Contoh Stase Logbok Pranikash Dan Konsepsi

BUKU LOGBOOK PRAKTIK PROFESI
STASE ASUHAN KEBIDANAN PRA NIKAH DAN PRA

KONSEPSI
IDENTITAS MAHASISWA
PROGRAM STUDI PENDIDIKAN PROFESI

BIDAN PROGRAM PROFESI
Nama Mahasiswa : ISRAINI SURIATI.S.ST.M.Keb

NIM : 202210163
Tempat/ Tanggal Lahir : Cilellang, 20 Februari 1989
No. Hp : 081343882814
Email : israinisuriati@umpalopo.ac.id
Alamat : Perumahan Tolauro, Blok F no.07
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
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 : PMB HJ. BIDAN ROSMIATI, S.ST
Bagian : PMB
ii
C. KOMPETENSI YANG INGIN DICAPAI
1. Konseling pranikah
2. Konseling Kesehatan reproduksi pada wanita

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
E. Bentuk Kegiatan
No Target Stase Tanggal Pelaksanaan Catatan TTD Preseptor
1 CBD 20 JANUARI 2023 Mampu memberikan
asuhan dengan baik
dan sistematik
2 Refleksi Kasus 20 JANUARI 2023 Mampu Melaksanan

Kasus dengan baik
3 OMP 20 JANUARI 2023 Telah diberikan feed

Back
4 Journal reading 20 JANUARI 2023 Telah diberikan feed

Back
5 BST 20 JANUARI 2023 Telah diberikan feed

Back
Jenis 20 JANUARI 2023

keterampilan NY. I KIE ANAMNESIS
BST: persiapan RM.XXXXX
menjadi calon Ibu telah bersedia
orang tua melakukan kunjungan
/anamneses ulan
pranikah/
prakonsepsi KIE
persiapan
kehamilan
Jenis 20 JANUARI 2023 Scrining HIV dilakuakn
keterampilan dengan baik
BST 2:
Follow Up 13 April 2023 Follow Up 13 April
2023
iv
v
LAPORAN CASE BASED DISCUSSION (CBD)
STASE PRANIKAH PRAKONSEPSI
ASUHAN KEBIDANAN PADA NN I DENGAN AMENOREA
TAHUN AKADEMIK 2022/2023
Preseptor Pembimbing Pendidikan : Nur Laela, S.ST., M. Keb
Disusun Oleh : ISRAINI SURIATI.S.ST.M.Keb

202210163
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
PADA NN’I” TAHUN AKADEMIK 2023
pangkajene, 20 januari 2023
Preseptor Pendidikan Precptor Lahan Mahasiswa
Nur Laela, S.ST., M. Keb ISRAINI SURIATI.S.ST.M.KEB

ROSMIATI, S.ST
NBM: 1259290 NIM: 202210163
vii
DAFTAR ISI
DAFTAR ISI ...................................................................................................... i
PENDAHULUAN
1. Latar Belakang .................................................................................................. 2
2. Tujuan ............................................................................................................... 3
TINJAUAN TEORI
A. KONSEP DASAR TENTANG KESEHATAN REPRODUKSI...................... 5
B. KONSEP DASAR AMENOREA ..................................................................... 6
DOKUMENTASI SOAP DAN RENCANA TINDAK LANJUT ................... 11
PEMBAHASAN ................................................................................................. 15
KESIMPULAN ................................................................................................... 16
REFERENSI........................................................................................................ 17
i
PENDAHULUAN
1. Latar Belakang
Kesehatan Reproduksi adalah kesejahteraan fisik, mental dan sosial yang utuh bukan
hanya bebas dari penyakit atau kecatatan, dalam segala aspek yang berhubungan
dengan sistem reproduksi, fungsi serta prosesnya. Baik laki-laki maupun perempuan
memerlukan landasan psikis yang memadai agar perkembangan emosinya
berlangsung dengan baik. Faktor yang mempengaruhi kesehatan reproduksi meliputi
Faktor sosial-ekonomi dan demografi (kemiskinan, tingkat pendidikan yang rendah
dan pengetahuan tentang perkembangan seksual dan reproduksi, serta tempat tinggal
didaerah terpencil). Faktor budaya dan lingkungan (praktek tradisional, kepercayaan
banyak anak banyak rejeki). Faktor psikologis (akibat dari keretakan orang tua,
depresi, kehilangan rasa kebebasan). Faktor biologis (cacat sejak lahir, cacat pada
saluran reproduksi pasca penyakit menular seksual).
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.

2
klimakterium (Kumalasari dan Andhyantoro, 2013)
Amenore suatu keadaan atau kondisi dimana pada seorang wanita tidak mengalami
menstruasi pada masa menstruasi sebagaimana mestinya atau secara sederhana
disebut dengan tidak haid pada suatu periode atau masa menstruasi. 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
Kesehatan Reproduksi, adalah: Suatu keadaan sejahtera secara utuh, tidak hanya
sebatas sehat secara fisik, tetapi juga mental dan sosial , tidak semata-mata
terbebas dari penyakit dalam semua hal yang berkaitan dengan alat/organ, fungsi,
sistem, atau proses reproduksi. Sehat Fisik, Kesehatan fisik terwujud apabila
sesorang tidak merasa dan mengeluh sakit atau tidak adanya keluhan dan memang
secara kasat mata tidak terlihat sakit. Semua organ tubuh berfungsi normal atau
tidak mengalami gangguan. Sehat Mental, hendaknya jangan diartikan secara
sempit sebagai kelaianan jiwa atau sering disebut gila, kita jangan menggunakan
ukuran kita sendiri mengenai batasan seseorang terhadap tekanan kejiwaan,
karena setiap orang memiliki daya tahan tubuh yang berbeda terhadap tekanan
kejiwaan tersebut, yang sangat dipengaruhi oleh berbagai hal yang menjadi latar
belakangnya. Sebagai contoh: seseorang anak mengalami depresi saat dipaksa
berhenti sekolah dan dinikahkan dengan orang lain oleh orang tuanya, dengan
tujuan melunasi hutang orang tuanya.
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 yangterjadi 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 beradadibawah label perdarahan uterus difungsional.
4) Metroragia , apabila menstruasi terjadi denganinterval 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 yaitu pernah mengalami menstruasi danselanjutnya 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 akibatgangguan
perkembangan. Amenore dalam ilmu TCM (Traditional
Chinese Medicine) disebut sebagai Jing-Bi disebabkan karena
malnutrisi, keadaan emosional (stress),perubahan lingkungan,
dan beberapa penyakit organreproduksi 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 untukmenjalani
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 asamdengan
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 efekestrogenik.
10
DOKUMENTASI SOAP DAN RENCANA TINDAK LANJUT
No. RM : 2X XX XX
Nama Pengkaji : ISRAINI SURIATI.S.ST.M.KEB
Tanggal MRS : 20-1-2023 Jam 10.00 WitaTanggal
Pengkajian : 19-1-2023 Jam 11.00 Wita
Tempat Pengkajian : PMB
IDENTITAS ISTRI/ SUAMI
1. Nama Istri : NN I
2. Umur : 22 Tahun
3. Suku : Luwu /Toraja
4. Agama : Islam
5. Pendidikan: SMA
6. Pekerjaan : Wiraswasta
7. Alamat : Songka
8. No. HP : 081 343 XXX XXX
a. Subjecktif ( S )
- Nn. I mengatakan sudah 3 bulan lebih belum mendapatkan
menstruasi
- Nn I mengeluh cemas dengan keadaannya
- Nn. I mengatakan haid pertama menstruasi umur 13 tahun
- Nn. I mengatakan siklus menstruasinya ± 30 hari.
- Nn. I mengatakan menstruasinya teratur
11
- Nn. I mengatakan menstruasinya 4 – 6 hari
- Nn. I mengatakan ganti pembalut 2 -3/hari
- Nn. I mengatakan sifat darahnya merah segar dan ada gumpalan
- Nn. I mengatakan tidak pernah nyeri perut bagian bawah saat
menstruasi
- Nn. I mengatakan belum pernah menikah
b. Objecktif ( O)
- Keadaan umum : Baik
- Kesadaran :Composmentis
- TTV :
- TTV TD : 100/80 mmHg R: 22x/menit N

: 81 x/menit S : 360 C TB: 160 cm BB :43 kg LILA :23
- Pemeriksaan fisik head to toe :
- Wajah : Nampak 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 I usia 21 tahun amenorea sekunder
d. Penatalaksanaan ( P )
- Jelaskan pada pasien tentang hasil pemeriksaan
Nn I 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 I 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 untukmengurangi 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
E. sinaga., N. Saribanon., S. Nailus., U. Salamah., Y. Andani A.Trisnawati,

