Ginekologi UKDI MANTAP Batch November

(1)

GYNECOLOGY

1 1 dr. Nashria dr. Nashria

(2)

(3)

2 2

Neoplasm

Cervix Cervix Uterine Corpus Uterine Corpus Ovarium Ovarium

Abnormal

Menstrual

Cycle

Menstruation Menstruation Abnormal uterine Abnormal uterine bleeding bleeding Endometriosis Endometriosis Amenorrhea Amenorrhea menopause menopause

Infertility

Sperm Analysis Sperm Analysis Polycystic ovarian Polycystic ovarian syndrome syndrome Woman Fertility Woman Fertility Test Test

Infection

Gonorrhea Gonorrhea Trichomoniasis Trichomoniasis Candidiasis Candidiasis Bacterial Vaginosis Bacterial Vaginosis PID PID Syphilis Syphilis Condiloma Condiloma acuminata acuminata Barth

Bartholinolinabsceabscessss

Congenital

infection

Toxoplasmosis Toxoplasmosis Rubella Rubella CMV CMV Varicella Varicella

(4)

NEOPLASM

3

(5)

4

Neoplasma

Abnormal, excessive growth of tissue

Malignant

Vs

Benign

(myoma,ovarian

cyst)

Solid

Vs

Cystic

Common

symptoms:

Abnormal

bleeding

Pelvic mass

Vulvovaginal

symptoms

(6)

Clinical Aspects : Benign vs Malignant Tumor

 enign 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

Malignant tumor

 Clinical significant much greater :

invasive, rapid growing _more

often cause bleeding, ulceration, infection

 Para neoplastic syndrome

(endocrinopathies)

 cachexia

(7)

(8)

Tumor of the Uterine Cervix



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)

7 •

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

Risk Factors

Classification

Cervix:

lower

1/3 of

uterus;

at and

below

level of

internal

cervical

os

(9)

Pedoman teknis Ca Payudara dan Ca

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)

8

HPV and human immunodeficiency virus (HIV)

(10)

HPV and Uterine Cervix - Pathogenesis

9

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

(11)

• 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.

Why in transformation zone?

10

• Increases in estrogen stimulation result in advancement of columnar epithelium toward the vagina (during pregnancy, in women taking oral contraceptives, in newborns).

(12)

(13)

(14)

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

(15)

Prevention

Primary prevention

:

healthy lifestyles and vaccination

aga

inst H

PV

(qu

adr

iva

len

t

vacc

ine

-

gen

oty

pes 6

, 11, 16

&18 ; bivale

nt vaccin

e -

genot

ypes 16 &1

8)

Secondary prevention:

scree

ning fo

r precanc

er

lesio

ns

& early diagnosis followed by adequate treatment.

Tertiary prevention:

diagnosis and treatment of confirmed

cancer. Treatment: surgery, radiotherapy and sometimes

chemotherapy. Palliative if incurable

16

(16)

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

18

Pedoman teknis Ca Payudara dan Ca

(17)

Screening for cervical cancer

Screening for cervical cancer Visual Inspection Test

Visual Inspection Test

Aceto

Aceto White White Sign Sign Pre Pre Cancerous Cancerous LessionLession 19

(18)

Screening for cervical cancer Visual Inspection Test

Aceto White Sign Pre Cancerous Lession 20

(19)

Screening for Cervical Cancer

21

(20)

•

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

.

Exception....

23

(21)

• The United States Preventive Services Task Force stated screening may stop at age 65 if :

• 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.

DISCONTINUE

ACOG guideline 2008

(22)

Summary Recommendation

27

Keluhan

Lesi anatomis

Rekomendasi

skrining

-

IVA

+

-

PAP SMEAR

(23)

Methods to Improve Accuracy of Pap Smears

• 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 28

(24)

LSIL: low-grade squamous intraepithelial neoplasia; HSIL: high-grade squamous intraepithelial neoplasia; CIN: cervical intraepithelial neoplasia.

