GYNECOLOGY

dr. Nashria
dr. Reagan Resadita
 Siklus
Infeksi
Keganasan
2 Menstruasi Infertilitas
Kongenital
Abnormal
Menstruasi Toxoplasmosis
Serviks Analisis Sperma
Perdarahan
Uterus Abnormal
Rubella
Polycystic
Korpus Uteri Endometriosis ovarian
syndrome
CMV
Amenorrhea
Tes Fertilitas
Ovarium
Wanita Varicella
Menopause
 Neoplasma
3 Pertumbuhan jaringan yang berlebihan dan abnormal
Benigna VS Maligna Solid VS Cystic Gejala Utama
Tumor Benigna  Perdarahan abnormal
 Dapat menyebabkan penyakit
klinis yang signifikan  Massa pelvis
 Peningkatan tekanan pada
mioma uteri menyebabkan
nyeri punggung belakang,  Gejala vulvovaginal
obstipasi dan retensi urin Lokasi Tersering
 Komplikasi: Perdarahan
abnormal, ulserasi, infeksi
sekunder
 Perubahan menjadi maligna

Tumor Maligna
 Menyebabkan penyakit klinis
yang lebih signifikan seperti
invasif, pertumbuhan cepat
mudah berdarah, ulserasi dan
infeksi
 Sindrom Para neoplastic
(endocrinopathies)
 cachexia
 Tumor Serviks Uteri
lokasi: Berada di 1/3 bawah uterus, dibawah os cervicalis interna
4
Klasifikasi Faktor Resiko
 Tumor Benigna  Infeksi HPV tipe16, 18, 45 dan 56
Leiomyoma (myoma)  Status sosial ekonomi
 Menikah/ memulai aktivitas seksual
 Tumor Maligna pada usia muda (kurang 20 tahun)
A. Karsinoma serviks  Berganti ganti pasangan seksual.
1. Squamous cell  Berhubungan seks dengan laki laki
carcinoma 91 % yang berganti ganti pasangan
2. Adenocarcinoma  Riwayat infeksi di daerah kelamin
3. Adenosquamous atau radang panggul
carcinoma  Perempuan yang melahirkan banyak
4. Adenoacanthoma anak
 Perempuan perkokok(2,5x lebih
B. Sarcoma ( sangat tinggi)
jarang)
 Perokok pasif (1,4x lebih tinggi)
 Patogenesis
5

• Infeksi terjadi melalui kontak kulit ke kulit

• Lesi biasanya belum timbul hingga 3-5
tahun setelah terpapar
 Zona Transformasi
6
 Displasia adalah hilangnya
diferensiasi normal dari epitel serviks
 Tempat paling sering terjadinya
displasia dan SCC adalah junctio
epitelium skuamosum dan
kolumnar (zona transformasi)
 Daerah ini paling rentan terhadap
infeksi virus, perubahan pH vagina
dan fluktuasi level estrogen
 Peningkatan estrogen menstimulus
epitel kolumnar bergerak keluar
menuju vagina (kehamilan,
konsumsi pil kontrasepsi, bayi baru
lahir).
 Penurunan estrogen menstimulus
epitel kolumnar untuk masuk
kembali ke kanalis endoserviks
7
 Tanda Klinis & Gejala
8 Tanda Klinis
Nodul, ulkus, erosi serviks
Advanced: crater-shaped
ulcer with high or friable
warty mass
Perdarahan
Mobilitas serviks tergantung
derajat ca
Gejala
Perdarahan vagina, rektal,
urethra
Penekanan:obstipasi, anuria
hidronefrosis  gagal ginjal 
uremia
Infeksi:discar vagina yang bau
Pencegahan
Primer: Gaya hidup sehat
dan vaksinasi HPV
(kuadrivalen- genotipe 6,
11, 16 &18 ; bivalen- genotipe 16
&18)
Sekunder: Skrining untuk lesi
pra kanker & diagnosis awal
diikuti dengan terapi
Tersier: Diagnosis dan
terapi dari kanker yang
terbukti. Terapi: operasi,
radiotherapy dan
terkadang chemotherapy.
Dianjurkan paliatif jika tidak
dapt disembuhkan
 Screening for cervical cancer Visual Inspection Test
9
 Perempuan berusia 30-50
tahun
 Pasien klinik IMS dengan
discharge dan nyeri abdomen
bawah (semua usia)
 Perempuan yang tidak hamil
 Perempuan yang mendatangi
puskesmas, klinik IMS< dan
klinik KB yang meminta
screening
 Jika hasl tes IVA negatif,
skrining dilakukan minimal 5
tahun sekali. Jika hasil tes IVA
positif harus melakukan tes IVA
6 bulan kemudian