S. L. (2017). [ No Title ]. In Manajemen Kesehatan Menstruasi (pp. 25–26).
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 Studiesand Beyond.
core.ac.uk/download/pdf/12348799.pdf. diakses 24 November 2015
17
LEMBAR MONITORING PRE DAN POST CONFERENCE
NAMA MAHASISWA : Israini Suriati.S.ST.,M.Keb

NIM : 202210163
TEMPAT PRAKTIK :BPM Bidan Rosmiati,S.ST
MATERI BIMBINGAN :
PRE CONFERENCE POST CONFERENCE

Hari / Masukan Tanda Tangan Hari / Masukan Tanda Tangan
Tanggal Pembimbing Pembimbing Tanggal Pembimbing Pembimbing
20 Hari ini telah 20 Telah melakukan
Januari dilakukan KIE Januari SOP dengan baik
2023 Anamnesis Pran 2023 dan sistematik
PUKUL: nikah dan PUKUL:
11.00 Prakonsepsi 11.00
WITA WITA
Preseptor Lahan
(HJ.Bd. Rosmiati.S.ST.)
18
LEMBAR BIMBINGAN PRE CONFERENCE

NIM : 202210163
TEMPAT PRAKTIK :BPM Bidan Rosmiati,S.ST
MATERI BIMBINGAN :
HAL YANG DIDISKUSIKAN CATATAN PEMBIMBING KLINIK
Mahasiswa telah siap melakukan praktik stase II dan siap

melaksanakan praktik dan menjalankan TATIB yang telah berlaku
1. Kesiapan Mahasiswa dan ditetapkan oleh pihak institusi dan pihak lahan.
Mahasiswa siap dan bersedia masuk sesuai dengan aturan ship

2. Rencana Kegiatan (Kontrak Belajar) yang telah di susun dan ditetapkan oleh CI lahan.
1. Umpan Balik
1. Mahasiswa siap menegerjakan seluruh tugas dan target
yang telah ditetapkan sebagai standar dari kelulusan
mahasiswa
2. Hadir dengan tepat waktu
Pembimbing Klinik Mahasiswa Pembimbing Institusi
Hj. ROSMIATI,S.ST (ISRAINISURIATI.S.ST.,M.Keb) (.,Nur Laela, S.ST., M. Keb

)
19
LEMBAR BIMBINGAN POST CONFERENCE

NIM : 202210163
TEMPAT PRAKTIK : BPM Bidan Rosmiati,S.ST
MATERI BIMBINGAN :
HAL YANG DIDISKUSIKAN CATATAN PEMBIMBING KLINIK
Mahasiswa melakukan praktik stase II Asuhan Kebidanan

pada Pra Nikah dan Pra Konsepsi dan menyelesaikan
1. Kesiapan Mahasiswa target yang terdiri dari 10
1. Mahasiswa masuk sesuai dengan aturan ship yang

telah di susun dan ditetapkan oleh CI lahan.
2. Mahasiswa menyelesaikan Praktik dengan baik
2. Rencana Kegiatan (Kontrak Belajar) 3. Mahasiswa melaksanakan praktik sesusi dengan
aturan dan tatib yang berlaku
1. Mahasiswa mendapatkan nilai yang sangat

3. Umpan Balik memuaskan
2. Tingkatkan Pegetahuan dan Keterampilan
Hj. ROSMIATI,S.ST (ISRAINISURIATI.S.ST.,M.Keb) ( Nur Laela, S.ST., M.

Keb………………)
20
REFLEKSI KASUS
1. DESKRIPSI KASUS
Pada tanggal 20 januari 2023, Nona I datang Ke PMB HJ. BIDAN ROSMIATI,
S.ST di antar oleh ibunya. Nn. N mengatakan bahwa sampai saat ini dirinya
belum pernah menstruasi. Nn I mengeluh cemas dengan keadaannya Nn. N
mengatakan belum pernah menikah . Dari hasil pemeriksaan didapatkan
keadaan umum : baik kesadaran :composmentis TTV TD : 100/80 mmHg R:
22x/menit N
: 81 x/menit S : 360 C TB: 160 cm BB :43 kg LILA :23 cm dan Pemeriksaan
head to toe dalam batas normal
2. EMOSI PRIBADI
Pada saat saya melihat Nn. I, saya menydari Nona I terlihat cemas dan bingug
dengan kondisi kesehatan reproduksinya saat ini. Perasaan pertama setelah
melihat Nona I 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.
21
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
22
estrogen
6. TINDAK LANJUT
Pada kasus Nona I , 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
23
LAPORAN PRAKTIK PROFESI READING JURNAL
TENTANG FAKTOR YANAG BERHUBUNGAN DENGAN
KEJADIAN AMENOREA
TAHUN AKADEMIK 2023
Disusun Oleh : ISRAINI SURIATI.S.ST.M.KEB
202210163
PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM

PROFESI FAKULTAS KEPERAWATAN DAN KEBIDANAN
ITKES MUHAMMADIYAH SIDRAP
24
HALAMAN PENGESAHAN READING JURNAL
TENTANG FAKTOR YANAG BERHUBUNGAN DENGAN
KEJADIAN AMENOREA
TAHUN AKADEMIK 2023
Hj. ROSMIATI,S.ST (ISRAINISURIATI.S.ST.,(Nur Laela, S.ST., M. Keb

M.Keb) ………………………)
KATA PENGANTAR
Assalamualaikum Warahmatulahi Wabarakatuh

Dengan mengucapkan puji syukur kehadirat Allah, penulis dapat
menyelesaikan jurnal reading yang berjudul asuhan kebidanan pada kasus FAKTOR
YANAG BERHUBUNGAN DENGAN KEJADIAN AMENOREA ”. 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, 20 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)
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)
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, sepertiadenoma
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
Tanggal 8 menikah ISRAINI
SURIATI.S.ST.M.KEB
/1/2023 O:
- Keadaan umum : Baik
Jam :19.56
- 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
amenorea primer
P:
- Jelaskan pada pasien
tentang hasil pemeriksaan
Hasil : Nn K telah
mengetahui kondisi
kesehatannya saat ini
- Berikan KIE pada pasien Preseptor lahan
mengenai amenore primer
Hasil : Nn K sudah
mendapatkan konseling dan
edukasi mengenai
amenorea primer
- Anjurkan pasien untuk
istirahat yang cukup
- Hasil : Nn K sudah HJ.Rosmiati,S.ST
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
Jurna; Stieks FAKTOR Remaja - Pemberian -
Pada asuhan kebidanan Responden untuk 1 hari
Indramayu: YANAG yang konseling mengenai yang telah saya lakukan berpartisipasi aktif
https://ojs.stikesi BERHUBUN mengalami nutrisi dalam dengan kasus amenorea dalam menjaga
ndramayu.ac.id/i GAN amenorea penanganan amenorea ada kesenjangan antara kesehatan khususnya
ndex.php/JKIH/a DENGAN primer primer asuhan kebidanan yang bagi
rticle/download/ KEJADIAN berjumlah - Faktor -
telah diberikan dengan responden dengan
AMENOREA status gizi gemuk
306/154/ 293 orang prognostik dalam intervensi yang dan obesitas perlu
PADA tercantum pada jurnal ini
penelitian ini ialah melakukan olah raga
WANITA
kelainan genetika teratur dan
USIA SUBUR
melakukan diet
- sehat
Jurnal Kesehatan . Hubungan - Pemberian Pada asuhan kebidanan - Kecemasa 1 hari
Andalas Anxietas konseling mengenai yang telah saya lakukan n remaja mengenai
dengan nutrisi dalam dengan kasus amenorea amenorea primer
http://jurnal.fk.un Kejadian penanganan primer tidak ada berkurang
and.ac.id/index.ph Amenore amenorea primer kesenjangan antara
p/jka/article/view/ Sekunder - Faktor asuhan kebidanan yang
211 pada prognostik dalam telah diberikan dengan
Mahasiswi penelitian ini ialah intervensi yang
Fakultas kelainan genetika tercantum pada jurnal ini
Kedokteran
Universitas
Andalas:
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 17 tahun dengan
amenorea primer sejalan dengan hasil reading jurnal pertama yang oleh (E. Bacchi, 2013) dalam
jurnal reading yang saya telaah, Hasil penelitian menunjukkan bahwa sebagian besar status gizi
responden adalah gemuk sebanyakc 36 responden (47,4%), responden menggunakan obat KB
sebanyak 48 responden (63,2%) dan responden mempunyai tingkatan stres sedang sebanyak 37
responden (48,7%). Analisis bivariat dengan chi-square menunjukkan ada hubungan positif
antara status gizi dengan kejadian amenorrhea, ada hubungan positif antara stres dengan kejadian
amenorrhea serta ada hubungan positif antara penggunaan obat KB dengan kejadian amenorrhea.
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 yangmengalami
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
Bartini. (2019). Buku Ajar Asuhan Kebidanan Kehamilan. EGC.

