Ginekologi UKDI MANTAP Batch November

GYNECOLOGY

1

dr. Nashria

2 Neoplasm

Abnormal Menstrual Cycle

Infertility

Congenital infection

Gonorrhea

Menstruation Cervix

Infection

Sperm Analysis Abnormal uterine bleeding

Toxoplasmosis Trichomoniasis Candidiasis Rubella Bacterial Vaginosis

Uterine Corpus

Endometriosis

Polycystic ovarian syndrome PID CMV Syphilis

Amenorrhea Woman Fertility Test

Ovarium menopause

Condiloma acuminata Varicella Bartholin Barth olin absce abscess ss

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NEOPLASM

Neoplasma Abnormal, excessive growth of tissue

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Common symptoms:

Malignant Vs

Solid

Benign

Vs

Abnormal bleeding

(myoma,ovarian cyst)

Cystic

Pelvic mass Vulvovaginal symptoms

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Clinical Aspects : Benign vs Malignant Tumor 









enign Tumor

Malignant tumor

May cause significant clinical disease



Exert pressure : uterine myoma  low back pain, obstipation, urine retention Superimposed complication : abnormal bleeding, ulceration, secondary infection Undergo malignant transformation





Clinical significant much greater : invasive, rapid growing  more often cause bleeding, ulceration, infection Para neoplastic syndrome (endocrinopathies) cachexia

Common Location of tumors

Tumor of the Uterine Cervix 7

Cervix: lower 1/3 of uterus; at and below level of internal cervical os

Classification Benign tumor Leiomyoma (myoma)  Malignant tumor A. Carcinoma of the cervix 1. Squamous cell carcinoma 91 % 2. Adenocarcinoma 3. Adenosquamous carcinoma 4. Adenoacanthoma B. Sarcoma ( very rare) 

Risk Factors •

•

HPV infection: type 16, 18, 45 and 56 Sexual factor:  –  –

 –

•

•

early marriage, young age of first coitus multiple sexual partners

Cigarette smoking Socio economic status, Parity, Race

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FAKTOR RISIKO a. Menikah/ memulai aktivitas seksual pada usia muda (kurang 20 tahun) b. Berganti ganti pasanan seksual. c. Berhubungan seks dengan laki laki yang berganti ganti pasangan d. Riwayat infeksi di daerah kelamin atau radang panggul e. Perempuan yang melahirkan banyak anak  f. Perempuan perkokok(2,5x lebih tinggi) g. Perokok pasif (1,4x lebih tinggi) HPV and human immunodeficiency virus (HIV) co -infection accelerates progression towards cancer. Pedoman teknis Ca Payudara dan Ca

HPV and Uterine Cervix - Pathogenesis 9

• •

Infection through genital skin to skin contact lesions usually do not occur until 3-5 years

10 •

•

•

•

•

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Why in transformation zone? Dysplasia : loss of the normal cytoplasmic differentiation or   maturation of cervical epithelium. The area of development of dysplasia and SCC is at the junction of the squamous and columnar   epithelia (transformation zone) This area is most susceptible to viral infection. Responds to changes in vaginal pH due to fluctuating estrogen levels. Increases in estrogen stimulation result in advancement of columnar epithelium toward the vagina (during pregnancy, in women taking oral contraceptives, in newborns). Decreases in estrogen stimulation are followed by "retreat" of columnar epithelium

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Clinical sign & symptoms Symptoms 

Bleeding

:

vaginal, rectal, urethral



Exert pressure

:

obstipasi, anuria hydronephrosis  renal failure  uremia



Infection

:

odor watery vaginal discharges

Physical signs  

Nodule, ulcer, exuberant erosion of the cervix Advanced: crater-shaped ulcer with high or friable warty mass



Freely bleeding on examination



Mobility of the cervix depend on the stage

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Prevention Primary prevention: prevention: healthy lifestyles and vaccination against aga inst HPV HPV(qu (quadr adriva ivalen lentt vacc vaccine ine - gen genoty otypes pes 6, 6, 11, 16 &18 ; bivalent bivalent vaccine vaccine - genot genotypes ypes 16 &18) &18)

Secondary prevention: scree screening ning for for precancer precancer lesio lesions ns & early diagnosis followed by adequate treatment.