Pedoman teknis Ca Payudara dan Ca

Serviks, kemenkes
 Screening for Cervical Cancer
10
• The United States Preventive Services Task Force Kecuali...
stated screening may stop at age 65 if : • Women at increased risk
11
• recent normal smears
• not at high risk for cervical cancer. of CIN :
• The American Cancer Society guideline stated that 1. in utero DES
women age 70 or older may elect to stop cervical (diethylstilbestrol)
cancer screening if : exposure,
• had three consecutive satisfactory, 2. immunocompromise,
normal/negative test results and no abnormal 3. a history of CIN II/III or
test results within the prior 10 years. 4. Cancer
• Not recommended in women who have had total should continue to be
hysterectomies for benign indications (presence of screened at least
CIN II or III excludes benign categorization). annually.
• Screening of women with CIN II/III who undergo
hysterectomy may be discontinued after three
consecutive negative results have been obtained.
• However, screening should be performed if the
ACOG guideline 2008
woman acquires risk factors for intraepithelial
neoplasia, such as new sexual partners or
immunosuppression.
 Screening for Cervical Cancer – Pap Smear
12
• Mendeteksi perubahan Keluhan Lesi anatomis Rekomendasi
pada morphology skrining
sel(dysplasia) yang
merupakan precursors
dari carcinoma.
- - IVA
Syarat: + - PAP SMEAR
• Lakukan Paps smear
pada fase proliferasi (1 + + Biopsi
minggu setealah mens
berakhir) Unreliable Pap smear due to inflammation:
• Tidak melakukan  First, diangose and treat inflammation
hubungan sexual 24-48
jam sebelum paps smear  Repeat pap smear after the condition resolves to diminish
the false positive result.
• Tidak menggunakan
lubrikan vagina.
Source: Emedicine
 Squamous Cell Carcinoma
Cervical dysplasia:
Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope

©2015 UpToDate®
 Tanda dan Gejala
Perubahan prekanker serviks sering tidak disertai tanda
dan gejala
14
 Diagnosis
Tests may include:
 another Pap test if mild changes found
 HPV test, which may be done on a sample of
cervical cells taken during a Pap test
 colposcopy and biopsy
 endocervical curettage during colposcopy
 Treatment
 Often, milder changes (such as CIN I or low-grade SIL)
return to normal without any treatment& the doctor
may do repeat testing later.
 More severe abnormalities (such as CIN III or high-
grade SIL) are more likely to develop into invasive
cervical cancer, especially if they are not treated.
 Treatment options : cryosurgery, laser surgery, cone
biopsy, hysterectomy
15
Terapi Penjelasan
Krioterapi Perusakan sel sel
16
prakanker dengan cara
dibekukan (dengan
membentuk bola es pada
permukaan serviks)
elektrokauter Perusakan sel sel
prakanker dengan cara
dibakar dengan alat
kauter, dilakukan leh
SpOG dengan anestesi
Loop ElectroSutgican Pengambilan jaringan
Excision Procedure (LEEP) yang mengandung sel
prakanker dengan
menggunakan alat LEEP
Konikasi Pengangkatan jaringan
yang megandung sel
prakanker dengan operasi
Histerektomi Pengangkatan seluruh
rahim termasuk leher rahim
 Clinical staging of Cervical Cancer
17
 Tumor Korpus Uteri
Tumor Benigna Tanda dan Gejala
18
• Leiomyoma (myoma): • Menorrhagia – heavy &
Paling sering (sel otot halus) prolonged menstruation
• Etiological factors: (common)
estrogen, ras kulit hitam, • Pelvic pressure：urinary
nullipara frequency, constipation
• Spontaneous abortion, Infertility
Type of Leiomyoma
1. Submucous : beneath A palpable abdominal tumor :
endometrium, if arising from pelvis, well defined
pedunculated  margins , firm consistency, smooth
geburt myoma surface, mobile from side to side.
2. Intramural/interstitial: • Pelvic examination：Uterus —
within uterine wall enlarged and irregular, hard
3. Subserous/subperitone • Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
al: at the serosal
Terapi
surface or bulge  Observation: for small myoma,
outward from premenopause
myometriuml ; if  Operation : myomectomy or
pedunculated : satelite hysterectomy
myoma Whorl like pattern / Pusaran air
19
Influencing factors of Myoma Uterine
 Specific Signs of Uterine Fibroid
20
 Perubahan Sekunder Myoma
21

Jenis Degenerasi Ganas

Myoma uteri yang menjadi
leiomyosarkoma hanya 0,32
– 0,6% dari seluruh myoma

Leiomyosarkoma
merupakan 50-75% dari
semua jenis sarkoma uteri

Kecurigaan malignansi:
apabila myoma uteri cepat
membesar dan terjadi
pembesaran myoma pada
menopause.
 Tumor Korpus Uteri
22
A. Karsinoma endometrium
75% terjadi pada periode pos
menopause
Etiologi: paparan estrogen terlalu
banyak, obesitas, manopause
terlambat, PCOS, estrogen
secreting ovarian tumor, konsumsi
estrogen dari luar, diabetes dan
hipertensi
Adenokarsinoma endometrium
Adenoacanthoma
Karsinoma adenoskuamos
B. Sarkoma uteri
1. Leiomiosarkoma
2. Tumor mesodermal campuran
3. Sarkoma stromal endometrium
Kejadiannya sangat jarang
Diagnosis
Perdarahan post menopause
Siklus menstruasi iregular
Curretage
Tumor Ovarium Ovarian teratoma
Mortalitas tinggi dari semua tumor gyn (silent
lady killer) Bizarre tumor, biasanya
Gejala benigna, rata2 mengenai wanita
 Low abdominal discomfort (fullness, di usia 30 tahun
bowel symptom)
 Loss of weight, malaise, anorexia
Kista dermoid berkembang dari
 Pain due to torsion, hemorage or
rupture sel germinal totipotensial (oosit
 Pressure symptom primer) yang tetap berada di
Benign Tumor ovarium, sehingga berkembang
 Small can be felt by bimanual menjadi semua bentuk sel matur
 Medium may have long pedicle and seperti rambut, gigi, tulang,
rise out of pelvis
jaringan saraf.
 Benign mucinous cyst may be vary in
size
 Benign teratoma cyst the commonest
undergo torsion
 Benign solid tumor are less common
 Meig syndrome : solid tumor, ascites,
pleural effusion
 Malignant Tumor
 Early detection would improve
prognosis, bimanual, USG or tumor
marker
23
24
Siklus Menstruasi Abnormal
 Menstrual cycle
25

