Lbm 6 Repro Nindy

LBM 6 nindy

How the cycles of normal menstruation? •

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The start of the menstrual cycle begins on the first day of bleeding. On about the 5 th day, the brain begins producing hormones that cause a few follicles to grow and mature in the ovaries. These follicles then start producing the hormone estrogen. The lining of the uterus (endometrium) responds to the estrogen by becoming thicker and developing more blood vessels. Somewhere around the 14 th or 15th day of the cycle (if your cycles are in the neighborhood of 27-30 days), the most mature follicle bursts and releases an egg or ovum. This is called ovulation. ovulation. The egg then enters the Fallopian tube. The ruptured follicle begins to secrete the hormone progesterone. Progesterone increases the supply of blood and nutrients to the uterus If the egg unites with a sperm from a man, it becomes fertilized and travels down the Fallopian tube, finally settling into the lining of the uterus. If the egg does not become fertilized, it soon breaks down, and the follicle stops producing progesterone. The loss of progesterone causes the lining of the uterus to break apart and bleed. The menstrual period then begins, starting another cycle.

How the cycles of normal menstruation? •

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The start of the menstrual cycle begins on the first day of bleeding. On about the 5 th day, the brain begins producing hormones that cause a few follicles to grow and mature in the ovaries. These follicles then start producing the hormone estrogen. The lining of the uterus (endometrium) responds to the estrogen by becoming thicker and developing more blood vessels. Somewhere around the 14 th or 15th day of the cycle (if your cycles are in the neighborhood of 27-30 days), the most mature follicle bursts and releases an egg or ovum. This is called ovulation. ovulation. The egg then enters the Fallopian tube. The ruptured follicle begins to secrete the hormone progesterone. Progesterone increases the supply of blood and nutrients to the uterus If the egg unites with a sperm from a man, it becomes fertilized and travels down the Fallopian tube, finally settling into the lining of the uterus. If the egg does not become fertilized, it soon breaks down, and the follicle stops producing progesterone. The loss of progesterone causes the lining of the uterus to break apart and bleed. The menstrual period then begins, starting another cycle.

Why she had menstruation over 15 days ? •

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Perdarahan Perdarahan Uterus Disfungsional (DUB) (DUB ) Perdarahan Perdarahan abnormal dari uterus baik dalam jumlah, frekuensi maupun lamanya, yang terjadi didalam atau diluar haid sebagai wujud klinis gangguan fungsional mekanisme kerja poros hipotalamus-hipofisis-ovarium, endometrium tanpa kelainan organik alat reproduksi, seperti radang, tumor, keganasan, kehamilan atau gangguan sistemik lain. Perdarahan Perdarahan uterus disfungsional dapat berlatar belakang kelainan-kelainan elainan-kelainan ovulasi, suklus haid, jumlah perdarahan dan anemia yang ditimbulkannya

Berdasarkan kelainan tersebut maka perdarahan uterus disfungsional dapat dibagi seperti table

Dasar kelainan Ovulasi

Bentuk klinis PUD ovulatorik PUD anovulatorik

Siklus

Metroragia Polimenorea Oligomenorea Amenorea

Jumlah perdarahan

Menoragia Perdarahan bercak prahaid Perdarahan bercak paskahaid

Anemia

PUD ringan PUD sedang PUD berat

Causes: Abnormal uterine bleeding is a symptom and not a disease. Its causes include the following: •

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Early pregnancy complications (abortion, ectopic pregnancy, hydatidiform mole).

Pelvic inflammatory disease (PID). Benign tumors (uterine fibroids,cervical polyps endometriosis, adenomyosis) malignant tumors ( endometrial and cervical carcinoma) Dysfunctional uterine bleeding.

Clinical types: 1.

Menorrhagia (regular & cyclical):

- cyclical bleeding at normal intervals which is excessive in amount or duration. e.g. 5/28 or 8/28. - causes: benign organic disease of genital tract(fibroids, adenomyosios, PID) and may be dysfuctional (ovulatory). 2. Polymenorrhoea (regular & cyclical):

- Cyclical bleeding which is normal in amount but occurring at too-frequent intervals of less than 21 days, e.g. 5/20. Her the uterus is normal. - cause: ovarian endometriosis, PID, DUB.

Clinical types: 3.

Polymenorrhagia:

- Cyclical bleeding which is both excessive and too frequent, e.g. 9/20-12/20. - Caused by: DUB, PID. 4. Metrorrhagia (irregular or acyclical): - bleeding of any amount which acyclical occurring irregularly or continuously. - always originates in the uterus. - causes(organic) : complications of early pregnancy, ulceration or infection of benign tumors, malignancies (perimenopausal)

Clinical types:

5. Intermenstrual bleeding: - often dysfunctional (fall in oestrogen secretion following ovulation); 60% of ovulatory women have erythrocytes in their cervical mucus if examined.