Manuaba, I.B.G. 2013 Memahami Kesehatan Reproduksi Wanita. Jakarta : EGC
Merin,2013. Amenorrhea: Cytogenetic Studiesand Beyond.
core.ac.uk/download/pdf/12348799.pdf.
Nugroho dan utama, 2014. Masalah Kesehatan Reproduksi Wanita. Yogyakarta:Medical Book
DAFTAR TILIK ASUHAN KEBIDANAN PADA PRANIKAH
DANPRAKONSEPSI
PROGRAM STUDI PENDIDIKAN PROFESI
BIDANITKES MUHAMMADIYAH SIDRAP

TAHUN AJARAN 2021/2022
2
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
JENIS KETERAMPILAN BIMBINGAN BED SIDE TEACHING (BST)
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 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 PMB HJ. BIDAN ROSMIATI, S.ST
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 cukupPersiapan
Alat
1. Timbangan
2. Pengukur tinggi badan
3. Pengukur lila
4. Food model
5. Lembar balik
6. dokumentasi
7. Bolpoin
23
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 mengkonsumsimakanan 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
24
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
25
CEKLIS PERSIAPAN KEHAMILAN SEHAT
Petunjuk penilaian :
0 = tidak dilakukan
1 = dilakukan tidak sempurna
2 = dilakukan dengan sempurna
NO ASPEK YANG DINILAI NILA

I
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
26
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
HJ.Rosmiati.S.ST.
27
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

Skenario Seorang perempuan datang ke PMB HJ. BIDAN
ROSMIATI, S.ST bersamapasangannya membawa pengantar dari
KUA untuk mendapatkan
layanan pranikah.
Persiapan pasien Menjelaskan tujuan dilakukan anamnesa
6. Ventilasi cukup
Persiapan Alat
8. Lembar dokumentasi
9. Bolpoin
28
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
29
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
30
CEKLIST ANAMNESA PRANIKAH/PRAKONSEPSI
0 = tidak dilakukan
NO BUTIR YANG NILA

DINILAI I
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
31
25 Teruji melaksanakan dengan percaya diri dan tidak ragu-ragu
Score : 10
Total Score : 52
Nilai Akhir = (Total score :52) x

100 Sidrap, 21 Januari 2023
CI lahan
HJ.rosmiati,S.ST
32
KIE PERSIAPAN MENJADI ORANG TUA
PRODI KIE PERSIAPAN MENJADI ORANG TUA

KEBIDANA NO DOKUMEN NO REVISI HALAMAN
N
PROGRAM
PROFESI
TETAP DITETAPKA
N ( )
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
Skenario Seorang perempuan datang ke PMB HJ. BIDAN
ROSMIATI, S.ST bersamapasangannya 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
33
CEKLIST KIE PERSIAPAN MENJADI ORANGTUA
0 = tidak dilakukan
NO BUTIR YANG NILA
DINILAI I
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
34
Nilai akhir = (Total score :42) x 100
HJ.rosmiati,S.ST
35
36
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
37 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
HJ.Rosmiati.S.ST.
38
STANDAR OPERATING
PROSEDUR
PRODI PEMERIKSAAN
KEBIDANAN IVA
PROGRAM NO DOKUMEN NO REVISI HALAMAN
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 PMB HJ. BIDAN ROSMIATI, S.ST
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
4. Konseling pasca tindakan IVA
Referensi Peraturan Menteri Kesehatan No 35 Tahun 2015 Tentang
39 Penanggulangan Kanker Payudara dan Kanker Leher Rahim
40
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 tindaklanjut
atau pengobatan yang mungkin diperlukan.
Pastikan semua peralatan dan bahan yang diperlukan tersedia,
termasuk spekulum steril atau yang telah di DTT, kapas lidi dalam
2 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 apabila ada
6 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.
41
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.
42 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 PMB HJ.
BIDAN ROSMIATI, S.ST/klinik. Akan lebih baik jika
kepastian waktu rujukandapat disampaikan
pada waktu itu juga.
Score : 44
C TEKNIK
Score : 4
Total Score : 58
NILAI AKHIR = (Total Score/ ) x 100
CI lahan
HJ.Rosmiati.S.ST.
42
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)
Menghidupkan lampu sorot, diarahkan dengan benar padabagian
9
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%
selama 30 menit
17 Melepas spekulum dengan hati – hati
43
Memberitahukan kepada pasien bahwa pemeriksaan sudahselesai,
18 merapikan pasien dan menyampaikan hasil
Pemeriksaan
Membereskan alat dan membuang sampah pada
19
tempatnya
Score : 28
C TEKNIK
Score : 4
Total Score : 42
NILAI AKHIR = (Total Score/42) x 100
Sidrap, 21 Januari 2023CI
lahan
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,
sacrificed to minimise energy loss, together with
lower circulating glucose levels, elevated insulin-
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 on
glucose levels in a state of energy deficiency.[14] 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 Hormone

stress management in Replacement in Women with Exercise-
Womenwith Exercise- AssociatedReproductive Dysfunction
Associated Reproductive
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’
and reduced workloads are helpful for restoration of
also concern over a possible increased risk of car-
menses. Dueck and colleagues[52] were able to effect
diovascular disease occurring because of changes in
some changes in the reproductive system but their
lipid profiles associated with estrogen deficiency. programme was only over 15-week period. An
There is also a tendency for amenorrhoeic athletes amenorrhoeic athlete experienced a transition from
to have slightly less favourable lipid profiles,[28-30] negative to positive energy balance, increasedbody
and this has been taken to mean an increased risk of 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
mineral density and reduce fracture rates in post-
pears to be an increased risk of exercise-related
menopausal women.[55] A series of studies in youn-
fractures.[31-37] Estrogen status and heredity are ma-
ger women with a range of reproductive abnormal-
jor determinants of bone mass, and together with ities including hypothalamic amenorrhoea and
diet, probably explain most of the variance in bone ovarian failure has suggested that bone density will
mineral density seen in amenorrhoeic athletes.[38,39] increase but not usually to levels found in normally
However, amenorrhoea in gymnasts appears less menstruating healthy young women (table I ).[56-62]
likely to cause bone loss than in runners.[40] There Metka and colleagues[56] observed an increase in
is conflicting evidence over whether luteal phase 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-
drome using the same regimen also had an increase
plex nature of these changes raises the significant
in bone mineral density, but not to normal val-
question as to whether hormone replacement alone
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 and5
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; placebo
n = 16 MPA only 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.
ues.[59] There were no controls. In the only random-

ues.[57] The study was uncontrolled. There were no
differences, in terms of bone mineral density, be-
tween two patients with anorexia nervosa taking
low dose oral contraceptive pills, and two untreated
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-
ised controlled study, 48 women with anorexia
nervosa were treated with cyclic conjugated
estrogen and medroxyprogesterone (26
controls).[60] There was no difference between the
groups, and body-
1029
Esw
troegig
enhtThwearaspay fsoirgA
nim
fiecnaonrtrhporeeidc iActholretoesf
response. 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 therewas 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 re- ducing
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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Phys Sportsmed 1981; 8: 42-52
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controlled study with fracture rates as the major of therapy for exercise-associated amenorrhea: a brief report.
Clin J Sport Med 1995; 5: 246-50
Estrogen Therapy for Amenorrhoeic Athletes 1031
3. Loucks AB, Verdun M, Health EM. Low energy availability, not

stress of exercise alters LH pulsatility in exercising women. 25. Sahota O, Hosking DJ. The contribution of nutritional factors to
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4. Warren MP, Perlroth NE. The effect of intense exercise on the 2001; 4: 15-20
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Steril 1981; 36: 183-7 terol levels in amenorrheic athletes: effects of endogenous
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Available online at www.sciencedirect.com
ScienceDirect
Stress Management With Girls Secondary