Image source:https://embryology.med.unsw.edu.au/
 FSH
26
•Hormon yang diproduksi oleh
hipofisis akibat rangsangan
dari GnRH.
•FSH akan menyebabkan
pematangan dari folikel.
•Dari folikel yang matang akan
dikeluarkan ovum. Kemudian
folikel ini akan menjadi korpus
luteum dan dipertahankan
untuk waktu tertentu oleh LH
LH
•LH mempertahankan korpus luteum
untuk tetap menghasilkan ovarium.
•Dibawah pengaruh LH, korpus luteum
mengeluarkan estrogen dan
progesteron, dengan jumlah
progesteron jauh lebih besar.
•Kadar progesteron meningkat dan
mendominasi dalam fase luteal,
sedangkan estrogen mendominasi
fase folikel.
•Walaupun estrogen kadar tinggi
merangsang sekresi LH, progesteron
dengan kuat akan menghambat
sekresi LH dan FSH.
 Progesteron
27
Estrogen
•Hormon ini diproduksi oleh korpus
•Estrogen dihasilkan oleh luteum.
ovarium. •Progesteron mempertahankan
•Estrogen berguna untuk ketebalan endometrium sehingga
pembentukan ciri-ciri dapat menerima implantasi zygot.
perkembangan seksual pada •Kadar progesteron terus
wanita yaitu pembentukan dipertahankan selama trimester awal
payudara, lekuk tubuh, kehamilan sampai plasenta dapat
rambut kemaluan. membentuk hormon HCG.
• Estrogen juga berguna pada
siklus
membentuk
menstruasi dengan
ketebalan
GnRH
endometrium, menjaga •GnRH merupakan hormon yang diproduksi oleh
kualitas dan kuantitas cairan hipotalamus di otak.
cerviks dan vagina sehingga • GnRH akan merangsang pelepasan FSH (Folicle
sesuai untuk penetrasi sperma. Stimulating Hormon) di hipofisis.
• Bila kadar estrogen tinggi, maka estrogen akan
memberikan umpan balik ke hipotalamus
sehingga kadar GnRH akan menjadi rendah,
begitupun sebaliknya..
28
 Normal Menstrual Bleeding
29 • Occurs approximately once a
month (every 26 to 35 days).
• Lasts a limited period of time (3 to
7 days).
• May be heavy for part of the
period, but usually does not
involve passage of clots.
• Often is preceded by menstrual
cramps, bloating and breast
tenderness, although not all
women experience these
premenstrual symptoms.
• Average : 35-50 cc

Lect. By dr. Hasto Wardoyo, Sp. OG

30 Ovulasi
 Terjadi 14 hari sebelum mens • >> kadar
berikutnya progesterone 2ng/ml
 Tanda dan tes : • LH surge (dg
 Rasa sakit di perut bawah (mid cycle
Radioimunoassay)
pain/mittleschmerz) • USG  folikel >1,7 cm
 Perubahan temperatur basal  efek
termogenik progesteron
 Perubahan lendir serviks
 Uji membenang (spinnbarkeit): Fase
folikular : lendir kental, opak,
menjelang ovulasi  encer, jernih,
mulur
 Fern test : gambaran daun pakis
 Fertility Test
31  LH-FSH Ratio : the relative value of 2 gonadotropin hormone
produce by the pituitary gland in women
 Luteinizing hormone (LH) and Follicle stimulating hormone
(FSH) stimulate ovulation by working in different ways.
 in premenopusal women, the normal LH-FSH ration is 1:1 as
measured on day three of the menstrual cycle
 Variation from this ratio used to diagnose PCOS or other
disorders, explain infertility or verify that woman has entered
menopause
 FSH stimulates the ovarian follicle to mature. Then a large
surge of LH stimulates the follicle to release an egg to
fertilization
 On day 3 of the cycle, LH should be low. If LH is elevated on
this day, possible even as high as FSH, then it suggest problem
with ovulation. Ovulation requires an LH surge, and if LH is
already elevated, it may not surge and ovulated
32
33

Abnormal Uterine Bleeding

 34

Malignancy and
Polyp Adenomyosis leiomyoma
hyperplasia

Coagulopathy Ovulatory disorder Endometrial iatrogenic Not Yet Classified

 Polip
35 • Endocervical polip
• Endometrial polip

Adenomyosis
• Part of endometrial that penetrate to myometrium

Leiomyoma
• Submucosal
• SUbserosal
• intramural

Malignancy and hyperplasia

- Endometrial cancer
 Coagulopathy
• Von Willebrand disease
36
• Gangguan agregasi platelet

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

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

Iatrogenic
Drugs : rifampicin, griseofulvin, trisiklik,
phenothiazine, anticoagulant, antiplatelet,
 Treatment of uterine bleeding
37

Infrequent bleeding

1. Therapy should be directed at the underlying cause

when possible.
2. If the CBC and other initial laboratory tests & history
and physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid

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

ACOG 2008
39 • Hysteroscopy may be necessary, and dilation and curettage is
a last resort.
• Transfusion may be indicated in severe hemorrhage.
• Ferrous gluconate 325 mg tid.