- common with cervical and endometrial polyps, fibroids and cervical carcinoma

Why she complained that she had irregular menstrual cycles , sometimes twice in a month ?

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What is the probability? Oligomenorhage  siklus lbih panjang, >35 hari, fase proliferasi lbih panjang, bisa karena adanya gangguan proliferasi/pematangan sel2 endometrium, yg dipengaruhi hormone estrogen

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Polimenorhage  mens >1x dlm sebulan, Pengaruh dr obesitas, hormonal mempengaruhi siklus menstruasinya, obesitas  kelebihan estrogen  menorhagia Polimenorhage = metroraghia? Polimenorhage : mens > 1x sebulan, berkelanjutan, berulang2 memang seperti itu tiap bulannya, dlm mens nya ttep 4-7 hr Metrorhagia : mens > 1x sebulan yg tdk teratur, haid berkepanjangan, keadn patologis, bisa krna kelainan hormonal, siklusnya pendek, lama mensnya >15hr,  jumlah darah mensnya normal

Why she had abdominal pain ?

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Dysmenorrhea primer terjadi karena banyak faktor, diantaranya faktor endokrin, yaitu penurunan kadar progesteron yang dapat meningkatkan prostaglandin, antara lain PGE2 dan PGF2 alfa yang mana akan merangsang miometrium sehingga terjadi peningkatan kontraksi dan disritmia uterus. Akibatnya akan terjadi penurunan aliran darah ke uterus dan ini akan mengakibatkan iskemia. Prostaglandin dan endoperoksid juga menyebabkan sensitisasi dan selanjutnya menurunkan ambang rasa sakit pada ujung-ujung syaraf aferen nervus pelvicus terhadap rangsang fisik dan kimia (Qittun,2008).

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Dysmenorrhea sekunder yaitu rasa nyeri kram pada perut bawah yang disebabkan karena adanya kelainan pada daerah pelvis, misalnya endometriosis, mioma uteri, stenosis serviks, malposisi uterus atau adanya IUD dan biasanya muncul seminggu sebelum menstruasi berlangsung (McFerren, 1996).

Etiologi:

Penyebab dari dismenore sekunder adalah: endometriosis, fibroid, adenomiosis, peradangan tuba falopii, perlengketan abnormal antara organ di dalam perut, dan pemakaian IUD.

Perbedaan gambaran klinis dismenore primer dan sekunder Dismenore primer Onset singkat setelah menarche

Dismenore sekunder Onset dapat terjadi kapan saja setelah menarche (khasnya setelah 25 tahun).

Nyeri kram di perut bawah atau pelvis dengan awal keluarnya darah selama 8-72 jam.

Pola nyeri sama setiap siklus.

Waktu dari nyeri berubah-ubah sepanjang siklus menstruasi.

Memburuk setiap waktu, dapat unilateral, dapat memburuk pada waktu berkemih

Nyeri pada paha dan pinggang, sakit kepala, diare, mual dan muntah dapat dijumpai.

Tidak dijumpai kelainan patologis pelvis.

Dijumpai gejala ginekologi: dispareunia danmenorragia.

Dijumpai abnormalitas pelvis patologis.

Why she had frequent foul-smelling vaginal discharge between menstrual cycles ? •

Normal Vaginal Discharge - All women have some vaginal discharge. Normal discharge may appear clear, cloudy white, and/or yellowish when dry on clothing. It may also contain white flecks and at times may be thin and stringy. Changes in normal discharge can occur for many reasons, including menstrual cycle, emotional stressors, nutritional status, pregnancy, usage of medications - including birth control pills, and sexual arousal.

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Effects of the Menstrual Cycle - The menstrual cycle affects the vaginal environment. You may notice increased wetness and clear discharge around mid-cycle. The pH balance of the vagina fluctuates during the cycle and is the least acidic on the days just prior to and during menstruation. Infections, therefore, are most common at this time.

Correlation her mother died cause by cervical cancer and her condition ? •

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First-degree relatives of women with myomas have a 2.5 times increased risk of developing myomas (23, 24). Women reporting myomas in two first-degree relatives are more than twice as likely to have strong expression of VEGF-a (a myoma-related growth factor) than women who have myomas but no family history (25). Monozygous twins are reported to be hospitalized for treatment of myomas more often than dizygous twins, but these findings may be the result of reporting bias (26). William H. Parker, M.D. Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, California

What the correlation between general physical examination (anemic and obese )? •

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A prospective study found that the risk of myomas increased 21% with each 10 kg increase in body weight and with increasing body mass index (30). Similar findings have been reported in women with greater than 30% body fat (31). Obesity increases conversion of adrenal androgens to estrone and decreases sex hormone –binding globulin. The result is an increase in biologically available estrogen, which may explain an increase in myoma prevalence and/ or growth. William H. Parker, M.D. Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, California

