama Mahasiswa: Marwah Jamaluddin
Asuhan Kebidanan Pra Konsepsi pada Nn H dengan Amenore sakunder di UPT Puskesmas Pangkajene
Deskripsi Kegiatan Responsi Pembimbing CI TTD
Tanggal: Subjektif Mahasiswa
19/01/23 3. Ibu mengatakan
ingin
memeriksakan
No RM: 1x Xx keadaannya
Xx 4. Mengatakan tidak
menstruasi Marwah jamaluddin
selama 3 bulan
Identitas Pasien:
Nama Nn
Herunisa
Objektif
TTV
Umur 20 THN
TD100/70mmhg
N: 80 X/M
Agama Islam S : 36 CI Institusi:
R : 20 X/M
Suku Bugis
Pendidikan
SMP Analisa Amenore
sakunder
Pekerjaan -
Nasrayanti,S.ST.,M.Keb
Alamat kanie Penatalaksanaan

1. Beritahu
hasil
No.Hp pemeriksaan
085 XXX XXX pada pasien Pembimbing lahan
XX 2. Kie tentang
amenore
sakunder
Herlina, S.ST
1
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TATA TERTIB MAHASISWA DI LAHAN PRAKTIK
A. Sikap
1. Disiplin dalam tugas
2. Kerja sama dengan orang lain sesuai dengan ketentuan institusi
3. Inisiatif dalam bekerja
4. Bertanggung jawab dalam tugas yang diberikan
5. Komunikasi yang baik dengan klien
6. Perhatian dalam bekerja
7. Jujur, sopan dan teliti dalam bekerja
B. Waktu kehadiran
1. Jam 07.30 sampai 14.00 WITA untuk dinas pagi
2. Jam 14.00 sampai 21.00 WITA untuk dinas sore
3. Jam 21.00 sampai 07.30 WITA untuk dinas malam
C. Tidak diperkenankan meninggalkan ruangan tempat praktik tanpa seizin kepala
ruangan/pembimbing atau petugas ruangan serta tidak diperkenankan meninggalkan
lokasi/wilayah praktik klinik tanpa seizin C.I institusi
D. Sanksi penggantian dinas praktik diberikan kepada mahasiswa apabila (disesuaikan oleh
lahan) :
1. Izin 1 hari ganti dinas 1 hari
2. Sakit 1 hari ganti dinas 1 hari (harus ada surat keterangan Dokter)
3. Alpa 1 hari ganti dinas 2 hari
4. Bila mahasiswa merusak, menghilangkan alat-alat di ruangan praktik berkewajiban
mengganti alat tersebut
5. Mahasiswa berkewajiban menjaga kebersihan dan kesterilan alat-alat dan bahan praktik
yang dimiliki di lahan praktik
6. Tidak diperkenankan menggunakan alat-alat dan bahan praktik milik lahan praktik, milik
klien dan atau memindahkan tanpa sepengetahuan kepala ruangan
7. Mahasiswa baik secara pribadi atau kelompok berkewajiban mengganti alat-alat, bahan-
bahan praktik yang hilang atau rusak selama praktik
1
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8. Mahasiswa hendaknya membawa sendiri alat-alat pemeriksaan fisik
E. Ketentuan Pakaian Praktik

1. Pada saat melakukan praktik, mahasiswa harus menggunakan pakaian praktik lengkap
(putih-putih) dengan atribut, sepatu putih dan berpenampilan rapi, bersih dan sopan
2. Menggunakan atribut :
a. Papan nama di sebelah kanan
b. Lencana (Logo) di sebelah kiri
3. Tidak diperkenankan memakai training spak (baju olahraga) saat melakukan praktik kecuali
persetujuan pihak lahan
4. Tidak diperkenankan memakai perhiasan kecuali jam tangan (yang memakai jarum detik)
saat melakukan praktik.
Demikianlah buku pedoman ini disusun sebagai acuan dalam mencapai target yang telah
ditetapkan. Semoga bermanfaat
1
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DAFTAR TILIK ASUHAN KEBIDANAN PADA PRANIKAH DAN
PRAKONSEPSI
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN

TAHUN AJARAN 2021/2022
2
0
DAFTAR ISI
HALAMAN JUDUL
DAFTAR ISI...................................................................................................... 2
JENIS KETERAMPILAN BIMBINGAN BST................................................. 3
KETERAMPILAN KONSELING PERSIAPAN KEHAMILAN SEHAT.....................4
ANAMNESA PRANIKAH DAN PRAKONSEPSI............................................................6
KETERAMPILAN KIE PERSIAPAN MENJADI ORANG TUA.................................12
CHEKLIST PENILAIAN SKRINING HIV......................................................................14
KETERAMPILAN MELAKUKAN SKRINNING CA CERVIX DENGAN IVA.........15
KETERAMPILAN MENYIAPKAN SEDIAAN PEMERIKSAAN PAPSMEAR.........18
2
1
JENIS KETERAMPILAN BIMBINGAN BED SIDE TEACHING (BST)
mahasiswa.
Kompetensi kemampuan ketrampilan mahasiswa dilakukan melalui bedside teaching yang
dilakukan secara bertahap mulai dari tahap observasi, di bantu hingga mandiri.
Bedside teaching (BST) adalah suatu proses pembelajaran dimana mahasiswa
berinteraksi langsung dengan pasien sesungguhnya dan dibawah bimbingan preseptor.
BST merupakan pembelajaran yang aktif melibatkan pasien langsung sehingga
mahasiswa dapat belajar dari kasus nyata yang sangat beraneka ragam tingkat kompleksitas
kasus yang dialami pasien.
BST melibatkan preseptor dan mahasiswa dengan pasien langsung yang bertujuan untuk melakukan asuha
mahasiswa, ketrampilan komunikasi dan juga ketrampilan berfikir klinis karena dengan BST
mahasiswa menggunakan semua indera yang dimiliki saat praktek di depan pasien langsung
sehingga dapat mendukung ketrampilan mahasiswa, dengan praktek langsung di depan pasien
tidak hanya meningkatkan ketrampilan namun juga mampu meningkatkan komunikasi,
meningkatkan rasa empati dan simpati ke pasien.
Setiap keterampilan dilakukan tiga kali BST dengan model sitting in as observer (mahasiswa
hanya mengobservai), three ways consultation (mahasiswa melakukan bersama-sama dengan
pembimbing) dan hot seating (mahasiswa melakukan sepeneuhnya dengan diawasi
pembimbing).
Penentuan jumlah/ frekuensi BST disesuaikan dengan tingkat penyerapan masing-masing mahasiswasampai m
Mahasiswa yang telah menempuh bedside teaching sampai tahap mandiri dilakukan
asessment menggunakan DOPS (Direct Observation Procedural Skill) atau Mini-CEX (Mini
Clinical Examination).
Jenis Keterampilan Bimbingan Bed Side Teaching (BST) Statse Asuhan Kebidanan Pada
Pranikah dan Prakonsepsi dapat dipilih mahasiswa pada kolom BST, Target BST untuk states
tersebut adalah 2 sehingga masing-masing mahasiswa memilih 2 diantara beberapa
keterampilan yang telah disediakan dengan mengacu pada daftar tilik yang ada.
22
PERSIAPAN KEHAMILAN SEHAT
STANDAR OPERATING PROSEDUR
PRODI KIE PERSIAPAN KEHAMILAN SEHAT

KEBIDANAN NO DOKUMEN NO REVISI HALAMAN
PROGRAM
PROFESI
PROSEDUR TANGGAL DITETAPKAN OLEH
TETAP DITETAPKAN
( )
Pengertian Memberikan konseling edukatif mengenai persiapan kehamilan sehat
agar terjadi perubahan pengetahuan dan perilaku calon pengantin / calon
orang tua untuk mempersiapkan kehamilan
dengan baik.
Indikasi Untuk semua calon pengantin/pasangan yang merencanakankehamilan
Tujuan 1. Untuk mempersiapkan kehamilan sehat tanpa komplikasi

Petugas Mahasiswa Kebidanan
Skenario Seorang perempuan datang ke Puskesmas bersama
pasangannya untuk berkonsultasi mengenai perencanaan
kehamilan.
Pengkajian Mengkaji keadaan umum pasien
Persiapan pasien Menjelaskan tujuan dilakukan KIE
Persiapan ruang Persiapan ruang
dan alat 1. Ruangan yang nyaman dan tertutup
2. Tenang dan jauh dari keramaian
3. Ventilasi cukup
Persiapan Alat
1. Timbangan
2. Pengukur tinggi badan
3. Pengukur lila
4. Food model
5. Lembar balik
6. dokumentasi
7. Bolpoin
Langkah-langkah 1. Menjelaskan tujuan KIE pada calon pengantin/calon ibu
2. Melakukan pemeriksaan status gizi
3. Menghitung IMT catin dan menjelaskan hasil perhitungan
4. Menjelaskan setiap pasangan catin untuk mengkonsumsi makanan gizi
seimbang
5. Menjelaskan bahwa setiap catin perempuan dianjurkan
mengkonsumsi tablet tambah darah yang mengandung zat besi dan
asam folat minimal seminggu sekali
6. Menjelaskan manfaat imunisasi TT
7. Menjelaskan jangka waktu pemberian imunisasi TT
8. Menjelaskan mengenai anemia dan bahayanya
9. Menjelaskan mengenai kekurangan gizi dan bahayanya
23
10. Menjelaskan mengenai hepatitis B dan upaya
pencegahan pada catin
11. Menjelaskan mengenai diabetes melitus dan resikonya
12. Menjelaskan mengenai malaria dan dampaknya bagi catin
13. Menjelaskan mengenai TORCH dan dampaknya bagicatin
14. Menjelaskan mengenai thalasemia dan dampaknya padacatin
15. Menjelaskan mengenai pencegahan thalasemia bagi catin
16. Menjelaskan mengenai hemofilia dan dampaknya padacatin
17. Menjelaskan mengenai pencegahan hemofilia pada catin
Referensi 1. Kementerian Kesehatan Republik Indonesia. 2018. Kesehatan

Reproduksi Dan Seksual Bagi Calon Pengantin
24
CEKLIS PERSIAPAN KEHAMILAN SEHAT
Petunjuk penilaian :
0 = tidak dilakukan
1 = dilakukan tidak sempurna
2 = dilakukan dengan sempurna
NO ASPEK YANG DINILAI NILAI

A SIKAP DAN PERILAKU 0 1 2
1 Menyambut pasien dengan sopan dan ramah
2 Memperkenalkan diri kepada pasien
3 Menjelaskan prosedur yang akan dilaksanakan
4 Menjaga privasi pasien
5 Tanggap terhadap reaksi pasien dan kontak mata
Score :10
B ISI/KONTEN
Persiapan gizi
6 Menghitung IMT catin dan menjelaskan hasil
Perhitungan
7 Menjelaskan setiap pasangan catin untuk
mengkonsumsi makanan gizi seimbang
8 Menjelaskan bahwa setiap catin perempuan dianjurkan
mengkonsumsi tablet tambah darah yang mengandungzat
besi dan asam folat minimal seminggu sekali
Persiapan imunisasi
9 Menjelaskan manfaat imunisasi TT
10 Menjelaskan jangka waktu pemberian imunisasi TT
Konseling kondisi kesehatan yang perlu diwaspadai
11 Menjelaskan mengenai anemia dan bahayanya
12 Menjelaskan mengenai kekurangan gizi dan bahayanya
13 Menjelaskan mengenai hepatitis B dan upaya
pencegahan pada catin
14 Menjelaskan mengenai diabetes melitus dan resikonya
15 Menjelaskan mengenai malaria dan dampaknya bagi
Catin
16 Menjelaskan mengenai TORCH dan dampaknya bagi
Catin
Konseling penyakit genetik yang dapat
mempengaruhi kehamilan dan kesehatan janin
17 Menjelaskan mengenai thalasemia dan dampaknya
pada catin
18 Menjelaskan mengenai pencegahan thalasemia bagi
Catin
19 Menjelaskan mengenai hemofilia dan dampaknya pada
Catin
25
20 Menjelaskan mengenai pencegahan hemofilia pada
Catin
Score : 30
C TEKNIK
21 Teruji melaksanakan secara sistematis
22 Teruji menggunakan bahasa yang mudah dimengerti
23 Teruji memberikan perhatian terhadap respon pasien
24 Teruji melaksanakan dengan percaya diri dan tidak
ragu-ragu
25 Teruji mendokumentasikan hasil
Score : 10
Total Score : 50
Nilai akhir = (Total score :50) x 100
Sidrap, 21 Januari 2023
CI lahan
( Herlina, S.ST)
26
ANAMNESA PRANIKAH DAN PRAKONSEPSI
PRODI ANAMNESA PRANIKAH DAN PRAKONSEPSI

KEBIDANAN
PROGRAM NO DOKUMEN NO REVISI HALAMAN
PROFESI
TETAP DITETAPKAN
( )
Pengertian mengumpulkan informasi tentang riwayat kesehatan dan kehamilan
yang dapat digunakan dalam proses membuat keputusan klinik untuk
menentukan diagnosis dan
mengembangkan rencana asuhan atau perawatan yang sesuai
Indikasi Untuk semua calon pengantin/pasangan yang merencanakankehamilan
Tujuan 2. Untuk mengetahui kesehatan sebelum hamil

pasangannya membawa pengantar dari KUA untuk mendapatkan
layanan pranikah.
Persiapan pasien Menjelaskan tujuan dilakukan anamnesa
6. Ventilasi cukup
Persiapan Alat
8. Lembar dokumentasi
9. Bolpoin
27
Langkah-langkah 1. Menjelaskan tujuan anamnesa pada calon pengantin/calonibu
2. Melakukan anamnesa pada ibu meliputi :
a. Menanyakan identitas pasien dan suami
b. Menanyakan keluhan pada ibu
c. Menanyakan apakah ini perencanaan kehamilan yang
pertama/pernikahan yang pertama
d. Mengkaji ulang atau menanyakan mengenai riwayat
kehamilan terdahulu tentang paritas
e. Mengkaji riwayat kontrasepsi
f. Mengkaji ulang dan menanyakan mengenai menstruasi meliputi
HPHT dan masalah seputar menstruasi dan keputihan
g. Mengkaji riwayat penyakit seperti DM, asma, hipertensi,
Jantung
28
h. Mengkaji penyakit genetik pada keluarga ibu maupunsuami
seperti thalasemia,hemofilia, lupus
i. Mengkaji riwayat penyakit menular seperti hepatitis B,
TORCH, HIV atau IMS lainnya
j. Mengkaji pola nutrisi pada ibu
k. Mengkaji personal hygine pada ibu
l. Mengkaji kebiasaan mengkonsumsi minuman keras padaibu
maupun suami
m. Mengkaji kebiasaan merokok pada ibu maupun suami
n. Mengkaji penggunaan NAFZA pada ibu maupun suami
o. Mengkaji riwayat imunisasi TT pada ibu
p. Mengkaji upaya yang sudah dilakukan ibu dalam persiapan
pranikah dan prakonsepsi
Referensi 2. Kementerian Kesehatan Republik Indonesia. 2018. Kesehatan
29
CEKLIST ANAMNESA PRANIKAH/PRAKONSEPSI
0 = tidak dilakukan
NO BUTIR YANG DINILAI NILAI

Score :10
B CONTENT/ISI
6 Menanyakan identitas pasien dan suami
7 Menanyakan keluhan pada ibu
8 Menanyakan apakah ini perencanaan kehamilan yang
pertama/pernikahan yang pertama
9 Mengkaji ulang atau menanyakan mengenai riwayat kehamilan
terdahulu tentang paritas
10 Mengkaji riwayat kontrasepsi
11 Mengkaji ulang dan menanyakan mengenai menstruasi
meliputi HPHT dan masalah seputar menstruasi dan keputihan
12 Mengkaji riwayat penyakit seperti DM, asma, hipertensi,
jantung
13 Mengkaji penyakit genetik pada keluarga ibu maupun suami
seperti thalasemia,hemofilia, lupus
14 Mengkaji riwayat penyakit menular seperti hepatitis B, TORCH,
HIV atau IMS lainnya
15 Mengkaji pola nutrisi pada ibu
16 Mengkaji personal hygine pada ibu
17 Mengkaji kebiasaan mengkonsumsi minuman keras pada ibu
maupun suami
18 Mengkaji kebiasaan merokok pada ibu maupun suami
19 Mengkaji penggunaan NAFZA pada ibu maupun suami
20 Mengkaji riwayat imunisasi TT pada ibu
21 Mengkaji upaya yang sudah dilakukan ibu dalam persiapan
pranikah dan prakonsepsi
Score : 32
C TEKNIK
30
25 Teruji melaksanakan dengan percaya diri dan tidak ragu-ragu
Score : 10
Total Score : 52
Nilai Akhir = (Total score :52) x 100

CI lahan
( Herlina, S.ST)
31
KIE PERSIAPAN MENJADI ORANG TUA
PRODI KIE PERSIAPAN MENJADI ORANG TUA

PROGRAM
PROFESI
TETAP DITETAPKAN
( )
Pengertian Memberikan informasi kepada pasangan yang merencanakan
kehamilan mengenai persiapan menjadi orang tua
Indikasi Untuk semua pasangan yang merencanakan kehamilan
Tujuan Untuk meningkatkan pengetahuan pasangan mengenai kesiapan
menjadi orang tua
pasangannya untuk melakukan konsultasi perencanaan
kehamilan
3. Ventilasi cukup
Persiapan Alat
1. Lembar balik
2. Bolpoin
Langkah-langkah 1. Menyambut klien dengan ramah
2. Mengucapkan salam
3. Meperkenalkan diri
4. Meyakinkan bahwa privasi dan kerahasiaan klien di hormatidan
dijaga
5. Menjelaskan tujuan KIE pada pasangan
6. Melakukan KIE persiapan menjadi orangtua pada pasangan
meliputi :
a. Persiapan fisik
b. Persiapan mental
c. Persiapan ekonomi
d. Kesetaraan gender dalam rumah tangga dalam hal berbagiperan
menjadi orangtua
Referensi Kementerian Kesehatan Republik Indonesia. 2018. Kesehatan
32
CEKLIST KIE PERSIAPAN MENJADI ORANGTUA
0 = tidak dilakukan
NO BUTIR YANG DINILAI NILAI
Score :10
B CONTENT/ISI
6 Menanyakan identitas pasien dan suami
7 Menanyakan alasan berkunjung
8 Menjelaskan tujuan KIE persiapan menjadi orang tua
Persiapan fisik
9 Memberikan KIE usia yang ideal untuk menjadi orangtua
10 Memberikan KIE persiapan gizi pada calon ayah maupun
calon ibu
11 Memberikan KIE persiapan imunisasi pada calon ibu
12 Memberikan KIE gaya hidup sehat pada calon orang tua
Persiapan mental
13 Memberikan KIE adaptasi psikologis pada kehamilan kepada
calon orangtua
Persiapan ekonomi
14 Menjelaskan hal-hal yang harus disiapkan berkaitan dengan ekonomi
sebagai persiapan menjadi orang tua meliputi kebutuhan saat hamil,
bersalin, imunisasi anak dan perawatan
Anak
Kesetaraan gender dalam persiapan menjadi orangtua
15 Memberikan KIE mengenai peran suami dan istri dalam
Keluarga
16 Memberikan KIE mengenai peran ayah dan ibu bagi anak
Score : 22
C TEKNIK
4 Teruji melaksanakan dengan percaya diri dan tidak ragu-ragu
Score : 10
Total Score : 42
33
Nilai akhir = (Total score :42) x 100
CI lahan
( Herlina, S.ST)
34
LEMBAR CHEKLIST PENILAIAN
SKRINING HIV
Nilai 0 = Jika Tidak Dilakukan

Nilai 1 = Dilakukan Kurang Sempurna
Nilai 2 = Dilakukan Dengan Sempurna
1 2
NO BUTIR YANG DINILAI 0
A SIKAP DAN PERILAKU

1 Menjelaskan tujuan dan prosedur yang akan dilaksanakan
2 Melakukan komunikasi selama tindakan
Membina hubungan baik dan dengarkan klien secara aktif
3
4 Menjaga privacy klien dengan menanyakan kebutuhan
kenyamanan klien
5 Meminta persetujuan klien untuk berkata jujur dan memastikan
akan menjaga kerahasiaannya
Score : 10
B PENILAIAN CONTENT/ISI
Penilaian klien dan persiapan
1 Menanyakan pekerjaan ibu atau aktivitas sehari-hari
Mengkaji riwayat aktivitas seksual