Amenorrhea
Blazej Meczekalski1, Olga Niwczyk 1, Gregory Bala2 and
Anna Szeliga1
Abstract Introduction
Functional hypothalamic amenorrhea (FHA) is the mostcommon Functional hypothalamic amenorrhea (FHA) is a chronic
cause of secondary amenorrhea in women of repro-ductive age. endocrine disorder caused by a disturbance in the pulsatile
FHA is predominantly caused by stress,decreased caloric intake, secretion of hormones in the hypothalamus, which in turn
excessive exercise, or a combinationthereof. These physical, results in suppression of the hypothal-
psychological, and metabolicstressors cause aberration in the amicepituitaryeovarian axis. Inhibition of pulsatile
pulsatile release of gonadotropin-releasing hormone (GnRH) and gonadotropin-releasing hormone (GnRH) secretion in the
subsequently hypothalamus decreases follicle-stimulating hormone
impair function of the hypothalamic–pituitary–ovarian (HPO)
(FSH) and luteinizing hormone (LH) secretion from the
axis. Various neurotransmitters acting in the central nervous pituitary gland. This sequence leads to the suppression of
system are involved in control of the HPO axis and of these, hormonal and reproductive functions of the ovary [1,2].
kisspeptin is one of the most important. Corticotropin-releasing
hormone (CRH), also inhibits the pulsatile secretion of GnRH and
Secondary amenorrhea, which is characterized as amen-
orrhea occurring in a previously menstruating woman, af-
also acts as an intermediary between stress factors and the
fects approximately 3%e5% of the mature female
reproductive system. One of the main ongoing concerns in patients
population. FHA is responsible for 25%e35% of secondary
with FHA is chronic hypoestrogenism, a condition, which is
amenorrhea, making it the most common cause of sec-
associated with sexual dysfunction and infertility. It may also lead ondary amenorrhea in our population [3]. FHA will
to osteoporosis, and predispose to neurode- generative and negatively affect the health of women of childbearing age in
cardiovascular diseases.28 adolescent with secondary amenorrhea. a variety of ways. Chronic hypoestrogenism associated
Treatment of stress management to secondary amenorrhea for with this disease has a negative effect on the skeletal
adolescent with significacy p system, cardiovascular system, nervous system, sexual
=0.001 function, and mental health. Beyond hypoestrogenism,
multiple other metabolic and neuroendocrine alterations
Addresses
1 presented in FHA affect bone homeostasis. For instance,
Department of Gynecological Endocrinology, Poznan University of
Medical Sciences, Poznan, Poland
recent studies have shown direct, beneficial roles of
2
Appletree Medical Group, Ottawa, ON K1R 5C1, Canada kisspeptin in bone physiology, therefore decreased
kisspeptin level can also impair bone health [4]. Further-
Corresponding author: Meczekalski, Blazej (blazejmeczekalski@ more, connection between decreased leptin and IGF-1,
yahoo.com) elevated ghrelin and cortisol level as endocrine media-
tors of bone loss in FHA is an object of ongoing research
[5]. Moreover, disturbance in the secretion of gonado-
Current Opinion in Pharmacology 2022, 67:102288
tropins results in significant impairment of reproductive
This review comes from a themed issue on Endocrine and metabolic function due to concomitant anovulation [1,2].
diseases (2023)
Edited by Stephanie Constantin and Ivana Bjelobaba Three main factors contribute to the development of FHA,
For complete overview about the section, refer Endocrine and
namely: stress, excessive exercise, and decreased food
metabolic diseases (2023) intake. An overall decreased energetic balance causes
dysregulation of hypothalamic nuclei, which in turn disrupt
Available online 11 September 2022
the action of kisspeptin/neurokinin B/dynorphin
https://doi.org/10.1016/j.coph.2022.102288 (KNDy) neurons. Decreased secretion of kisspeptin, in
1471-4892/© 2022 The Author(s). Published by Elsevier Ltd. This is an turn, contributes to abnormal pulsatile secretion of GnRH,
open access article under the CC BY-NC-ND license (http:// eventually causing FHA. Variability in susceptibility to
creativecommons.org/licenses/by-nc-nd/4.0/). 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 GnRHontogeny expression in both the arcuate nucleus (ARC) and the
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 of
nowadays there is a growing population living under 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 subsequently
influence kisspeptin expression and function. in GnRH secretion [21]. Specifically, NKBis responsible
for stimulation of KNDy to secrete kisspeptin and in turn
Treatment of stress management to secondary the downstream induction of GnRH release. In contrast,
amenorrhea for adolescent DYN neurons exert an inhibitory effect, suppressing
The gene KISS1 (KISS1) encoding the KISS1 protein was kisspeptin secretion, and in turn suppressing GnRH
first discovered in 1996 by a team from Hershey, 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 Kisses express estradiol a receptors (ERa) and progesterone
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 1q32 central regulator of systemic feedback for the repro-
and has four exons, the first two untranslated. The gene ductive system [12]. Because of those receptors, ovarian
encodes a precursor protein composed of 145 amino steroids can modulate the expression of KISS1 at the
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 acid the pulsatile release of GnRH [20]. Kisspeptin exerts the
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 these component in ovulation. The action of kisspeptin with
shorter proteins collectively share an N-terminal domain regard to reproduction descends all the wayto the level of
truncated at variable lengths but preser- ving a C-terminal the ovary. Kisspeptin exerts its influence on processes
sequence of Arg-Phe-NH2. This group of proteins is such as steroidogenesis, follicular matura- tion, ovulation,
collectively referred to as kisspeptins [10]. and ovarian senescence [23]. Furtherstudies, however, are
required to fully elucidate all aspects of the mechanisms
In 2001, KISS1 was identified as a ligand for the G by which kisspeptin is involvedin the physiology of
protein-coupled receptor 54 (GPR54) protein which was reproduction.
first described in the rat brain and then in humans, where
it is referred to as KISS1R [11]. Upon binding to KISS1, Changes at the level of KNDy neurons are responsible for
KISS1R activates phospholipase C and stimulates the the changes observed in menopause. Hypertrophy of
synthesis of intracellular secondary messengers, inositol KNDy neurons in the infundibular nucleus has been
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 preoptic observed. These changes are associated with a subse-
area and in the arcuate nucleus of the hypothalamus quent increase in the secretion of neurokinin B and
[13,14]. By stimulating the secretion of GnRH, KISS1 kisspeptin in the area [24].
stimulates the secretion of FSH and LH from the pituitary
gland. Mutations that inactivate the KISS1 or KISS1R A similar change was observed in oophorectomized
genes have been found to cause hypogonadotropic monkeys, which suggest that ovarian impairment and the
hypogonadism, while activating mutations cause loss of negative feedback by estrogen plays a key role in this
premature puberty [15,16]. 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 of
have shown that caloric restriction due to decreased food KNDy neuron hyperactivity, it also indicates that elevated
intake leads to a decrease in KISS1 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 a
(VMS) pathogenesis [25]. Additionally, decreases in pleiotropic response in different tissues, including
KNDy neuronal activity was associated with a decrease in promoting catecholamine release, mobilization of energy
skin vasodilation. All these observations support the stores, maintaining energy supply, and maintaining
hypothesis that KNDy neurons participate in the gen- negative influence on the immune system. Without
eration of hot flashes [26]. exposure to stress factors, CRH and consequently ACTH
and cortisol are secreted in a circadian, pulsating manner
Stress: A biological and hormonal with peak output in the early morning hours. This
background harmonic, pulsatile pattern of hormone secretion is
Homeostasis was coined as a term in the early 1900s by disrupted when challenged by a stressor. During an
Walter B. Cannon, the pioneer of stress response theory. episode of stress, CRH secretion significantly increases to
He characterized this new term as a state of steady inactivate the whole HPA axis. Additionally, other stress
ternal conditions. His work laid the foundation for future mediators are also released to synchronously stimulate the
study in which extended his theory to include conditions HPA axis. Glucocorticoids act in a negative feedback loop
which he described as threats to homeo- stasisdstressors. to control the basal activity of the HPA axis and eventually
Since this foundational work, understanding the human to terminate the stress response, preventing the negative
body’s reaction to stress factors has been studied catabolic effects of anelongated exposure to
extensively. Exposure to stress initiates a complex glucocorticoids.
biological response which draws interaction between
nervous, endocrine, and immune systems [27]. Two major The aim of these actions is to support essential organs so
components of the stress-response system are the as to ensure survival.
hypothalamicepituitaryeadrenal (HPA) axis and
sympathetic nervous system, which function coop- Impact of stress on reproductive function Since the
eratively in orchestrating the stress response [28]. origin of the human species, stress has beenan integral
part of everyday life, affecting manydifferent systems
The sympathetic nervous system forms part of the of the human body, including theendocrine, nervous,
autonomic nervous system and is responsible for imme- and immune systems. Moreover, as
diate response to stress factors, a process, which is known as reproductive function is not essential for survival and