4. Primary childbearing years – ages 16 to early 40s

A. Contraceptive complications and pregnancy are the most
common causes of abnormal bleeding in this age group.
Anovulation accounts for 20% of
cases.
B. Adenomyosis, endometriosis, and fibroids increase in
frequency as a woman ages, as do endometrial hyperplasia
and endometrial polyps. Pelvic inflammatory
disease and endocrine dysfunction may also occur.

ACOG 2008
 Dysmenorrhea
40
Dysmenorrhea refers to the symptom of painful menstruation. It can be
divided into 2 broad categories: primary (occurring in the absence of
pelvic pathology) and secondary (resulting from identifiable organic
diseases).
Primary
Usual duration of 48-72 hours (often starting several hours before or just after
the menstrual flow)
Cramping or laborlike pain
Background of constant lower abdominal pain, radiating to the back or thigh
Often unremarkable pelvic examination findings (including rectal)

Current evidence suggests that the pathogenesis of primary dysmenorrhea is

due to prostaglandin F2α (PGF2α), a potent myometrial stimulant and
vasoconstrictor, in the secretory endometrium.
 Secondary
Dysmenorrhea beginning in the 20s or 30s, after previous
41
relatively painless cycles
Heavy menstrual flow or irregular bleeding
Dysmenorrhea occurring during the first or second cycles
after menarche
Pelvic abnormality with physical examination
Poor response to nonsteroidal anti-inflammatory drugs
(NSAIDs) or oral contraceptives (OCs)
Infertility
Dyspareunia
Vaginal discharge

Drug Therapy
Dysmenorrhoea can be effectively treated by drugs that inhibit
prostaglandin synthesis and hence uterine contractility.
These drugs include aspirin, mefenamic acid, naproxen or
ibuprofen.
42 Endometriosis
Penyakit estrogen dependen yang sering menyebabkan morbiditas, nyeri pelvis yang berat,
operasi berulang dan infertilitas.

Secara klinis ditemukan jaringan endometrial-like diluar uterus, yang menyebabkan reaksi
inflamasi

Lokasi paling sering: GI tract

Lokasi lain: urinary tract, soft tissues & diaphragm

 Pathophysiology
43  In situ from wolffian or mullerian duct remnants (“metaplastic theory”)
 Coelemic metaplasia
 Sampson’s theory
 Iron-induced oxidative stress
 Stem cells

Sign Symptom
Classic signs:  Dysmenorrhea
 severe dysmenorrhea, dyspareunia,  Heavy or irregular bleeding
 chronic pelvic pain,  Cylical/noncylical pelvic pain
 infertility  Lower abdominal or back pain
 Dyschezia, often with cycles of
diarrhea/constipation
 Bloating, nausea, and vomiting
 Inguinal pain
 Dysuria
 Dyspareunia with or without penetration
 Nodules may be felt upon pelvic exam
 Imaging may indicate pelvic mass/endometriomas
44 Physical exam and imaging
 Physical examination has poor  Imaging studies
sensitivity, specificity, and
 Transvaginal or endorectal USG may reveal US
Predictive value in diagnosis
feature varying from cyst with internal echoes to
endometriosis.
solid masses, usually devoid of vascularity
 Combination of History, Physical
 CT may reveal endometrioma appearing as cystic
exam and laboratory and
masses; however, apperance are non specific and
diagnostic studies is indicated to
imaging modalities should not be relied upon on for
determine cause of pelvic pain
diagnosis
and rule out non endometriosis
concerns  MRI : may detect even smallest lesion and
distinguish hemorragic signal of endometrial
 Pain mapping may help isolate
implant
location spesific disease such as
nodulas masses in posterior  MRI demonstrated to accurately detect
rectovaginal septum rectovaginal disease and obliteration in more than
90% of cases when USG gel was inserted in the
 Absence of evidence during exam
vaginal and rectum
is not evidence of disease absence
 Endometriosis therapy
45
Medical Therapies Indications for surgical management:
• Gonadotropin-releasing
hormone agonists (GnRH),
• oral contraceptives,
• Danazol®,
• aromatase inhibitors,
• Progestins
• Surgical Intervention
• Laparoscopy
• Hysterectomy/Oophorect
omy/Salpingo-
oophorectomy
• Nonsurgical Therapies
• Medical Therapies
• Alternative Therapies
• Diagnosis of unresolved pelvic
pain
• Severe, incapacitating pain with
significant functional impairment
and reduced quality of life
• Advanced disease with
anatomic impairment
(distortion of pelvic organs,
endometriomas, bowel or
bladder dysfunction)
• Failure of expectant/medical
management
• Endometriosis-related
emergencies, ie, rupture or
torsion of endometrioma, bowel
obstruction, or obstructive
uropathy
46 Endometriosis therapy

