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dr. Nashria
dr. Reagan Resadita
Abnormal
Congenital
Neoplasm
2 Menstrual Infertility Infection
infection
Cycle
Gonorrhea
Menstruation
Toxoplasmosis
Cervix Sperm Analysis
Trichomoniasis
Abnormal uterine
bleeding Candidiasis
Rubella
Bacterial Vaginosis
Polycystic ovarian
Uterine Corpus Endometriosis
syndrome
PID
CMV
Amenorrhea Syphilis
Condiloma
Woman Fertility acuminata
Ovarium
Test Varicella
menopause
Bartholin abscess
3
NEOPLASM
Neoplasma
Abnormal, excessive growth of tissue
Common
4
Malignant symptoms:
Vs Solid Abnormal
Benign Vs bleeding
(myoma,ovarian Cystic Pelvic mass
cyst) Vulvovaginal
symptoms
5
Clinical Aspects : Benign vs Malignant Tumor
+ - PAP SMEAR
+ + Biopsi
Methods to Improve Accuracy of Pap Smears
Perform a Pap smear when the patient is in the proliferative phase (in the
28
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,
dysplasia, malignancy, etc.
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.
2015 UpToDate
33
AAFP Guideline
34
Terapi Penjelasan
36 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
37
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
pedunculated : satelite myoma
41
Influencing factors of
Myoma Uterine
SYMPTOMS SIGN
42
Menorrhagia heavy & A palpable abdominal tumor :
prolonged menstruation arising from pelvis, well defined
(common) margins , firm consistency, smooth
Pelvic pain : occurs in surface, mobile from side to side.
pregnancy if undergoing
degeneration or torsion Pelvic examinationUterus
Pelvic pressureurinary enlarged and irregular, hard
frequency, constipation
Spontaneous abortion Diagnosis : Bimanual exam, USG,
Infertility hysteroscopy, Laparacospy
TREATMENT
Observation: for small myoma,
premenopause
Operation : myomectomy or
hysterectomy
Image source:https://embryology.med.unsw.edu.au/
51
Normal Menstrual Bleeding
Malignancy and
Polyp Adenomyosis leiomyoma
hyperplasia
Adenomyosis
Part of endometrial that penetrate to myometrium
Leiomyoma
Submucosal
SUbserosal
intramural
Ovulatory disurbance
Endocrinopatie (PCOS, Hypotiroid, obesity, anorexia)
Extreme exercise, stress
endometrial
Endometrial inflammation
Endometrial infecton
Defisiensi endothelin-1, defisiensi Prostaglandin F2-alpha
Iatrogenic
Drugs : rifampicin, griseofulvin, trisiklik,
phenothiazine, anticoagulant, antiplatelet,
Treatment of uterine bleeding
63
Infrequent bleeding
1. Therapy should be directed at the underlying cause when
possible.
2. If the CBC and other initial laboratory tests & history and
physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid
ACOG 2008
Treatment of frequent or heavy bleeding
64
1. NSAID
improves platelet aggregation
increases uterine vasoconstriction.
NSAIDs are the first choice in the treatment of menorrhagia because they are well
tolerated and do not have the hormonal effects of oral contraceptives.
a. Mefenamic acid (Ponstel) 500 mg tid during the menstrual period.
b. Naproxen (Anaprox, Naprosyn) 500 mg loading dose, then 250 mg tid
during the
menstrual period.
c. Ibuprofen (Motrin, Nuprin) 400 mg tid during the menstrual period.
2. Ferrous gluconate 325 mg tid.
3. Patients with hypovolemia or a hemoglobin level below 7 g/dL should be
hospitalized for hormonal therapy and iron replacement.
Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops.
Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper
slowly to one pill qd.
If bleeding continues, IV vasopressin (DDAVP) should be administered.
ACOG 2008
65 Hysteroscopy may be necessary, and dilation and curettage
is a last
resort. Transfusion may be indicated in severe hemorrhage.
Ferrous gluconate 325 mg tid.
ACOG 2008
Dysmenorrhea
66
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 F2 (PGF2), 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
decreased blood flow to the myometrium.
Secondary
Dysmenorrhea beginning in the 20s or 30s, after previous
67
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.