Cervical dysplasia:

Abnormal changes in the cells on the surface of the cervix, seen underneath a miscroscope

(25)

(26)

(27)

36

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 Procedure (LEEP)

Pengambilan jaringan yang mengandung sel prakanker dengan menggunakan alat LEEP

Konikasi Pengangkatan jaringan yang megandung sel prakanker dengan operasi

Histerektomi Pengangkatan seluruh rahim termasuk leher rahim

(28)

(29)

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

Tumor of the Uterine Corpus

(30)

Influencing factors of

Myoma Uterine

(31)

• Menorrhagia – heavy & prolonged menstruation (common)

• Pelvic pain : occurs in pregnancy if undergoing degeneration or torsion • Pelvic pressure：urinary

frequency, constipation • Spontaneous abortion • Infertility

SYMPTOMS

A palpable abdominal tumor : arising from pelvis, well defined margins , firm consistency, smooth surface, mobile from side to side. • Pelvic examination

enlarged and irregular, hard

• Diagnosis : Bimanual exam, USG, hysteroscopy, Laparacospy

SIGN

42

 _Observation: _for _small _myoma,

premenopause

 _{Operation : myomectomy or}

hysterectomy

TREATMENT

(32)

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}

(33)

Tumor of the Uterine Corpus

Malignant Tumors

45

(34)

Tumor of the Ovary

46

(35)

Tumor of the Ovary

 Ovarian cancer has highest mortality of

all gynecological tumor

 Called as silent lady killer

 Symptom (many ovarian tumor cause

no symptom only discover during routine examinatiion.

 Low abdominal discomfort (fullness,

bowel symptom)

 Loss of weight, malaise, anorexia  Pain due to torsion, hemorage or

rupture

 Pressure symptom  Endocrinopaties

 Abnominal gross swelling

 Benign Tumor

 Small can be felt by bimanual, moile  Medium may have long 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

(36)

_{Also 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

(37)

Menstrual cycle abnormalities

(38)

Menstrual cycle

50

(39)

(40)

• 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

Normal Menstrual Bleeding 52

(41)

•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.

_{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.

FSH

_LH

(42)

Ovulasi



Terjadi 14 hari sebelum mens

berikutnya



Tanda dan tes :

 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

54 •

>> kadar

progesterone 2ng/ml

•

LH surge (dg

Radioimunoassay)

•

USG



folikel >1,7 cm

(43)

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

(44)

(45)

59

(46)

60

Polyp Adenomyosis leiomyoma Malignancy and hyperplasia

(47)

61

Polip

• Endocervical polip • Endometrial polip

Adenomyosis

• Part of endometrial that penetrate to myometrium

Leiomyoma

• Submucosal • SUbserosal • intramural

Malignancy and hyperplasia

- Endometrial cancer

(48)

62

Coagulopathy

•

•Von WVon Willebraillebrandnddiseasdiseasee

•

•GanGanggugguananagragregaegasisi plaplatelteletet

Ovulatory disurbance

•

•EndocrinopatEndocrinopatieie (PCOS, Hypot(PCOS, Hypotiroid, obesity, iroid, obesity, anorexia)anorexia)

•

•Extreme exercise, stressExtreme exercise, stress

endometrial

•

•Endometrial inflammationEndometrial inflammation

•

•Endometrial infectonEndometrial infecton

•

•DefisiDefisiensiensiendoendothelinthelin-1, defisiensi-1, defisiensiProstProstaglanaglandin din F2-alpF2-alphaha

Iatrogenic

Drugs :

rifampicin, griseofulvin, trisiklik,

phenothiazine, anticoagulant, antiplatelet,

(49)

Treatment of uterine bleeding

63

Infrequent bleeding

1. 1. Therapy should

Therapy should be directed

be directed at the unde

at the underlying cause

rlying cause when

when

possible.