Tertiary prevention: diagnosis and treatment of confirmed cancer. Treatment: surgery, radiotherapy and sometimes chemotherapy. Palliative if incurable

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Kelompok Sasaran Screening  

 

Perempuan berusia 30-50 tahun Pasien klinik IMS dengan discharge dan nyeri abdomen bawah (semua usia) Perempuan yang tidak hamil Perempuan yang mendartangi puskesmas, klinik IMS< dan klinik KB yang meminta screening

Pedoman teknis Ca Payudara dan Ca

Screening for cervical cancer Visual Inspection Test 19 Aceto White Sign

Pre Cancerous Lession

Screening for cervical cancer Visual Inspection Test 20 Aceto White Sign

Pre Cancerous Lession

Pedoman teknis Ca Payudara dan Ca

Screening for Cervical Cancer  21

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•

Exception.... Women at increased risk of CIN : 1. in utero DES (diethylstilbestrol) exposure, 2. immunocompromise, 3. a history of CIN II/III or  4.Cancer 

should continue to be screened at least annually.

•

The United States Preventive Services Task Force stated screening may stop at age 65 if : 24 recent normal smears not at high risk for cervical cancer. The American Cancer Society guideline stated that women age 70 or older may elect to stop cervical cancer screening if : had three consecutive satisfactory, normal/negative test results and no abnormal test results within the prior 10 years. Not recommended in women who have had total hysterectomies for benign indications (presence of CIN II or III excludes benign categorization). Screening of women with CIN II/III who undergo hysterectomy may be discontinued after three consecutive negative results have been obtained. However, screening should be performed if the woman acquires risk factors for intraepithelial neoplasia, such as new sexual partners or immunosuppression. • •

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•

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•

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DISCONTINUE ACOG guideline 2008

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Summary Recommendation Keluhan

Lesi anatomis

Rekomendasi skrining

-

-

IVA

+

-

PAP SMEAR

+

+

Biopsi

Methods to Improve Accuracy of Pap Smears 28

•

•

•

Perform a Pap smear when the patient is in the proliferative phase (in the week following cessation of menses). The patient should avoid intercourse or intravaginal products for 24-48 hours before the examination. Use no lubricant prior to performing the Pap smear.

Technique: 1. Rotate the Ayers spatula through a 360-degree arc over the squamocolumnar junction if visible. 2. Gently brush the spatula over the entire slide, taking care to avoid a thick  smear or shearing of cells by excessive pressure. 3. Collect the endocervical specimen using a cytobrush (about one full turn with the brush mostly inside the cervix), or use a saline-moistened cotton swab for pregnant women. 4. Apply this to the same slide using a rolling motion as noted in step 5. 5. Rapidly apply fixative to the slide. If using a spray, hold it about 10 inches from the slide to avoid dispersing the cells. 6. Provide the cytologist with complete clinical information about the patient including age menopausal status hormone use history of radiation

Terminology Precancerous Lesion Squamous Cell Carcinoma

Cervical dysplasia: Abnormal changes in the cells on the surface of the cervix, seen underneath a miscroscope LSIL: low-grade squamous intraepithelial neoplasia; HSIL: high-grade squamous intraepithelial neoplasia; CIN: cervical intraepithelial neoplasia.

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Terapi

Penjelasan

Krioterapi

Perusakan sel sel prakanker   dengan cara dibekukan (dengan membentuk bola es pada permukaan serviks)

elektrokauter

Perusakan sel sel prakanker   dengan cara dibakar dengan alat kauter, dilakukan leh SpOG dengan anestesi

Loop ElectroSutgican Excision Pengambilan jaringan yang Procedure (LEEP) mengandung sel prakanker   dengan menggunakan alat LEEP Konikasi

Pengangkatan jaringan yang megandung sel prakanker   dengan operasi

Histerektomi

Pengangkatan seluruh rahim termasuk leher rahim

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Tumor of the Uterine Corpus 40

Benign tumor  •

•

Leiomyoma (myoma): most common tumor in the body (smooth muscle cells) Etiological factors: related to estrogen, three times more in black  often found in nulliparous

Type of Leiomyoma 1. Submucous : beneath endometrium, if pedunculated  geburt myoma 2. Intramural/interstitial: within uterine wall 3. Subserous/subperitoneal: at the serosal surface or bulge outward from myometriuml ; if

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Influencing factors of Myoma Uterine

SYMPTOMS 42

Menorrhagia – heavy & prolonged menstruation (common) Pelvic pain : occurs in pregnancy if undergoing degeneration or torsion • Pelvic pressure：urinary frequency, constipation Spontaneous abortion Infertility •