Mild – Moderate Pain Moderate-Severe Pain

NSAID GnRH agonis
Oral contraceptive Danazole
progestin Aromatase inhibitor
 47 Endometriosis therapy
Oral contraceptive
 Generally well tolerated,
fewer metabolic and
hormonal side effect than
similar therapies
 Relieve dismenorrhea throuh
ovarian supresion and
continous progestin
administration
 Often simple, effective
choice to manage
endometriosis through
avoidance or delay menses
for upwards of 2 years
Non Steroidal Anti Progestins
Inflamatory
 Inhibit growth of lesion by infucing
 Proven efficacy fot ecidualization followed by
treatment of primary athropy uterine type tissue
dismenorhea  Compared to GnRH therapy,
both modalities show
 Acceptable side
comparable effectiveness
effects
 Medroxyprogesterone acetat
 Reasonable cost proven for pain suppresion both
 Ready availability oral and injectable
 Adverse effect : weight gain, fluid
retention, depresion, breakhrough
bleeding
 48 Endometriosis therapy
Aromatase Inhibitor
 Endometriotic implan express
aromatase and consequently
generate esterogen, maintaining
own viability
 Inhibit local esterogen production
in endometrioticimplant
 Significantly reduce pain,
compared with GnRH agonit
alone.
GnRH agonist
 Produced hypogonadic state
through down regulation of
pituitary gland
 Efective as other therapies in
relieving pain and reduce
progression
 No fertility improvement
 High cost, bone density loss,
intolerable hypoesterogeninc
side effect
 Preoperative therapy reported
to reduce pelvic vascularity
and size of lesion, reduce
intraoperative blood loss
Danazol
 Among oldest of medical
therapy for endometriosis
 Inhibit midcycle FSH and
LH surge and prevent
steroidogenesis in corpus
luteum
 Higher incidence of
adverse effect more
recent therapy
 Androgenic manifestation
(oily skin, ane, weight gain,
deepening voice,
hirsutism) maybe
intolerable
 Amenorrhea
49
Amenorrhea is the absence of
menstruation.
 Primary
 Absence of menses by age 14
without secondary sexual
development
 Absence of menses by age 16
with normal secondary sexual
characteristic
 Secondary
 Absence of menses for 6 month
in a previous menstruating
female

Lect. By dr. Hasto Wardoyo, Sp. OG

50
 Terminology Definition
51 Definisi heavy
Prolonged menstrual
bleeding
menstrual
Menstrual period exceeding 8 days inbleeding dkk
duration on regular basis

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

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

Absent menstrual bleeding No bleeding in a 90 days period

(amenorhea)
Infrequent menstrual One or two episode in a 90 day period
bleeding
Frequent menstrual bleeding More than four time episode in a 90 day period

Heavy menstrual bleeding Excessive menstrual blood loss that interferences with the woman
physical, emotional, social, and material quality of life and can occur
alone or in combination with other symptom

Heavy and prolonged Less common than HMB, its important to make a distinction from HMB
menstrual bleeding given they may have different etiologies and respond to different
therapies
Light Menstrual Bleeding Based on patient complaint, rarely related to pathology
 52
Terminology Definition
Acute Abnormal Uterine Episode of bleeding in a woman of reproductive age, who is not
Bleeding pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss

Chronic Abnormal uterine Bleeding from the uterine corpus that is abnormal in duration,
bleeding volume, and/or frequency and has been present for the majority of
the last 6 month
Irregular Non Menstrual Irregular episode of bleeding, often light and short, occurring
Bleeding between normal menstrual period. Mostly associated with benign
or malignant structure lesion, may occur during or following sexual
intercourse
Post menopausal bleeding Bleeding occurring >1 year after the acknowledge menopause
Precocious menstruation Usually associated with other sign of precocious puberty, occur
before 9 years of age
 Amenorrhea primer
53

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

MENARKE
II. GADIS USIA 16 TH TANDA SEKS SEKUNDER (+) TETAPI
BELUM MENARKE
54
Diagnosis of
primary
amenorrhea
 55