2. 2. If the

If the CBC and

CBC and other initial

other initial laboratory tests

laboratory tests & history

& history and

and

physical examination are normal



_reassurance

3. Ferrous gluconate, 325 mg bid-tid

ACOG 2008 ACOG 2008

(50)

Treatment of frequent or heavy bleeding

1

1.. NNSSAAIIDD

•

• impimprovroveses plaplateletelett aggaggregregatiationon •

• increases uterine vincreases uterine vasoconstriction.asoconstriction. •

• NSAIDs are theNSAIDs are the first choice in the treatment of menorrhagiafirst choice in the treatment of menorrhagia because they are wellbecause they are well tolerated and do not have the hormonal effects of oral contraceptives.

tolerated and do not have the hormonal effects of oral contraceptives. a. Mefen

a. Mefenamicamic acid (Pacid (Ponstelonstel) 500 mg tid) 500 mg tid durinduring the menstrg the menstrual peual period.riod. b. Naproxen

b. Naproxen (Anaprox, Napros(Anaprox, Naprosyn) 500 mg loadinyn) 500 mg loading dose, then 250 mg tidg dose, then 250 mg tid during the

during the

menstrual period. menstrual period. c. Ibuprofen (

c. Ibuprofen (Motrin, Nuprin) 400 mg tidMotrin, Nuprin) 400 mg tid during the menstrual during the menstrual period.period. 2.

2. Ferrous gluconateFerrous gluconate 325 mg tid.325 mg tid. 3.

3. Patients Patients withwith hypovolemiahypovolemia or a or a hemoglobin hemoglobin level below level below 7 g/dL7 g/dL should beshould be hospitalized for hormonal therapy and iron replacement.

hospitalized for hormonal therapy and iron replacement. •

• Hormonal therapy: estrogen (Premarin) 25 mg IV Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops.q6h until bleeding stops.

Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper slowly to one pill qd.

slowly to one pill qd. •

• IfIf bleedbleedinging conticontinues, nues, IV vasoIV vasopresspressinin (DDA(DDAVP) shoVP) should be auld be admindministereistered.d. 64

(51)

65

••

Hysteroscopy may be necessary, and

Hysteroscopy may be necessary, and dilation and curettage

dilation and curettage

is a last

resort.

resort. Transfusion

Transfusion

may be indicated in severe hemorrhage.

•

Ferro

Ferrous gluc

us gluconate

onate 325 m

325 mg tid.

g tid.

4. 4. Primary childbearing years

Primary childbearing years

–

ages 16 to early 40s

A. Contraceptive complications and pregnancy are the most

common causes of abnormal bleeding in this age

common causes of abnormal bleeding in this age group.

group.

Anovulation accounts for 20% of

cases.

B. Adenomyosis, endometriosis, and fibroids increase in

frequency as a woman ages, a

frequency as a woman ages, as do endometrial hyperplasia

s do endometrial hyperplasia

and endometrial polyps. Pelvic inflammatory

disease and endocrine dysfunction may also occur.

ACOG 2008

(52)

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).

_{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)}

Primary

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

(53)

_{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}

Secondary

_{Dysmenorrhoea can be effectively treated by drugs that inhibit}

prostaglandin synthesis and hence uterine contractility.

_{These drugs include aspirin, mefenamic acid, naproxen or ibuprofen.}

Drug Therapy

67

(54)

Endometriosis

68

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

(55)

Sign Symptom

69

 _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}

Classic signs:

 _{severe dysmenorrhea, dyspareunia,}  _{chronic pelvic pain,}

 _infertility

 _{In situ from wolffian or mullerian duct remnants (“metaplastic theory”)}  _{Coelemic metaplasia}

 _{Sampson’s theory}

 _{Iron-induced oxidative stress}  _{Stem cells}

(56)

 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

 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

(57)

• Surgical Intervention • Laparoscopy • Hysterectomy/Oophorecto my/Salpingo-oophorectomy • Nonsurgical Therapies • Medical Therapies Alternative Therapies 71

Indications for surgical management:

•

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

Medical Therapies

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

Endometriosis therapy

(58)

Endometriosis therapy

Mild – Moderate Pain



NSAID



Oral contraceptive



progestin

Moderate-Severe Pain



GnRH agonis



Danazole



Aromatase inhibitor

72

(59)

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

 Acceptable side effects  Reasonable cost

 Ready availability

(60)

Progestins

 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.