•

• •

SIGN A palpable abdominal tumor : arising from pelvis, well defined margins , firm consistency, smooth surface, mobile from side to side. • Pelvic examination Uterus —  enlarged and irregular, hard • Diagnosis : Bimanual exam, USG, hysteroscopy, Laparacospy

TREATMENT  

Observation: for small myoma, premenopause Operation : myomectomy or  hysterectomy

Perubahan Sekunder Myoma 44

Jenis Degenerasi Ganas Myoma uteri yang menjadi

leiomyosarkoma hanya 0,32 – 0,6% dari

seluruh myoma Leiomyosarkoma merupakan

50-75% dari semua jenis sarkoma uteri

Kecurigaan malignansi: apabila

myoma uteri cepat membesar dan terjadi pembesaran myoma pada menopause.

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Tumor of the Uterine Corpus Malignant Tumors

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Tumor of the Ovary

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Tumor of the Ovary 

 

Ovarian cancer has highest mortality of all gynecological tumor 



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Called as silent lady killer 

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Symptom (many ovarian tumor cause no symptom only discover during routine examinatiion. 

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Low abdominal discomfort (fullness, bowel symptom)

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Loss of weight, malaise, anorexia

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Pain due to torsion, hemorage or rupture

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Pressure symptom

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Endocrinopaties

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Abnominal gross swelling

Benign Tumor





Small can be felt by bimanual, moile Medium may have l ong pedicle and rise out of pelvis Benign mucinous cyst may be vary in sixe Benign teratoma cyst the commonest undergo torsion Benign solid tumor are less common Meig syndrome : solid tumor, ascites, pleural effusion

Malignant Tumor 

Early detection would improve prognosis, bimanual, USG or tumor marker 

Also

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called a dermoid cyst of the ovary, this is a bizarre tumor, usually benign, in the ovary that typically contains a diversity of tissues including hair, teeth, bone, thyroid, etc. A

dermoid cyst develops from a totipotential germ cell (a primary oocyte) that is retained within the egg sac (ovary). Being totipotential, that cell can give rise to all orders of cells necessary to form mature tissues and often recognizable structures such as hair, bone and sebaceous (oily) material, neural tissue and teeth. Dermoid

cysts may occur at any age but the prime age of detection is in the childbearing years. The average age is 30. Up to 15% of women with ovarian teratomas have them in both ovaries. Dermoid cysts can range in size from a centimeter (less th h lf i h) t 45 ( b t 17

Ovarian teratoma

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Menstrual cycle abnormalities

Menstrual cycle 50

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Normal Menstrual Bleeding 52

•

•

•

•

•

Occurs approximately once a month (every 26 to 35 days). Lasts a limited period of time (3 to 7 days). May be heavy for part of the period, but usually does not involve passage of clots. Often is preceded by menstrual cramps, bloating and breast tenderness, although not all women experience these premenstrual symptoms. Average : 35-50 cc

FSH 53

In sexually-mature females, FSH (assisted by LH) acts on the follicle to stimulate it to release estrogens. FSH produced by recombinant DNA technology (Gonal-f®) is available to promote ovulation in women planning to undergo in vitro fertilization (IVF) and other forms of assisted reproductive technology. •

•

LH In

sexually-mature females, a surge of LH triggers the completion of meiosis I of the egg and its release (ovulation) in the middle of the menstrual cycle; stimulates the now-empty follicle to develop into the corpus luteum, which secretes progesterone during the latter half of the menstrual cycle.

Ovulasi

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Terjadi 14 hari sebelum mens berikutnya Tanda dan tes : 

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Rasa sakit di perut bawah (mid cycle pain/mittleschmerz) Perubahan temperatur basal  efek  termogenik progesteron Perubahan lendir serviks 



Uji membenang (spinnbarkeit): Fase folikular : lendir kental, opak, menjelang ovulasi  encer, jernih, mulur  Fern test : gambaran daun pakis

•

•

•

>> kadar  progesterone 2ng/ml LH surge (dg Radioimunoassay) USG  folikel >1,7 cm

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Fertility Test 

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LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by the pituitary gland in women Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate ovulation by working in different ways. in premenopusal women, the normal LH-FSH ration is 1:1 as measured on day three of the menstrual cycle Variation from this ratio used to diagnose PCOS or other disorders, explain infertility or verify that woman has entered menopause FSH stimulates the ovarian follicle to mature. Then a large surge of LH stimulates the follicle to release an egg to fertilization On day 3 of the cycle, LH should be low. If LH is elevated on this day, possible even as high as FSH, then it suggest problem with ovulation. Ovulation requires an LH surge, and if LH is already elevated, it may not surge and ovulated