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. Itwas
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 in mechanism remained unknown. The discovery of kiss-
muscular action. Moreover, behavioral changes will also peptin and gonadotropin-inhibitory hormone (GnIH)
occur in order to improve vigilance and prepare to address was a monumental breakthrough in the early 21st
potential threats. In contrast to that, the para- sympathetic century. Further discovery of their role in controllingthe
nervous system enables body recovery after the stressor HPG axis provided the missing element in under-
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 to
stress factors. The integrated HPA axis is responsible be a key factor driving the HPG axis by direct stimu-
primarily for delayed stress response. The first step in lation of GnRH neurons. In 2008, Iwasa et. all pioneered
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 the
ventricular nucleus of the hypothalamus to 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 this
hormone (ACTH), which will sequentially stimulate theory by showing that a number of other stressors also
secretion of glucocorticoids from the adrenal cortex into 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 found
that exposure to both acute and chronic stress elevates the to be comparable to that in healthy women. Bacaopoulou
expression of GnIH mRNA in the hypothalamus. This leads [38] observed a negative correlation between peripheral
to dysregulation of the HPG axis and suppression of kisspeptin levels and body mass index (BMI) in anorectic
reproduction. Interestingly, glucocorticoste- roid patients. In this study, the authors found that amenorrheic
receptors have been found on the surface of GnIH adolescents tended to have a lower serum kisspeptin
neurons. During experimental trials it was found that, concentration, although this finding was not statistically
when administered, corticosterone increases GnIHmRNA significant. In cases of anorexia nervosa, serum kisspeptin
expression and reduces GnRH activity [32]. This provides levels have been shown to correlate positively with body
evidence that not only kisspeptin but also GnIH weight, body mass index, and fat mass.
contributes to mediation of the inhibitory effects of
corticosteroids on the human reproductive axis during In an interesting observation, Hoffman et al. [39] were
stressful events. able to establish a negative correlation between serum
kisspeptin concentrations and physical activity. In their
Undoubtedly, further studies are required to fully un- commentary, the authors suggested that this negative
derstand the complex neural interactions involved in the relationship may function as a compensatory mechanism to
modulation of reproductive function by stress. prevent physical activity and body mass loss in anorectic
patients.
The role of kisspeptin in stress-related KISS1 secreting neurons are believed to be in contact with
amenorrhea the proopiomelanocortin as well as cocaine- and
As a key regulator of reproductive physiology, kiss- amphetamine-regulated transcript (POMC/CART)
peptin has a positive influence on the pulsatile secretion neurons and agouti-related peptide/neuropeptide Y
of GnRH. It is because of this that understanding its role (AgRP/NPY). This may be a potential route of
and function is invaluable when discussing reproductive communication between systems in the hypothalamus as
pathophysiology such as FHA [33]. The pulsatility and both leptin and neuropeptide Y have been shown to
serum levels of kisspeptin as they relate to LH secretion was stimulate the expression of the KISS1 gene. It seems
studied by Podfigurna et al. [34] in more than 70 women unlikely, however, that the stimulating effect of leptin on
with functional amenorrhea. It was found that both KISS1-secreting neurons would occur through theaction
hormones are co-secreted and serum levels were of NPY, since leptin directly inhibits the formation of
temporally coupled. Additionally, a negative correlation NPY [40].
between the serum concentration and pulse frequency of
kisspeptin and serum levels of cortisol were observed. This Other notable hormonal messengers acting between the
correlation, among other hormonal parameters, supports metabolic and kisspeptin systems are ghrelin, insulin- like
the hypothesis that stress-induced compensatory changes growth factor-1 (IGF-1), and the hormones of the HPA
are the main direct and indirect factors driving axis [38]. Ghrelin, the secretion of which increases in
reproductive inhibition in patients with FHA. states of energy deficiency, suppresses the hypothalamic
expression of KISS1 mRNA [40]. In contrast, IGF- 1 has
Research published in 2020 revealed that patients with been shown to increase KISS1 mRNA expression in the
FHA were characterized by lower serum kisspeptin levels at anteroventral periventricular nucleus (AVPV) in female
baseline as well as having higher serum CRH levels when rats [41]. IGF-1 receptor blockade, however, does not
compared to healthy controls [35]. 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 of
can be restored with ovulation induction, but the aims of kisspeptin-54 in patients with hypothalamic amenorrhea
restoring the ovarian cycle are multipledfor metabolic specifically [48]. FHA patients were administered
function, bone protection as well as fertility. This subcutaneous kisspeptin-54 or saline twice-weekly.
endpoint should be achieved by the elimination of those Women in the treatment arm presented significantly
causative factors (such as stress, weight loss, excessive higher serum levels of FSH and LH after 2 months of bi-
exercise), which were initially responsible for the weekly dosing than did women in the placebo arm. No
development of an amenorrheic state. This approach, significant side effects to treatment were observed in
however, is often very difficult to introduce in clinical participants under this administration schedule.
practice, as it requires enthusiastic patient participation Intravenous administration of kisspeptin caused
and their willingness to undertake a real lifestyle change. If augmentation of LH pulsatility (3-fold increase in mean
the lifestyle interventions have not been successful, An peak number of pulses) when compared to placebo in all
Endocrine Society Clinical Practice Guideline FHA patients [49]. Additionally, the mean serum levels
recommends that treatment with pulsatile gonadotropin- of both FSH and estradiol were also significantly elevated
releasing hormone should be considered as first line during high-dose infusion of this peptide when compared
treatment [44]. Pulsatile GnRH pump rep- resents a safer, with placebo. For the first time it was reported that
more physiologic alternative to ovulation induction using constant intravenous kisspeptin-54 administration may
injectable gonadotropins. Unfortu- nately, there is no temporarily increase both basal and pulsatile LH release in
commercially available GnRH pump in most countries; patients with HA. The study protocol also established a
therefore, gonadotropin use for ovulation induction dose range within which kisspeptin-54 therapy is able to
remains only obtainable treatment in many cases. restore LH secretion (both basal and pulsatile).
Hormonal replacement therapy can be initiated. Such Another milestone in the field of kisspeptin research was
therapy, based not on traditional combined contracep- 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 with
progestin with limited anti-gonadotropic action can also FHA [50]. Abbara et al. demonstrated that serum LH and
be introduced. Should a patient with FHA who is treated FSH levels increased sooner after administration of
with such estrogeneprogestin therapy decidethey wish to KissR agonist in women with FHA than it did in healthy
become pregnant, initiating therapy with a GnRH women. This new KISSR agonist MVT-602 demonstrated
pulsatile pump can be considered [45]. many favorable properties, including better stability,
potency, and water solubility compared to native
In recent years, novel pharmacological approaches have 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 tool. secretion plays an important role in the regulation of
reproductive function. Continued research can further
Feasibility studies into the use of kisspeptin have been elucidate new details in this pathway and expand our
conducted in animal models. When administered, kiss- understanding of stress as a biological factor impacting
peptin provoked LH and FSH secretion in all mamma- the HPG axis.
lian animals [46]. The first human trial of kisspeptin
administration in patients with functional hypothalamic As a signaling bridge between the HPA and HPG axis,
amenorrhea was reported by Jayasena et al., in 2009 [47]. kisspeptin pathophysiology requires further studies.
An initial randomized controlled trial was conducted to Additionally, the most important yet challenging endpoint
compare acute and chronic kisspeptin administration and is to establish the practicality of using kisspeptin in the
its effect on serum LH and FSH. After acute subcutaneous treatment of patients with FHA. It is likely that novel and
kisspeptin administration, a 10-fold increase in LH newly developed kisspeptin receptor agonists are on the
secretion was observed while FSH secretion increased horizon. It is thus imperative that efforts should be
2.5-fold. When administered chronically over 2. 28 focused on carefully establishing the safety and efficacy
adolescent with secondary amenorrhea. Treatment of parameters of these new pharmacological tools.
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.
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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
14. Hrabovszky E, Ciofi P, Vida B, et al.: The kisspeptin system ofthe
have read and agreed to the published version ofthe human hypothalamus: sexual dimorphism and relationship with
manuscript. 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/ NEJMoa073443.
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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 HypotalamusSecondary