68 Endometriosis
An estrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic
pain, multiple surgeries, and impaired fertility
Sign Symptom
Classic signs: Dysmenorrhea
severe dysmenorrhea, dyspareunia, Heavy or irregular bleeding
chronic pelvic pain, Cylical/noncylical pelvic pain
infertility Lower abdominal or back pain
Dyschezia, often with cycles of
diarrhea/constipation
Bloating, nausea, and vomiting
Inguinal pain
Dysuria
Dyspareunia with or without penetration
Nodules may be felt upon pelvic exam
Imaging may indicate pelvic mass/endometriomas
70 Physical exam and imaging
Physical examination has poor Imaging studies
sensitivity, specificity, and Predictive
value in diagnosis endometriosis. Transvaginal or endorectal USG may reveal US feature
varying from simple cyst to complex cyst with internal
Combination of History, Physical echoes to solid masses, usually devoid of vascularity
exam and laboratory and diagnostic
studies is indicated to determine CT may reveal endometrioma appearing as cystic
cause of pelvic pain and rule out non masses; however, apperance are non specific and
endometriosis concerns imaging modalities should not be relied upon on for
diagnosis
Pain mapping may help isolate
location spesific disease such as MRI : may detect even smallest lesion and distinguish
nodulas masses in posterior hemorragic signal of endometrial implant
rectovaginal septum MRI demonstrated to accurately detect rectovaginal
Absence of evidence during exam is disease and obliteration in more than 90% of cases
not evidence of disease absence when USG gel was inserted in the vaginal and rectum
71 Endometriosis therapy
Heavy menstrual bleeding Excessive menstrual blood loss that interferences with the woman
physical, emotional, social, and material quality of life and can occur
alone or in combination with other symptom
Heavy and prolonged Less common than HMB, its important to make a distinction from HMB
menstrual bleeding given they may have different etiologies and respond to different
therapies
Light Menstrual Bleeding Based on patient complaint, rarely related to pathology
81
term
Acute Abnormal Uterine Episode of bleeding in a woman of reproductive age, who is not
Bleeding pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss
Chronic Abnormal uterine Bleeding from the uterine corpus hat is abnormal in duration,
bleeding volume, and/or frequency and has been present for the majority of
the last 6 month
Irregular Non Menstrual Irregular episode of bleeding, often light and short, occurring
Bleeding between normal menstrual period. Mostly associated with benign
or malignant structure lesion, may occur during or following sexual
intercourse
Post menopausal bleeding Bleeding occurring >1 year after the acknowledge menopause
Precocious menstruation Usually associated with other sign of precocious puberty, occur
before 9 years of age
83
Diagnosis of
primary
amenorrhea
84
Diagnosis of
secondary
amenorrhea
85
Functional
86 hypothalamic
amenorrhea:
the hypothalamic-
pituitary-ovarian axis is
suppressed due to an
energy deficit stemming
from stress, weight loss
(independent of original
weight), excessive
exercise, or disordered
eating.
It is characterized by a
low estrogen state without
other organic or structural
disease
Menses typically return
after correction of the
underlying nutritional
deficit.
87 Menopause
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
89 II. Pathophysiology
2. Urinary Symptoms
- urgency
- frequency
- nocturia
4. Atrophic Changes
92 Vagina
*vaginitis due to thinning of epithelium, PH and lubrication.
*dysparnuedue to decrease vascularity and dryness
Decrease size of cervix and mucus with retract of segumocolumnar (SC)
junction into the endocervical canal.
Decrease size of the uterus, shrinking of myoma & adenomyosis.
Decrease size of ovaries, become non palpable.
Pelvic floor - relaxation prolapse.
Urinary tract atrophy lose of urethral tone caruncle
Hypertonic Bladder - detrusor instability
Decrease size of breast and benign cysts.
5. Skin Collagen collagen & thickness elasticity of the skin.
6. Reversal of premenstrual syndrome
93 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.
94 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 of 28 day per pack
& Oestrogen & Progetin in 2nd 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
combined continuous regimens decrease risk of Cancer.
95 Benefits of HRT:
Vagina- vaginal thickness of epithelium
dyspareunia & vaginitis.
Urinary tract enhancing normal bladder
function.
Osteoporosis decrease fractures by
more than 50%
CVS decrease by 30% by observation
studies but recent studies shows no
benefits.