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Abnormal Uterine Bleeding

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Polyp

Coagulopathy

Adenomyosis

Ovulatory disorder

Malignancy and hyperplasia

leiomyoma

Endometrial

iatrogenic

Not Yet Classified

Polip 61

• Endocervical polip • Endometrial polip

Adenomyosis • Part of endometrial that penetrate to myometrium

Leiomyoma • Submucosal • SUbserosal • intramural

Malignancy and hyperplasia - Endometrial cancer 

Coagulopathy 62

• Von Willebra Willebrand nd diseas disease e • Gan Ganggu gguan an agr agrega egasi si pla platel telet et

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

endometrial • Endometrial inflammation • Endometrial infecton Defisiensi ensi endo endothelin thelin-1, -1, defisiensi Prost Prostaglan aglandin din F2-alp F2-alpha ha • Defisi

Iatrogenic Drugs : rifampicin, griseofulvin, trisiklik, phenothiazine, anticoagulant, antiplatelet,

Treatment of uterine bleeding 63

Infrequent bleeding 1. Therapy should be directed at the underlying underlying cause when possible. 2. If the CBC and other initial laboratory tests & history and physical examination are normal reassurance 3. Ferrous gluconate, 325 mg bid-tid

ACOG 2008

Treatment of frequent or heavy bleeding 64 1. NSAID improv improves es platele platelett aggreg aggregati ation on increases uterine vasoconstriction. v asoconstriction. NSAIDs are the first choice in the treatment of menorrhagia because they are well tolerated and do not have the hormonal effects of oral contraceptives. a. Mefenamic Mefenamic acid (Ponstel (Ponstel)) 500 mg tid during during the menstrual menstrual period. period. b. Naproxen (Anaprox, Naprosyn) Naprosyn) 500 mg loading loading dose, then 250 mg tid during the menstrual period. c. Ibuprofen (Motrin, (Motrin, Nuprin) 400 mg tid during the menstrual period. 2. Ferrous gluconate 325 mg tid. 3. Patients with hypovolemia or a hemoglobin level below 7 g/dL should be hospitalized for hormonal therapy and iron replacement. Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops. Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper slowly to one pill qd. If bleeding bleeding continues, continues, IV vasopress vasopressin in (DDAVP) (DDAVP) should should be admin administere istered. d. • • •

•

•

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

•

4. Primary childbearing years –  years – ages ages 16 to early 40s A. Contraceptive complications and pregnancy are the most common causes of abnormal bleeding in this age group. Anovulation accounts for 20% of cases. B. Adenomyosis, endometriosis, and fibroids increase in frequency as a woman ages, as a s do endometrial hyperplasia and endometrial polyps. Pelvic inflammatory disease and endocrine dysfunction may also occur. ACOG 2008

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Dysmenorrhea Dysmenorrhea refers to the symptom of painful menstruation. It can be divided into 2 broad categories: primary (occurring in the absence of pelvic pathology) and secondary (resulting from identifiable organic diseases).

Primary

Usual duration of

48-72 hours (often starting several hours before or just after the menstrual flow) Cramping or laborlike pain Background of constant lower abdominal pain, radiating to the back or thigh Often unremarkable pelvic examination findings (including rectal) Current evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2α (PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium. The response to prostaglandin inhibitors in patients with dysmenorrhea supports the assertion that dysmenorrhea is prostaglandin-mediated. Substantial evidence attributes dysmenorrhea to prolonged uterine contractions and

Secondary 67

Dysmenorrhea

beginning in the 20s or 30s, after previous relatively painless cycles Heavy menstrual flow or irregular bleeding Dysmenorrhea occurring during the first or second cycles after menarche Pelvic abnormality with physical examination Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives (OCs) Infertility Dyspareunia Vaginal discharge

Drug Therapy Dysmenorrhoea

can be effectively treated by drugs that inhibit prostaglandin synthesis and hence uterine contractility. These drugs include aspirin, mefenamic acid, naproxen or ibuprofen.