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 should 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 released
primary or secondary amenorrhea. Primary amenorrhea is by the hypothalamus in a pulsatile fashion, and stimulates
defined as the absence of menarche by age 15 in the presence both the synthesis and secretion of luteinizing hormone (LH)
of mature breast development, or three years after thelarche and follicle stimulating hormone (FSH) from the anterior
(4). Delayed puberty is defined as the absence of thelarche by pituitary (7). In patients with FHA, studies have shown that
the age of 13 (4). Secondary amenorrhea is defined as the GnRH secretion is suppressed, LH pulsatility is impaired
absence of menses for more than three cycles in someone who (8,9,10,11), and total LH and FSH levels are reduced
was previously menstruating regularly, or longer than six (11,12,13,14). FHA is therefore classified as a form of
months in someone with irregular cycles (5,6). FHA is the hypogonadotropic hypogonadism, which results in a
most common form of primary and secondary amenorrhea in hypoestrogenic state (8,12,13,14). In FHA, suppressionof the
adolescent girls (7). With specific regard to secondary HPO axis is caused by common triggers including
amenorrhea, FHA and polycysticovarian syndrome (PCOS) psychological stress, disordered eating, weight loss, and
are the most common causes,other than pregnancy (1). If excessive exercise (1,2,3).
prolonged, FHA has potential consequences for metabolic, Though amenorrhea is often associated with eating disorders
bone, cardiovascular, mental, and reproductive health. This such as anorexia nervosa, FHA is often found to be the
article will highlight what is underlying etiology for amenorrheic patients who
Address for Correspondence: Tania Dumont MD, University of Ottawa, Children’s Hospital of Eastern Conflict of interest: None declared
Ontario, 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 Gibson MES et
Endocrinol2020;12(Suppl al. Functional Hypothalamic
1):18-27 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)=45.5kg 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 criteriafor
Patients with FHA have increased cortisol levels
secondary amenorrhea and 23% disclosed disordered eating. Of
(10,12,13,14,20,29,33), as well as blunted responses to the
the girls with amenorrhea, 40% reported fasting or purging.
injection of human CRH (hCRH) (13,29,33). In addition, the
Interestingly, body mass index (BMI) (BMI; kg/ m2) was not
neurotransmitter ƴ-aminobutyric acid has also been linked to
significantly different between those who were eumenorrheic
suppression of GnRH (13). Thyroid hormone changes are also
or amenorrheic (18). Studies have shown that patients with
noted in FHA. Patients with FHA tend to have lower total
FHA exhibit more cognitive restraint (19),drive for thinness
triiodothyronine (T3) and total thyroxine (T4) concentrations
(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, with (11,14,34) and patients appear to be clinically euthyroid (34).
the highest rates seen in long distance runners (25). Since the Metabolic disturbances are also observed, with decreased
early 1990s, the Female Athlete Triad (FAT) has been used to leptin (8,12,14,19,35,36), decreased fasting insulin
describe athletes who also present with disordered eating, (12,14,35), decreased insulin-like growth factor-1 (IGF-1)
osteoporosis, and amenorrhea (26). In 2017, the American (8,12), increased fasting peptide YY (19), and increased
College of Obstetricians and Gynecologists revised the fasting ghrelin in patients with FHA (19,22). These changes
definition of FAT to be more inclusive. The criteria are now: reflect the overall energy deficit in patients with FHA.
low energy availability with or without disordered eating,
menstrual dysfunction, and low bone density (27). Though the
menstrual dysfunction in FAT is thought to be hypothalamic in Diagnosis of FHA
nature, FAT differs from FHA because athletes are not required The diagnosis of FHA can be challenging in adolescents,as
to be amenorrheic to meet criteria for FAT. Moreover, not all this is commonly a time when the HPO axis is developing.
patients with FHA are athletes or meet the criteria for FAT. However, primary amenorrhea should always be investigated,
Onset of amenorrhea can also be seen in the setting of stress as 98% of girls will achieve menarche bythe age of 15 (37).
(12,28,29,30). In a study of adolescent girls with FHA, Furthermore, 90% of menstrual cycles will range between 21-
identified stressors included common life events such as 45 days, even in the first few post- menarchal years (38),
changing schools, newly engaging in sexual activity, and highlighting the importance of investigating secondary
breaking up with a boyfriend. Chronic illness of a family amenorrhea in this age group.As FHA is a non-organic cause
member and the death of a friend were also observed.Lastly, of amenorrhea, it is often considered a diagnosis of exclusion.
50% of the adolescents in this study described familyconflict Table 1 summarizes the vast differential diagnoses of
(12). Patients with FHA have also been shown to copeless well amenorrhea, which should be taken into consideration.
with stress, including their autonomic responses, compared to
History: A pubertal history should include onset and timing of
those with PCOS and eumenorrheic controls (31).
breast and pubic hair development, as well as growth spurt. A
Lastly, there may also be a genetic basis to the development of detailed menstrual history should be obtained to characterize the
FHA. One study identified six heterozygous gene mutations type of amenorrhea and its onset. One should look for
in patients with FHA that are shared among patients who have possible triggers including stressful life events, disordered
congenital (idiopathic) hypogonadotropic hypogonadism, eating, weight loss (regardless of initial weight), or excessive
suggesting a possible vulnerability to the effects of stressors exercise. Disordered eating can include avoidance of certain
on the HPO axis. Mutations found involved the fibroblast foods (typically foods high in fat, sugar, and calories),
growth factor receptor 1 gene FGFR, 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 If weight loss has been identified as a contributing factor, it is
delay important to note the weight at which the patient became
Hypothalamus amenorrheic and the tempo of the weight loss. Lastly, it is
Central nervous system lesion (hydrocephalus, tumor) important to inquire about how the weight loss was achieved, as
Chronic medical illness well as how they feel about the weight loss, as this helps
Congenital hypogonadotropic hypogonadism (Kallman determine whether a formal eating disorder diagnosis should be
syndrome) considered. The type of exercise should be noted, as well as the
FHA (stress, weight loss, disordered eating, exercise) duration and intensity. Patients should be asked about their past
Pituitary medical history, including chronic illness or malignancy. A list
Congenital hypogonadotropic hypogonadism of medications should be obtained, and previous or current
Empty Sella syndrome treatments with chemotherapy or radiation should be noted. A
Hyperprolactinemia sexual history, taken alone with the adolescent in complete
Iatrogenic (surgery, radiation) privacy, should be obtained, including use of contraceptives.
Infarction (Sheehan syndrome) On review of symptoms, patients should be asked about
Infiltrative disease possible associated symptoms in a head to toe approach. To
Medications (amphetamines, antidepressants, antihypertensives, reiterate, one should ask about possible triggers affecting the
antipsychotics, dopamine antagonists,contraceptives, opiates) hypothalamus, such as stress, disordered eating, weight loss,
Neurofibromatosis or excessive exercise. Headaches, visual disturbances, or
Trauma galactorrhea could suggest the presence of a prolactinoma or
Tumor or cyst another central nervous system disorder. A history of anosmia
Thyroid could point to Kallman syndrome. Changes in energy,
Hyperthyroidism temperature regulation, or bowel movement frequency could
Hypothyroidism be related to an underlying thyroid disorder. Patients should be
Adrenal asked about signs of hyperandrogenism, such as acne or
Adrenal insufficiency hirsutism, as this could point to a diagnosis of PCOS or late-
Androgen-secreting tumor onset congenital adrenal hyperplasia. More significant
CAH virilization (clitoromegaly, severe hirsutism, voice changes)
Cushing syndrome could point to an androgen secreting tumour of either adrenal
Ovary or ovarian origin. Vasomotor symptoms such as hot flashes or
Androgen-secreting tumor night sweats could be indicative of primary ovarian
Gonadal agenesis or dysgenesis (ex. Turner syndrome, Swyer insufficiency (POI). Inquire about symptoms of pregnancy,
syndrome) such as weight gain, nausea, fatigue, vomiting, or breast
Iatrogenic (surgery, radiation) tenderness. Abdominal pain, either cyclic or chronic, could
Medications (antiandrogens, contraceptives) indicate a possible Müllerian anomaly. Lastly, a thorough
PCOS family history, including the menstrual history of the
POI biological mother, should be obtained. ǫuestions about
Uterus possible triggers and sexual history should be reserved for the
Adhesions (Asherman syndrome) confidential portion of the interview. Commonly, the “Home
Levonorgestrel IUS environment, Education and employment, Eating, peer-
Müllerian anomaly related Activities, Drugs, Sexuality, Suicide/depression, and
Pregnancy Safety from injury and violence-HEEADSSS” format is used
Outflow tract (39).
Cervical agenesis
Physical examination: The physical examination should
Cervical stenosis
first begin with a general inspection of the patient’s well
(acquired) Imperforate being. The patient’s height and weight should be measured
hymen Vaginal agenesis and plotted on growth curves that ideally have previously
Vaginal septum (transverse) been completed by the referring or primary care provider in
CAH: congenital adrenal hyperplasia, PCOS: polycystic ovarian syndrome,
POI: primary ovarian insufficiency, IUS: intrauterine system, FHA: functional order to facilitate comparisons and trends. The BMI (kg/ m2)
hypothalamic amenorrhea, Ref. 1,3,6,41. should be calculated and plotted. Vital signs should
20
1):18-27 Amenorrhea
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 is
eating disorders. Look for stigmata of Turner syndrome 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 or
restrictive or purging behaviours, which include cachexia, 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, particularly routine use of the progesterone withdrawal challenge,as it
if there are concerns regarding central nervous system may be unreliable in determining the degree of
symptoms in the history. Palpate the thyroid gland for a estrogenization as this test is associated with false negative
goiter or nodules and examine for other signs of thyroid withdrawals (1,3,43,44).
disease (exophthalmos or proptosis, lid lag, hair or nail Radiological investigations: An ultrasound of the pelvis is
changes). Palpate the abdomen for masses. Look for signs helpful to identify the presence of a uterus and ovaries, and to
of insulin resistance (acanthosis nigricans), rule out an adnexal mass. If a Müllerian anomaly is suspected,
hyperandrogenism (acne or hirsutism), or virilization magnetic resonance imaging (MRI) of the pelvis, or a 3D
(male pattern hair loss, change in muscle mass distribution, transvaginal ultrasound, if the patient is coitarchal, may better
clitoromegaly, or voice deepening). Complete Tanner characterize the specific anomaly (45,46,47). Head imaging
staging should be done to document pubertal development with computed tomography or MRI is not typically required
(40). The papilla and surrounding breastmay also be unless the adolescent girl presents with galactorrhea (+/-
examined for residual signs of galactorrhea. Perform an hyperprolactinemia), headaches or visual disturbances,
external genital examination with the aid of labial traction suggesting a possible intracranial lesion (1,41,48). It may also
to assess for a patent hymen and lower vagina. This be indicated if there is a negative progesterone withdrawal
examination can also aid in determining the extent of challenge (4).
estrogenization of the vulva. Typically, a reddened and thin
hymen is seen in an estrogen-deficient state, whereas a light Due to the risk of osteopenia and osteoporosis associated with
pink and plumper hymen is seen in the presence of hypoestrogenism, patients with prolonged amenorrhea, of six
adequate estrogen levels. The presence of leukorrhea can months or more, should be considered for baseline bone
also point to adequate estrogenization. Lastly, a bimanual mineral density (BMD) assessment measured by dual-energy
examination can be performed in patients who are sexually X-ray absorptiometry (DEXA/DXA) scan and lateral spine
active, to palpate for a uterus and to rule out an adnexal radiograph to assess for asymptomatic vertebral fractures
mass. Typically, patients with FHA will have a physical (15,41,49,50,51,52,53). In adolescents,
examination within normal limits. Table 2. Typical hormone pattern in functional
Endocrinological investigations: Initial blood work-up hypothalamic amenorrhea
should include measurement of the beta subunit of human Hormone Level
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 Table2 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