(61)

GnRH agonist

 Produced hypogonadic state

through down regulation of pituitary gland

 Efective as other therapies in relieving

pain and reduce progression

 No fertility improvement  High cost, bone density loss,

intolerable hypoesterogeninc side effect

 Preoperative therapy reported to

reduce pelvic vascularity and size of lesion, reduce intraoperative blood

Danazol

 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

(62)

Amenorrhea

 Amenorrhea is the absence of menstruation.  Primary

Absence of menses by age 14 without secondary sexual

development

Absence of menses by age 16 with normal secondary sexual

characteristic

 Secondary

Absence of menses for 6 month in a previous menstruating

female 77

(63)

(64)

(65)

Definisi heavy menstrual bleeding dkk

80 Prolonged menstrual

bleeding

Menstrual period exceeding 8 days in duration on regular basis

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

(66)

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

(67)

83

_{Diagnosis of}

primary

(68)

84 84

Diagnosis of

secondary

amenorrhea

(69)

85

(70)

86 86

Functional

hypothalamic

amenorrhea:

•

• thethe hypothalamic- hypothalamic-pituitary-ovarian axis is pituitary-ovarian axis is suppressed

suppressed due to andue to an energy deficit stemming energy deficit stemming from stress, weight loss from stress, weight loss (independent of original (independent of original weight), excessive weight), excessive exercise, or disordered exercise, or disordered eating. eating. • • It is characterized by aIt is characterized by a low estrogen state without low estrogen state without other organic or structural other organic or structural disease

disease •

• Menses typically returnMenses typically return after correction of the after correction of the underlying nutritional underlying nutritional

(71)

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

(72)

II. Pathophysiology



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.

(73)

(74)

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

91

(75)

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.

 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

(76)

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.

(77)

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

(78)

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%

(79)

INFERTILITAS

(80)

Infertility

105

(81)

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

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.

(82)

(83)



Infeksi



Gangguan ovulasi



Gangguan anatomi

108 •Penuaan (usia) •POF

•Polikistik Ovarii (PCOS)

•Kelainan pada hipotalamus-hipofisis

•Hiperprolaktin

•Kelainan kongenital

Gangguan Ovulasi

(84)

(85)

Analisa Sperma

110

(86)

ANALISA SPERMA

 Fertilitas seorang pria ditentukan

oleh jumlah dan kualitas spermanya

 Normozoospermia

 Jumlah sperma ≥ 20 juta/ml  Oligozoospermia

 Jumlah sperma < 20 juta/ml  Astenozoospermia

 Motilitas sperma a<25% atau

a+b <50%

 A: bergerak cepat dan lurus

 B: Bergerak lambat dan tidak lurus  C : bergerak ditempat

 D : tidak bergerak  Teratozoospermia

 Morfologi sperma normal < <30%

 oligoAstenoTeratozoospermia – sindroma

OAT

 Azoopermia 0 sperma + plasma semen  Aspermia 0 sperma + 0 plasma semen

(87)

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%

(88)

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

(89)

(90)

Therapy

115

Lifestyle modification: may help attenuate all symptoms of PCOS and reduce the long-term risk of infertility, CVD and T2DM.

• First line of PCOS management.

• Increased exercise, improved diet, and weight loss can help to reduce the

metabolic abnormalities associated with PCOS.

• Weight loss 5-10%correct oligoanovulation & improve conception.

Estrogen and progestin oral contraceptive (OCP)

therapy: treatment of acne, hirsutism and irregular menstrual cycles.

Can be used to normalize androgen levels and attenuate the signs of

hyperandrogenism as well as to regulate menstrual cycles. This also helps to

reduce the risk of heavy and irregular menstrual bleeding associated with the loss of normal estrogen and progestrone levels.

Anti-androgens (e.g.

spironolactone,finasteride,

flutamide):treatment of acne and hirsutism.

Spironolactone and flutamide competitively inhibits DHT and testosterone by binding to their receptors in peripheral cells (e.g. hair follicles).

Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the more potent DHT in peripheral cells.

Anti-androgens can be used synergistically with OCPs, whichact centrally to suppress androgen release.