Diagnosis of
secondary
amenorrhea
56
 Functional hypothalamic amenorrhea:
57
• the hypothalamic-pituitary-ovarian axis is
suppressed due to an energy deficit
stemming from stress, weight loss
(independent of original weight), excessive
exercise, or disordered eating.
• It is characterized by a low estrogen state
without other organic or structural disease
• Menses typically return after correction of
the underlying nutritional deficit.
 Menopause
58
Definisi: Berhentinya siklus menstruasi untuk selamanya bagi wanita
yang sebelumnya mengalami menstruasi setiap bulan, yang
disebabkan oleh jumlah folikel yang mengalami atresia terus meningkat,
sampai tidak tersedia lagi folikel, serta dalam 12 bulan terakhir
mengalami amenorea, dan bukan disebabkan oleh keadaan patologis,
rata-rata usia 50 tahun
Perimenopause
It is 3-5 years period before menopause with increase frequent
irregular anovulatory bleeding followed by episodes of
ammenorrhea and intermittent menopausal symptoms.
Menopause:
- The point in time at which menstrual cycles permanently cease. It is
a retrospective diagnosis after 12 months of ammenorrhea women
classified as being menopause.
- Mean age – 51 years.
 II. Pathophysiology
 pada usia sekitar 50 tahun fungsi ovarium menjadi sangat menurun.
59 Folikel mencapai jumlah yang kritis, maka akan terjadi gangguan
sistem pengaturan hormon
 insufisiensi korpus luteum, siklus haid anovulatorik dan pada akhirnya
terjadi oligomenore
 Masa perimenopause aktivitas folikel dalam ovarium mulai
berkurang.
 Ketika ovarium tidak menghasilkan ovum dan berhenti
memproduksi estradiol, kelenjar hipofise berusaha merangsang
ovarium untuk menghasilkan estrogen, sehingga terjadi
peningkatan produksi FSH.
 Pada pascamenopause kadar LH dan FSH akan meningkat, FSH
biasanya akan lebih tinggi dari LH sehingga rasio FSH/ LH menjadi
lebih besar dari satu.
 Hal ini disebabkan oleh hilangnya mekanisme umpan balik negatif
dari steroid ovarium dan inhibin terhadap pelepasan gonadotropin.
Diagnosis menopause dapat ditegakkan bila kadar FSH lebih dari 30
mIU/ml
60
61
62
 III. Symptoms of Menopause:
63

1. Hot flushes - cutaneous 3. Psychological changes

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

2. Urinary Symptoms
- urgency
- frequency
- nocturia
 4. Atrophic Changes
64  Vagina
*vaginitis due to thinning of epithelium, ↓ PH and lubrication.
*dysparnue→due to decrease vascularity and dryness
 Decrease size of cervix and mucus with retract of segumocolumnar (SC)
junction into the endocervical canal.
 Decrease size of the uterus, shrinking of myoma & adenomyosis.
 Decrease size of ovaries, become non palpable.
 Pelvic floor - relaxation →prolapse.
 Urinary tract →atrophy →lose of urethral tone →caruncle
Hypertonic Bladder - detrusor instability
 Decrease size of breast and benign cysts.
5. Skin Collagen – ↓ collagen & thickness → ↓ elasticity of the skin.
6. Reversal of premenstrual syndrome
 Diagnosis
65
 Diagnosis menopause dibuat setelah terdapat
amenorea sekurang-kurangnya 12 bulan terakhir, kadar
FSH > 30 mIU/ml dan kadar E2 < 30pg/ml (Rogerio, 2000;
Baziad, 2003).

Terapi
 Estrogen – a minimum of 2mg of oestradiol is needed to
mantain bone mass and relief symptoms of menopause.
 Women with uterus – add progestin at last 10 days to
prevent endometrial Hyperplastic
 Sequential Regimens - used in patient close to
menopause.
Oestrogen – in the first ½ of 28 day per pack
& Oestrogen & Progetin in 2nd 1/12 of 28 day pack..
66 Benefits of HRT:
Vagina-↑ vaginal thickness of epithelium
→↓ dyspareunia & vaginitis.
Urinary tract – enhancing normal bladder
function.
Osteoporosis – decrease fractures by
more than 50%
CVS – decrease by 30% by observation
studies but recent studies shows no
benefits.
Colon Cancer decrease up to 50%
 Post Menopausal Bleeding:
67
 Vaginal bleeding occurs after 12 months of Amenorrhea in middle
age women who are not receiving replacement therapy.

Etiologi:
 Endometrial Ca:
The most common Gynecological malignancy.
-Endometrial neoplasia can progress from simple hyperplasia to investive Ca
caused by unopposed oestrogen.
 The mechanism of many End. Ca. is prolonged oestrogen stimulation of the
endometrium unopposed by progesterone. The source may be:
a. Exogenous Estrogen (E2) (ERT)
b. Peripheral Aromatization of Androstendione to estrone –obesety or PCO
c. Estrogen (E2) producing tumor (like granuloza cell ovarian tumour)
d. Tamoxifen Stimulation of Endometrium
 PMS (Pre Menstrual Syndrome)
68
the cyclic recurrence in the luteal phase of
the menstrual cycle of a combination of
distressing physical, psychological, and/or
behavioral changes of sufficient severity to
result in deterioration of interpersonal
relationships and/or interference with
normal activities..

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

Lect. By dr. Hasto Wardoyo, Sp. OG ACOG 2008

69
INFERTILITAS
70
Infertility
 Infertilitas
71

failure of a couple to conceive after 12 months of regular intercourse

without use of contraception in women less than 35 years of age; and
after six months of regular intercourse without use of contraception in
women 35 years and older

40% faktor istri

40% faktor suami
20% pada keduanya
wanita: 35-60% faktor tuba & peritonium
10-25% kasus: Unexplained infertility

Faktor Suami
a. 35% : faktor sperma
-b. Gangguan transportasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan
kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome,
Myotonic distrophy), kelainan hipotalamus-hipofisa
-c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.
72
 Faktor Istri:
73 Infeksi
Gangguan ovulasi
Gangguan anatomi
Gangguan Ovulasi

•Penuaan (usia)
•POF
•Polikistik Ovarii (PCOS)
•Kelainan pada hipotalamus-
hipofisis
•Hiperprolaktin
•Kelainan kongenital
74
75