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A random sample of women aged 35 to 49 was evaluated by self-reported bleeding patterns and by abdominal and transvaginal sonography to determine presence, size, and location of myomas (54). Of the 878 women screened, 564 (64%) had myomas, and 314 (36%) did not. Forty-six percent of the women with myomas reported ‘‘gushing blood’’ during their menstrual periods compared with 28% without myomas. Gushing blood and length of periods were related to size of myomas (large myomas RR ¼ 1.9, CI 1.5 –2.5), but not to presence of submucous myomas or to multiple myomas. William H. Parker, M.D. Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, California

DD? Mioma Uteri 1. Teori Stimulasi Berpendapat bahwa estrogen sebagai faktor etiologi, mengingat bahwa : Mioma uteri sering kali tumbuh lebih cepat pada masa hamil Neoplasma ini tidak pernah ditemukan sebelum monarche Mioma uteri biasanya mengalami atrofi sesudah menopause Hiperplasia endometriumsering ditemukan bersama dengan mioma uteri Mioma servikalis (terletak di dekat leher rahim) • • • •

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2. Teori Cellnest atau genitoblas Terjadinya mioma uteri itu tergantung pada sel-sel otot imatur yang terdapat pada cell nest yang selanjutnya dapat dirangsang terus menerus olehestrogen. (Prawirohardjo, 1996:282)

Mioma Submukosa

Mioma intramural

Mioma Subserosa atau subperitoneal

Tumbuhnya tepat di bawah endometrium. Paling sering menyebabkan perdarahan yang banyak, sehingga memerlukan histerektomi, wlaupun ukurannya kecil. Adanya mioma submukosa dapat dirasakan sebagai suatu “curet bump” (benjolan waktu kuret). Kemungkinan terjadinya degenerasi sarcoma  juga lebih besar pada jenis ini. Sering mempunyai tangkai yang panjang sehingga menonjol melalui cervix atau vagina, disebut mioma submucosa bertangkai yang dapat menimbulkan “miomgeburt”, sering mengalami nekrose atau

Terdapat di dinding uterus di antara serabut miometrium.Karena pertumbuhan tumor, jaringan otot sekitarnya akan terdesak dan terbentuk simpai yang mengelilingi tumor. Bila di dalam dinding rahim dijumpai banyak mioma, maka uterus akan mempunyai bentuk yang berbenjol-benjol dengan konsistensi yang padat. Mioma yang terletak pada dinding depan uterus, dalam pertumbuhannya akan menekan dan mendorong kandung kemih ke atas, sehingga dapat menimbulkan keluhan miksi.

Letaknya di bawah lapisan tunica serosa, kadang-kadang vena yang ada di bawah permukaan pecah dan menyebabkan perdarahan intra abdominal. Kadangkadang mioma subserosa timbul di antara dua ligalatum, merupakan mioma intraligamenter, yang dapat menekan uterus dan A. Iliaca. Ada kalanya tumor ini mendapat vascularisasi yang lebih banyak dari omentum sehingga lambat laun terlepas dari uterus, disebut sebagai parasitic mioma. Mioma subserosa yang bertangkai dapat mengalami torsi. (Sastrawinata S:154)

Endometriosis •

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Adalah suatu keadaan di mana jaringan endometrium yang masih berfungsi terdapat di luar kavum uteri. Jaringan ini terdiri atas kelenjar-kelenjar& stroma,terdapat di miometrium di sebut Adenomiosis dan bila di luar uterus di sebut Endometriosis,,

Endometriosis •

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Endometriosis terdapat pada wanita yang lebih muda&yang umumnya infertil. Jaringan endometrium di temukan di luar kavum uteri&di luar miometrium. Endometrium sering di temukan di ovarium,peritonium&ligamentum sakrouterinum,kavum douglasi,dinding blkg uterus,tuba fallopii,plika vesikouterina,ligamentum rotondum&sigmoid,septum rektovaginal,kanalis iunginalis,apendiks,umbilikus,serviks uteri,vagina,kandungkencing,vulva,perineum,parut laparatomi,kelenjar limfe,pleura&perikardium.

Patologi •

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Gambaran mikroskopik dari endometrium sangat variabel,lokasi yg sering terdapat pd kedua ovarium tampak kista2 biru kecil sampai kista besar berisi darah tua menyerupai coklat(endometrioma). Darah tua keluar sedikit2 krn luka pd dinding kista &dapat menyebabkan perlekatan antara permukaan ovarium dgn uterus,sigmoid&dinding pelvis.

Gambaran klinik Gejala” : - Nyeri perut bawah yang progretif dekat paha dan selama haid. - Dismenorea - Nyeri pada waktu haid - Hypermenorea - Infertilitas

DIAGNOSIS Atas dasar anamnesis pemeriksaan fisik, pemeriksaan laparaskopi, biopsi . Pemeriksaan lab tidak memberi tanda yang khas.Foto roentgen.

PENANGANAN Endometriosis tdd: tx Hormonal, pembedahan, radiasi.