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Endometriosis An estrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic pain, multiple surgeries, and impaired fertility Clinically defined as presence of endometrial-like tissue found outside uterus, resulting i n sustained inflammatory reaction

Most common location: GI tract

Other locations: urinary tract, soft tissues & diaphragm

Pathophysiology 69

    

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

Sign Symptom Classic signs:  severe dysmenorrhea, dyspareunia,  chronic pelvic pain,  infertility

         

Dysmenorrhea Heavy or irregular bleeding Cylical/noncylical pelvic pain Lower abdominal or back pain Dyschezia, often with cycles of diarrhea/constipation Bloating, nausea, and vomiting Inguinal pain Dysuria Dyspareunia with or without penetration Nodules may be felt upon pelvic exam

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Physical exam and imaging Physical examination has poor sensitivity, specificity, and Predictive value in diagnosis endometriosis.

Combination of History, Physical exam and laboratory and diagnostic studies is indicated to determine cause of pelvic pain and rule out non endometriosis concerns Pain mapping may help isolate location spesific disease such as nodulas masses in posterior rectovaginal septum Absence of evidence during exam is not evidence of disease absence

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Imaging studies Transvaginal or endorectal USG may reveal US feature varying from simple cyst to complex cyst with internal echoes to solid masses, usually devoid of vascularity

CT may reveal endometrioma appearing as cystic masses; however, apperance are non specific and imaging modalities should not be relied upon on for diagnosis MRI : may detect even smallest lesion and distinguish hemorragic signal of endometrial implant

MRI demonstrated to accurately detect rectovaginal disease and obliteration in more than 90% of cases when USG gel was inserted in the vaginal and rectum

Endometriosis therapy

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Medical Therapies •

• • • •

Gonadotropin-releasing hormone agonists (GnRH), oral contraceptives, Danazol®, aromatase inhibitors, Progestins

Indications for surgical management: • •

•

•

Surgical Intervention Laparoscopy Hysterectomy/Oophorecto my/Salpingooophorectomy • •

•

• •

Nonsurgical Therapies Medical Therapies Alternative Therapies •

diagnosis of unresolved pelvic pain severe, incapacitating pain with significant functional impairment and reduced quality of life advanced disease with anatomic impairment (distortion of pelvic organs, endometriomas, bowel or bladder dysfunction) failure of expectant/medical management endometriosis-related emergencies, ie, rupture or torsion of endometrioma, bowel obstruction, or obstructive uropathy

Endometriosis therapy

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Mild – Moderate Pain 

NSAID



Oral contraceptive



progestin

Moderate-Severe Pain GnRH agonis

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Danazole



Aromatase inhibitor 



Endometriosis therapy

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Oral contraceptive 





Generally well tolerated, fewer metabolic and hormonal side effect than similar therapies Relieve dismenorrhea throuh ovarian supresion and continous progestin administration Often simple, effective choice to manage endometriosis through avoidance or delay menses for upwards of 2 years

Non Steroidal Anti Inflamatory 

Proven efficacy fot treatment of primary dismenorhea

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Acceptable side effects

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Reasonable cost

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Ready availability

Endometriosis therapy

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Progestins 

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Inhibit growth of lesion by infucing ecidualization followed by athropy uterine type tissue Compared to GnRH therapy, both modalities show comparable effectiveness Medroxyprogesterone acetat proven for pain suppresion both oral and injectable Adverse effect : weight gain, fluid retention, depresion, breakhrough bleeding

Aromatase Inhibitor 





Endometriotic implan express aromatase and consequently generate esterogen, maintaining own viability Inhibit local esterogen production in endometrioticimplant Significantly reduce pain, compared with GnRH agonit alone.

Endometriosis therapy

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GnRH agonist 

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

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Produced hypogonadic state through down regulation of pituitary gland

Danazol 



Efective as other therapies in relieving pain and reduce progression No fertility improvement

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High cost, bone density loss, intolerable hypoesterogeninc side effect

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Preoperative therapy reported to reduce pelvic vascularity and size of lesion, reduce intraoperative blood

Among oldest f medical therapy for endometriosis Inhibit midcycle FSH and LH surge and prevent steroidogenesis in corpus luteum Higher incidence of adverse effect more recent therapy Androgenic manifestation (oily skin, ane, weight gain, deepening voice, hirsutism) maybe intolerable

Amenorrhea

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

Amenorrhea is the absence of menstruation.