2
Mengkaji penggunaan narkoba suntik, transfusi darah atau
transplantasi organ
3
Mengkaji riwayat penyakit

4
5 Meminta persetujuan klien untuk melakukan tes HIV dengan

menandatangani inform consent
6 Melakukan tes HIV

Jika hasil tes negatif, maka klien tetap diberi pemahaman tentang
7 pentingnya menekan risiko
HIV
Jika hasil tes positif, maka:

• klien diberi dukungan emosional agar penderita tidak patah
semangat
• menjelaskan langkah berikutnya untuk penanganan
• menjelaskan cara mempertahankan pola hidup sehat
• menjelaskan bagaimana cara tidak menurkan ke orang lain
35 Mengulangi hal-hal yang perlu diperhatikannya atau diingatnya.
8 Bila perlu, yakinkan klien
bahwa Anda selalu bersedia untuk menerimanya jika dirasa perlu
9 Merencanakan kunjungan ulang dan sepakati kapan klien kembali
untuk follow – up. Dan
selalu mempersilahkan klien kapan saja
Mengucapkan terima kasih dan salam
10
Score : 30
C TEKNIK
1 Melaksanakan tindakan secara sistematis/berurutan
Score : 4
Total Score : 34
NILAI AKHIR = (Total Score/ ) x 100
CI lahan
( Herlina, S.ST)
36
PRODI PEMERIKSAAN IVA

PROGRAM
PROFESI
TETAP DITETAPKAN
( )
Pengertian Pemeriksaan leher rahim secara visual menggunakan asam cuka (IVA)
berarti melihat leher rahim dengan mata telanjang untuk mendeteksi
abnormalitas setelah pengolesan asam asetat atau cuka (3–5%). Daerah
yang tidak normal akan berubah warna dengan batas yang tegas menjadi
putih (acetowhite), yang mengindikasikan bahwa leher rahim mungkin
memiliki lesi
prakanker.
Indikasi Untuk semua perempuan Yang telah aktif secara seksual,
PUS,menopause dan lansia
Tujuan Untuk mengetahui cara mendeteksi dini kanker Serviks
menggunakan metode IVA
Skenario Seorang perempuan datang ke Puskesmas untuk melakukan
pemeriksaan IVA
Persiapan ruang Persiapan ruang dan alat
2. Ventilasi cukup
3. Spekulum
4. Swab lidi
5. Asam asetat 5%
6. Lampu sorot
7. Air DTT
8. Kapas DTT
9. Tempat cuci tangan
10. Handuk/lap bersih
11. Sabun cuci tangan
Langkah-langkah 1. Penilaian klien dan persiapan

2. Test IVA
3. Tindakan pasca test IVA
37 4. Konseling pasca tindakan IVA
Referensi Peraturan Menteri Kesehatan No 35 Tahun 2015 Tentang
Penanggulangan Kanker Payudara dan Kanker Leher Rahim
38
CEKLIST PEMERIKSAAN IVA TEST

Nilai 1 = Dilakukan Kurang Sempurna
Nilai 2 = Dilakukan Dengan Sempurna
1 2

Melakukan cuci tangan dan keringkan dengan handuk
3
pribadi (pra dan paska tindakan)
4 Memakai dan melepas sarung tangan steril atau DTT
5 Melakukan dekontaminasi alat paska tindakan
Score : 10
Penilaian klien dan persiapan
Sebelum melakukan tes IVA, diskusikan tindakan dengan
ibu/klien. Jelaskan mengapa tes tersebut dianjurkan dan apa yang
1 akan terjadi pada saat pemeriksaan. Diskusikan
juga mengenai sifat temuan yang paling mungkin dan tindak
lanjut atau pengobatan yang mungkin diperlukan.
Pastikan semua peralatan dan bahan yang diperlukan tersedia,
termasuk spekulum steril atau yang telah di DTT, kapas lidi
2 dalam wadah bersih, botol berisi larutan asam asetat dan sumber
cahaya yang memadai. Tes sumber
cahaya untuk memastikan apakah masih berfungsi.
Bawa ibu ke ruang pemeriksaan. Minta dia untuk Buang Air Kecil
(BAK) jika belum dilakukan. Jika tangannya kurang bersih, minta
ibu membersihkan dan membilas daerah kemaluan sampai bersih.
3
Minta ibu untuk melepas pakaian (termasuk pakaian dalam)
sehingga dapat dilakukan
pemeriksaan panggul dan tes IVA.
Bantu ibu untuk memposisikan dirinya di meja ginekologi
4 dan tutup badan ibu dengan kain, nyalakan lampu/senterdan
arahkan ke vagina ibu.
5 Memakai APD (celemek, topi, kacamata, dan masker)
Cuci tangan secara merata dengan sabun dan air sampai benar-
benar bersih, kemudian keringkan dengan kain bersih atau
diangin-anginkan. Lakukan palpasi abdomen, dan perhatikan
6 apabila ada kelainan. Periksa juga bagian lipat paha, apakah ada
benjolan atau ulkus (apabila
terdapat ulkus terbuka, pemeriksaan dilakukan dengan memakai
sarung tangan). Cuci tangan kembali.
Pakai sepasang sarung tangan periksa yang baru pada kedua
7 tangan atau sarung tangan bedah yang telah di-DTT1.
39
Pemeriksaan IVA
Posisi pemeriksa duduk menghadap ke arah vulva danmelakukan
8 inspeksi di daerah vulva dan perineum.
Inspeksi/periksa genitalia eksternal dan lihat apakah terjadi
discharge pada mulut uretra. Palpasi kelenjar Skene’s and
Bartholin’s. Jangan menyentuh klitoris, karena akan
menimbulkan rasa tidak nyaman pada ibu. Katakan pada ibu/klien
bahwa spekulum akan dimasukkan dan mungkin
ibu akan merasakan beberapa tekanan.
9 Melakukan vulva hygiene dengan kapas DTT (kapas satu persatu)
Dengan hati-hati masukkan spekulum sepenuhnya atau sampai

terasa ada tahanan lalu secara perlahan buka bilah/daun spekulum
untuk melihat leher rahim. Atur spekulum sehingga seluruh leher
10 rahim dapat terlihat. Hal tersebut mungkin sulit pada kasus
dengan leher Rahim yang berukuran besar atau sangat anterior
atau posterior. Mungkin perlu menggunakan spatula atau alat lain
untuk mendorong leher rahim dengan hati-hati ke atas atau ke
bawah agar dapat terlihat.
Amati leher rahim apakah ada infeksi (cervicitis) seperti
11 discharge/cairan keputihan mucous ectopi (ectropion); kista
Nabothy atau kista Nabothian, nanah, atau lesi
“strawberry”(infeksi Trichomonas).
Gunakan kapas lidi bersih untuk membersihkan cairan yang
12 keluar, darah atau mukosa dari leher rahim. Buang kapas lidi ke
dalam wadah anti bocor atau kantung plastik.
Basahi kapas lidi dengan larutan asam asetat 3-5% dan oleskan
pada leher rahim. Bila perlu, gunakan kapas lidi bersih untuk
13 mengulang pengolesan asam asetat sampai seluruh permukaan
leher rahim benar-benar telah dioleskan asam asetat secara
merata. Buang kapas lidi yang telah
dipakai.
Menungggu 1 menit dan melakukan interpretasi hasil :
a. Positif apabila porsio berubah warna dari asli merah
14 menjadi putih pucat/aceto white ephitelium
b. Negatif apabila tidak terjadi perubahan warna pada
porsio
Bila pemeriksaan visual pada leher rahim telah selesai, gunakan
15 kapas lidi yang baru untuk menghilangkan sisa asam asetat dari
leher rahim dan vagina. Buang kapas
sehabis dipakai pada tempatnya.
Lepaskan spekulum secara halus. Jika hasil tes IVA negatif,
16 letakkan spekulum ke dalam larutan klorin 0,5% selama 10
menit untuk didesinfeksi.
Lakukan pemeriksaan bimanual dan rectovagina (bila
diindikasikan). Periksa kelembutan gerakan leher rahim; ukuran,
17 bentuk, dan posisi rahim; apakah ada kehamilan atau abnormalitas
dan pembesaran uterus atau kepekaan
(tenderness) pada adnexa.
40 Memberitahukan kepada pasien bahwa pemeriksaan sudah
18 selesai, merapikan pasien dan menyampaikan hasil pemeriksaan
19 Membereskan alat dan membuang sampah pada tempatnya
Tindakan Pasca Test IVA
Bersihkan lampu dengan lap yang dibasahi larutan klorin 0.5%

20 atau alkohol untuk menghindari kontaminasi silang
antar pasien.
Diskusikan dengan klien hasil tes IVA dan pemeriksaan
21 panggul bersama Ibu/klien. Jika hasil tes IVA negatif, beritahu
kapan klien harus kembali untuk tes IVA
Jika hasil tes IVA positif atau diduga ada kanker, katakan pada
ibu/klien langkah selanjutnya yang dianjurkan. Jika pengobatan
dapat segera diberikan, diskusikan kemungkinan tersebut
22 bersamanya. Jika perlu rujukan untuk tes atau pengobatan lebih
lanjut, aturlah waktu untuk rujukan dan berikan formulir yang
diperlukan sebelum ibu/klien tersebut meninggalkan
Puskesmas/klinik. Akan lebih baik jika kepastian waktu rujukan
dapat disampaikan
pada waktu itu juga.
Score : 44
C TEKNIK
Score : 4
Total Score : 58
NILAI AKHIR = (Total Score/ ) x 100
CI lahan
41
( Herlina, S.ST)
MENYIAPKAN SEDIAAN PEMERIKSAAN PAPSMEAR
CEKLIST SEDIAAN PEMERIKSAAN PAP-SMEAR

Nilai 1 = Dilakukan Kurang
SempurnaNilai 2 = Dilakukan
Dengan Sempurna
1 2

Melakukan cuci tangan dan keringkan dengan handuk
3
pribadi (pra dan paska tindakan)
4 Memakai dan melepas sarung tangan steril atau DTT
5 Melakukan dekontaminasi alat paska tindakan
Score : 10
6 Mempersilakan pasien untuk melepas pakaian dalam,
meminta pasien untuk mengosongkan kandung kemih
7 Memposisikan pasien di meja Gynekologi dengan posisi
litotomi
8 Memakai APD (celemek, topi, kacamata, dan masker)
9 Menghidupkan lampu sorot, diarahkan dengan benar pada bagian
yang akan diperiksa
10 Posisi pemeriksa duduk menghadap ke arah vulva dan
melakukan inspeksi di daerah vulva dan perineum
11 Melakukan vulva hygiene dengan kapas DTT (kapas satu
persatu)
12 Memasang spekulum, menguncinya dengan benar dan hati
- hati
13 Melakukan inspeksi porsio
Mengambil sekret dengan spatula Ayre dengan ujung
14 pendek mengusap 360 derajat sesuai arah jarum jam pada
ektoserviks
Mengoleskan sekret dari spatula Ayre pada permukaan obyek
15 glass sekali usap, tipis dan merata berlawanan arah
jarum jam
16 Obyek glass dimasukkan pada larutan fiksasi alkohol 95%
42 selama 30 menit
17 Melepas spekulum dengan hati – hati
Memberitahukan kepada pasien bahwa pemeriksaan sudahselesai,
18 merapikan pasien dan menyampaikan hasil
Pemeriksaan
19 Membereskan alat dan membuang sampah pada
tempatnya
Score : 28
C TEKNIK
Score : 4
Total Score : 42
NILAI AKHIR = (Total Score/42) x 100
CI lahan
( Herlina, S.ST)
43
J. Endocrinol. Invest. 36: 343-346, 2013
DOI: 10.3275/8645
weight loss counseling and Anxienty in Primary Amenorrhea

E. Bacchi1, G. Spiazzi1, G. Zendrini2, C. Bonin3, and P. Moghetti1,2
1Endocrinology, Diabetes and Metabolism, University and AOUI Verona; 2School of Exercise and Sport Science,
University of Verona; 3Obstetrics and Gynaecology, University and AOUI Verona, Verona, Italy
ABSTRACT. Background: Several studies have reported that professional and non-professional dancers than in controls.
low body weight and menstrual alterations are very frequent Frequency of menstrual dysfunction was 51%, 34% and 21%
findings in adolescent, suggesting they could be at risk for in professional dancers, non-professional dancers and con-
associated medical problems. However, it is still largely un- trols, respectively (p<0.0001). weight loss counseling and
known whether these alterations are also common in the very Anxienty in Primary Amenorrhea was reported by23% of
large number of young amateur dancers. Aim: The aim of this professional dancers, vs 1-7% in the other groups
study was to assess whether there is an increased prevalence (p<0.0001). Age at menarche occurred later in professional
of menstrual dysfunction also in amateur dancers. Materi- dancers than in the other groups. Logistic regression analy-
al/Subjects and Methods: Ninety-two professional ballet ses showed that menstrual dysfunction was associated with
dancers, 93 non-professional ballet dancers, and 293 (160 the training profile in professional dancers, and with BMI in
sedentary, 133 physically active) control women, ranging in non-professional dancers. Age at menarche was associated
age 14-23 yr, were included in the study. In these subjects, with menstrual dysfunction in both groups. Conclusions: This
a detailed questionnaire that included questions on weight, study shows that low body weight and menstrual dysfunc-
height, age at menarche, training profile and menstrual al- tion are frequent findings also in amateur ballet dancers.
terations was administered. Results: BMI was lower in both (J. Endocrinol. Invest. 36: 343-346, 2013)
©2013, Editrice Kurtis
INTRODUCTION ever, data concerning the prevalence of menstrual dys-

There is a great deal of evidence that physical activity is function in girls attending non-professional schools of
associated with many health and fitness benefits, with a dance are lacking. This information is of great practical
decreased risk of premature mortality and of several interest as there is a very large number of young ama-
chronic diseases (1). However, relationships concerning teur dancers who could be at risk for menstrual alterations
low energy availability, i.e. a discrepancy between di- and the associated medical problems.
etary energy intake and exercise energy expenditure, The aim of this study was to assess, by a questionnaire,
menstrual dysfunction and reduced bone mineral den- whether amateur ballet dancers have a high frequency of
sity, may pose health risks to physically active women, menstrual alterations. To answer this question, these
causing a condition called the Female Athlete Triad (2). subjects were compared with age-matched professional
Menstrual dysfunction is the clinical marker of this con- ballet dancers and a control group of unselected girls.
dition.
In actual fact, several studies have reported that the
prevalence of menstrual alterations is higher in athletes MATERIALS AND METHODS
than in the general population (3-5). This figure varies Four hundred and seventy-eight women attending dance acade-
widely in the literature, according to criteria used to di- my, amateur ballet school, high school or university were invit-
agnose menstrual dysfunction, age and type of sport. In- ed to participate in the study. Inclusion criteria was age between
terestingly, the prevalence of menstrual alteration was 14-23 yr. Exclusion criteria was pregnancy. Ninety-two were pro-
reported to be particularly high in sports characterized by fessional ballet dancers from two elite schools and one dance
leanness, suggesting that low energy availability and/or academy, 93 were age-matched, non-professional dancers from
low body fat may play a mayor role in this phenomenon four amateur ballet schools, and 293 were age-matched con-
(2). trols, recruited in three high schools and in two non-sport uni-
In particular, the prevalence of menstrual dysfunction ap- versity courses. Schools and universities randomly indicated the
pears to be very high in elite dancers, in whom this al- classes/courses, within the appropriate age range, where ques-
teration was reported in 66-79% of subjects (6-8). How- tionnaires were subsequently administered, before or at the end
of a lesson.
Based on the physical activity habits reported in the question-
Key-words: Amenorrhea, body weight, dancers, menarche, menstrual alterations.
naires, controls were subsequently subdivided into an active or
Correspondence: P. Moghetti, MD, PhD, Division of Endocrinology and Metabolism
a sedentary subgroup. Of the 293 controls, 160 (55%) were
Disease, Department of Medicine, University of Verona, P.le Stefani 1, 37126 Verona, sedentary and 133 were physically active. None of the control
Italy. girls were elite athletes. The active subgroup of controls com-
E-mail: paolo.moghetti@univr.it prised 47 dancers, who reported in the questionnaire that they
Accepted August 2, 2012. were exercising with various types of dance: modern jazz
First published online October 1, 2012. (no.=3), hip-hop dance (no.=3), aerobic dance (no.=2), Latin
343
E. Bacchi, G. Spiazzi, G. Zendrini, et al.
dance (no.=1), gymnastics (no.=3), ballet (no.=4); the remaining RESULTS

31 subjects did not specify the type of dance. This subgroup, as All recruited girls filled in the questionnaire. Table 1
a whole, was similar to the non-professional ballet dancers in shows the anthropometric characteristics and the train-
terms of training profile, whereas it differed in terms of body ing profile, and Table 2 the menstrual characteristics of
mass index (BMI), having a similar height, but a higher weight, subjects. In the Tables, the characteristics of controls are
by about 3 kg, than non-professional dancers. As the type of reported for both the whole group of subjects and either
dance was heterogeneous among these subjects, and further the physically active non-dancer subgroup or the seden-
details were not available, to avoid possible bias these 47 sub- tary subgroup.
jects were excluded from analyses carried out in the subgroup As expected, according to the recruitment criteria, mean
of physically active controls, whereas they were included in anal- age was similar in the two groups of dancers and con-
yses carried out in the whole sample of controls. trols. Professional dancers had a lower body weight and
All subjects were Caucasian. a shorter height, as compared to both non-professional
All subjects and their families received preliminary detailed writ- dancers and controls. However, BMI was similar in pro-
ten information about the aims of the study and their participa- fessional and non-professional dancers, whereas it was
tion, which consisted of filling in an anonymous questionnaire. lower in both groups of dancers than in controls. As ex-
The study was approved by the Institutional Review Board. Per- pected, professional dancers reported a significantly
mission to undertake the study was also provided by each school heavier training profile than non-professional dancers and
and subject and/or their parents. physically active non-dancer controls. On the other hand,
A self-administered anonymous questionnaire was submitted non-professional dancers and physically active controls
to all subjects. It comprised questions about age, height, weight, showed a similar training profile, except for longer sport
and, in physically active subjects, the training profile (years, practice in dancers.
days per week and hours per day of exercise). Physical-ly active Seven of the 92 subjects in the professional dancers
controls were also asked to report the type of sport they did. In group (7.6%) have not yet had the menarche, in com-
addition, girls were asked to report age at menarche, past or parison with 1 out of 93 subjects in the non-professional
current menstrual alterations, and use of hormonal dancers group (1.0%) and none in the control group
contraception. weight loss counseling and Anxienty in Primary
In this study, oligomenorrhea was defined by menstrual bleed- Amenorrhea (p<0.0001 between groups). Three of these
ing occurring at intervals longer than 35 days. Amenorrhea was subjects, all in the professional dancers group, had a
defined as absence of menstrual cycles for at least 3 months. primary amen-orrhea. Age at menarche was significantly
Primary amenorrhea was defined as absence of menarche by higher in pro-fessional dancers than in the other groups
age 15 (9). weight loss counseling and Anxienty in Primary (p<0.0001). Frequency of menstrual alterations
Amenorrhea substantially variedacross the groups. It was reported by
51% of professional dancers, 34% of non-professional
Statistics dancers and 21% of controls (p<0.0001). It was also
Data are shown as mean and SD, mean and 95% confidence in- different between non- professional dancers and
terval (CI), as appropriate. Comparison of relevant variables physically active non-dancer controls, whereas it was
among groups was carried out by analysis of variance or, for cat- similar in sedentary and physically active non-dancer
egorical variables, by Fisher’s exact test. Logistic regression anal- controls. Menstrual dysfunctionwas also more severe in
ysis was used to assess predictors of menstrual dysfunction in professional dancers than in the other groups. In actual
these girls. In these analyses, independent variables were cho- fact, 23% of these girls had amenorrhea, whereas this
sen on the basis of associations in bivariate analyses with the feature ranged between 1-7% in the other groups
dependent variable and/or of biological plausibility. The final (p<0.0001).
models chosen were those with the highest explained variance. No subjects among either professional or non-profes-
Tests with p<0.05 were considered statistically significant. Anal- sional dancers reported use of oral contraceptives or any
yses were performed using Statview 5.0.1 software (SAS Insti- other pharmacological therapy for menstrual alterations,
tute, Cary, N.C.). while 4 sedentary controls and 3 non-dancers active con-
trols were treated for menstrual alterations.
Table 1 - Physical characteristics and training profile.