Colon Cancer decrease up to 50%
104
INFERTILITAS
105
Infertility
Infertilitas
106
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 Infeksi
Gangguan ovulasi
Gangguan anatomi Gangguan Ovulasi
Penuaan (usia)
POF
Polikistik Ovarii (PCOS)
Kelainan pada hipotalamus-
hipofisis
Hiperprolaktin
Kelainan kongenital
109
110
Analisa Sperma
111 ANALISA SPERMA
Fertilitas seorang pria ditentukan A: bergerak cepat dan lurus
oleh jumlah dan kualitas B: Bergerak lambat dan tidak lurus
spermanya
C : bergerak ditempat
Normozoospermia
D : tidak bergerak
Jumlah sperma 20 juta/ml
Teratozoospermia
Oligozoospermia
Morfologi sperma normal < <30%
Jumlah sperma < 20 juta/ml
oligoAstenoTeratozoospermia sindroma
Astenozoospermia OAT
Motilitas sperma a<25% atau Azoopermia 0 sperma + plasma semen
a+b <50%
Aspermia 0 sperma + 0 plasma semen
112 Motilitas spermatozoa dan viabilitas
Digunakan untuk kriteria D tidak bergerak uji viabilitas
Pewarnaan supravital menggunakan Eosin Y dengan prinsip sperma hidup
tidak dapat menyerap zat warna dan sebaliknya denan sperma mati
(disintegrasi membran sel)
Dilihat dibawah mikroskop
Sperma hidup kepala bening
Sperma mati kepala ungu
Dari 100 sperma yang dihitung
80 sperma kepala bening
20 sperma kepala ungu
Uji Viabilitas 80%
Sindroma Ovarium Polikistik
113
Kelainan endokrin
wanita usia reproduktif
Definisi klinis
Terdapatnya
hiperandrogenemia yang
berhubungan dengan
anovulasi kronik pada wanita
tanpa adanya kelainan dasar
spesifik pada adrenal atau
kelenjar hipofisa
Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia
114
Source: http://www.pathophys.org/pcos/
Therapy
Lifestyle modification: may help First line of PCOS management.
115 all symptoms of PCOS
attenuate Increased exercise, improved diet, and weight loss can help to reduce the
and reduce the long-term risk of metabolic abnormalities associated with PCOS.
infertility, CVD and T2DM. Weight loss 5-10% correct oligoanovulation & improve conception.
Estrogen and progestin oral Can be used to normalize androgen levels and attenuate the signs of
contraceptive (OCP) hyperandrogenism as well as to regulate menstrual cycles. This also helps to
therapy: treatment of acne, reduce the risk of heavy and irregular menstrual bleeding associated with the loss
hirsutism and irregular menstrual of normal estrogen and progestrone levels.
cycles.
Anti-androgens (e.g. Spironolactone and flutamide competitively inhibits DHT and testosterone by
spironolactone,finasteride, binding to their receptors in peripheral cells (e.g. hair follicles).
flutamide): treatment of acne and Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the
hirsutism. more potent DHT in peripheral cells.
Anti-androgens can be used synergistically with OCPs, which act centrally to
suppress androgen release.
Metformin: treatment of glucose Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin
intolerance, hyperinsulinemia, and sensitivity and decreasing hepatic gluconeogenesis and lipogenesis; it can
anovulation. Reducing circulating therefore be used to help prevent and treat T2DM. Treating these factors can also
insulin levels may secondarily induce ovulation.
reduce ovarian androgen synthesis. Combined treatment with metformin and clomiphene citrate (see below) more
effective than either agent alone in inducing ovulation.
Source: http://www.pathophys.org/pcos/
Clomiphene Clomiphene citrate is a selective estrogen receptor modulator (SERM). It
induces ovulation by interfering with estrogen feedback to the brain and
thus increasing FSH release. There is increased risk of multigestational
116 pregnancy (e.g. twins or triplets) because of the large number of antral
follicles in polycystic ovaries. Clomiphene citrate treatment should be
limited to 12 cycles because longer-term treatment is associated with
increased risk of ovarian cancer due to ovarian hyperstimulation.
Gonadotropin therapy: recombinant FSH and Exogenous gonadoptropins can be administered to mimic physiological
hCG can be used to induce ovulation in mechanisms of follicle development. FSH is given to promote growth of a
cases where treatment with clomiphene dominant follicle to a particular size, and then human chorionic
citrate and metformin has been unsuccessful. gonadotropin is used to induce ovulation.
Ovarian drilling: a laparoscopic surgical Ovarian drilling involves the creation of ~10 perforations in the ovary using
procedure that may be used to treat either cautery or laser. The ablation of some of the ovarian theca is thought
clomiphene citrate-resistant anovulation. to help induce ovulation by decreasing androgen production.