Metformin: treatment of glucose intolerance, hyperinsulinemia, and anovulation. Reducing circulating insulin levels may secondarily

reduce ovarian androgen synthesis.

Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin sensitivity and decreasing hepatic gluconeogenesis and lipogenesis; it can

therefore be used to help prevent and treat T2DM. Treating these factors can also induce ovulation.

Combined treatment with metformin and clomiphene citrate (see below) more effective than either agent alone in inducing ovulation.

(91)

116

Clomiphene Clomiphene citrate is a selective estrogen receptor modulator (SERM). It

induces ovulation by interfering with estrogen feedback to the brain and thusincreasing FSH release. There is increased risk of multigestational 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 hCG can be used to induce ovulation in cases where treatment with clomiphene citrate and metformin has been unsuccessful.

Exogenous gonadoptropins can be administered to mimic physiological mechanisms of follicle development.FSH is given to promote growth of a dominant follicle to a particular size, and then human chorionic

gonadotropin is used to induce ovulation.

Ovarian drilling: a laparoscopic surgical procedure that may be used to treat clomiphene citrate-resistant anovulation.

Ovarian drilling involves thecreation of ~10 perforations in the ovary using either cautery or laser. The ablation of some of the ovarian theca is thought

to help induce ovulation by decreasing androgen production.

IVF:used for the treatment of infertility in women who have not responded to other therapies to induce ovulation.

IVF involves the retrieval of oocytes from the ovaries and in vitro

combination with sperm to produce embryos. Viable embryos are then transferred into the uterus. Women with PCOS have similar success and live birth rates compared to women without PCOS.

(92)

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

(93)

(94)

GYNECOLOGIC INFECTIONS

(95)

Cervicitis

123

*Tidak mudah

membedakan servisitis

dari vaginitis

•4 faktor risiko u/ prediksi

servisitis:

1. umur < 21 th 2. Lajang 3. CS > 1 org dlm 3 bln terakhir 4. CS dg pasangan baru dlm 3 bln terakhir

•Servisitis menular seksual =

Servisitis mukopurulenta



_{Biasanya asimtomatis}



_{Datang karena mitra}

menderita IMS



_Penyebab:

(96)

CERVICITIS GO

Definisi: peradangan serviks o/k N. Gonorrhoeae (diplokokus Gram negatif, terlihat di luar dan di dalam leukosit)

Klinis: asimtomatis; keputihan warna kuning Px:

- vulva tenang

- inspeculo: dd vagina eritem/tenang

- ektoserviks: eritem/normal

- endoserviks: eritem, edem, ektopi, bleeding,

discar mukopurulen

Diagnosis:

•Gram: pmn > 30; DGNI (+) • Kultur: Media Thayer Marthin •PCR

(97)

Komplikasi Gonorhea Pada Pria

Infeksi

Pertama:

Uretritis

Komplikasi Lokal:

-Tysonitis

-Parauretritis

-Littritis

-Cowperitis

Komplikasi asenden :

-Prostatitis

-Vesikulitis

-Funikulitis

-Epididimitis

-Trigonitis

125

Komplikasi Gonorhea pada

_Wanita

Infeksi

pertama:

-Uretritis

-Servisitis

Komplikasi Lokal:

-Parauretritis

-Bartholinitis

Komplikasi

asenden :

-Salphingitis

-PID

(98)

CERVISITIS NON GO

Peradangan serviks bukan o/k GO Penyebab: C. trachomatis (terbanyak) Klinis: asimtomatis; keputihan kuning Px: vulva tenang

inspeculo: dd vagina eritem/normal ektoserviks: eritem/normal

endoserviks: eritem, edem, ektopi, swab bleeding, discar mukopurulen C. Trachomatis  _{immunofluoresence} dg antibodi monoklonal 126

(99)

Vaginitis

127

•

Penyebab umumnya: Trikomonas, Kandida, bakteri

anaerob



_{keputihan tidak selalu ditularkan secara}

seksual

•

Tanda : abnormalitas volume, warna, bau dari discar

vagina

(100)