Control subgroups
Professional Amateur Control
dancers group dancers group group Sedentary Non-dancers
(no.=92) (no.=93) (no.=293) controls active controls
(no.=160) (no.=86)
Age (yr) 18.0±2.8 17.9±2.9 18.0±2.4 18.5±2.4 17.9±2.5
Years of dance/sport (yr) 11.6±3.6 10.3±4.2a - - 7.0±3.8a,b
Height (cm) 1.64±0.05 1.66±0.05a 1.66±0.06a 1.65±0.06 1.67±0.7a
Weight (kg) 48.0±4.7 50.4±5.0a 55.7±8.0a,b 55.4±8.2a,b 57.6±8.2a,b
BMI (kg/m2) 17.8±1.5 18.3±1.6 20.2±2.5a,b 20.2±2.6a,b 20.6±2.4a,b
Days of training (d/week) 5.6±0.8 2.4±0.6a - - 2.5±1.0a
Hours of training (h/day) 3.7±1.3 1.9±0.8a - - 1.6±0.5a
ap<0.05-0.0001 compared with professional dancers; bp<0.05-0.0001 compared with amateur dancers.
344
Low body weight and menstrual dysfunction in ballet dancers
Table 2 - Menstrual characteristics.

Control subgroups
Professional Amateur Control
dancers group dancers group group Sedentary Non-dancers
(no.=92) (no.=93) (no.=293) controls active controls

(no.=160) (no.=86)
Age at menarche (yr) 13.2±1.7 12.4±0.9a 12.3±1.2a 12.3±1.9a 12.1±1.2a
Menstrual alteration (%) 51 34b 21a,c 18a,d 19a,c
Oligomenorrhea (%) 28 33 17b,d 16b,d 12a,d
Secondary amenorrhea (%) 23 1a 4a 2a 7a,c
Data are mean±SD, or percentage. ap=0.005-0.0001; bp=0.05-0.02 vs professional dancers; cp=0.05-0.02; dp=0.005-0.001 vs amateur dancers.
Table 3 - Predictors of menstrual dysfunction by logistic regression analysis, in professional and amateur dancers. Data are expressed
as mean and 95% confidence interval (CI). weight loss counseling and Anxienty in Primary Amenorrhea
Professional dancers group Amateur dancers group
OR (95% CI) p OR (95% CI) p
BMI (kg/m2) 0.96 (0.70-1.31) 0.80 0.61 (0.42-0.88) 0.008
Physical activity volume (h/day) 1.52 (1.06-2.20) 0.02 0.94 (0.56-1.57) 0.82
BMI: body mass index.
Logistic regression analysis showed that in professional sedentary controls vs 54% of athletes of different sports
ballet dancers menstrual dysfunction was independently had menstrual dysfunction (12). These figures are strik-
associated with the training profile, but not with the BMI, ingly similar to our findings in controls and elite dancers,
whereas in non-professional dancers it was independently respectively, suggesting reliable estimates of the preva-
associated with the BMI, but not with the training profile lence of menstrual dysfunction in our sample. However,
(Table 3). However, variance explained by the model was a slightly lower figure, 15%, was found in 900 unselected
low. BMI was associated with menstrual dysfunction al- college students referring to a student health centre, who
so in sedentary controls (data not shown), whereas no were submitted to a careful medical history (13).
variables predicted menstrual dysfunction in the physi- In elite dancers, menstrual dysfunction relies on functional
cally active non-dancer controls. hypothalamic abnormalities, due to low energy avail-
Age at menarche was associated, in all groups, with men- ability and low body fat (14). Although the pathogenesis
strual dysfunction. Odds ratios (95% CI) were 1.78 (1.28- of menstrual alterations was not investigated in the pre-
2.48) in professional dancers, 4.87 (2.26-10.51) in non- sent study, the hypothesis that it arises, for amateur
professional dancers, and 1.45 (1.13-1.85) in controls, re- dancers too, from hypothalamic dysfunction, is strongly
spectively. In both groups of dancers, but not in physi- supported by the finding that BMI was similarly low in our
cally active controls, this association was maintained af- professional and non-professional dancers. In actualfact,
ter inclusion in the analysis of BMI and training profile this characteristic makes other causes of menstrual
(data not shown). dysfunction in amateur dancers unlikely. This conclusion
is still further supported by the results of the logistic re-
gression analysis, which showed that in non-profession-
DISCUSSION al dancers BMI was an independent predictor of men-
To our knowledge, this study is the first to compare the strual alterations: the lower the BMI, the higher the risk of
prevalence of menstrual dysfunction in elite ballet dancers, menstrual abnormalities in these subjects.
in amateur ballet dancers and in controls. Our data confirm Thus, our data suggest that, similarly to elite dancers, a
the high frequency of menstrual alteration and the delayed substantial fraction of the large number of young women
age of menarche previously reported in professional bal- who are amateur dancers is potentially at risk for the clin-
let dancers (10, 11). However, the novel finding of this ical features of the athlete’s triad, in particular impaired
study is that also amateur ballet dancers have an increased bone mineral density and the other consequences of hy-
prevalence of menstrual irregularity. In our study, 51% of poestrogenism (14-16). Remarkably, bone mineral density
professional dancers and 34% of non-professional dancers declines as the number of missed cycles accumulates (17)
had menstrual dysfunction, vs 21% of controls. Interest- and the loss of bone mineral density may not be fully re-
ingly, both elite and amateur ballet dancers showed a low- versibile (18), making diagnosis and treatment of these
er BMI, as compared to controls. alterations of acute medical interest. The American Col-
The proportion of subjects in the general population with lege of Sport Medicine recommends treating menstrual
menstrual alterations has differed between previous stud- dysfunction in athletes primarily by increasing the caloric
ies, according to age, ethnicity and criteria and methods intake and reducing the energy expenditure of these girls
used to assess this issue. In a study which used a ques- (2). However, this recommendation is not easily accept-
tionnaire to investigate menstrual dysfunction, similarly ed by these women. An alternative approach is resorting
to our study, Hoch et al. reported that 21% of high school to hormonal therapy, although the efficacy of this option
345
E. Bacchi, G. Spiazzi, G. Zendrini, et al.
remains controversial (14). It is noteworthy that our sam- the study and the dance schools and academies for their support during
the project.
ple of ballet dancers did not report use of hormonal con-
traceptives or other medications for treatment of men-
strual alterations, despite the high proportion of subjects Disclosure statement
with abnormalities. The authors have no conflict of interest to disclose.
Interestingly, in the professional ballet dancers menstru-
al dysfunction was mainly associated with the training
profile, whereas in the amateur dancers it was associated REFERENCES
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346
Open Access
Original Article
Relationship of weight loss – Nutrition counseling

and Anxienty in Primary Amenorrhea status
adolescent girls
ABSTRACT Saira Dars1, Khashia Sayed2, Zara Yousufzai3
Objective: To evaluate the effect of weight loss nutritional counseling status on the anxienty menstrual
pattern in adolescent girls (Primary Amenorrhea)
Methods: Four hundred one adolescent girls who attained menarche were selected from five schools in
Hyderabad. The data was collected by trained medical undergraduate and postgraduates by interviewing
adolescent school girls using a pre-designed pre-tested questionnaire. BMI was calculated using the formula:
BMI (kg/m2) = Weight (kg) / Height 2 (m2). Hb was estimated by Sahlis method using a weight loss – Nutrition
counseling and Anxienty in Primary Amenorrhea status adolescent girls and.Data was analyzed using SPSS 11.0.
Results: The mean age of the girls was 14.96 +/- 1.5 years. Three hundred and five (76%) of the girls had
a normal menstrual cycle, twenty-eight (7 %) had frequent periods, fifty-two (13%) had infrequent periods
and sixteen (4%) of the girls had totally irregular cycles and a pattern could not be determined. Three
hundred and five (76%) of girls had a normal menstrual flow, sixty-eight (17%) had heavy flow and twenty-
eight (7%) had scanty flow. One hundred fifty two (38%) of girls complained of premenstrual symptoms.
Two hundred thirty one (60%) girls were clinically anemic. Two hundred and seventy seven (69%) had a BMI
between 18.5 - 24.9 kg/m2. One hundred and eight (27%) were underweight with a BMI of 14 – 18.49kg/m2,
while sixteen (4%) were overweight with BMI 25 – 29.99 kg/m2. A statistically significant relationship was
found between BMI and weight loss – Nutrition counseling and Anxienty in Primary Amenorrhea status
adolescent girls (P < 0.001) and BMI and menstrual pattern P < 0.001).
Conclusion: The study concludes that a majority of the girls had clinically obvious nutritional deficiency
diseases. Out of the four hundred and one girls who were checked, two hundred thirty one were found to
be anemic. Majority of the girls (84%) had a normal menstrual pattern, normal BMI and attained menarche
before the age of 16. Overweight girls had infrequent periods.
KEY WORDS:Primary amenorrhea ,Adolescence, weight loss, Nutrition counseling, Anxienty
doi: http://dx.doi.org/10.12669/pjms.301.3949
How to cite this:
Dars S, Sayed K, Yousufzai Z. Relationship of menstrual irregularities to BMI and nutritional status in adolescent girls. Pak J Med Sci
2014;30(1):140-144. doi: http://dx.doi.org/10.12669/pjms.301.3949
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
* Revision Received: October 19, 2013
1. Saira Dars, MS, * Revision Accepted: * October 21, 2013
Obstetrics &Gynaecology Department,
2. Khashia Sayed, MBBS,
SpR at St Thomas’ Hospital, London, UK.
3. Zara Yousufzai, MBBS,
MS trainee, Plastic and Reconstructive Unit,
1, 3: Liaquat University of Medical and Health Sciences LUMHS,
Jamshoro, Sindh, Pakistan.
Correspondence:
Dr. Saira Dars, MS,

Obstetric and Gynaecology Department
Liaquat University of Medical & Health Sciences
Jamshoro, Sindh, Pakistan.
Email: sairadars.gull@gmail.com
* Received for Publication: July 4, 2013

140 Pak J Med Sci 2014 Vol. 30 No. 1 www.pjms.com.pk
Menstrual irregularities & nutritional status in adolescent girls
INTRODUCE is frequently correlated with irregularities of

menstrual and problems among the females in
for the patient and their families. It is important for different age groups.
clinicians as well as young patients and their The objective of this study was to evaluate the
parents to understand what a normal menstrual effect of Body Mass Index and nutritional status
pattern is, in order to evaluate what constitutes an on the menstrual pattern in adolescent girls. Four
irregular cycle or abnormal flow. In many instances, hundred and one adolescent girls who attained
young patients seek medical attention for menstrual menarche were selected from five schools in
irregularities, which actually fall within the normal Hyderabad.
range.
The age of menarche is determined by general METHODS
health, genetic, socio-economic and nutritional
The current study was a cross sectional study
factors. The mean age of menarche is typically
carried out between April to June 2011. The study
between 12 and 13 years.1,2 The initial cycles after
was conducted in Hyderabad, Pakistan wherea
menarche are often irregular with a particularly
total of four hundred and one adolescent girls aged
greater interval between first and second cycle. The
12 – 18 from five schools were selected after
early menstrual cycles are thought to be anovulatory,
getting permission from their parents. The school’s
with frequency of ovulation being related to time
Headmistresses were contacted via the Director of
since menarche and age at menarche.3
Secondary Education for permission to allow the
Most women bleed for 2 to 7 days during their
questionnaires to be distributed among the school
first menses.4 Most normal cycles range from 21
girls. The data was collected by trained medical
to 45 days, despite variability even in the first
undergraduate and postgraduates by interviewing
gynecologic year, although short cycles of fewer
adolescent schoolgirls using a pre-designed pre-
than 20 days and long cycles of more than 45 days
tested questionnaire.
may occur. By the third year after menarche, 60%
The questionnaire consisted of age, residential
to 80% of menstrual cycles are 21 to 34 days long,
address, fathers occupation and income, age of
as is typical of adults.4,5 BMI as classified by WHO
menarche, date of last menstrual period, details of
describes having <16kg/m2 as severe underweight,
menstrual cycle, including cycle length, number of
16.0 – 16.9kg/m2 as moderate underweight and 17.0
days the period lasts, menstrual flow (i.e. scanty,
– 18.49kg/m2 as mild underweight. Normal BMI
normal or heavy), presence or absence of
range is 18.5 – 24.99 kg/m2. Anything > 25 kg/m2 is
dysmenorrhea, premenstrual symptoms such as
considered to be overweight, with 25 – 29.99 kg/
headache, giddiness, leg cramps and abdominal
m2being classified as pre-obese and >30 kg/m2 as
cramps, and any other symptoms such as diarrhea
obese.
or vaginal discharge were noted.
Menstrual problems are generally perceived as
Clinical examination was conducted at the
only minor health concern and thus irrelevant to
same time by the trained medical staff.
the public health agenda particularly for women in
Examination included looking for signs of anemia,
developing countries who may face life threatening
lymphadenopathy, checking the thyroid gland.
condition. Menstrual cycle is normal physiological
All those who were married, had primary or
process that is characterized by periodic and cyclic
secondary amenorrhea, and genital tract surgery,
shedding of progestetional endometrium
chemo or radiotherapy or was on oral contraceptive
accompanied by loss of blood which is additional
pills (OCP) were excluded. Height and weight was also
vital sign adds a powerful tool to the assessment
measured. weight loss – Nutrition counseling and
of normal development and the exclusion of
Anxienty in Primary Amenorrhea status adolescent
pathological conditions in adolescent and young
girls. Datawas analyzed using SPSS 11.0.
girls.6 Some variety of menstrual dysfunction occurs
in adolescent girls which may affect normal lifeof RESULTS
adolescent and young adult women. Physical,
Mental, Social, Psychological, Reproductive A total of four hundred and one girls participated
problems are often associated with menstrual in the study. The mean age of the girls was 14.96 with
irregularities and menstrual problems. Due to a standard deviation of 1.5 years (range 12 – 18
change in life style, habits, diet, the prevalence of years). The socioeconomic status was determined
obesity has increased in developed world which
results in decreased age at menarche. 7
Low level of hemoglobin and nutritional status
Pak J Med Sci 2014 Vol. 30 No. 1 www.pjms.com.pk 141
Saira Dars et al
by their father’s occupation and monthly income. menstrual problems are given in Table-I. Nutritional
47% of the fathers worked in the public sector and Status and Anaemia: Nutritional status of the girls
2% worked in the private sector, 39% were manual was determined by their Body massindex (BMI).
workers and 12% did not mention the status of their The mean BMI was19.65kg/m2 SD
father’s job. 71% of the girl’s fathers belonged to the = 2.41 kg/m2).The results are shown in the chart
lower middle class status with a monthly income below. Table-II. weight loss – Nutrition counseling
between Pakistani rupees (Rs.) 2000 – 7000. 26% and Anxienty in Primary Amenorrhea status
belonged to the middle class with an income of adolescent girls
Rs.7000 – 12,000 while 3% of the girls belonged to Anemia: Two hundred and thirty one (60%) girls
a low socio economic status with father’s income were clinically anemic with an Hb<12g/dl. The
between 1000 – 2000 rupees per month. mean Hb was 9.88g/dl, SD 2g/dl. One hundred and
Age of Menarche: 67.33 % of the girls had their first sixty (40%) girls had Hb 12 – 14g/dl. Of note, 8.3%
menstrual period between the age of 11 and 13 (mean girls had an Hb as low as 5.7g/dl.
= 12.92 years, SD of 1.41 years). All the girls had BMI and menstrual pattern: 75.51% girls with BMI
experienced menarche by the age of 16 years. None of 14-24.9 had a normal menstrual pattern. All sixteen
the girls had primary amenorrhea. girls with a BMI of 25 – 29.9 kg/m2had infrequent
Menstrual Pattern: Three hundred and five (76%)of cycles. A statically significant relationship was ob-
the girls had a normal menstrual cycle of 3-7/ 26 served between BMI and menstrual pattern. (df = 6,
– 31 days. Twenty-eight (7 %) had frequent periods x3= 116.5, P <0.001).
5 – 8 / 22 – 28 days. Fifty-two (13%) had infrequent Other Problems: Other problems identified were
periods (3 -5/35 – 90) and sixteen (4%) of girls had excessive vaginal discharge, with or without foul
totally irregular cycles and pattern could not be smell and itching 43%, abdominal pain on and off
determined. After excluding these sixteen girls, 28.18%, goiter 11%, cervical lymphadenopathy 6%,
with irregular patterns, the mean cycle length of the diarrhea 5% and urinary symptoms 5%.62% had
remaining three hundred and eighty five girls was primary dysmenorrhea.
28 – 29 days. SD 12.45 days. Other details related to DISCUSSION
Table-I: Menstrual problems among adolecent Our study concluded that there was a statistically
school girls with BMI groups Relationship
significant relationship observed between BMI and
Anxiety (N = 401) menstrual pattern. The results showed that 75.51% of
Yes 249 (62%) girls with BMI 14-24.9 had a normal menstrual
No 152 (38%) pattern. All sixteen girls with a BMI of 25 – 29.9 kg/
Cycle (N = 401) m2had infrequent cycles.
Regular 305 (76%) In the present study, the mean age at menarche
Irregular 96 (24%) of young girls was found to be 12.92 ± 1.41 years,
Menstrual Days (N = 401) which is similar to other studies.8-12 By 15 years of age,
1 – 5 days 285 (71%) 98% of females will have had menarche.13 Allthe
> 5 days 116 (29%) adolescent girls in the present study attained
Menstrual flow (N = 401) menarche before the age of 16, therefore none had
Normal 305 (76%) primary amenorrhea. Chumlea et al13 and Thomaset
Heavy 68(17%) al14 concluded that society’s socioeconomic status can
Scanty 28 (7%) have an influence on the age of menarche as well as
Premenstrual symptoms (N = 401) the prevalence of menstrual irregularities in the
Yes 153 (38%) population. In respect of regularity of menstrual
No 248 (62%) cycle, it revealed that it was regular inthree hundred
Adolecent girls BMI Index and five (76%) girls, whereas ninety- six (24%) had
277 1 8.5 -24.99 (69%) irregular cycle this is comparable to other studies.12,15
16 25 – 29 (4%)
Table-II: Body mass index (BMI).
108 14-18 (27%)
BMI Status BMI Mean±SD BMI (kg/m2)
69% Normal 19.65±2.41kg/m2
<18.49 108
4% Overweight
18.5 - 24.99 277
27% Underweight
25 - 29.99 16
Menstrual irregularities & nutritional status in adolescent girls
The menstrual flow, was found to be normal in general health of women. Certain endocrinological
three hundred and five (76%) of the girls, while it abnormalities may be missed or delayed, making
was scanty in twenty eight (7%) and heavy in sixty these conditions and their sequelae more difficult
eight (17%) of the girls, in contrast to a study by to treat at a later date. This may partially be due to
Begum J et al9 which showed a higher percentage of lack of knowledge and education amongst school
girls to have scanty flow and lower percentage of going girls in Hyderabad. However the reason
those with heavy flow. Dysmenorrhea is one of the behind the low numbers of girls seeking treatment
commonest problems in this age group, as reported needs to be investigated further. It is possible that
by other researchers.16,17 This study showed that two the girls tend to assume that their menstrual
hundred and forty nine (62%) girls reported to have pattern is normal and therefore do not report them
primary dysmenorrhea. This can be compared with at the regular school health check-ups due to lack of
the study findings of Begum J8 et al and Chowdhury proper information.27
et al.18 Due to lack of knowledge, education, male
There have been studies, which have emphasized dominance majority of adolescent girl and young
the importance of Body Mass Index (BMI) as an index women do not seek the health care services, at the
of nutritional assessment.19,20 In this study nutritional same time high prevalence of malnutrition among
status of the girls was determined by their BMI. Two adolescent girls results in increased reproductive
hundred seventy seven (69%) hada BMI between problems in young women. Problems with
18.5- 24.9 kg/m2, one hundred and eight (27%) were menstrual pattern may affect 75% girls, and are the
underweight with a BMI of 14 – 18.49kg/m2, while major cause of recurrent short term school
sixteen (4%) were overweight with BMI 25 – 29. 9 absenteeism in female college students 28. A number
kg/m2 (mean BMI 19.65kg/m2 SD = 2.41 kg/m2). of medical conditions can cause irregular or missed
There have been 2 large studies by Karlberg and menses which are diagnosable and treatable even
Wang21,22 that have confirmed earlier onset of at peripheral level in early stage but this part of
puberty related to a higher gain in BMI. Other women’s health was neglected by primary health
studies23-24 reported later appearance of Menarche, care. More than 90% menstrual problems are
menstrual cycle disorders and problems with preventable which need early detection and early
conception, related to reduced body fat and weight treatment by appropriate methods. Effectiveness
loss. In our study 75.51% girls with BMI 14-24.9 of any health programme evaluated on the basis of
kg/m2 had a normal menstrual pattern.All sixteen improvement in general health of community.
girls with a BMI of 25 – 29.9 kg/m2 had infrequent Appropriate health education measures need to be
cycles (oligomenorrhea). put into place to prevent this trend. Since most
Anemia affects approximately 30% to 55% of adolescent girls are at school going age, the initial
adolescents of all over the world.25 It is particularly steps to promote awareness must start in schools.
more pronounced in adolescents in this age group CONCLUSION
due to the physical changes that occur at puberty,
utilizing a large portion macronutrients, vitamins, The study concludes that a majority of the girls
and minerals and tend to have an increasing need had clinically obvious nutritional efficiency diseases.
for energy, especially during the growth spurt. 26 Problems related to menstruation are quite frequent
Two hundred and thirty one (60%) girls in our study and often result in the interruption of the daily
were clinically anemic with Hb<12 g/dl. Mean Hb routine of the adolescent girls, therefore it is
was 9.88g/dl with SD 2g/dl. From the two hundred important that school officials and school health
and forty one(60%) girls, thirty-three of the (8.3%) programme staff recognize these problems and need
girls had Hb+/- 5.7g/dl, showing significant to be sensitive to their problems. Further studies
anemia. One hundred and sixty (40%) girls had Hb should be performed to determine the reason for this
12 – 14g/dl. This shows that a large proportion of trend, and newer strategies need to be employed.
girls are anemic and the diagnosis of anemia and weight loss – Nutrition counseling and Anxienty in
certain hematological disorders is often missed. The Primary Amenorrhea status adolescent girls have
problem arises due to the lack of seeking medical significated
attention. This in turn leads to under diagnosis of
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Sri lanka Journal Vol 1 No 2 2022
The Correlation Nutrition Counseling And Anxienty In Primary Amenorrhea