27
BMD Z-scores are used as these values are adjusted forage improve BMD in patients with FHA. This recommendation
and gender. They must also be further interpreted in relation to is based on two small studies (57,58). In a study by Kopp-
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 a
define osteoporosis. Rather, a diagnosis of osteoporosis nutritional supplement to improve overall energy balance. In
requires the presence of both a clinically significant fracture 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 about
multidisciplinary approach, which includes nutritional
which patients are at risk for fractures (declining BMD Z-
therapy, psychological therapy, and modification of exercise
scores), versus those who may be showing signs of recovery
regimen has been recommended (59,60).
(53). BMD should be repeated every six to 12 months to
assess for trajectory of BMD Z-score, in patients where risk In all patients with FHA, if lifestyle modification is the
factors remain present. Spine radiographs should also be primary treatment modality, a follow up should be done every
monitored at a similar interval to assess for asymptomatic two to three months to determine whether the desired effect is
vertebral fracture (or immediately if symptomatic), being achieved (60).
particularly if there is decline in BMD Z-score (53). Psychological therapy: Adolescent girls and young adult
Other investigations: A karyotype should be performed if women with FHA have been shown to cope less well with
a chromosomal abnormality, such as Turner syndrome is stress (31), and are also at a higher risk of depression (50). In
suspected and/or if gonadotropins are elevated. If the study by Kondoh et al (29), patients with FHA related to
gonadotropins are elevated and POI is diagnosed, other psychogenic stress, aged 15-33, were treated with
testing would be required including autoimmune antibodies psychoeducation which focused on stress management. A
and Fragile X testing. greater proportion of these patients recovered compared to
those with weight-associated FHA; 81.8% versus 54.0%.
Stress Management Their average time to recovery was also slightly shorterat
17.2±4.1 months versus 19.4±5.0 months. A small
The menstrual cycle has been recognized as an important vital randomized controlled trial (RCT) looked at the effect of a
sign in adolescent girls (55,56), and the absenceof menses 20-week intervention with cognitive based therapy (CBT)
may be an indication of compromised overall health. As such, in patients with FHA (61). In this study, the eight patients
the main goal of management in FHA is the resumption of randomized to the CBT arm had a higher rate of ovarian
menses. correlation effect stress management of function activity (87.5%) compared to those eight patients that were in
hypotalamus secondary managemen with significance p < the observation arm (25.0%). Ovarian activity was
0.005 about 45 adolesncent determined by measuring plasma estradiol and progesterone
levels, in order to confirm ovulation. BMI did not significantly
Lifestyle modification: Addressing possible triggers such as
change during the intervention. CBT has also been shown to
weight loss, disordered eating, or excessive exercise isa
have an impact on metabolic health in these patients. In a
primary focus in the management of FHA. In one studyby
follow-up study by Michopoulos et al (62), patients
Kondoh et al (29), patients with FHA related to weight loss
randomized to the CBT arm had an improvement in cortisol,
were treated by a nutritionist for at least six months. 54.0% of
TSH, and leptin concentrations compared to those in the
these patients resumed menses with an average recovery time
observation arm.
of 19.4±5.0 months. to resume menses. A common
recommendation in the literature is thata 1-2 kg weight gain from Other forms of psychological therapy have been studied. In a
current weight, or a 5% increasein body weight, can result in small prospective study, 12 patients with FHA, aged 20-33,
the resumption of menses and were given a 45-70 minute hypnotherapy session and then
observed for 12 weeks (63). Nine patients (75%) resumed
menses, and one patient became pregnant during this time.
22
1):18-27 Amenorrhea
All patients also reported increased general well-being and been successful with lifestyle modification, and who arenot in
improved self confidence. 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 of its use in patients with FHA is attracting interest and has
patients with FHA. started to be studied. Zanker et al (76) published a case report
of a 24-year-old amenorrheic athlete, whom they followed for
Pharmacological therapy: The main role of
12 years. They measured her body weight every three months
pharmacological therapy in FHA is to promote bone health
and her BMD by DXA every 11-13 months. After being on
and prevent the development of osteoporosis. A lack of
COCs for five years, the BMD of her lumbar spine and
estrogen during premenopausal years has been linked to
proximal femur declined by 9.8% and 12.1%, respectively.
decreased BMD. This is based on studies looking at the
Her weight dropped concomitantly from 45.1 to 41.4 kg. Over
outcomes of premenopausal women undergoing bilateral
the next 3.7 years, she was treated with transdermal estrogen
oophorectomy (64,65). In one study, vertebral bone loss could
and an oral progestin. Her lumbar spine BMD gradually
be detected as early as six months post-operatively (64). An
increased by 9.4%, despite a further
increase in the frequency of fragility fractures of the radius
0.8 kg decline of body mass. In the last 2.9 years of the study,
and femoral neck was also observed (65). Similarly, in
she continued the transdermal estrogen, gained a total of 8.1 kg
patients with FHA, the associated hypoestrogenic state can
of body mass, and had a 16.9% increase in her proximal femur
result in reduced bone density (15,50,51). In young women
BMD. Furthermore, an RCT by Ackerman et al. (79) from
less than 20 years of age, missing even 50% of menstrual
2019 showed an improvement in BMD in athletes with oligo-
cycles can result in a significant decrease in BMD (52).
amenorrhea receiving transdermal estrogen. In this study, 43
Therefore, studies have looked at the effects of hormone
patients were randomized to receive a 100 mcg 17 -estradiol
replacement therapy on BMD in patients with FHA.
transdermal patch twice weekly with cyclic micronized
A systematic review by Liu and Lebrun (66) summarized progesterone (200 mg, 12 days per month), 40 patients to
ten studies evaluating the impact of hormone therapy on receive a daily pill with 30 µg EE + 0.15mg desogestrel, and
BMD in women with FHA. They found seven studies 38 patients received no hormonal treatment. All patients also
which demonstrated a positive effect of combined oral received 800 IU of vitamin D and ≥1200 mg of calcium per
contraceptives (COCs) on BMD (67,68,69,70,71,72,73), day. BMD was assessed at baseline, six, and 12 months.
two studies that showed no effect (74,75), and one case Patients randomized to the patch arm had significantly higher
report where a negative effect was observed (76). Of the spine and femoral neck BMD Z-scores at 12 months
studies that showed a positive effect, two were small RCTs compared to the pill and the no treatment arm, and higher hip
(67,68). Hergenroeder et al (67) showed a significant BMD Z-scores than the pill arm. The results of this landmark
increase in both the total BMD and lumbar spine BMD of study are promising and lend support to the use of transdermal
five patients receiving 35 µg ethinyl estradiol (EE) + 0.5- estrogen in patients with FHA.
1 mg norethindrone, compared to five controls. Castelo-
In amenorrheic adolescents, 1200-1500 mg of calcium
Branco et al (68) showed a significant increase in lumbar
supplementation (80) as well as vitamin D 400-1000 IU (1)
spine BMD in 24 patients taking 30 µg EE + 0.15 mg
are recommended daily to support bone health. However,
desogestrel and 22 patients taking 20 µg EE + 0.15 mg
other therapies such as testosterone or bisphosphonates are not
desogestrel, compared to 18 control patients who showed a
currently recommended to improve BMD in patients with
decrease in BMD. Of the studies that showed no effect, one
FHA (41,81), as the literature available focuses mainly on
cohort study looking at female long distance runners, found
patients with anorexia nervosa and the current evidence is
no difference in BMD after one year in nine patients who
limited.
started on a COC (75). However, in the same study 11
patients with FHA who were not using a COC showeda Fertility: Patients with FHA may experience escape ovulation
significant reduction in BMD over the same time period. and therefore contraception is important if they do not desire
Currently, the Endocrine Society has recommended against pregnancy (41). In addition, adolescents with FHA may inquire
using COCs for the sole purpose of improvingBMD, due to about future fertility. Ovarian reserve is typically normal in
conflicting evidence. Instead, a trial of short-term these patients, as evidenced by theirnormal anti- Müllerian
transdermal estrogen with a cyclic oral progestin is hormone (AMH) levels (42). In
recommended in amenorrheic adolescents who have not
23
27
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 menses
When compared to injectable gonadotropins, chances of (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 are RCTs have looked at the effects of treatment with
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 et ovulatory cycles, which the authors stated was higher than the
al study are significantly lower. This may be explained by the expected rate of spontaneous ovulation of 10%. In a small
differences in study populations between these studies, with RCT, recombinant human leptin (metreleptin; starting dose
lower BMI and baseline gonadotropin levels in the Dumont et 0.08 mg per kg of body weight per day) administered
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 levelswere 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 hypothesized also been studied, and while acute administration appears to
that GnRH pulsatility could therefore be stimulated by opioid stimulate release of LH and FSH, chronic administration
antagonism. Though naltrexone has been shown to increase results in tachyphylaxis. Thus, the authors concluded that
GnRH pulsatility and increase rates of ovulation acute administration of kisspeptin may have therapeutic
(86,87,88,89), its use has not become standard practice. potential in patients with FHA (96). The Endocrine Society
has recommended against the use of leptin or kisspeptin in the
Cardiovascular considerations: Patients with prolonged
management of patients with FHA, as more research is
FHA may be at higher risk of cardiovascular complications
needed in this area (41).
in the future (90). Studies in pre-menopausal adult women
have shown hypothalamic hypoestrogenism is associated
with a higher risk of coronary artery disease (91). Other Conclusion
possible effects include vascular endothelial dysfunction FHA is a common cause of both primary and secondary
and reduced regional blood flow, as was shown in young amenorrhea in adolescent girls. Common triggers include
amenorrheic athletes (92). These athletes were also found to stress, weight loss, and excessive exercise. As FHA is a
have abnormal lipid profiles, including elevated total diagnosis of exclusion, a comprehensive workup should be
cholesterol and low-density lipoprotein cholesterol (92). As performed to rule out anatomic and organic causes of
a follow-up study, Rickenlund et al (93) investigated the amenorrhea. Prolonged FHA can have negative consequences
effects of using a COC (30 µg EE + 0.15 mg on many aspects of a young women’s health, including
levonorgestrel) on these cardiovascular endpoints in metabolic, bone, cardiovascular, mental, and reproductive
amenorrheic athletes. While an improvement in vascular implications. The main goal in these patients is the
endothelial function after nine months of COC use was resumption of menses. Lifestyle modifications arethe first line
found, the lipid profile did not significantly change, with focus for adolescent girls with FHA and a multidisciplinary
the exception of a small increase in high-density approach, including a pediatric gynecologist and/or
lipoprotein cholesterol. As this study was small, the authors endocrinologist, pediatric sport psychologist, and sport
indicated the need for larger, long-term studies to determine dietician is beneficial. Pharmacological therapy can be
the clinical importance of their findings. As of now, the considered in order to promote bone health, with transdermal
majority of recommendations surrounding estrogen being a promising option for patients. Further
research on novel agents, such as recombinant
24
1):18-27 Amenorrhea
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.
women with anorexia nervosa and hypothalamic amenorrhea. J Clin
Endocrinol Metab 1999;84:2049-2055.
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Metrop Life Found 1983;64:3-9.
Authorship Contributions 18. Selzer R, Caust J, Hibbert M, Bowes G, Patton G. The association
between secondary amenorrhea and common eating disordered weight
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Tania Dumont. 19. Scheid JL, Williams NI, West SL, VanHeest JL, De Souza MJ.
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BUKU LOGBOOK PRAKTIK PROFESI