Analisa Sperma
76 ANALISA SPERMA
 Fertilitas seorang pria ditentukan A: bergerak cepat dan lurus
oleh jumlah dan kualitas B: Bergerak lambat dan tidak lurus
spermanya
C : bergerak ditempat
Normozoospermia
D : tidak bergerak
 Jumlah sperma ≥ 20 juta/ml
Teratozoospermia
Oligozoospermia
 Morfologi sperma normal < <30%
 Jumlah sperma < 20 juta/ml
 OligoAstenoTeratozoospermia – sindroma
Astenozoospermia OAT
 Motilitas sperma a<25% atau Azoopermia  0 sperma + plasma semen
a+b <50%
Aspermia  0 sperma + 0 plasma semen
77 Motilitas spermatozoa dan viabilitas
 Digunakan untuk kriteria D  tidak bergerak  uji viabilitas
 Pewarnaan supravital menggunakan Eosin Y dengan prinsip sperma hidup
tidak dapat menyerap zat warna dan sebaliknya denan sperma mati
(disintegrasi membran sel)
 Dilihat dibawah mikroskop
 Sperma hidup  kepala bening
 Sperma mati  kepala ungu
 Dari 100 sperma yang dihitung
 80 sperma kepala bening
 20 sperma kepala ungu
 Uji Viabilitas 80%
 Sindroma Ovarium Polikistik
78 Kelainan endokrin
 wanita usia reproduktif

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

Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia
79

Source: http://www.pathophys.org/pcos/

Lifestyle modification: may help
attenuate 80 all symptoms of PCOS
and reduce the long-term risk of
infertility, CVD and T2DM.
Therapy
• First line of PCOS management.
• Increased exercise, improved diet, and weight loss can help to reduce the
metabolic abnormalities associated with PCOS.
• Weight loss 5-10%  correct oligoanovulation & improve conception.

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

Metformin: treatment of glucose Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin
intolerance, hyperinsulinemia, and sensitivity and decreasing hepatic gluconeogenesis and lipogenesis; it can
anovulation. Reducing circulating therefore be used to help prevent and treat T2DM. Treating these factors can also
insulin levels may secondarily induce ovulation.
reduce ovarian androgen synthesis. Combined treatment with metformin and clomiphene citrate (see below) more
effective than either agent alone in inducing ovulation.
Source: http://www.pathophys.org/pcos/
Clomiphene Clomiphene citrate is a selective estrogen receptor modulator (SERM). It
induces ovulation by interfering with estrogen feedback to the brain and
thus increasing FSH release. There is increased risk of multigestational
81 pregnancy (e.g. twins or triplets) because of the large number of antral
follicles in polycystic ovaries. Clomiphene citrate treatment should be
limited to 12 cycles because longer-term treatment is associated with
increased risk of ovarian cancer due to ovarian hyperstimulation.

Gonadotropin therapy: recombinant FSH and Exogenous gonadoptropins can be administered to mimic physiological
hCG can be used to induce ovulation in mechanisms of follicle development. FSH is given to promote growth of a
cases where treatment with clomiphene dominant follicle to a particular size, and then human chorionic
citrate and metformin has been unsuccessful. gonadotropin is used to induce ovulation.

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

IVF: used for the treatment of infertility in IVF involves the retrieval of oocytes from the ovaries and in vitro
women who have not responded to other combination with sperm to produce embryos. Viable embryos are then
therapies to induce ovulation. transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.
82 Fertility Test
 LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
 Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.
 in premenopusal women, the normal LH-FSH ration is 1:1 as measured on
day three of the menstrual cycle
 Variation from this ratio used to diagnose PCOS or other disorders, explain
infertility or verify that woman has entered menopause
 FSH stimulates the ovarian follicle to mature. Then a large surge of LH
stimulates the follicle to release an egg to fertilization
 On day 3 of the cycle, LH should be low. If LH is elevated on this day,
possible even as high as FSH, then it suggest problem with ovulation.
Ovulation requires an LH surge, and if LH is already elevated, it may not
surge and ovulated
83
 Kista Gartner

Kista yang terdapat didinding

lateral vagina
Berkembang dari sisa duktus
mesonephric atau duktus
gartner
Biasanya asimtomatis
 Kista dan Abses Bartholini
85
 Kista bartholini adalah kista yang
terbentuk akibat sumbatan pada
ductus/ kelenjar bartolini & retensi
sekret
 Umum pada wanita umur
reproduksi
 Lokasi pada labia mayora.
 apabila terinfeksi  abses
 Abses 3 kali lebih umum dari pada
kista
86 Patologi
 Abses Bartholini merupakan
polymikrobal infeksi
 Neisseria gonorrhoeaea
yang paling umum
 Jika tidak inflamasi 
asimtomatik
 Simtom: nyeri vulva,
dispareunia, kesulitan
berjalan/olah raga
Isolates from Bartholin's Gland
Abscesses
Aerobic organisms
Neisseria gonorrhoeae
Staphylococcus aureus
Streptococcus faecalis
Escherichia coli
Pseudomonas aeruginos
Chlamydia trachomatis
Anaerobic organisms
Bacteroides fragilis
Clostridium perfringens
Peptostreptococcus
species
Fusobacterium species
87 Patofisiologi
Infeksi bakteri  cepat menjadi abses  keluar
lewat duktus  tersumbat: abses membesar
Radang bisa berulang (68-75%)
Jika menahun  terbentuk kista
88 Penatalaksanaan
Asimtomatik  tidak perlu terapi
Incisi dan drainase  tx cepat & mudah 
kemungkinan rekuren
WORD CATHETER
MARSUPIALIZATION
INCISI & DRAINASE
 WORD CATHETER
 Pembuatan 5 mm incisi pada
kista atau abses
 Masukkan kateter Word dan
dikembangkan dengan 2-3 ml
saline  selama 3-4 minggu
 Jika tidak ada bukti infeksi 
tidak perlu antibiotik