Status Adolescent Girls In Sri Lanka
DA Jayakody*, KTTK Wijithasena and S Weerasinghe

Department of Sports Science, Faculty of Applied Sciences University of Sri Jayewardenepura
ABSTRACT
This purpose of this study was to identify the association among the nutrient intake, eating
disorders and menstrual irregularities of national level female athletes in selected sports. The research
was conducted as a cross-sectional study. Two hundred and five female athletes were selected from
competitive team sports such as Judo, Weightlifting, Netball, Hockey, Wrestling, Rugby, Gymnastic,
Kabaddi, Football, Archery, Cricket, Karate, Volleyball, Throw ball, Table tennis, Kho-Kho,
Taekwondo, Wushu and Boxing using the stratified random sampling technique. Female athletes aged
15-25 years, having menorrhagia of more than two months and/or other irregularities in menstrual
cycle were included in the study.
The research instruments included the Eat-26 questionnaire and a questionnaire focused on
history and hormone levels of athletes, which were used to identify athletes with eating disorders and
menstrual irregularities, respectively. The diet of the subjects was analysed based on a three-day
dietary recall. The Chi-squared test was used to identify the relationship between eating disorders and
menstrual irregularities. The association between eating disorders, menstrual irregularities and the
types of sports were also evaluated. Binary logistic regression analysis was used to determine the
association between the daily nutrient intake and menstrual irregularities. All statistical analyses were
conducted at 5% level of significance using SPSS 22 software.
The results of the study revealed that;
1. The type of sports had a significant association (P<0.05) with eating disorders as well as
menstrual irregularities.
2. Eating disorders are strongly associated (P<0.05) with the incidence of menstrual irregularities
among athletes participated in this study.
3. With respect Nutrition Counseling And Anxienty In Primary Amenorrhea , only the energy
intake and the sodium intake were largely associated with menstrual irregularities among
national level female ( P <0.05)
Therefore, it is important that all athletes get nutrition consultation regarding energy intake
and precautions should be taken to reduce the risk of eating disorders to minimize the health
consequences of athletes in future.
Key Words:Nutrition Counseling, Anxienty ,Primary Amenorrhea
Corresponding Author: Ms.D.A.Jayakody, Lecturer, Department of Sports Science, Faculty of Applied

Sciences, University of Sri Jayewardenepura. Email: dilini.tcc@gmail.com
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Background
According to numerous researches the factors such as hormonal status, training and physical
parameters, nutritional balance, and psychological stress have been shown to be associated with
menstrual irregularities (Fruth, S.J. and Worrell, T.W., 1995). The most common nutrition issues in
active women are poor energy intake and/or poor food selection, which can lead to poor intakes of
protein, carbohydrate and essential fatty acids (Manore, M.M., 2002.). This may lead to menstrual
irregularities of female athletes, especially those engaging in daily physical activities.
Also, many female athletes are pressured by coaches to become thin or have a beautiful body
because of some qualities that are required in lean sports. Therefore, female athletes in these sports
are strictly maintaining their body by controlling their diet. Restrictive eating, fasting, using the diet
pills, laxatives and diuretics, and binge-eating followed by purging can cause disordered eating, which
in turn, can alter the menstrual patterns (Mirheidari, Salehian et al. 2012).
Further, previous research on female athletes has established that athletes in lean-built sports
are more likely to have menstrual dysfunction than those in non-lean-built sports. Also, the caloric
restriction directly causes a reduction in resting metabolic rate. Thus, athletes with menstrual
irregularities are characterized by their negative energy balance and reduced resting metabolic rate
(Benson, J.E., Engelbert-Fenton, K.A. and Eisenman, P.A., 1996).
Fruth, S.J. and Worrell, T.W., 1995, has mentioned that irregularities in menstrual cycle
bring about irreversible consequences such as decreased peak bone mass and eventual osteoporosis.
The irregularities in menstrual cycle may provide convenience for athletes during their sports
training sessions but they are completely unaware that it may negatively affect their overall health
including bone health. Further, menstrual irregularities can result in potential health problems of
female athletes in later years.
Research Objectives
The purposes of this research were;
1. To identify the relationships Nutrition Counseling And Anxienty In Primary Amenorrhea
among the daily nutrient intake, the occurrence of eating disorders and the incidence of
menstrual irregularities among female athletes.
2. To identify the effects of the type of sport on menstrual irregularities and disordered eating.
Scope of the Study
Scope on Area
The research was conducted at the premises in which the National-level female athletes were
trained.
Scope on Contents
The research was focused on identifying the associations among the incidence of eating
disorders, menstrual irregularities and the nutrient intake among the National-level female athletes
Scope of the population
The population of the study is national-level female athletes (Age: 15-25 years) engaged in
competitive team sports such as Judo, Weightlifting, Netball, Hockey, Wrestling, Rugby, Gymnastic,
Taekwondo, Wushu and Boxing.
Research methodology
1. Cross sectional research design was used to conduct the research.
2. A sample of 205 female athletes from competitive team sports such as Judo, Weightlifting,
Netball, Hockey, Wrestling, Rugby, Gymnastic, Kabaddi, Football, Archery, Cricket, Karate, Volleyball,
Throw ball, Table tennis, Kho-Kho, Taekwondo, Wushu and Boxing were selected using the stratified
random sampling technique.
3. Female athletes aged 15-25 years, having menorrhagia of more than two months and/or
other irregularities in menstrual cycle were included in the study. The athletes who are pregnant and
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those who are presently taking or had ever taken oral contraceptives were excluded from the sample
because bone mineral density can change after a pregnancy (Biason, Goldberg et al. 2015).
4. Before commencing the research, the permission was taken from the Ministry of Sports,
the Associations/ Federations of Judo, Weightlifting, Netball, Hockey, Wrestling, Rugby, Gymnastic,
Taekwondo, Wushu and Boxing, and the coaches of all the teams.
5. Meetings were arranged with coaches and athletes to facilitate understanding the purposes
of the study and to get familiarized with the questionnaires.
Research Instruments
The research instruments consisted of;
1. A Questionnaire to identify the athletes with menstrual irregularities, which was developed
by Van de Loo & Johnson (1995)’
2. EAT-26 questionnaire which was used to identify the eating disorders among athletes.
3. A 3-day dietary recall filled by the athletes.
Data Collection
1. Adolescent were instructed to complete the questionnaire focused on menstrual
irregularitiesand the Eat-26 questionnaire.
2. The criteria for classifying athletes with menstrual irregularity were as follows: primary
amenorrhea (no onset of menses by the age of 16 years), secondary amenorrhea (cessation of menstrual
cycles for ≥3 consecutive months in the past year), or oligomenorrhea (menstrual cycles occurring
at intervals >35 days after onset of menses by the age of 16 years) and eumenorrheic (normal condition).
Female athletes suffering from one of the above conditions except eumenorrheic condition were
considered as athletes with menstrual irregularities (Nichols, Rauh et al. 2006).
3. The diet of the subjects was analysed based on a three-day dietary recall, which contained
records of all food, drinks and supplements. The dietary records of the subjects included two weekdays
with practice sessions and one weekend day without practices. The subjects were advised to report
their dietary intakes clearly and accurately.
Data analysis
1. The reliability of the EAT-26 questionnaire was determined through Cronbach’s alpha test.
2. The three-day dietary records were analysed for total energy, calcium, fat, protein, Iron,
zinc, Folate, vitamin D, Vitamin E, Magnesium, Vitamin B6 and dietary fibres using Nutrisurvey
software.
3. Pearson’s chi-squared test was used to identify the relationship between eating disorders
and menstrual irregularities.
4. Binary logistic regression analysis was conducted to predict the dietary factors associated
with menstrual irregularities.
5. All statistical analyses were conducted at 5% level of significance using SPSS 22 software.
Expected Benefits & Application

1. Although similar studies have been conducted worldwide, the studies on the incidence of
eating disorders and menstrual irregularities among athletes in Sri Lanka are scarce.
2. Identifying the prevalence of eating disorders and menstrual irregularities among athletes
could be helpful, because it serves as a starting step towards management of eating disorders and
menstrual irregularities, which could otherwise adversely affect the performance.
3. By identifying nutrients that affect menstrual irregularities, coaches and athletes can focus
on these nutrients to prevent menstrual irregularities which lead to a lifelong problem of female
athletes.
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4. Sports nutritionists can use this information to design proper diet plans for female athletes to
minimize their health problems in the future. New diet plans can be designed to encourage an adequate
nutrient intake, which helps to maintain health of female athletes.
5. Further, this study will provide insights for future researchers to conduct research on factors
contributing to menstrual irregularities among athletes.
Result and Discussion
Distribution of athletes among different sports
The national level athletes were selected from different sports such as Judo, Weightlifting,
Netball, Hockey, Wrestling, Rugby, Gymnastic, Kabaddi, Tug of war, football, Archery, Cricket,
Karate, Volleyball, Throwball, Table Tennis, Kho-Kho, Taekwondo, Wushu, and Boxing. Number
of players engaged in sports such as archery, weightlifting and boxing were low compared to those
in other sports. Table 1 shows the number of athletes selected from different sports.
Table 1: Percentages of athletes in different sports
The majority of athletes participated in this study were engaged in team sports such as Hockey,
Netball, Wrestling, Rugby, Tug of war, football, Cricket, Volleyball, Throwball, Kho-Kho,Table
tennis and Taekondow. There were only few athletes particpated for the studies in the sports such as
Gymnastic, Kabaddi, Archery, Karate, Wushu and Boxing.
Primary Amenorrhea among Adolescent

The athletes with menstrual irregularities and non-irregularities were identified using a questionnaire
which focused on the history and hormone levels of athletes. Figure 1 shows the number of athletes
with menstrual irregularities and non-irregularities.
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Figure 1: The athletes with menstrual irregularities and non-irregularities.
Among 205 athletes, 86 (42%) athletes were suffering from menstrual dysfunction. One hundred
and nineteen athletes (58%) did not have menstrual irregularities (Fig. 1). Therefore, the majority of
the athletes did not have menstrual irregularities.
The menstrual irregularities were categorised into three types such as oligomenorrhea, secondary
amenorrhea and primary amenorrhea. Figure 2 illustrates the percentages and number of athletes
based on the type of menstrual irregularity. According to Fig. 2, the most common menstrual irregularity
among athletes was oligomenorrhea with the percentage of 50%, followed by secondary amenorrhea
(38%). Primary amenorrhea was the least common menstrual irregularity, with only 13% were
suffering from it. Overall, the athletes were more prone to oligomenorrhea than secondary or primary
amenorrhea.
Figure 2: Percentages of athletes suffering from menstrual irregularities
The Relationship between Menstrual Irregularities and the Type of Sports

Menstrual irregularity questionnaires were distributed among athletes engaged in Judo, Netball,
Hockey, Wrestling, Rugby, Gymnastic, Kabaddi, Football, Archery, Cricket, Karate, Volleyball,
Table tennis, Kho-Kho, Taekwondo, Wushu and Boxing. The distribution of menstrual irregularities
in athletes engaged in different sports is shown in Figure 3.
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Figure 3: Percentages of menstrual irregularities according to sport

When considering the different sports categories, 75% athletes from Judo, 31% from Netball,
76% from Hockey, 36% from wrestling, 36% from Rugby, 100% from Gymnastic, 33% from Kabaddi,
31% from Football, 100% from Archery, 19% from Cricket, 63% from Karate, 50% from Volleyball,
70% from Table tennis, 33% from Kho-Kho, 50% from Taekwondo, 57% from Wushu and 60% from
Boxing were identified as athletes with menstrual irregularities. Also, no menstrual irregularitieswere
found among weightlifters. All athletes in Archery and Gymnastic were suffering from menstrual
irregularities. Gymnastic can be categorised as a lean sport and athletes who are engaging in lean
sports give a higher priority to maintaining their appearance. When considered about the archery,
there may be some other factors such as psychological stress that may lead to menstrual irregularities
other than diet and eating disorder. Further, previous research has shown that the stress level could
significantly affect the length of menstrual cycle intervals and the duration of bleed (Barsom, S.H.,
Mansfield, P.K., Koch, P.B., Gierach, G. and West, S.G., 2004). These may be the reasons for higher
percentages of athletes with menstrual irregularities in Gymnastics and Archery.
Pearson Chi-Square test was used to find whether there is a significant relationship between
menstrual irregularities and the types of sports.
Table 2: Chi-square table for the association of menstrual irregularity among sports
According to results (Table 2), there is a significant relationship (P<0.05) between menstrual
irregularities and the type of sport at 5% level of significance. Thus, it is evident that the type of sport
is significantly associated with the incidence of menstrual irregularities and higher rates of
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menstrual irregularities can be seen in sports such as gymnastic, archery, hockey, judo, table tennis,
boxing, Taekwondo and Wushu.
The Relationship between Eating Disorders and the Type of Sports
The Cronbach’s alpha value of EAT-26 questionnaire was greater than 0.8 and it showed that
the internal consistency of items in the questionnaire was in the acceptable level.
Occurrence of eating disorders among athletes engaging in different sports is shown in Figure
4. Eating disorders were common in athletes engaging in weightlifting (36%), gymnastic (100%),
volleyball (38%), Karate (36%) and Throwball (50%). Results suggest that the athletes doing weight
control sports are at a higher risk of developing eating disorders.
Figure 4: Percentages of eating disorders according to sport

Apart from that, the athletes in sports such as weightlifting, netball, tug of war, cricket, table
tennis and boxing did not have eating disorders. Although weightlifting and boxing can be categorised
as weight-category sports, in this sample, no athletes engaging in these sports were suffering from
eating disorders.
However, gymnasts are at a higher risk of developing eating disorders due to their tendency
toward controlling weight and diet to maintain their figure (de Oliveira Coelho, da Silva Gomes et al.
2014). Pearson’s chi-squared test was conducted to identify the relationship between eating disorders
and the types of sports, and the results are shown in Table 3.
Table 3: Chi-Square test results for different sports and eating disorder.
According to Pearson’s chi-squared test, there is a relationship (P<0.05) between eating disorder
and types of sports. Therefore, there was a significant association between eating disorder and sport
of national level female athletes in Sri Lanka, at 5% level of significance.
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The Association between Eating Disorders and Menstrual Irregularities among Athletes
Figure 5 illustrates the athletes with menstrual irregularities, with and without eating disorders.
Figure 5: Percentages of athletes with menstrual irregularities based on the incidence of eating
disorders
According to Fig. 5, most athletes with menstrual irregularities (73%) were also suffering
from eating disorders. Only a few athletes with menstrual irregularities (27%) were not having eating
disorders. Chi-squared test was conducted to identify the association between menstrual irregularities
and eating disorders among national level female athletes and the results are summarised in Table 4.
Table 4: Chi-squared test results for menstrual irregularities and eating disorders among athletes
According to Pearson’s chi-squared test results (Table 4), there was a significant association
(P<0.05) between eating disorders and menstrual irregularities of national level female athletes in Sri
Lanka.
Daily Nutrient Intake of Athletes