Primary 

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

Absence of menses by age 14 without secondary sexual development Absence of menses by age 16 with normal secondary sexual characteristic

Secondary 

Absence of menses for 6 month in a previous menstruating female

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Menstrual period exceeding 8 days inbleeding duration on regular basis Definisi heavy menstrual dkk 

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Shortened menstrual bleeding

Uncommon, define as bleeding of no longer than 2 days

Irregular menstrual bleeding

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

Absent menstrual bleeding (amenorhea)

No bleeding in a 90 days period

Infrequent menstrual bleeding

One or two episode in a 90 day period

Frequent menstrual bleeding

More than four time episode in a 90 day period

Heavy menstrual bleeding

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

Heavy and prolonged menstrual bleeding

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

81 term Acute Abnormal Uterine Bleeding

Episode of bleeding in a woman of reproductive age, who is not pregnant, of sufficient quantity to require immediate intervention to prevent further blood loss

Chronic Abnormal uterine bleeding

Bleeding from the uterine corpus hat is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 month

Irregular Non Menstrual Bleeding

Irregular episode of bleeding, often light and short, occurring between normal menstrual period. Mostly associated with benign or malignant structure lesion, may occur during or following sexual intercourse

Post menopausal bleeding

Bleeding occurring >1 year after the acknowledge menopause

Precocious menstruation

Usually associated with other sign of precocious puberty, occur before 9 years of age

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Diagnosis of primary amenorrhea

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Diagnosis of secondary amenorrhea

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Functional hypothalamic amenorrhea:

86 •

•

•

the hypothalamicpituitary-ovarian axis is suppressed due to an energy deficit stemming from stress, weight loss (independent of original weight), excessive exercise, or disordered eating. It is characterized by a low estrogen state without other organic or structural disease Menses typically return after correction of the underlying nutritional

Menopause

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I. Definition permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of  amenorrhea without any other obvious pathological or physiological cause ; mean age 51,4 y.o

II. Pathophysiology

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The number of primordial follicle decline even before birth but dramatic just before menopause.  Increase FSH, LH from about 10 years before menopause.  Close to menopause: There will be -anovulation -inadequate Leuteal phase → decrease progesterone but not estrogen level → lead to DUB and endometrial Hyperplasia - at menopause dramatic decrease of estrogen→menstruation ceases and symptoms of menopause started.  But still ovarian stroma produce →small androstenedione and testosterone but, main postmenopausal astrogen is estrone produced by Peripheral fat from adrenal androgen. 

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III. Symptoms of Menopause: 1. Hot flushes - cutaneous vasodilation - occurs in 75% of women - more severe after surgical menopause - continue for 1 year  - 25% continue more than 5 years 2. Urinary Symptoms - urgency - frequency

3. Psychological changes decreased level of central neurotransmitters - Depression - Irritability - Anxiety - Insomia - lose of concentration

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4. Atrophic Changes Vagina  *vaginitis due to thinning of epithelium, ↓ PH and lubrication. *dysparnue→due to decrease vascularity and dryness 

Decrease size of cervix and mucus with retract of segumocolumnar (SC)  junction into the endocervical canal.

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Decrease size of the uterus, shrinking of myoma & adenomyosis.

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Decrease size of ovaries, become non palpable.

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Pelvic floor - relaxation →prolapse.

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Urinary tract →atrophy →lose of urethral tone →caruncle Hypertonic Bladder - detrusor instability

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Decrease size of breast and benign cysts.

5.

Skin Collagen –  ↓ collagen & thickness → ↓ elasticity of the skin.

6.

Reversal of premenstrual syndrome

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Diagnosis and Investigations: The Triad of: -Hot flushes -Amenorrhea -increase FSH > 15 i.u./L  Before starting treatment: You should perform -breast self examination -mammogram -pelvic exam (Pap Smear) -weight, Blood pressure  No indication to perform -bone density -Endometrial Biopsy but any bleeding should be investigated before starting and treatment. 

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Treatment: Estrogen – a minimum of 2mg of oestradiol is needed to mantain bone mass and relief symptoms of menopause.  Women with uterus – add progestin at last 10 days to prevent endometrial Hyperplastic  Sequential Regimens - used in patient close to menopause. Oestrogen – in the first ½ of 28 day per pack  & Oestrogen & Progetin in 2 nd 1/12 of 28 day pack.  Combined continuous therapy who has Progesterone everyday – is useful for women who are few years past the menopause and who do not to have vaginal bleeding.  There is evidence that increase risk of endometrial cancer with sequential regimens for > 5 years while on 

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Benefits of HRT: Vagina-↑ vaginal thickness of epithelium →↓ dyspar eunia & vaginitis. Urinary tract – enhancing normal bladder function. Osteoporosis – decrease fractures by more than 50% CVS – decrease by 30% by observation studies but recent studies shows no benefits. Colon Cancer decrease up to 50% 

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INFERTILITAS

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Infertility

Infertilitas 106 failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 years of age; and after six months of regular intercourse without use of contraception in women 35 years and older  40% faktor istri 40% faktor suami 20% pada keduanya wanita: 35-60% faktor tuba & peritonium 10-25% kasus: Unexplained infertility

Faktor Suami a. 35% : faktor sperma -b. Gangguan transfortasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome, Myotonic distrophy), kelainan hipotalamus-hipofisa -c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.