STASE ASUHAN KEBIDANAN PRA NIKAH DAN PRA

PROGRAM STUDI PENDIDIKAN PROFESI

Nama Mahasiswa : ISRAINI SURIATI.S.ST.M.Keb

PROGRAM STUDI PENDIDIKAN PROFESI PROGRAM PROFESI

REKTOR ITKES MUHAMMADIYAH SIDRAP

Dengan senantiasa memanjatkan puji dan syukur kepada Allah SWT,

Pangkajene, 11 Zulhijjah 1443 H

DR.Muhammad Tahir, SKM.,M.

Syukur Alhamdulillah kami panjatkan ke hadirat Allah SWT, karena atas

Jazakumullahu khairan katsiran Fastabiqulkhaerat.

Sidrap, 20 Oktober 2022

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

Asuhan Kebidanan pada Pra

2. Konseling Kesehatan reproduksi pada wanita

4. Teknik pengambilan dan pengiriman sediaan pap smear

5. Melakukan deteksi dini dan kolaborasi interprofesional dalam kasus : a)

8. Identifikasi gangguan masalah dan kelainan-kelainan sistem

10. Melakukan dokumentasi pada asuhan kebidanan pada pranikah

11. Pemeriksaan dan konseling pranikah

14. konseling persiapan kehamilan

16. Melakukan dokumentasi pada asuhan kebidanan pada prakonsepsi

2 Refleksi Kasus 20 JANUARI 2023 Mampu Melaksanan

3 OMP 20 JANUARI 2023 Telah diberikan feed

4 Journal reading 20 JANUARI 2023 Telah diberikan feed

5 BST 20 JANUARI 2023 Telah diberikan feed

Jenis 20 JANUARI 2023

Preseptor Pembimbing Pendidikan : Nur Laela, S.ST., M. Keb

Disusun Oleh : ISRAINI SURIATI.S.ST.M.Keb

PROGRAM STUDI PENDIDIKAN PROFESI BIDAN PROGRAM PROFESI

STASE PRANIKAH DAN PRANKONSEPSI

JUDUL KASUS AMENOREA

PADA NN’I” TAHUN AKADEMIK 2023

pangkajene, 20 januari 2023

Preseptor Pendidikan Precptor Lahan Mahasiswa

Nur Laela, S.ST., M. Keb ISRAINI SURIATI.S.ST.M.KEB

DAFTAR ISI ...................................................................................................... i

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

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

memerlukan landasan psikis yang memadai agar perkembangan emosinya

berlangsung dengan baik. Faktor yang mempengaruhi kesehatan reproduksi meliputi

Faktor sosial-ekonomi dan demografi (kemiskinan, tingkat pendidikan yang rendah

didaerah terpencil). Faktor budaya dan lingkungan (praktek tradisional, kepercayaan

saluran reproduksi pasca penyakit menular seksual).

Wanita rentan terhadap penyakit yang menyerang organ reproduksinya. Kebanyakan

kesehatan pribadinya. Faktor lain pun dikarenakan biaya untuk pemeriksaan ke

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

semua wanita pernah mengalami gangguan menstruasi selama masa hidupnya.

menstruasi pada masa menstruasi sebagaimana mestinya atau secara sederhana

Peran Bidan dalam upaya meningkatkan kesehatan reproduksi yaitu melakukan

berperilaku hidup sehat, memperbaiki keadaan kesehatan seperti perbaikan gizi,

melahirkan generasi kehidupan (Kumalasari dan Andhyantoro, 2013)

Beberapapenyebabmenstruasi mengalami penyimpangan yang akibatnya

kurang subur (infertil) (Merin, 2013)

Untuk melaksanakan manajemen asuhan kebidanan dalam pranikah sesuai

dengan Evidance Based Midwifery

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

A. KONSEP DASAR TENTANG KESEHATAN REPRODUKSI

terjadi secara periodik. Masalah gangguan pada gangguan reproduksi, yaitu:

a. Infertilitas : Infertilitas adalah suatu keadaan dimana seseorang wanita