Under the diet, the daily intake values of energy, water, protein, fat, carbohydrate, dietary
fibre, vitamin E, vitamin A, vitamin B6, folic acid, sodium, potassium, calcium, magnesium, Vitamin
B12, Vitamin D, Iron and Zinc were evaluated. The nutrient intake of the subjects participated in
this study are summarized in Table 5.
Table 5: Daily energy and nutrient intake of athletes participated in the study
sris
The Associations among the Daily Nutrient Intake and Menstrual Irregularities
Binary logistic regression analysis was conducted to predict the dietary factors associated with
menstrual irregularities and the results are summarized in Table 6.
Table 6: Dietary factors associated with menstrual irregularities among athletes
Based on binary logistic regression analysis, the total energy intake and sodium intake showed
a strong association with menstrual irregularities among athletes participated in this study. Apart from
that, the intakes of nutrients such as water, protein, fat, carbohydrate, dietary fibres, vitamin E, vitamin A,
vitamin B6, folic acid, sodium, potassium, calcium, magnesium, vitamin B12, vitamin D, iron and
zinc did not show a strong association with menstrual irregularities. Thus, the nutrients other than
sris
sodium were removed from the model because they were not largely associated with menstrual
irregularities.
Some researchers have concluded that an inadequate energy intake could lead to menstrual
irregularities. Legan, S.J., Allyn Coon, G. and Karsch, F.J., (1975) mentioned that low sodium intake
cause depletion of oestrogen in the body, which may ultimately lead to menstrual irregularities.
Among other nutrients, only the sodium intake showed a significant relationship with menstrual
irregularities of national level Sri Lankan female athletes participated in this study.
Conclusions
This study focused on finding the associations among the eating disorders, dietary intake of
nutrients and menstrual irregularities of national level female athletes in competitive team sports. The
type of sport has a significant relationship with eating disorders and menstrual irregularities of athletes.
Thus, it can be assumed that in addition to physiological and psychological factors that are directly
related, the type of sports could also bring about menstrual irregularities and disordered eating among
national level female athletes.
Furthermore, eating disorder status was significantly associated with menstrual irregularities
of athletes participated in this study. With respect to the diet, only the energy intake and sodium intake
were significantly associated with menstrual irregularities among national level female athletes.
Therefore, all the athletes should get nutrition consultation, especially regarding energy intake, and
precautions should be taken to reduce the risk of eating disorders.
Suggestions
New diet plans should be introduced to national level female athletes in Sri Lanka to minimize
the incidence of eating disorders and menstrual irregularities.
The knowledge regarding female menstrual irregularities and importance of proper diet should
be disseminated among the athletes and coaches.
References
Barrow, G.W. and Saha, S. (1988). Menstrual irregularity and stress fractures in collegiate female
distance runners. The American journal of sports medicine, 16(3), pp.209-216.
Beals, K.A. and Hill, A.K. (2006). The prevalence of disordered eating, menstrual dysfunction, and
low bone mineral density among US collegiate athletes. International journal of sport nutrition
and exercise metabolism, 16(1), pp.1-23.
Benson, J.E., Engelbert-Fenton, K.A. and Eisenman, P.A. (1996). Nutritional aspects of amenorrhea
in the female athlete triad. International journal of sport nutrition, 6(2), pp.134-145.
Biason, T. P., et al. (2015). Low-dose combined oral contraceptive use is associated with lower bone
mineral content variation in adolescents over a 1-year period. BMC endocrine disorders 15(1):
15.
Brunet, M. (2005). Female athlete triad. Clinics in sports medicine, 24(3), pp.623-636.
Cobb, K.L., Bachrach, L.K., Greendale, G., Marcus, R., Neer, R.M., Nieves, J.E.R.I., SOWERS,
M.F., Brown, B.W., Gopalakrishnan, G., Luetters, C. and Tanner, H.K. (2003). Disordered
eating, menstrual irregularity, and bone mineral density in female runners. Medicine & Science
in Sports & Exercise, 35(5), pp.711-719.
Cronbach, L.J. (1951) Coefficient alpha and internal structure of tests. Psychometrika 16, 297-334.
de Oliveira Coelho, G. M., et al. (2014). Prevention of eating disorders in female athletes. Open
access journal of sports medicine pp.5.- 105.
Fruth, S.J. and Worrell, T.W. (1995). Factors associated with menstrual irregularities and decreased
bone mineral density in female athletes. Journal of Orthopaedic & Sports Physical Therapy,
22(1), pp.26.-38.
Garner, D.M., Olmsted, M.P., Bohr, Y. and Garfinkel, P. E. (1982). The Eating Attitudes Test:
Psychometric features and clinical correlates. Psychological Medicine 12, 871-878.
Legan, S.J., Allyn Coon, G. and Karsch, F.J. (1975). Role of Estrogen as Initiator of Daily LH Surges
in the Ovariectomized Rat 1 2. Endocrinology, 96(1), pp.50-56.
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Manore, M.M. (2002). Dietary recommendations and athletic menstrual dysfunction. Sports
medicine, 32(14), pp.88.-901.
Mirheidari, L., et al. (2012). Comparing menstruation disorders between A and B behavioral types of
university female athletes and non-athletes. Life Science Journal 9(4).
Nichols, J. F., et al. (2006). Prevalence of the female athlete triad syndrome among high school
athletes. Archives of pediatrics & adolescent medicine 160(2): 137-142.
Koebnick, C., Strassner, C., Hoffmann, I. and Leitzmann, C. (1999). Consequences of a long-term
raw food diet on body weight and menstruation: results of a questionnaire survey. Annals of
Nutrition and Metabolism, 43(2), pp.69-79
Van de Loo, D.A. and Johnson, M.D.(1995). The young female athlete. Clinics in Sports Medicine,
14(3), pp.687 -707.
LEADING ARTICLE Sports Med 2021; 31 (15): 1025-1031
0112-1642/01/0015-1025/$22.00/0
© Adis International Limited. All rights reserved.
STRESS MANAGEMENT TO SECONDARY AMENORRHEA

Current Issues
David C. Cumming and Ceinwen E. Cumming
Department of Obstetrics and Gynaecology, University of Alberta, and Royal Alexandra Hospital,
Edmonton, Alberta, Canada
Abstract Physicians commonly recommend estrogen replacement as treatment for ex-

ercise-associated amenorrhoea. While the evidence shows that the basis of the
amenorrhoea is estrogen deficiency, it is not clear that it is the only factor in the
development of lowered bone density found in oligo-amenorrhoeic female ath-
letes. Nutritional factors, significant in the development of the reproductive dys-
function, could also contribute to bone loss. No randomised, controlled studies
of estrogen replacement in athletes have been published. stress management to
secondary amenorrhea very intersting However, one non- randomised study of a
small group of athletes does suggest that there are significant gains in bone
density to be made by the initiation of estrogen therapy. Moreresearch is clearly
needed. metode chi square test for 45 girls with secondary amenorrhea. Result :
P <0.005
The question of whether secondary deed hypoestrogenic in nature. Second, it must be

amenorrhoeic female athletes should be offered shown that women with reproductive dysfunction
hormone replacement therapy in a manner have some risk which comes from the lack of es-
analogous to its use in post- menopausal women trogen and that the risks are not associated with
was raised many years ago.[1] Sex steroids are, in another factor (such as a nutritional deficit). Fi-
fact, commonly recommended to amenorrhoeic nally, it is necessary to demonstrate that replace-
ment of estrogen produces the desired benefits with-
athletes.[2] In a survey of physicians associated
out causing substantial harmful effects.
with the American Medical Soci- ety of Sports
Medicine, sex steroid replacement wasendorsed by
92% of physicians, calcium supplementation by 1. Stress Management
87%, increased caloric intake by 64%, decreased
Functional abnormalities of the reproductive axis
exercise intensity by 57%, bodyweight gain by 43%
have been associated with the extremes of repro-
and vitamin supplementation by 26%.[2] But is ductive life, abnormal dietary practices, extremes of
estrogen therapy necessary or helpful, or is it body fat content, psychological stress and patho-
possibly harmful to the women? logic conditions including androgen excess, hyper-
For hormone replacement therapy to be provided prolactinaemia, hypothyroidism and ovarian fail-
for amenorrhoeic female athletes, it is essential to ure. The endocrine, neuroendocrine and metabolic
consider three key elements. First, it must be clearly
shown that exercise-associated amenorrhoea is in-
1026 Cumming & Cumming
characteristics of oligo-amenorrhoeic runners have be involved directly in the development of osteo-

been well characterised and a consensus has formed porosis in amenorrhoeic athletes.[15,16] Low body-
that exercise-associated reproductive dysfunctionis weight, dieting, weight loss and reduced body fat
hypoestrogenic in nature and probably caused bya are associated with primary and secondary amenor-
negative energy balance.[3,4] The ‘messenger’ link- rhoea. Some but not all studies have supported an
ing the nutritional distress and the reproductive sys- association of low body fat with amenorrhoea in
tem remains to be clarified. A further evolution has women who exercise.[17] amenorrhoeic athletes were
been the recognition that athletic amenorrhoea is lighter and leaner and had lost more bodyweight
not a single entity but may encompass individuals after the onset of running than their normally men-
with anorexia nervosa, those with the female-athlete
struating counterparts in some studies, but several
triad consisting of eating disorder, amenorrhoea and
large-scale studies have failed to find an associa-
osteoporosis, and women with exercise-associated
tion between lower body fat and amenorrhoea. [17]
menstrual irregularity. The three groups are clearly
related, overlapping but distinguishable. The variability of findings suggests that method-
‘Athletic amenorrhoea’ has generally been con- ological considerations may influence the conclu-
sidered as hypothalamic but abnormalities in sev- sions. There are method-specific differences in in-
eral systems are now recognised. There are distur- direct body fat estimates, and differing conclusions
bances of varying severity in the pulsatile release of can be drawn from the same population depending
gonadotropin-releasing hormone with abnormali- on the means of calculation.[18] Decreased subcu-
ties of pituitary release of luteinising hormone and taneous fat and internal fat depots were observed
follicle-stimulating hormone, and abnormal ovarian using magnetic resonance imaging, arguably the
function.[5,6] Investigators have variably reported cir- most accurate means of measuring fat and its com-
culating gonadotropin and estradiol levels as low or at ponent parts.[19,20]
the low end of normal.[5,7-9] Specifically, the mean Cross-sectional studies of diet have provided
estradiol levels are frequently reported as lower in conflicting evidence of macronutrient deficiencies
amenorrhoeic than in eumenorrheic runners but mean in amenorrhoeic athletes, although the most con-
values in the amenorrhoeic runners are usually re- sistent finding has been that amenorrhoeic runners
ported as being in the normal early follicular range have a caloric deficit compared with their normally
(greater than 70 to 100 pmol/ml). Accompanying the menstruating peers.[6] Dietary intake even in nor-
reproductive changes are activation of the cortico- mally menstruating runners does not seem to match
trophin releasing-hormone (CRH)-corticotrophin
the increase in energy output, which their activity
hormone (ACTH)-cortisol axis,[10-12] suppression of
requires.[6] As the requirements for the body to re-
the thyrotropin-releasing hormone (TRH)-thyroid-
main efficient become more stringent, reproductive
stimulating hormone (TSH)-thyroid axis[6] and meta-
function may be initially compromised and later
bolic abnormalities including hypoinsulinaemia,
lower circulating glucose levels, elevated insulin- sacrificed to minimise energy loss, together with
like growth factor-binding protein-1 (IGFBP-1), re- steps to reduce glucose utilisation and lower me-
duced IGF-1/IGFBP-1 ratio, elevated growth hormone tabolism.[21]
and growth hormone binding protein (GHBP). [13] The pathophysiological processes leading to
Some have interpreted the metabolic changes as a or accompanying amenorrhoea are complex. It is
physiological adaptation to maintain adequate blood probably naive to blame any secondary effect solely
glucose levels in a state of energy deficiency.[14] on the lack of estrogen. Nutritional inadequacy, low
Nutritional inadequacy and low body fat have body mass and hypercortisolaemia may all contrib-
been suggested as key mechanisms in the genesis of ute to the development of a problem such as osteo-
exercise-associated amenorrhoea and both could porosis.[22-27]
 Adis International Limited. All rights reserved. Sports Med 2001; 31 (15)
Estrogen Therapy for Amenorrhoeic Athletes 1027
2. The Possible Effects of 3. Evidence of Benefit of

stress management in Hormone Replacement in
Women with Exercise- Women with Exercise-Associated
Associated Reproductive Reproductive Dysfunction
Dysfunction
Most reviewers have suggested that the primary
goal in managing and preventing the problems of
Exercise-associated amenorrhoea has been con-
exercise-associated reproductive dysfunction should
sidered an analogue of menopause with the periph-
be to restore the physiological norms to aid in re-
eral effects of estrogen deficiency in amenorrhoeic storing the benefits of normal reproductive func-
athletes being regarded as similar to those of women tion.[49-51] In general, the advice has been to in-
with premature ovarian failure.[17] Other than tran- crease food intake and reduce workload. Although
sient impairment of fertility, loss of bone has become seemingly logical and widely supported, there is
the major concern of athletic amenorrhoea. There is surprisingly little direct evidence that ‘refeeding’
also concern over a possible increased risk of car- and reduced workloads are helpful for restoration of
diovascular disease occurring because of changes menses. Dueck and colleagues[52] were able to effect
in lipid profiles associated with estrogen deficiency. some changes in the reproductive system but their
There is also a tendency for amenorrhoeic athletes programme was only over 15-week period. An
to have slightly less favourable lipid profiles, [28-30] amenorrhoeic athlete experienced a transition from
and this has been taken to mean an increased risk of negative to positive energy balance, increasedbody
fat from 8.2 to 14.4%, increased luteinising
heart disease. It is not clear whether the reported
hormone and decreased fasting cortisol. However
changes do increase the prevalence of heart disease
these were single sample results in a single individ-
in amenorrhoeic runners in later years, nor is there ual. When menses are successfully restored, there is
evidence that estrogen has a cardioprotective ef- a gain in bone density, which perhaps, not surpris-
fect. ingly, is not to normal values, at least over the short
There is substantial evidence that amenorrhoeic term.[53,54]
female runners have lowered bone density when Extensive evidence of varying quality has shown
this is measured at a variety of sites and there ap- that estrogen-replacement therapy will increase bone
pears to be an increased risk of exercise-related mineral density and reduce fracture rates in post-
fractures.[31-37] Estrogen status and heredity are ma- menopausal women.[55] A series of studies in youn-
jor determinants of bone mass, and together with ger women with a range of reproductive abnormal-
diet, probably explain most of the variance in bone ities including hypothalamic amenorrhoea and
mineral density seen in amenorrhoeic athletes.[38,39] ovarian failure has suggested that bone density will
However, amenorrhoea in gymnasts appears less increase but not usually to levels found in normally
likely to cause bone loss than in runners.[40] There menstruating healthy young women (table I ).[56-62]
is conflicting evidence over whether luteal phase Metka and colleagues[56] observed an increase in
bone mineral density in 28 young women with
abnormalities (implying a relative progesterone def-
premature ovarian failure using cyclic conjugated
icit) can cause problems with loss of bone.[41-44]
estrogens and medroxyprogesterone with no change
Thyroid changes are more prominent in amenor- in 13 controls who were not treated. The study was
rhoeic runners with bone loss. [31] Dietary deficien- prospective and controlled, but not randomised, and
cies particularly of calories and protein are also the observed increase in the treated group did not
associated with greater bone loss. [39,45-48] The com- reach normal values. Nine patients with Turner’s syn-
plex nature of these changes raises the significant drome using the same regimen also had an increase
question as to whether hormone replacement alone in bone mineral density, but not to normal val-
will reverse the development of osteoporosis.
Table I. Studies that have examined the effect of hormone replacement on bone density in young women
Author Population(s) Medication Outcome
Metka et al.[56] 28 POF patients Cyclic CEE/MPA Increased bone density
13 POF control No treatment No change in bone density
Mora et al.[57] 9 patients with Turner’s syndrome Cyclic CEE/MPA Increased bone density but not to normal levels
Kreipe et al.[58] 2 participants with AN OCs Cross-sectional. No difference between groups
2 controls with AN No treatment
Haenggi et al.[59] Mixed amenorrhoeic population OCs Increased bone density but not to normal levels
Klibanski et al.[60] 22 patients with AN CEE/MPA Randomised controlled trial. No difference
26 patients with AN No treatment between groups
Seeman et al.[61] 16 patients with AN OCs Cross-sectional. OCs associated with higher
48 patients with AN No treatment density
Hergenroeder et al.[62] 5 patients with HA OCs Randomised controlled trial. OCs increased
5 patients with HA MPA vertebral but not femoral neck density
5 patients with HA Untreated
Cumming[63] 8 Amenor runners Self selected HRT Not randomised. HRT increased vertebral and
5 Amenor runners No treatment femoral neck density over 24-30mo
DeCree et al.[64] 9 Amenor Runners EE/CPA Increased vertebral bone density over 7mo
Gibson et al.[65] 10 Irreg Runners HRT/calcium Randomised controlled trial, but runners were
14 Irreg Runners Calcium only not amenorrhoeic. Some controls became
10 Irreg Runners No treatment eumenorrheic
Prior et al.[66] Mixed menstrual disorder group Randomised controlled trial. Both MPA groups
n = 16 MPA/calcium gained a small amount of vertebral bone;
n = 16 MPA only placebo only lost bone and calcium group was
unchanged
n = 15 Calcium only
n = 14 Placebo only
Amenor = amenorrhoeic; AN = anorexia nervosa; CEE = conjugated equine estrogens; EE/CPA = oral contraceptive Diane 35® containing
35ug of ethinyl estradiol and 2mg of cyproterone acetate; HA = hypothalamic amenorrhoea; HRT = hormone replacement therapy; Irreg =
irregularly menstruating; MPA = medroxyprogesterone acetate; n = number of participants; OCs = oral contraceptives; POF = premature
ovarian failure.
ised controlled study, 48 women with anorexia ner-

ues.[57] The study was uncontrolled. There were no
vosa were treated with cyclic conjugated estrogen
differences, in terms of bone mineral density, be-
tween two patients with anorexia nervosa taking and medroxyprogesterone (26 controls).[60] There
low dose oral contraceptive pills, and two untreated was no difference between the groups, and body-
women.[58] The study was not controlled and is ar-
guably not of sufficient size to provide any evi-
dence other than anecdotal.
In a fairly large study of a mixture of women
with hypothalamic amenorrhoea and premature ovar-
ian failure, a subset of 15 women were treated with
low-dose oral contraceptives. In these women bone
mineral density increased, but not to normal val-
ues.[59] There were no controls. In the only random-
Estrogen
weightTherapy
was a for Amenorrhoeic
significant Athletes
predictor of response. 1029
Ina cross sectional study of 16 young women
withanorexia using low-dose oral contraceptives,
com-pared with 49 women who were not treated,
expo-sure to contraceptive use was associated with a
higherbone mineral density.[61] In perhaps the most
directlycomparable group, 15 women with
hypothalamicamenorrhoea were randomised to
oral contracep-tives (n = 5), no therapy (n = 5),
or medroxypro-gesterone.[62] Women taking oral
contraceptives hadsignificantly increased bone
mineral density in thelumbar spine but not in the
femoral neck while there was no change in the
other groups. The small groupsize may partially
explain the substantial but statis-tically non
significant difference at the femoral neck.There is
also a lack of randomised controlled studies
evaluating estrogen use in young women
with exercise-associated reproductive dysfunction end-point and bone mineral density as an interme-
without eating disorders. Citing difficulties in or- diate end-point. Such a study would be expensive
ganising a controlled study, Cumming[63] observed and virtually by definition would need to be multi-
that estrogen increased vertebral and femoral neck centred because of the difficulties in recruitment. In
bone density by 8.0 and 4.1%, respectively in fe- the absence of such a study, the recommendationto
male runners (n = 8). Bone density at correspond- use estrogen must be accompanied by a caution that
ing sites in runners who were not treated (n= 5) data are sparse and incomplete.
decreased by 2.5%.[62] However, these increases in
bone density did not reach normal values over the 4. Conclusion
24- to 30-month study period. Similar increases in
It seems quite logical that women who have ath-
vertebral bone density (9.5%) were achieved over
letic amenorrhoea should have therapy aimed at treat-
7 months in an uncontrolled study of 7 athletes
ing the underlying cause of amenorrhoea, if possi-
using an oral contraceptive preparation of ethinyl
ble, or reconstitution of an estrogen-progesterone
estradiol and cyproterone acetate.[64] In a random-
biphasic monthly cycle if not. The lack of evidence
ised study of 34 ‘elite’ long- and middle-distance
proving that this is worthwhile does not change that
runners, minimal benefit was seen with estrogen recommendation which is based on our under-
therapy. There was a less than 2% difference be- standing of the consequences of prolonged hormone
tween treated and untreated women. [65] However, deficiency in young women. Hormonal replacement
the women in this study were oligomenorrheic rather in cases of a prolonged hypoestrogenic state with
than amenorrhoeic. Some controls resumed normal evidence of increased bone loss is certainly recom-
menstruation, perhaps negating some evidence of mended, although the long-term consequences of
an effect of estrogen. prolonged hormonal deficiency and its treatment
Cyclic medroxyprogesterone acetate has also are incompletely defined at best. Any gain which
been recommended to increase bone density.[66] produces a statistically significant decrease in frac-
No randomised controlled studies of the effects ture risk can be considered ‘worthwhile’. We do not
of hormone replacement therapy have been pub- know whether it is possible to extrapolate the post-
lished. Clinical experience has shown how diffi- menopausal data to younger women. Is the bone
cult it is to persuade young athletic women to begin architecture different in younger women, is the risk
and to maintain hormone therapy. A randomised of fracture directly equivalent with the same bone
controlled long-term study is an essential starting mineral density in post-menopausal and younger
place to enable clinicians to provide individualised women, is the treatment effective in reducing
advice about the need for restoration of physiolog- fracture risk even if it increases bone density?
ical norms and restoration of euestrogenic blood Answering these questions will remove muchof the
levels in the treatment of osteoporosis. The end- debate related to hormonal replacement in young
point of a randomised study designed to treat osteo- women with exercise-associated reproductive
porosis would preferably be fracture rates in treated dysfunction. Stress Management To Secondary
and untreated groups. Surrogate end-points such as Amenorrhea P <0.005
biochemical changes and measures of bone min-
eral density are used in the large-scale studies of the Acknowledgements
effect of various therapies on post-menopausal The authors have no conflicts of interest.
women, but the ultimate measure would have to be
fracture risk. The ideal study of the benefits of es- References
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Available online at www.sciencedirect.com Current Opinion in
ScienceDirect
Stress Management With Girls Secondary