107

Faktor Istri: 108

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Infeksi

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Gangguan ovulasi

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Gangguan anatomi

Gangguan Ovulasi •Penuaan (usia) •POF •Polikistik Ovarii (PCOS) •Kelainan pada hipotalamushipofisis •Hiperprolaktin •Kelainan kongenital

109

110

Analisa Sperma

ANALISA SPERMA

111 

Fertilitas seorang pria ditentukan oleh jumlah dan kualitas spermanya

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Normozoospermia

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Jumlah sperma ≥ 20 juta/ml

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Oligozoospermia

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Jumlah sperma < 20 juta/ml

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Astenozoospermia

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Motilitas sperma a tes amin 4. Clue cells --> Gram -

133

Pengobatan sindrom duh tubuh vagina karena vaginitis Pengobatan untuk trikomoniasis DITAMBAH Pengobatan untuk vaginosis bakterial . BILA ADA INDIKASI, Pengobatan untuk kandidiasis vaginalis

134

Pengobatan sindrom duh tubuh vagina karena infeksi serviks Pengobatan untuk gonore tanpa komplikasi DITAMBAH Pengobatan untuk klamidiosis

Lect. By dr. Retno Satiti, Sp.KK

Pelvic Inflammatory Disease 135 • Acute infection of the upper genital tract structures in women, involving any or all of the uterus, oviducts, and ovaries • Microbiology  – N. gonorrhea – 1/3 of cases  – Chlamydia – 1/3 of cases  – Mixed infection – strep, e.coli, klebsiella, anaerobes

• Risk factors  – Number of sexual partners  – Age • 15-25 years old w/ highest frequency  – Symptomatic male partner   – Previous PID African American women

• Clinical symptoms  – Abdominal pain  – Vaginal bleeding  – Vaginal discharge  – Dispareunia  – Disuria/ureteritis • Physical exam:  – Abdominal pain  – Fever   – Bimanual exam with CMT or adnexal tenderness  – Cervical discharge • Diagnosis  – Pregnancy test  – Cervical sample for GC/ Chlamydia  – Pelvic ultrasound

Indikasi Rawat Inap Pada pasien Penyakit Radang Panggul

136 • • • • • • •

Diagnosis tidak dapat dipastikan Indikasi bedah darurat : appendisitis, KET Dugaan abses panggul Pasien sedang hamil Kegagalan pengobatan saat rawat jalan Kemungkinan semakin parah jika rawat jalan Pasien tidak mau atau tidak menaati rejimen pengobatan bila dilakukan rawat jalan

Complication of Pelvic Inflammatory Disease Perihepatitis: Fitz-Hugh Curtis Syndrome (RUQ pain with pleuritic component),Tubo-ovarian abscess,Chronic pelvic pain – seen in 1/3 of patients,Infertility,Ectopic pregnancy

Pengobatan Penyakit Radang Panggul (Rawat Jalan) 137

138

Indikasi Rawat Inap Pada pasien Penyakit Radang Panggul Keterangan - Dilakukan hingga 2 hari menunjukan perbaikan klinis, lalu dilanjutkan oleh salah satu obat - Doksisiklin 2x100 mg PO 12 hari - Tetrasiklin 4x500 mg PO 14 hari

139

Sindroma Ulkus Genital * Sifilis * Chancroid = ulkus mole * Herpes genitalis * Limfogranuloma venereum * Granuloma inguinale

Ulkus Durum vs Ulkus Mole 140

Ulkus Durum

Ulkus Mole

Terkait dengan Sifilis  Cenderung tunggal  Dasar bersih  Tempat tersering : sulcus coronarius (pria), wanita (labia mayora)

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Chancroid / H. Ducreyi  Cenderung multiple  Dasar kotor, tampak kemerahan hingga nekrotik 

Sifilis

141

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Peny. Infeksi sistemik & kronis