IVF: used for the treatment of infertility in IVF involves the retrieval of oocytes from the ovaries and in vitro
women who have not responded to other combination with sperm to produce embryos. Viable embryos are then
therapies to induce ovulation. transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.
117 Fertility Test
LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.
in premenopusal women, the normal LH-FSH ration is 1:1 as measured on
day three of the menstrual cycle
Variation from this ratio used to diagnose PCOS or other disorders, explain
infertility or verify that woman has entered menopause
FSH stimulates the ovarian follicle to mature. Then a large surge of LH
stimulates the follicle to release an egg to fertilization
On day 3 of the cycle, LH should be low. If LH is elevated on this day,
possible even as high as FSH, then it suggest problem with ovulation.
Ovulation requires an LH surge, and if LH is already elevated, it may not
surge and ovulated
118
122
GYNECOLOGIC INFECTIONS
Cervicitis
123
*Tidak mudah
Servisitis menular seksual =
membedakan servisitis
Servisitis mukopurulenta
dari vaginitis
4 faktor risiko u/ prediksi
Biasanya asimtomatis
servisitis:
1. umur < 21 th Datang karena mitra
2. Lajang menderita IMS
3. CS > 1 org dlm 3 bln terakhir Penyebab:
4. CS dg pasangan baru dlm GO; Non-GO (C.trachomatis)
3 bln terakhir
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
* Sifilis
* Chancroid = ulkus mole
* Herpes genitalis
* Limfogranuloma venereum
* Granuloma inguinale
Ulkus Durum vs Ulkus Mole
140
Terjadi saat kehamilan > 4 bl (10 bl) < 4 bl sisitem imun blm berkembang penuh
Sklerosis Keratitis
sabre interstisialis,
Bilateral gigi
Neurosifilis hutschinson
sifilis 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
Kondiloma akuminata
Etiologi : HPV virus
Kondiloma lata
Etiologi : triponema
palidum (sifilis
sekunder)
Kista dan Abses Bartholini
154
Kista bartholini adalah kista yang
terbentuk akibat sumbatan pada
ductus/ kelenjar bartolini & retensi
sekret
Umum pada wanita umur
reproduksi
Lokasi pada labia mayora.
apabila terinfeksi abses
Abses 3 kali lebih umum dari pada
kista
155 Patologi
Abses Bartholini merupakan Isolates from Bartholin's Gland
polymikrobal infeksi Abscesses
Neisseria gonorrhoeaea Aerobic organisms
yang paling umum Neisseria gonorrhoeae
Jika tidak inflamasi Staphylococcus aureus
asimtomatik Streptococcus faecalis
Simtom: nyeri vulva, Escherichia coli
dispareunia, kesulitan Pseudomonas aeruginos
berjalan/olah raga Chlamydia trachomatis
Anaerobic organisms
Bacteroides fragilis
Clostridium perfringens
Peptostreptococcus
species
Fusobacterium species
156 Penatalaksanaan
157
Marsupialisasi
Membuka rongga tertutup mjd kantong
terbuka.
Untuk cegah kista berulang
Dengan lokal anestesi
Pembuatan insisi vertikal elips 1,5-3 cm
(sesuai garis Langer)
Cukup dalam sampai kulit vestibular
dinding kista
Pengeluaran isi kista dg sendok kuret
kecil sampai bersih
Dinding kista dijahit ke kulit vertibular
dengan jahitan interupted
159 Incisi dan drainase
Kekambuhan
Pemasangan balon kateter Word (Kambuh 3-17%)
Marsupialisasi (Kambuh 10-24%)
Eksisi risiko perdarahan
160 Patofisiologi
Spiramycin: fetal
prophylaxis
Pyrimethamine folic
acid antagonist. Should
not be used in the first
trimester because it is
potentially teratogenic.
Folinic acid: to
counteract bone
marrow depression by
pyrimethamine
173 Congenital Toxoplasmosis
maternal infection 3 month before conception or during pregnancy
Uptodate.com, medscape
175
176 Rubella
178
Risk of congenital defects:
Calcification
o intrahepatic
o Intracranial : may also see liver, heart, and renal
Poly hydramnion : due to neurologic impairment of swallowing
Limb Hipoplasia
Microcephaly
190
Zooster Lesion
Fetal Infection
Amniocentesis (culture or PCR of virus)
Fetal MRI : CNS
Alhamdulillah