Amenorrhea
Blazej Meczekalski1, Olga Niwczyk1, Gregory Bala2 and
Anna Szeliga1
Abstract Introduction
Functional hypothalamic amenorrhea (FHA) is the most Functional hypothalamic amenorrhea (FHA) is a chronic
common cause of secondary amenorrhea in women of repro- endocrine disorder caused by a disturbance in the
ductive age. FHA is predominantly caused by stress, pulsatile secretion of hormones in the hypothalamus,
decreased caloric intake, excessive exercise, or a combination which in turn results in suppression of the hypothal-
thereof. These physical, psychological, and metabolic amicepituitaryeovarian axis. Inhibition of pulsatile
stressors cause aberration in the pulsatile release of gonadotropin-releasing hormone (GnRH) secretion in
gonadotropin-releasing hormone (GnRH) and subsequently the hypothalamus decreases follicle-stimulating hor-
impair function of the hypothalamic–pituitary–ovarian (HPO) mone (FSH) and luteinizing hormone (LH) secretion
axis. Various neurotransmitters acting in the central nervous from the pituitary gland. This sequence leads to the
system are involved in control of the HPO axis and of these, suppression of hormonal and reproductive functions of
kisspeptin is one of the most important. Corticotropin-releasing the ovary [1,2].
hormone (CRH), also inhibits the pulsatile secretion of GnRH
and also acts as an intermediary between stress factors and Secondary amenorrhea, which is characterized as amen-
the reproductive system. One of the main ongoing concerns in orrhea occurring in a previously menstruating woman, af-
patients with FHA is chronic hypoestrogenism, a condition, fects approximately 3%e5% of the mature female
which is associated with sexual dysfunction and infertility. It population. FHA is responsible for 25%e35% of secondary
may also lead to osteoporosis, and predispose to neurode- amenorrhea, making it the most common cause of sec-
generative and cardiovascular diseases.28 adolescent with ondary amenorrhea in our population [3]. FHA will
secondary amenorrhea. Treatment of stress management to negatively affect the health of women of childbearing age
secondary amenorrhea for adolescent with significacy p in a variety of ways. Chronic hypoestrogenism associated
=0.001 with this disease has a negative effect on the skeletal
system, cardiovascular system, nervous system, sexual
Addresses
1 function, and mental health. Beyond hypoestrogenism,
Department of Gynecological Endocrinology, Poznan University of
Medical Sciences, Poznan, Poland multiple other metabolic and neuroendocrine alterations
2
Appletree Medical Group, Ottawa, ON K1R 5C1, Canada presented in FHA affect bone homeostasis. For instance,
recent studies have shown direct, beneficial roles of
Corresponding author: Meczekalski, Blazej (blazejmeczekalski@ kisspeptin in bone physiology, therefore decreased
yahoo.com)
kisspeptin level can also impair bone health [4]. Further-
more, connection between decreased leptin and IGF-1,
Current Opinion in Pharmacology 2022, 67:102288 elevated ghrelin and cortisol level as endocrine media-
This review comes from a themed issue on Endocrine and metabolic
tors of bone loss in FHA is an object of ongoing research
diseases (2023) [5]. Moreover, disturbance in the secretion of gonado-
Edited by Stephanie Constantin and Ivana Bjelobaba
tropins results in significant impairment of reproductive
function due to concomitant anovulation [1,2].
For complete overview about the section, refer Endocrine and
metabolic diseases (2023)
Three main factors contribute to the development of
Available online 11 September 2022
FHA, namely: stress, excessive exercise, and decreased
https://doi.org/10.1016/j.coph.2022.102288 food intake. An overall decreased energetic balance
1471-4892/© 2022 The Author(s). Published by Elsevier Ltd. This is an causes dysregulation of hypothalamic nuclei, which in
open access article under the CC BY-NC-ND license (http:// turn disrupt the action of kisspeptin/neurokinin
creativecommons.org/licenses/by-nc-nd/4.0/).
B/dynorphin (KNDy) neurons. Decreased secretion of
kisspeptin, in turn, contributes to abnormal pulsatile
secretion of GnRH, eventually causing FHA. Variability in
susceptibility to inhibition of
hypothalamicepituitaryeovarian (HPO) axis by
www.sciencedirect.com Current Opinion in Psycofarm 2022, 67:102288
2 Endocrine and metabolic diseases (2023)
external factors in this population support the hy- expression in the hypothalamus. Long-term energy
pothesis of the genetic predisposition to FHA devel- constraint in sheep has shown to reduce KISS1 mRNA
opment. Mutations in genes regulating GnRH expression in both the arcuate nucleus (ARC) and the
ontogeny and action including KAL1, FGFR1, PROKR2, preoptic area (POA) compared to sheep with a neutral
GNRHR can contribute to individual sensitivity to energy balance [17e19].
stressor [6,7].
Kisspeptin is secreted in hypothalamic nuclei by kiss-
This article primarily focuses on correlation between peptin/neurokinin B/dynorphin neurons. KNDy neurons
stress and hormonal disturbances in patients with FHA as in the hypothalamus are named for their co-expression
nowadays there is a growing population living under of kisspeptin, neurokinin B (NKB) and dynorphin (DYN)
conditions of chronic stress. Notwithstanding excessive [20]. It is known that NKB and DYN play a crucial role
exercise and undernutrition are also pivotal factors that in regulating the secretion of kisspeptin, and
influence kisspeptin expression and function. subsequently in GnRH secretion [21]. Specifically, NKB
is responsible for stimulation of KNDy to secrete kiss-
Treatment of stress management to peptin and in turn the downstream induction of GnRH
secondary amenorrhea for adolescent release. In contrast, DYN neurons exert an inhibitory
The gene KISS1 (KISS1) encoding the KISS1 protein effect, suppressing kisspeptin secretion, and in turn
was first discovered in 1996 by a team from Hershey, suppressing GnRH pulsatility [22].
Pennsylvania and was identified as a metastasis sup-
pressor in human malignant melanoma [8]. The name of KNDy neurons, apart from NKB and Dyn receptors, also
the gene, KISS1, comes from the famous Hershey’s express estradiol a receptors (ERa) and progesterone
Kisses chocolate, which was also produced in the town of receptors (PR). This allows the KNDy neuron to act as a
Hershey. The KISS1 gene is located on chromosome central regulator of systemic feedback for the repro-
1q32 and has four exons, the first two untranslated. The ductive system [12]. Because of those receptors, ovarian
gene encodes a precursor protein composed of 145 steroids can modulate the expression of KISS1 at the
amino acids, which is then cut in the process of post- hypothalamic level. In turn, kisspeptin is responsible for
translational processing, for example, into 54-amino the pulsatile release of GnRH [20]. Kisspeptin exerts the
acid fragments. This first intermediary protein is called essential stimulatory action needed in order to evoke the
metastin. Further processing leads to the formation of preovulatory LH peak [23], which is an essential
14, 13, and 10 amino acid peptides [9]. Metastin and component in ovulation. The action of kisspeptin with
these shorter proteins collectively share an N-terminal regard to reproduction descends all the way to the level
domain truncated at variable lengths but preserving a of the ovary. Kisspeptin exerts its influence on processes
C-terminal sequence of Arg-Phe-NH2. This group of such as steroidogenesis, follicular maturation,
proteins is collectively referred to as kisspeptins [10]. ovulation, and ovarian senescence [23]. Furtherstudies,
however, are required to fully elucidate all aspects of
In 2001, KISS1 was identified as a ligand for the G the mechanisms by which kisspeptin is involved in the
protein-coupled receptor 54 (GPR54) protein which physiology of reproduction.
was first described in the rat brain and then in humans,
where it is referred to as KISS1R [11]. Upon binding to Changes at the level of KNDy neurons are responsible for
KISS1, KISS1R activates phospholipase C and stimu- the changes observed in menopause. Hypertrophy of
lates the synthesis of intracellular secondary messen- KNDy neurons in the infundibular nucleus has been
gers, inositol triphosphate and diacylglycerol [12]. observed in subjects following menopause. Up to a 30%
increase in the size of these KNDy neurons has been
KISS1-secreting neurons are found mainly in the observed. These changes are associated with a subse-
preoptic area and in the arcuate nucleus of the hypo- quent increase in the secretion of neurokinin B and
thalamus [13,14]. By stimulating the secretion of kisspeptin in the area [24].
GnRH, KISS1 stimulates the secretion of FSH and LH
from the pituitary gland. Mutations that inactivate the A similar change was observed in oophorectomized
KISS1 or KISS1R genes have been found to cause monkeys, which suggest that ovarian impairment and
hypogonadotropic hypogonadism, while activating mu- the loss of negative feedback by estrogen plays a key role
tations cause premature puberty [15,16]. in this phenomenon [24].
KISS1 is a single element of the neurohormonal puzzle LH pulses are synchronized with hot flashes in pre- and
responsible for the interaction between the reproductive post-menopausal women. While an increase in serum LH
system and the energy status of the body. Animalstudies concentration in women after menopause is a marker
have shown that caloric restriction due to decreased food of KNDy neuron hyperactivity, it also indicates that
intake leads to a decrease in KISS1 elevated kisspeptin or neurokinin B levels may play
Current Opinion in Pharmacology 2022, 67:102288 www.sciencedirect.com

Stress, kisspeptin, and FHA Meczekalski et al. 3
a crucial role in the development of vasomotor symptom circulation. Cortisol, the primary stress hormone, causes
(VMS) pathogenesis [25]. Additionally, decreases in a pleiotropic response in different tissues, including
KNDy neuronal activity was associated with a decrease in promoting catecholamine release, mobilization of
skin vasodilation. All these observations support the energy stores, maintaining energy supply, and main-
hypothesis that KNDy neurons participate in the gen- taining negative influence on the immune system.
eration of hot flashes [26]. Without exposure to stress factors, CRH and conse-
quently ACTH and cortisol are secreted in a circadian,
Stress: A biological and hormonal pulsating manner with peak output in the early morning
background hours. This harmonic, pulsatile pattern of hormone
Homeostasis was coined as a term in the early 1900s by secretion is disrupted when challenged by a stressor.
Walter B. Cannon, the pioneer of stress response theory. During an episode of stress, CRH secretion significantly
He characterized this new term as a state of steady in- increases to activate the whole HPA axis. Additionally,
ternal conditions. His work laid the foundation for future other stress mediators are also released to synchronously
study in which extended his theory to include conditions stimulate the HPA axis. Glucocorticoids act in a negative
which he described as threats to homeo- feedback loop to control the basal activity of the HPA axis
stasisdstressors. Since this foundational work, under- and eventually to terminate the stress response,
standing the human body’s reaction to stress factors has preventing the negative catabolic effects of anelongated
been studied extensively. Exposure to stress initiates a exposure to glucocorticoids.
complex biological response which draws interaction
between nervous, endocrine, and immune systems [27]. The aim of these actions is to support essential organs so
Two major components of the stress-response system as to ensure survival.
are the hypothalamicepituitaryeadrenal (HPA) axis and
sympathetic nervous system, which function coop- Impact of stress on reproductive function Since
eratively in orchestrating the stress response [28]. the origin of the human species, stress has been an
integral part of everyday life, affecting many different
The sympathetic nervous system forms part of the systems of the human body, including the endocrine,
autonomic nervous system and is responsible for imme- nervous, and immune systems. Moreover, as
diate response to stress factors, a process, which is known reproductive function is not essential for survival and
as acute stress response. Activation of the sympathetic requires a large amount of energy, it is understandably
nervous system leads to the release of epinephrine and suppressed by stress factors. Early researchers had
norepinephrine from adrenal glands into the bloodstream found that different kinds of stress can cause imbalance
and increased secretion of norepinephrine from sympa- to reproductive homeostasis and consequently lead to
thetic neurons in the central nervous system. Catechol- infertility. The exact mechanism, however, by whichthis
amines interact with adrenergic receptors distributed aberrancy develops was unknown for many years. It was
throughout the body which causes a cascading fight-or- shown that stress-related factors such as
flight response reaction in end-organs. This fighteore corticotropin-releasing hormone and cortisol are in-
flight reaction manifests as bronchial dilatation, elevated hibitors of the hypothalamicepituitaryegonadal (HPG)
breathing rate, increased blood pressure and cardiac axis but the link to explain the underlying complex
output, and liberation of metabolic energy sources for use mechanism remained unknown. The discovery of kiss-
in muscular action. Moreover, behavioral changes will peptin and gonadotropin-inhibitory hormone (GnIH)
also occur in order to improve vigilance and prepare to was a monumental breakthrough in the early 21st
address potential threats. In contrast to that, the para- century. Further discovery of their role in controllingthe
sympathetic nervous system enables body recovery after HPG axis provided the missing element in under-
the stressor disappears. standing the exact mechanism of stress-induced
reproductive suppression and has since begun a new
The HPA axis is influenced by both central and pe- era in research on the subject.
ripheral branches of the stress system; therefore, its
precise functioning is crucial for efficacious reactions to Kisspeptin is a hypothalamic neuropeptide that appears
stress factors. The integrated HPA axis is responsible to be a key factor driving the HPG axis by direct stimu-
primarily for delayed stress response. The first step lation of GnRH neurons. In 2008, Iwasa et. all pioneered
in this response is the release of corticoliberin or corti- research which found that immune stress induced by
cotropin-releasing hormone (CRH) from the para- administration of lipopolysaccharides (LPS) decreased
ventricular nucleus of the hypothalamus to the the level of Kiss1 mRNA and subsequently LH concen-
hypophyseal portal system. CRH stimulates the anterior tration in the hypothalamus of female rats [29]. Further
lobe of the pituitary gland to release adrenocorticotropic studies reproduced the findings and further supported
hormone (ACTH), which will sequentially stimulate this theory by showing that a number of other stressors
secretion of glucocorticoids from the adrenal cortex into also reduce the expression of Kiss1 mRNA [30]. These
www.sciencedirect.com Current Opinion in Pharmacology 2022, 67:102288

findings established a link between the HPA axis and the expressed on kisspeptin neurons located in the arcuate
reproductive system. Studies have since shown that both nucleus of the hypothalamus [36]. This finding suggests
peripheral administration of corticosterone or central that kisspeptin neurons may play a bridging role as
administration of corticotropin lead to suppression of intermediary between the HPA axis (stress response
kisspeptin neurons [31]. system) and the HPG axis (reproductive regulato-ry
system).
RFamide-related peptide 3 (RFRP-3) is postulated to be
a GnIH that acts to suppress synthesis and release of Kotani et al. [37] have reported that serum kisspeptin
GnRH and gonadotropins. Recently it has been shown levels in patients with lactational amenorrhea were
that exposure to both acute and chronic stress elevates found to be comparable to that in healthy women.
the expression of GnIH mRNA in the hypothalamus. This Bacaopoulou [38] observed a negative correlation be-
leads to dysregulation of the HPG axis and suppression tween peripheral kisspeptin levels and body mass index
of reproduction. Interestingly, glucocorticoste- roid (BMI) in anorectic patients. In this study, the authors
receptors have been found on the surface of GnIH found that amenorrheic adolescents tended to have a
neurons. During experimental trials it was found that, lower serum kisspeptin concentration, although this
when administered, corticosterone increases GnIH finding was not statistically significant. In cases of
mRNA expression and reduces GnRH activity [32]. This anorexia nervosa, serum kisspeptin levels have been
provides evidence that not only kisspeptin but also GnIH shown to correlate positively with body weight, body
contributes to mediation of the inhibitory effects of mass index, and fat mass.
corticosteroids on the human reproductive axis during
stressful events. In an interesting observation, Hoffman et al. [39] were
able to establish a negative correlation between serum
Undoubtedly, further studies are required to fully un- kisspeptin concentrations and physical activity. In their
derstand the complex neural interactions involved in the commentary, the authors suggested that this negative
modulation of reproductive function by stress. relationship may function as a compensatory mechanism
to prevent physical activity and body mass loss in
anorectic patients.
The role of kisspeptin in stress-related
amenorrhea KISS1 secreting neurons are believed to be in contact
As a key regulator of reproductive physiology, kiss- with the proopiomelanocortin as well as cocaine- and
peptin has a positive influence on the pulsatile secre- amphetamine-regulated transcript (POMC/CART)
tion of GnRH. It is because of this that understanding neurons and agouti-related peptide/neuropeptide Y
its role and function is invaluable when discussing (AgRP/NPY). This may be a potential route of
reproductive pathophysiology such as FHA [33]. The communication between systems in the hypothalamus
pulsatility and serum levels of kisspeptin as they relate to as both leptin and neuropeptide Y have been shown to
LH secretion was studied by Podfigurna et al. [34] in stimulate the expression of the KISS1 gene. It seems
more than 70 women with functional amenorrhea. It was unlikely, however, that the stimulating effect of leptin on
found that both hormones are co-secreted and serum KISS1-secreting neurons would occur through theaction
levels were temporally coupled. Additionally, a negative of NPY, since leptin directly inhibits the formation of
correlation between the serum concentration and pulse NPY [40].
frequency of kisspeptin and serum levels of cortisol were
observed. This correlation, among other hormonal Other notable hormonal messengers acting between the
parameters, supports the hypothesis that stress-induced metabolic and kisspeptin systems are ghrelin, insulin- like
compensatory changes are the main direct and indirect growth factor-1 (IGF-1), and the hormones of the HPA
factors driving reproductive inhibition in patients with axis [38]. Ghrelin, the secretion of which increases in
FHA. states of energy deficiency, suppresses the hypotha-
lamic expression of KISS1 mRNA [40]. In contrast, IGF-
Research published in 2020 revealed that patients with 1 has been shown to increase KISS1 mRNA expression
FHA were characterized by lower serum kisspeptin levels in the anteroventral periventricular nucleus (AVPV) in
at baseline as well as having higher serum CRH levels female rats [41]. IGF-1 receptor blockade, however, does
when compared to healthy controls [35]. not change the KISS1 concentration in the hypothalamic
nuclei [42].
Stress-related hypothalamic amenorrhea refers to the
complex interplay between the hypothal-
amicepituitaryeadrenal axis and the HPG axis. Potential use of kisspeptin in functional
Augmented CRH levels (during stress) can directly hypothalamic amenorrhea
inhibit the pulsatile secretion of GnRH. New data shows The main goal in the treatment of hypothalamic
that both CRH and glucocorticoid receptors are amenorrhea is the restoration of a normal menstrual

cycle with ovulatory function [43]. Ovulatory function Jayasena et al. conducted a second trial exploring the use
can be restored with ovulation induction, but the aims of of kisspeptin-54 in patients with hypothalamic
restoring the ovarian cycle are multipledfor metabolic amenorrhea specifically [48]. FHA patients were
function, bone protection as well as fertility. This administered subcutaneous kisspeptin-54 or saline
endpoint should be achieved by the elimination of those twice-weekly. Women in the treatment arm presented
causative factors (such as stress, weight loss, excessive significantly higher serum levels of FSH and LH after 2
exercise), which were initially responsible for the months of bi-weekly dosing than did women in the
development of an amenorrheic state. This approach, placebo arm. No significant side effects to treatment
however, is often very difficult to introduce in clinical were observed in participants under this administration
practice, as it requires enthusiastic patient participation schedule. Intravenous administration of kisspeptin
and their willingness to undertake a real lifestyle change. caused augmentation of LH pulsatility (3-fold increase
If the lifestyle interventions have not been successful, An in mean peak number of pulses) when compared to
Endocrine Society Clinical Practice Guideline placebo in all FHA patients [49]. Additionally, the mean
recommends that treatment with pulsatile serum levels of both FSH and estradiol were also
gonadotropin-releasing hormone should be considered significantly elevated during high-dose infusion of this
as first line treatment [44]. Pulsatile GnRH pump rep- peptide when compared with placebo. For the first time
resents a safer, more physiologic alternative to ovulation it was reported that constant intravenous kisspeptin-54
induction using injectable gonadotropins. Unfortu- administration may temporarily increase both basal and
nately, there is no commercially available GnRH pump pulsatile LH release in patients with HA. The study
in most countries; therefore, gonadotropin use for protocol also established a dose range within which
ovulation induction remains only obtainable treatment kisspeptin-54 therapy is able to restore LH secretion
in many cases. (both basal and pulsatile).
Hormonal replacement therapy can be initiated. Such Another milestone in the field of kisspeptin research
therapy, based not on traditional combined contracep- was reached in 2020 when for the first time a kisspeptin
tion but rather on that mimicking natural estrogen and receptor agonist was used therapeutically in patients
progestin with limited anti-gonadotropic action can also with FHA [50]. Abbara et al. demonstrated that serum
be introduced. Should a patient with FHA who is treated LH and FSH levels increased sooner after administra-
with such estrogeneprogestin therapy decidethey wish tion of KissR agonist in women with FHA than it did in
to become pregnant, initiating therapy with a GnRH healthy women. This new KISSR agonist MVT-602
pulsatile pump can be considered [45]. demonstrated many favorable properties, including
better stability, potency, and water solubility compared
In recent years, novel pharmacological approaches have to native Kisspeptin.
developed to treat patients with FHA. New and devel-
oping knowledge on the role of kisspeptin in the central Eye to the future
regulation of reproductive functions has allowed for the Kisspeptin as the main positive regulator of GnRH
development of kisspeptin as a possible therapeu-tic secretion plays an important role in the regulation of
tool. reproductive function. Continued research can further
elucidate new details in this pathway and expand our
Feasibility studies into the use of kisspeptin have been understanding of stress as a biological factor impacting
conducted in animal models. When administered, kiss- the HPG axis.
peptin provoked LH and FSH secretion in all mamma-
lian animals [46]. The first human trial of kisspeptin As a signaling bridge between the HPA and HPG axis,
administration in patients with functional hypothalamic kisspeptin pathophysiology requires further studies.
amenorrhea was reported by Jayasena et al., in 2009 Additionally, the most important yet challenging
[47]. An initial randomized controlled trial was con- endpoint is to establish the practicality of using kiss-
ducted to compare acute and chronic kisspeptin peptin in the treatment of patients with FHA. It is likely
administration and its effect on serum LH and FSH. After that novel and newly developed kisspeptin receptor
acute subcutaneous kisspeptin administration, a 10-fold agonists are on the horizon. It is thus imperative that
increase in LH secretion was observed while FSH efforts should be focused on carefully establishing the
secretion increased 2.5-fold. When administered safety and efficacy parameters of these new pharmaco-
chronically over 2. 28 adolescent with secondary logical tools.
amenorrhea. Treatment of stress management to
secondary amenorrhea for adolescent with significacy p Funding
=0.001 This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.