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Etiologi: T. pallidum (Spirochaeta, spiral, Gram neg., Bergerak  berputar, atau maju spt pembuka tutup botol)

Transmisi: * Kontak seksual * Trans-Plasenta Patogenesis: kontak langsung dari lesi infeksius treponema  selaput lendir  kelenjar limfe  pemb.darah 

Perjalanan sifilis tanpa Tx: 1. Sifilis primer  2. Sifilis sekunder  3. Laten dini 4. Laten lanjut – tertier benign, kardiovaskuler, neurosifilis

Sifilis Primer

142

ulkus di genital eksterna, 3 mgg setelak CS  tunggal/multipel, uk 1-2 cm Papula erosi permukaan tertutup krusta ulserasi tepi meninggi & keras ulkus durum  pembesaran lln. Inguinal bilateral  sembuh spontan 4-6 mgg 

Sifilis sekunder (3-4 mgg setelah ulkus durum)

143

lesi kulit, selaput lendir, organ tubuh demam, malaise lesi kulit simetris, makula, papula folikulitis, papuloskuamosa,pustula moth-eaten alopecia - oksipital papula basah daerah lembab: kondilomata lata lesi pd mukosa mulut, kerongkongan, serviks: plakat • pembesaran kel. Limfe multipel • splenomegali • • • • • • •

Sifilis Laten

144

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Sifilis Laten Dini :  stadium sifilis tanpa gejala klinis  tes serologis reaktif < 1 th

•Sifilis laten lanjut  sifilis tersier  Muncul 2-20 tahun sesudah infeksi primer   Terjadi pada 30% kasus sifilis

Sifilis Tersier  Muncul beberapa lesi kulit, distribusi asimetris • Sulit menemukan TP dlm lesi  kurang infeksius • Terjadi kerusakan jaringan/organ  Lesi spesifik: Gumma - endarteritis obliterans – peradangan nekrosis - neurosifilis, kardiosifilis 

145

Sifilis Kongenital Didapat dari Ibu dg Sifilis awal Terjadi saat kehamilan > 4 bl (10 bl)  < 4 bl sisitem imun blm berkembang penuh Tidak pernah terjadi ulkus Manifestasi klinis awal lebih berat dibanding sifilis dapatan Sistem kardiovaskular sering terlibat Dapat mengenai mata, telinga, hidung Sering juga merusak sistem skeletal

146

 Sifilis kongenital dini: < 2 th • lesi kulit: terjadi segera, vesikobulosa, erosi, • papuloskuamosa, • mukosa: hidung, pharing: perdarahan • tulang: osteokondritis tl panjang • anemia hemolitik  • hepatosplenomegali • SSP

 Sifilis kongenital lanjut: > 2 th

147

Sklerosis –  sabre

Neurosifilis

Gangguan saraf pusat VIII  – tuli

Keratitis interstisialis,

Bilateral gigi hutschinson

Gigi Mulberry

Diagnosis: klinis + lab 148

1. Lab : medan gelap (dark field)  sifilis primer  2. Antibodi serum : VDRL (1/16), TPHA  S sekunder & tersier 

Terapi   sifi lis pri mer & sekunder  Benzatin penisilin G 2,4 juta IU, IM, ds tunggal anak: 50.000 IU/kg , IM, ds tunggal

 sifi lis laten: laten dini: Benzatin penisilin G 2,4 juta IU. IM, ds tunggal laten lanjut: Benzatin penisilin G 2,4 juta IU, IM/mgg, 3 mgg anak: 50.000 IU/kg,IM,ds tunggal 50.000 IU/kg,IM/mgg, 3 mgg

 Sifilis terstier : Benzatin penisilin G 2,4 juta IU/mgg, 3 mgg Tindak lanjut: ulang serologi, 6, 12, 24 bl Tx. Berhasil jika titer turun 4 x

149

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Lakukan pemeriksaan serologi tiap 3 bln pd tahun I

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Ulang serologi setiap 6 bln pd tahun II

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* Amati kembali pada tahun ke 3

Kondiloma Akuminata 150

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Termasuk dalam STD

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Pria = Wanita

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Predileksi :  –

Penularan : kontak kulit langsung Etiologi : Human Papilloma Virus (HPV) tipe 6,11,16,18, 30, 31, dsb 

Virus DNA

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Keluarga Papova

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Pria : perineum, sekitar anus, sulkus koronarius, glans penis, muara uretra eksterna, korpus penis Wanita : vulva, introitus vagina, porsio uteri (