89
 Marsupialisasi
 Membuka rongga tertutup mjd kantong
terbuka.
 Untuk cegah kista berulang
 Dengan lokal anestesi
 Pembuatan insisi vertikal elips 1,5-3 cm
(sesuai garis Langer)
 Cukup dalam sampai kulit vestibular
dinding kista
 Pengeluaran isi kista dg sendok kuret
kecil sampai bersih
 Dinding kista dijahit ke kulit vertibular
dengan jahitan interupted
91 Incisi dan drainase

Dilakukan pada pasien yang tidak respon pada

terapi konservatif  tidak ada infeksi aktif

Kekambuhan
• Pemasangan balon kateter Word (Kambuh 3-17%)
• Marsupialisasi (Kambuh 10-24%)
• Eksisi  risiko perdarahan
92
Kista Nabothian

 Kista nabothian merupakan benjolan kecil di leher

rahim yang berisi cairan.
 Benjolan ini terjadi karena adanya penyumbatan
dari kelenjar.
 Tidak didapatkan tanda dan gejala apapun, kista
nabothian biasanya di temukan pada saat
pemerikasaan spekulum.
 Kista nabothian tidak berbahaya, sehingga tidak
diperlukan pengobatan apapun.
93
INFEKSI KONGENITAL
94
Teratogen: TORCH
95
96
97
TOXOPLASMOSIS

In pregnancy, the most

common mechanisms of
acquiring infection:
1. consuming raw or very
undercooked meats or
contaminated water,
2. exposure to soil
(gardening without
gloves) or
3. Exposure to cat litter
98
99
100
101
 Amniocentesis should not
be offered at less than 18
weeks’ gestation
102 because of the high rate of
false-positive results.

Spiramycin: fetal
prophylaxis

Pyrimethamine  folic
acid antagonist. Should
not be used in the first
trimester because it is
potentially teratogenic.

Folinic acid: to
counteract bone
marrow depression by
pyrimethamine
103 Congenital Toxoplasmosis
maternal infection 3 month before conception or during pregnancy

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

 Spiramicin: 1g per 8 jam bersama makan
 >18 minggu (diberikan sampai lahir):
 Pirimetamin 50 mg 2x sehari, selama 2 hari, dilanjutkan 50 mg/hari
 Sulfadiazine loading 75 mg/kg, dilanjutkan 50 mg/kg 2x sehari
 Asam folat : 10-20 mg/hari hingga 1 minggu bebas pirimetamin

Uptodate.com, medscape
104
105 Rubella
106
After infecting the
placenta, the
rubella virus
spreads to the fetal
vascular system 
cytopathic
damage to blood
vessels  ischemia
107
Risk of congenital defects:

Before 11 weeks of gestation  90%

13 -14 weeks  11%
15-16 weeks  24%
After 16 weeks  0%
108
109
110
111 CMV
112
 Symptomatic CMV infection
113
 Petechiae (54 to 76 percent)
 Jaundice at birth (38 to 67 percent)
 Hepatosplenomegaly (39 to 60 percent)
 Small size for gestational age (39 to 50
percent)
 Microcephaly (36 to 53 percent)
 Sensorineural hearing loss (SNHL, present
at birth in 34 percent)
 Lethargy and/or hypotonia (27 percent)
 Poor suck (19 percent)
 Chorioretinitis (11 to 14 percent)
 Seizures (4 to 11 percent)
 Hemolytic anemia (11 percent)
 Pneumonia (8 percent)
114
115
 Treatment
116

 Once the diagnosis of congenital CMV infection is

confirmed, one option is pregnancy termination.
 A second proposed option: treatment of the mother with
antiviral agents (ganciclovir, foscarnet, and cidofovir.)
 These drugs are of moderate effectiveness in treating CMV
infection in the adult
 No proven value in preventing or treating congenital CMV
infection.
 The most promising therapy for congenital CMV
Source;
infection appears to be hyperimmune globulin.
http://www.peri
natology.com/e
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
DXMOTHER
117 Varicella Syndrome : USG findings

 Calcification
o intrahepatic
o Intracranial : may also see liver, heart, and renal
 Poly hydramnion : due to neurologic impairment of
swallowing
 Limb Hipoplasia
 Microcephaly
 Varicella Infection
118

Hepatic calcification Zooster Lesion Radioulnar hipoplasia and

missing hand
119 Management
 Fetal Infection
 Amniocentesis (culture or PCR of virus)
 Fetal MRI : CNS

 Maternal infection symptomatic

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

Maternal zooster outbreak in pregnancy is not associated with risk

of fetal malformation
120 Gynecology is done.... For now!

Alhamdulillah 