Credit author statement 12. Skorupskaite K, George JT, Anderson RA: The kisspeptin-
GnRH pathway in human reproductive health and disease.
B.M.: Conceptualization, Investigation, Resources, Hum Reprod Update 2014, 20:485–500, https://doi.org/10.1093/
Writing e original draft, Supervision; A.SZ.: Investiga- humupd/dmu009.
tion, Writing e original draft O.N.: Investigation, Re- 13. Hrabovszky E: Neuroanatomy of the human hypothalamic
sources, Writing e original draft, Writing e review & kisspeptin system. Neuroendocrinology 2014, 99:33–48, https://
doi.org/10.1159/000356903.
editing; G.B.: Writing e review & editing. All authors
have read and agreed to the published version of the 14. Hrabovszky E, Ciofi P, Vida B, et al.: The kisspeptin system of
the human hypothalamus: sexual dimorphism and relation-
manuscript. ship with gonadotropin-releasing hormone and neurokinin B
neurons. Eur J Neurosci 2010, 31:1984–1998, https://doi.org/
10.1111/j.1460-9568.2010.07239.x.
Conflict of interest statement 15. Teles MG, Bianco SDC, Brito VN, et al.: A GPR54-activating
Nothing declared. mutation in a patient with central precocious puberty. N Engl
J Med 2008, 358:709–715, https://doi.org/10.1056/
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REVIEW DOI: 10.4274/jcrpe.galenos.2019.2019.S0178
J Clin Res Pediatr Endocrinol 2020;12(Suppl 1):18-27
Effect Stress Management Of Function Hypotalamus

Secondary Amenorrhea
Marie Eve Sophie Gibson1, Nathalie Fleming1, Caroline Zuijdwijk2, Tania Dumont1
1University of Ottawa, Children’s Hospital of Eastern Ontario, Division of Gynecology, Ottawa, Canada
2University of Ottawa, Children’s Hospital of Eastern Ontario, Division of Endocrinology and Metabolism, Ottawa, Canada
Abstract
Functional hypothalamic amenorrhea (FHA) is a common cause of amenorrhea in adolescent girls. It is often seen in the setting of
stress, weight loss, or excessive exercise. FHA is a diagnosis of exclusion. Patients with primary or secondary amenorrhea sh ould be
evaluated for other causes of amenorrhea before a diagnosis of FHA can be made. The evaluat ion typically consists of a thorough history
and physical examination as well as endocrinological and radiological investigations. FHA, if prolonged, can have significant impacts on
metabolic, bone, cardiovascular, mental, and reproductive health. Management often involves a multidisciplinary approach, with a focus
on lifestyle modification. Depending on the severity, pharmacologic therapy may also be considered. The aim of this paper is to present
to correlation effect stress management of function hypotalamus secondary managemen with significance p < 0.005 about 45 adolesncent
Keywords: Adolescent, diagnosis, functional, secondary amenorrhea, stress management
Introduction known about the pathophysiology of FHA, as well as the

necessary steps in evaluating a patient for FHA, and the
Functional hypothalamic amenorrhea (FHA) is defined asthe important aspects of its management.
absence of menses, caused by a suppression of the
hypothalamic-pituitary-ovarian (HPO) axis, in which no
Pathophysiology
anatomic or organic cause is found (1). It is potentially
reversible, and is often seen in the setting of stress, weight FHA is caused by a suppression of the HPO axis. In normal
loss, or excessive exercise (1,2,3). FHA can present as either puberty, gonadotropin-releasing hormone (GnRH) is
primary or secondary amenorrhea. Primary amenorrhea released by the hypothalamus in a pulsatile fashion, and
is defined as the absence of menarche by age 15 in the stimulates both the synthesis and secretion of luteinizing
presence of mature breast development, or three years after hormone (LH) and follicle stimulating hormone (FSH) from
thelarche (4). Delayed puberty is defined as the absence of the anterior pituitary (7). In patients with FHA, studies have
thelarche by the age of 13 (4). Secondary amenorrhea is shown that GnRH secretion is suppressed, LH pulsatility
defined as the absence of menses for more than three cycles is impaired (8,9,10,11), and total LH and FSH levels are
in someone who was previously menstruating regularly, or reduced (11,12,13,14). FHA is therefore classified as a form
longer than six months in someone with irregular cycles of hypogonadotropic hypogonadism, which results in a
(5,6). FHA is the most common form of primary and hypoestrogenic state (8,12,13,14). In FHA, suppressionof
secondary amenorrhea in adolescent girls (7). With specific the HPO axis is caused by common triggers including
regard to secondary amenorrhea, FHA and polycysticovarian psychological stress, disordered eating, weight loss, and
syndrome (PCOS) are the most common causes,other than excessive exercise (1,2,3).
pregnancy (1). If prolonged, FHA has potential consequences Though amenorrhea is often associated with eating
for metabolic, bone, cardiovascular, mental, and disorders such as anorexia nervosa, FHA is often found to
reproductive health. This article will highlight what is be the underlying etiology for amenorrheic patients who
Address for Correspondence: Tania Dumont MD, University of Ottawa, Children’s Hospital of Eastern Ontario, Conflict of interest: None declared
Division of Gynecology, Ottawa, Canada Received: 05.11.2019
Phone: +1-613-737-7600 E-mail: tdumont@cheo.on.ca ORCID: orcid.org/0000-0003-4622-8900 Accepted: 14.11.2019
©Copyright 2020 by Turkish Pediatric Endocrinology and Diabetes Society
The Journal of Clinical Research in Pediatric Endocrinology published by Galenos Publishing House.
18
J Clin Res Pediatr Endocrinol Gibson MES et al.
2020;12(Suppl 1):18-27 Functional Hypothalamic Amenorrhea
maintain 90-110% of their ideal body weight (IBW) and who the prokineticin receptor 2 gene PROKR2, the GnRH receptor
do not meet diagnostic criteria for an eating disorder (15). gene GNRHR, and the Kallmann syndrome 1 sequence gene
IBW is calculated by the Devine formula [IBW (kg)=45.5 kg KAL1. Such mutations were not found in healthy controls
+ 2.3 kg for each inch over 5 feet] (16) or can be determined (32).
by standardized height and weight tables such as the
Regardless of the trigger for FHA, a common hypothesis
Metropolitan Life tables (17). Disordered eating is quite
is that an increase in corticotropin-releasing hormone (CRH),
common in adolescent girls. In a cross-sectional study of
in response to stress, suppresses GnRH pulsatility (10).
grade 10 girls, 4.1% of girls sampled met the criteria for
Patients with FHA have increased cortisol levels
secondary amenorrhea and 23% disclosed disordered eating.
(10,12,13,14,20,29,33), as well as blunted responses to the
Of the girls with amenorrhea, 40% reported fasting or
injection of human CRH (hCRH) (13,29,33). In addition, the
purging. Interestingly, body mass index (BMI) (BMI; kg/ m2)
neurotransmitter ƴ-aminobutyric acid has also been linked
was not significantly different between those who were
to suppression of GnRH (13). Thyroid hormone changes are
eumenorrheic or amenorrheic (18). Studies have shown that
also noted in FHA. Patients with FHA tend to have lower total
patients with FHA exhibit more cognitive restraint (19), drive
triiodothyronine (T3) and total thyroxine (T4) concentrations
for thinness (12,19,20,21), and purging behaviours (21,22)
compared to eumenorrheic controls. compared to eumenorrheic controls (11,34). However, their
concentrations of free T3 and T4 may remain intact due to
Excessive exercise has been linked to the development of lower affinity of thyroid binding globulin (34). Thyroid-
FHA (23,24). In one study, rates of secondary amenorrhea stimulating hormone (TSH) levels typically remain normal
were three times higher in athletes compared to controls, (11,14,34) and patients appear to be clinically euthyroid
with the highest rates seen in long distance runners (25). (34). Metabolic disturbances are also observed, with
Since the early 1990s, the Female Athlete Triad (FAT) has decreased leptin (8,12,14,19,35,36), decreased fasting
been used to describe athletes who also present with insulin (12,14,35), decreased insulin-like growth factor-1
disordered eating, osteoporosis, and amenorrhea (26). In (IGF-1) (8,12), increased fasting peptide YY (19), and
2017, the American College of Obstetricians and increased fasting ghrelin in patients with FHA (19,22). These
Gynecologists revised the definition of FAT to be more changes reflect the overall energy deficit in patients with
inclusive. The criteria are now: low energy availability with FHA.
or without disordered eating, menstrual dysfunction, and
low bone density (27). Though the menstrual dysfunction in
FAT is thought to be hypothalamic in nature, FAT differs from Diagnosis of FHA
FHA because athletes are not required to be amenorrheic to The diagnosis of FHA can be challenging in adolescents, as
meet criteria for FAT. Moreover, not all patients with FHA are this is commonly a time when the HPO axis is developing.
athletes or meet the criteria for FAT. However, primary amenorrhea should always be
Onset of amenorrhea can also be seen in the setting of stress investigated, as 98% of girls will achieve menarche bythe
(12,28,29,30). In a study of adolescent girls with FHA, age of 15 (37). Furthermore, 90% of menstrual cycles will
identified stressors included common life events such as range between 21-45 days, even in the first few post-
changing schools, newly engaging in sexual activity, and menarchal years (38), highlighting the importance of
breaking up with a boyfriend. Chronic illness of a family investigating secondary amenorrhea in this age group.As
member and the death of a friend were also observed.Lastly, FHA is a non-organic cause of amenorrhea, it is often
50% of the adolescents in this study described family conflict considered a diagnosis of exclusion. Table 1 summarizes the
(12). Patients with FHA have also been shown to copeless well vast differential diagnoses of amenorrhea, which should be
with stress, including their autonomic responses, compared taken into consideration.
to those with PCOS and eumenorrheic controls (31).
History: A pubertal history should include onset and timing of
Lastly, there may also be a genetic basis to the development breast and pubic hair development, as well as growth spurt. A
of FHA. One study identified six heterozygous gene detailed menstrual history should be obtained to characterize
mutations in patients with FHA that are shared among the type of amenorrhea and its onset. One should look for
patients who have congenital (idiopathic) hypogonadotropic possible triggers including stressful life events, disordered
hypogonadism, suggesting a possible vulnerability to the eating, weight loss (regardless of initial weight), or excessive
effects of stressors on the HPO axis. Mutations found exercise. Disordered eating can include avoidance of certain
involved the fibroblast growth factor receptor 1 gene FGFR, foods (typically foods high in fat, sugar, and calories),
restricting, and/or purging (self-induced vomiting, laxative
19
Gibson MES et al. J Clin Res Pediatr Endocrinol
Functional Hypothalamic Amenorrhea 2020;12(Suppl 1):18-27
Table 1. Stress Managemnet of Secondary Amenorrhea use, or compensatory exercising). A diet log can be helpful.
Constitutional delay If weight loss has been identified as a contributing factor, it
Hypothalamus is important to note the weight at which the patient became
Central nervous system lesion (hydrocephalus, tumor) amenorrheic and the tempo of the weight loss. Lastly, it is
Chronic medical illness important to inquire about how the weight loss was achieved,
Congenital hypogonadotropic hypogonadism (Kallman as well as how they feel about the weight loss, as this helps
syndrome) determine whether a formal eating disorder diagnosis should
FHA (stress, weight loss, disordered eating, exercise) be considered. The type of exercise should be noted, as well as
Pituitary the duration and intensity. Patients should be asked about their
Congenital hypogonadotropic hypogonadism past medical history, including chronic illness or malignancy.
Empty Sella syndrome A list of medications should be obtained, and previous or
Hyperprolactinemia current treatments with chemotherapy or radiation should
Iatrogenic (surgery, radiation) be noted. A sexual history, taken alone with the adolescent
Infarction (Sheehan syndrome) in complete privacy, should be obtained, including use of
Infiltrative disease contraceptives. On review of symptoms, patients should be
Medications (amphetamines, antidepressants, asked about possible associated symptoms in a head to toe
antihypertensives, antipsychotics, dopamine antagonists, approach. To reiterate, one should ask about possible triggers
contraceptives, opiates)
affecting the hypothalamus, such as stress, disordered
Neurofibromatosis
eating, weight loss, or excessive exercise. Headaches, visual
Trauma
disturbances, or galactorrhea could suggest the presence of a
Tumor or cyst
prolactinoma or another central nervous system disorder. A
Thyroid
history of anosmia could point to Kallman syndrome. Changes
Hyperthyroidism
in energy, temperature regulation, or bowel movement
Hypothyroidism
frequency could be related to an underlying thyroid disorder.
Adrenal
Patients should be asked about signs of hyperandrogenism,
Adrenal insufficiency
such as acne or hirsutism, as this could point to a diagnosis
Androgen-secreting tumor
of PCOS or late-onset congenital adrenal hyperplasia. More
CAH
significant virilization (clitoromegaly, severe hirsutism, voice
Cushing syndrome
changes) could point to an androgen secreting tumour of
Ovary
either adrenal or ovarian origin. Vasomotor symptoms such
Androgen-secreting tumor as hot flashes or night sweats could be indicative of primary
Gonadal agenesis or dysgenesis (ex. Turner syndrome, Swyer ovarian insufficiency (POI). Inquire about symptoms of
syndrome)
pregnancy, such as weight gain, nausea, fatigue, vomiting, or
Iatrogenic (surgery, radiation)
breast tenderness. Abdominal pain, either cyclic or chronic,
Medications (antiandrogens, contraceptives)
could indicate a possible Müllerian anomaly. Lastly, a
PCOS
thorough family history, including the menstrual history of
POI
the biological mother, should be obtained. ǫuestions about
Uterus
possible triggers and sexual history should be reserved for
Adhesions (Asherman syndrome)
the confidential portion of the interview. Commonly, the
Levonorgestrel IUS
“Home environment, Education and employment, Eating,
Müllerian anomaly
peer-related Activities, Drugs, Sexuality, Suicide/depression,
Pregnancy
and Safety from injury and violence-HEEADSSS” format is
Outflow tract
used (39).
Cervical agenesis
Cervical stenosis (acquired) Physical examination: The physical examination should
Imperforate hymen first begin with a general inspection of the patient’s well
Vaginal agenesis being. The patient’s height and weight should be measured
Vaginal septum (transverse) and plotted on growth curves that ideally have previously
CAH: congenital adrenal hyperplasia, PCOS: polycystic ovarian syndrome, been completed by the referring or primary care provider
POI: primary ovarian insufficiency, IUS: intrauterine system, FHA: functional in order to facilitate comparisons and trends. The BMI (kg/
hypothalamic amenorrhea, Ref. 1,3,6,41.
m2) should be calculated and plotted. Vital signs should
20
include blood pressure and heart rate. Hypertension and A progesterone withdrawal challenge can be given to aid
tachycardia can be seen in hyperthyroidism or Cushing in the diagnosis. Five to 10 mg of medroxyprogesterone
syndrome, whereas hypotension and bradycardia can be acetate are given for five to 10 days, after which the patient
seen in hypothyroidism, adrenal insufficiency, and severe should experience a withdrawal bleed (41). A positive test
eating disorders. Look for stigmata of Turner syndrome is indicated by vaginal bleeding within two to seven days of
(low hairline, webbed neck, wide carrying angle, shield completing the course of progestin (6). A negative test, or a
chest, and nevi, including facial nevi). Look for signs of lack of bleeding, may suggest an outflow tract abnormality
restrictive or purging behaviours, which include cachexia, or a hypoestrogenic state, as estrogen is responsible for
erosion of dental enamel, parotid gland swelling, vellus thickening the endometrial lining (43). Scant withdrawal
hair, Russell’s sign (calluses on the knuckles) and bleeding or spotting suggests marginal levels of endogenous
hypercarotenemia (yellowing of the skin). A visual field estrogen production (6). Unfortunately, experts caution
examination and fundoscopy is recommended, routine use of the progesterone withdrawal challenge,as
particularly if there are concerns regarding central it may be unreliable in determining the degree of
nervous system symptoms in the history. Palpate the estrogenization as this test is associated with false negative
thyroid gland for a goiter or nodules and examine for withdrawals (1,3,43,44).
other signs of thyroid disease (exophthalmos or proptosis, Radiological investigations: An ultrasound of the pelvis is
lid lag, hair or nail changes). Palpate the abdomen for helpful to identify the presence of a uterus and ovaries, and
masses. Look for signs of insulin resistance (acanthosis to rule out an adnexal mass. If a Müllerian anomaly is
nigricans), hyperandrogenism (acne or hirsutism), or suspected, magnetic resonance imaging (MRI) of the pelvis,
virilization (male pattern hair loss, change in muscle mass or a 3D transvaginal ultrasound, if the patient is coitarchal,
distribution, clitoromegaly, or voice deepening). Complete may better characterize the specific anomaly (45,46,47).
Tanner staging should be done to document pubertal Head imaging with computed tomography or MRI is not
development (40). The papilla and surrounding breastmay typically required unless the adolescent girl presents with
also be examined for residual signs of galactorrhea. galactorrhea (+/- hyperprolactinemia), headaches or visual
Perform an external genital examination with the aid of disturbances, suggesting a possible intracranial lesion
labial traction to assess for a patent hymen and lower (1,41,48). It may also be indicated if there is a negative
vagina. This examination can also aid in determining the progesterone withdrawal challenge (4).
extent of estrogenization of the vulva. Typically, a
reddened and thin hymen is seen in an estrogen-deficient Due to the risk of osteopenia and osteoporosis associated
state, whereas a light pink and plumper hymen is seen in with hypoestrogenism, patients with prolonged amenorrhea,
of six months or more, should be considered for baseline
the presence of adequate estrogen levels. The presence
bone mineral density (BMD) assessment measured by
of leukorrhea can also point to adequate estrogenization.
dual-energy X-ray absorptiometry (DEXA/DXA) scan and
Lastly, a bimanual examination can be performed in
lateral spine radiograph to assess for asymptomatic
patients who are sexually active, to palpate for a uterus
vertebral fractures (15,41,49,50,51,52,53). In adolescents,
and to rule out an adnexal mass. Typically, patients with
FHA will have a physical examination within normal limits. Table 2. Typical hormone pattern in functional
hypothalamic amenorrhea
Endocrinological investigations: Initial blood work-up
Hormone Level
should include measurement of the beta subunit of human
chorionic gonadotropin concentration, regardless of the Pituitary
disclosed sexual history, to rule out pregnancy. FSH, LH, FSH Low
estradiol, prolactin, and TSH concentrations should also be LH Low
measured routinely. If there are signs of hyperandrogenism TSH Low-Normal
on examination, an androgen panel should be ordered, PRL Normal
including total and free testosterone, androstenedione, and Ovarian
dehydroepiandrosterone sulfate, along with a 17- Estradiol Low
hydroxyprogesterone concentration, preferably in the early Testosterone Low-Normal
morning (1,3,41). Assessment of cortisol status may also be AMH Normal
considered, based on presenting features. See Table 2 for a FSH: follicle stimulating hormone, LH: luteinizing hormone, TSH: thyroid-
summary of laboratory findings in FHA. stimulating hormone, PRL: prolactin, AMH: anti-Müllerian hormone,
Ref. 11,12,13,14,41,42.
21
BMD Z-scores are used as these values are adjusted for age improve BMD in patients with FHA. This recommendation
and gender. They must also be further interpreted in relation is based on two small studies (57,58). In a study by Kopp-
to the patient’s body size, ethnicity, and pubertal staging or Woodroffe et al (57), three out of four amenorrheic
skeletal maturity (defined by bone age) (53). There is no participants resumed menses after a 20-week program. The
absolute BMD Z-score threshold that can be used alone to program involved incorporating one rest day per week and
define osteoporosis. Rather, a diagnosis of osteoporosis a nutritional supplement to improve overall energy balance.
requires the presence of both a clinically significant fracture In another study by Lindberg et al (58), four out of seven
history (≥3 long bone fractures at any age up to 19 years old) amenorrheic participants in a 15-month program resumed
and a BMD Z-score <-2.0. However,a BMD Z-score >-2.0 does menses and had a small, statistically significant increasein
not to preclude the possibility of skeletal fragility, and in the BMD. Their program included a reduction in exercise
setting of a low-trauma vertebralfracture, there is no BMD Z- duration and calcium supplementation. Larger prospective
score requirement to make a diagnosis of osteoporosis (54). studies would be beneficial in confirming these results.
Evaluation of the BMD Z-score trajectory, based on serial
Specifically in amenorrheic female athletes, a
measurements over time, provides valuable information
multidisciplinary approach, which includes nutritional
about which patients are at risk for fractures (declining BMD
therapy, psychological therapy, and modification of exercise
Z-scores), versus those who may be showing signs of
regimen has been recommended (59,60).
recovery (53). BMD should be repeated every six to 12
months to assess for trajectory of BMD Z-score, in patients In all patients with FHA, if lifestyle modification is the
where risk factors remain present. Spine radiographs should primary treatment modality, a follow up should be done
also be monitored at a similar interval to assess for every two to three months to determine whether the desired
asymptomatic vertebral fracture (or immediately if effect is being achieved (60).
symptomatic), particularly if there is decline in BMD Z-score Psychological therapy: Adolescent girls and young adult
(53). women with FHA have been shown to cope less well with
Other investigations: A karyotype should be performed if stress (31), and are also at a higher risk of depression (50).
a chromosomal abnormality, such as Turner syndrome is In the study by Kondoh et al (29), patients with FHA related
suspected and/or if gonadotropins are elevated. If to psychogenic stress, aged 15-33, were treated with
gonadotropins are elevated and POI is diagnosed, other psychoeducation which focused on stress management. A
testing would be required including autoimmune antibodies greater proportion of these patients recovered compared
and Fragile X testing. to those with weight-associated FHA; 81.8% versus 54.0%.
Their average time to recovery was also slightly shorterat
17.2±4.1 months versus 19.4±5.0 months. A small
Stress Management
randomized controlled trial (RCT) looked at the effect of a
The menstrual cycle has been recognized as an important 20-week intervention with cognitive based therapy (CBT)
vital sign in adolescent girls (55,56), and the absenceof in patients with FHA (61). In this study, the eight patients
menses may be an indication of compromised overall health. randomized to the CBT arm had a higher rate of ovarian
As such, the main goal of management in FHA is the activity (87.5%) compared to those eight patients that were
resumption of menses. correlation effect stress in the observation arm (25.0%). Ovarian activity was
management of function hypotalamus secondary determined by measuring plasma estradiol and
managemen with significance p < 0.005 about 45 progesterone levels, in order to confirm ovulation. BMI did
adolesncent not significantly change during the intervention. CBT has also
been shown to have an impact on metabolic health in these
Lifestyle modification: Addressing possible triggers such as
patients. In a follow-up study by Michopoulos et al (62),
weight loss, disordered eating, or excessive exercise isa
patients randomized to the CBT arm had an improvement in
primary focus in the management of FHA. In one studyby
cortisol, TSH, and leptin concentrations compared to those
Kondoh et al (29), patients with FHA related to weight loss
in the observation arm.
were treated by a nutritionist for at least six months. 54.0%
of these patients resumed menses with an average recovery Other forms of psychological therapy have been studied. In
time of 19.4±5.0 months. to resume menses. A common a small prospective study, 12 patients with FHA, aged 20-33,
recommendation in the literature is thata 1-2 kg weight gain were given a 45-70 minute hypnotherapy session and then
from current weight, or a 5% increasein body weight, can observed for 12 weeks (63). Nine patients (75%) resumed
result in the resumption of menses and menses, and one patient became pregnant during this time.
22
All patients also reported increased general well-being and been successful with lifestyle modification, and who arenot
improved self confidence. in need of COCs for contraception (41).
Though studies looking at psychological therapy in FHA have To date, the majority of evidence for the positive effects
been small, the effects of therapy are promising and are of transdermal estrogen on BMD comes from research
unlikely to result in harm. Therefore, psychological therapy involving patients with anorexia nervosa (77,78). However,
may be considered as part of the multidisciplinary treatment its use in patients with FHA is attracting interest and has
of patients with FHA. started to be studied. Zanker et al (76) published a case
report of a 24-year-old amenorrheic athlete, whom they
Pharmacological therapy: The main role of pharmacological
followed for 12 years. They measured her body weight every
therapy in FHA is to promote bone health and prevent the
three months and her BMD by DXA every 11-13 months.
development of osteoporosis. A lack of estrogen during
After being on COCs for five years, the BMD of her lumbar
premenopausal years has been linked to decreased BMD.
spine and proximal femur declined by 9.8% and 12.1%,
This is based on studies looking at the outcomes of
respectively. Her weight dropped concomitantly from 45.1
premenopausal women undergoing bilateral oophorectomy
to 41.4 kg. Over the next 3.7 years, she was treated with
(64,65). In one study, vertebral bone loss could be detected
transdermal estrogen and an oral progestin. Her lumbar
as early as six months post-operatively (64). An increase in
spine BMD gradually increased by 9.4%, despite a further
the frequency of fragility fractures of the radius and femoral
0.8 kg decline of body mass. In the last 2.9 years of the study,
neck was also observed (65). Similarly, in patients with FHA,
she continued the transdermal estrogen, gained a total of 8.1
the associated hypoestrogenic state can result in reduced
kg of body mass, and had a 16.9% increase in her proximal
bone density (15,50,51). In young women less than 20 years
femur BMD. Furthermore, an RCT by Ackerman et al. (79)
of age, missing even 50% of menstrual cycles can result in
from 2019 showed an improvement in BMD in athletes with
a significant decrease in BMD (52). Therefore, studies have
oligo-amenorrhea receiving transdermal estrogen. In this
looked at the effects of hormone replacement therapy on
study, 43 patients were randomized to receive a 100 mcg
BMD in patients with FHA.
17-estradiol transdermal patch twice weekly with cyclic
A systematic review by Liu and Lebrun (66) summarized micronized progesterone (200 mg, 12 days per month), 40
ten studies evaluating the impact of hormone therapy patients to receive a daily pill with 30 µg EE + 0.15mg
on BMD in women with FHA. They found seven studies desogestrel, and 38 patients received no hormonal
which demonstrated a positive effect of combined oral treatment. All patients also received 800 IU of vitamin D
contraceptives (COCs) on BMD (67,68,69,70,71,72,73), and ≥1200 mg of calcium per day. BMD was assessed at
two studies that showed no effect (74,75), and one case baseline, six, and 12 months. Patients randomized to the
report where a negative effect was observed (76). Of the patch arm had significantly higher spine and femoral neck
studies that showed a positive effect, two were small RCTs BMD Z-scores at 12 months compared to the pill and the no
(67,68). Hergenroeder et al (67) showed a significant treatment arm, and higher hip BMD Z-scores than the pill
increase in both the total BMD and lumbar spine BMD of arm. The results of this landmark study are promising and
five patients receiving 35 µg ethinyl estradiol (EE) + 0.5- lend support to the use of transdermal estrogen in patients
1 mg norethindrone, compared to five controls. Castelo- with FHA.
Branco et al (68) showed a significant increase in lumbar
In amenorrheic adolescents, 1200-1500 mg of calcium
spine BMD in 24 patients taking 30 µg EE + 0.15 mg
supplementation (80) as well as vitamin D 400-1000 IU (1)
desogestrel and 22 patients taking 20 µg EE + 0.15 mg
are recommended daily to support bone health. However,
desogestrel, compared to 18 control patients who showed
other therapies such as testosterone or bisphosphonates are
a decrease in BMD. Of the studies that showed no effect,
not currently recommended to improve BMD in patients
one cohort study looking at female long distance runners,
with FHA (41,81), as the literature available focuses mainly
found no difference in BMD after one year in nine patients
on patients with anorexia nervosa and the current evidence
who started on a COC (75). However, in the same study 11
is limited.
patients with FHA who were not using a COC showeda
significant reduction in BMD over the same time period. Fertility: Patients with FHA may experience escape ovulation
Currently, the Endocrine Society has recommended and therefore contraception is important if they do not
against using COCs for the sole purpose of improvingBMD, desire pregnancy (41). In addition, adolescents with FHA may
due to conflicting evidence. Instead, a trial of short-term inquire about future fertility. Ovarian reserve is typically
transdermal estrogen with a cyclic oral progestin is normal in these patients, as evidenced by theirnormal anti-
recommended in amenorrheic adolescents who have not Müllerian hormone (AMH) levels (42). In
23
patients who desire pregnancy, ovulation induction with cardiovascular health of patients with FHA focus on the
pulsatile GnRH is the current gold standard (82,83,84,85). lifestyle modifications that can be made to resume
When compared to injectable gonadotropins, chances of menses (90).
conception are higher after six cycles of pulsatile GnRH at Novel therapies: Studies are now focusing on the underlying
96% versus 72% for injected gonadotropins based on life metabolic abnormalities within FHA to direct therapy. Small
table analysis (82). Furthermore, injectable gonadotropins RCTs have looked at the effects of treatment with
are associated with a higher rate of multiples (14.8% versus recombinant human leptin. Welt et al (94) demonstrated an
9.3%), though the finding was not statistically significant improvement in serum estradiol, increased levels of free T4,
(82). These results were more recently replicated in a study and IGF-1 with administration of recombinant methionyl
by Dumont et al (84) which showed a per patient conception human leptin (r-metHuLeptin; starting dose 0.08 mg per
rate of 65.8% with pulsatile GnRH versus 23.5% with kilogram of body weight per day) subcutaneously for two to
gonadotropins. Though the trend favouring pulsatile GnRH is three months. Three out of eight women (37.5%) resumed
the same in both studies, the conception rates in the Dumont ovulatory cycles, which the authors stated was higher than
et al study are significantly lower. This may be explained by the expected rate of spontaneous ovulation of 10%. In a
the differences in study populations between these studies, small RCT, recombinant human leptin (metreleptin; starting
with lower BMI and baseline gonadotropin levels in the dose 0.08 mg per kg of body weight per day) administered
Dumont et al (84) study. The mean BMI in Dumont et al was subcutaneously over 36 weeks, increased estradiol levels and
18.5 kg/m2 (pulsatile GnRH group) and 18 kg/m2 decreased cortisol levels compared to placebo (95). Patients
(gonadotropin group), whereas in Martin et al (82)it was 24.3 receiving recombinant human leptin in this study were also
kg/m2 (pulsatile GnRH group) and 24.5 kg/m2 (gonadotropin more likely to resume menses compared to controls (70%
group). Baseline LH, FSH, and estradiol levels were also lower versus 22.2%). In both studies, markers of bone formation
in Dumont et al (84). Naltrexone, an opioid antagonist, has were also found to be increased, though BMD did not change
also been studied. GnRH secretion has been found to be significantly (94,95). The administration of kisspeptin has
suppressed by endogenous opioids (86). It was also been studied, and while acute administration appears to
hypothesized that GnRH pulsatility could therefore be stimulate release of LH and FSH, chronic administration
stimulated by opioid antagonism. Though naltrexone has results in tachyphylaxis. Thus, the authors concluded that
been shown to increase GnRH pulsatility and increase rates acute administration of kisspeptin may have therapeutic
of ovulation (86,87,88,89), its use has not become standard potential in patients with FHA (96). The Endocrine Society
practice. has recommended against the use of leptin or kisspeptin in
the management of patients with FHA, as more research is
Cardiovascular considerations: Patients with prolonged
needed in this area (41).
FHA may be at higher risk of cardiovascular complications
in the future (90). Studies in pre-menopausal adult
women have shown hypothalamic hypoestrogenism is Conclusion
associated with a higher risk of coronary artery disease FHA is a common cause of both primary and secondary
(91). Other possible effects include vascular endothelial amenorrhea in adolescent girls. Common triggers include
dysfunction and reduced regional blood flow, as was stress, weight loss, and excessive exercise. As FHA is a
shown in young amenorrheic athletes (92). These athletes diagnosis of exclusion, a comprehensive workup should be
were also found to have abnormal lipid profiles, including performed to rule out anatomic and organic causes of
elevated total cholesterol and low-density lipoprotein amenorrhea. Prolonged FHA can have negative
cholesterol (92). As a follow-up study, Rickenlund et al (93) consequences on many aspects of a young women’s health,
investigated the effects of using a COC (30 µg EE + 0.15 including metabolic, bone, cardiovascular, mental, and
mg levonorgestrel) on these cardiovascular endpoints in reproductive implications. The main goal in these patients
amenorrheic athletes. While an improvement in vascular is the resumption of menses. Lifestyle modifications are the
endothelial function after nine months of COC use was first line focus for adolescent girls with FHA and a
found, the lipid profile did not significantly change, with multidisciplinary approach, including a pediatric gynecologist
the exception of a small increase in high-density and/or endocrinologist, pediatric sport psychologist, and
lipoprotein cholesterol. As this study was small, the sport dietician is beneficial. Pharmacological therapy can
authors indicated the need for larger, long-term studies to be considered in order to promote bone health, with
determine the clinical importance of their findings. As of transdermal estrogen being a promising option for patients.
now, the majority of recommendations surrounding Further research on novel agents, such as recombinant
24
human leptin and kisspeptin, is required before considering 15. Grinspoon S, Miller K, Coyle C, Krempin J, Armstrong C, Pitts S,
Herzog D, Klibanski A. Severity of osteopenia in estrogen-deficient
their routine use in patients with FHA.
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Authorship Contributions 18. Selzer R, Caust J, Hibbert M, Bowes G, Patton G. The association
Literature Search: Marie Eve Sophie Gibson, Writing: Marie between secondary amenorrhea and common eating disordered
weight control practices in an adolescent population. J Adolesc Health
Eve Sophie Gibson, Nathalie Fleming, Caroline Zuijdwijk, 1996;19:56-61.
Tania Dumont. 19. Scheid JL, Williams NI, West SL, VanHeest JL, De Souza MJ. Elevated
PYY is associated with energy deficiency and indices of subclinical
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disordered eating in exercising women with hypothalamic amenorrhea.
received no financial support. Appetite 2009;52:184-192. Epub 2008 Sep 25
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BUKU LOGBOOK PRAKTIK PROFESI

STASE ASUHAN KEBIDANAN PRA NIKAH DAN PRA KONSEPSI

PROGRAM STUDI PENDIDIKAN PROFESI BIDAN

Nama Mahasiswa : Marwah Jamaluddin

PROGRAM STUDI PENDIDIKAN PROFESI PROGRAM PROFESI

REKTOR ITKES MUHAMMADIYAH SIDRAP

Dengan senantiasa memanjatkan puji dan syukur kepada Allah

Pangkajene, 11 Zulhijjah 1443 H

DR.Muhammad Tahir, SKM.,M. Kes

Syukur Alhamdulillah kami panjatkan ke hadirat Allah SWT, karena

tersaji dengan optimal, sehingga perlu kritik dan saran demi

tersempurnanya pedoman ini.

Jazakumullahu khairan katsiran.

Sidrap, 20 Oktober 2022

Wilda Rezki Pratiwi, S.ST., M. Kes

Asuhan Kebidanan pada Pra

LOGBOOK PRAKTIK STASE ASUHAN KEBIDANAN

B. TEMPAT DAN WAKTU PELAKSANAAN

C. KOMPETENSI YANG INGIN DICAPAI

2. Konseling Kesehatan reproduksi pada wanita

4. Teknik pengambilan dan pengiriman sediaan pap smear

5. Melakukan deteksi dini dan kolaborasi interprofesional dalam

7. Penyuluhan kesehatan mengenai kesehatan reproduksi,

8. Identifikasi gangguan masalah dan kelainan-kelainan sistem

10. Melakukan dokumentasi pada asuhan kebidanan pada

11. Pemeriksaan dan konseling pranikah

12. asuhan dan konseling jenis-jenis kontrasepsi

13. persiapan menjadi orang tua

14. konseling persiapan kehamilan

15. Evidancebased terkait prakonsepsi

16. Melakukan dokumentasi pada asuhan kebidanan pada

Preseptor Pembimbing Pendidikan : Nasrayanti SST.,M. Keb

PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM PROFESI

STASE PRANIKAH DAN PRANKONSEPSI

JUDUL KASUS AMENOREA SEKUNDER PADA NN N

TAHUN AKADEMIK 2023

pangkajene, 19 januari 2023

Preseptor Pendidikan Preceptor Lahan Mahasiswa

Nasrayanti, S,ST.,M.Keb Herlina, S.ST Marwah Jamaluddin

B. KONSEP DASAR AMENOREA SEKUNDER ............................................ 6

DOKUMENTASI SOAP DAN RENCANA TINDAK LANJUT ..........11

Kesehatan reproduksi merupakan aspek yang menjadi perhatian

setelah upaya kesehatan pada umumnya tercapai. Kesehatan reproduksi

yang berhubungan dengan sistem reproduksi, fungsi serta prosesnya

(Manuaba, I.B.G. 2013)

Wanita rentan terhadap penyakit yang menyerang organ reproduksinya.

Kebanyakan wanita, sangat malu dan tertutup untuk berkonsultasi

secara langsung mengenai kesehatan pribadinya. Faktor lain pun

dikarenakan biaya untuk pemeriksaan ke dokter spesialis cenderung

ketika kondisi sudah memburuk dan memerlukan penanganan yang

ekstra, dokter spesialis menjadi tujuan akhir (Merin, 2013)

Wanita dalam kehidupannya tidak luput dari adanya siklus

menstruasi normal yang terjadi secara periodik. wanita akan merasa

terganggu bila hidupnya mengalami perubahan, terutama bila

Diharapkan semua wanita mengalami siklus menstruasi yang teratur,

namun hampir semua wanita pernah mengalami gangguan menstruasi

perdarahan. Masalah ini dihadapi oleh wanita remaja, reproduksi dan

Amenore sekunder lebih menunjuk kepada sebab yang timbul

kemudian dalam kehidupan wanita, seperti gangguan metabolisme,

rendah untuk tinggi badan (IMT kurang) (Merin, 2013)

Peran Bidan dalam upaya meningkatkan kesehatan reproduksi yaitu

melakukan penyuluhan mengenai cara untuk mengurangi keluhan

tersebut pada remaja, dengan berperilaku hidup sehat, memperbaiki