(101)

TRIKOMONIASIS/Vaginitis Trikomonal

Definisi:

peny. Infeksi protozoa yg disebabkan oleh T. vaginalis

inkubasi: 3-28 hr

Diagnosa :

1. Discar vagina kuning kehijauan,atau berbuih dan bau busuk, strawberry cervix (+)

2. Peradangan pd dinding vagina 3. Lab: NaCl 0,9% : T. vaginalis motil 129

(102)

(103)

KANDIDOSIS VULVOVAGINAL/

Vulvovaginitis kandidal

Definisi : infeksi vagina dan/atau vulva oleh kandida khususnya C. albicans

Etiologi: Genus candida t/u C. albicans (80%) kandida: kuman oportunis: di seluruh badan

Predisposisi: hormonal, DM, antibiotik, imunosupresi, iritasi

Diagnosa :

• Keluhan gatal/panas/iritasi, keputihan tak bau/masam

* Dinding vagina &/vulva eritem/erosif

* Discar putih kadang disertai semacam sariawan (thrush) berupa pseudomembran yg melekat pd daerah erosif

• Discar putih kental spt susu/keju, bisa banyak, masam

• Dinding vagina dijumpai gumpalan keju * pH <= 4,5

(104)

Definisi: * gangguan pada vagina tanpa peradangan

* sindroma klinik akibat perubahan lingkungan lokal * pergantian flora normal Lactobasilus sp. oleh bakteri

anaerob: terutama G.vaginalis dll

Vaginosis bakterial (VB)

Inkubasi: bbrp hr-4 mgg

Diagnosa 3 dari 4 gejala:

1. Discar vagina, homogen, putih keabuan, melekat pd dinding vagina

2. PH vagina > 4,5

3. Discar bau spt ikan --> tes amin

4. Clue cells > Gram -132

(105)

Pengobatan sindrom duh tubuh vagina karena vaginitis Pengobatan untuk trikomoniasis

DITAMBAH

Pengobatan untuk vaginosis bakterial . BILA ADA INDIKASI,

Pengobatan untuk kandidiasis vaginalis 133

(106)

Pengobatan sindrom duh tubuh vagina karena infeksi

serviks

Pengobatan untuk gonore tanpa komplikasi

DITAMBAH

Pengobatan untuk klamidiosis

Lect. By dr. Retno Satiti, Sp.KK

(107)

• 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

Pelvic Inflammatory Disease

135

• Diagnosis

– Pregnancy test

– Cervical sample for GC/ Chlamydia

(108)

•

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

Indikasi Rawat Inap Pada pasien Penyakit Radang

Panggul

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

Complication of Pelvic Inflammatory Disease

136

(109)

Pengobatan Penyakit Radang Panggul (Rawat Jalan)

137

(110)

Indikasi Rawat Inap Pada pasien Penyakit Radang

Panggul

138

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

(111)

Sindroma Ulkus Genital

139

* Sifilis

* Chancroid = ulkus mole

* Herpes genitalis

* Limfogranuloma venereum

* Granuloma inguinale

(112)

Ulkus Durum vs Ulkus Mole

Ulkus Durum



Terkait dengan Sifilis



Cenderung tunggal



Dasar bersih



Tempat tersering : sulcus

coronarius (pria), wanita

(labia mayora)

Ulkus Mole



Chancroid / H. Ducreyi



Cenderung multiple



Dasar kotor, tampak

kemerahan hingga

nekrotik

(113)

• Peny. Infeksi sistemik & kronis

• Etiologi: T. pallidum (Spirochaeta, spiral, Gram neg., Bergerak

berputar, atau maju spt pembuka tutup botol)

Sifilis

141

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

(114)

Sifilis Primer



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

(115)

Sifilis sekunder

(

3-4 mgg setelah ulkus durum)

• 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

(116)

Sifilis Laten

 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 144

•

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

(117)

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

(118)

Sifilis kongenital dini: < 2 th

• lesi kulit: terjadi segera,

vesikobulosa, erosi,

• papuloskuamosa,

• mukosa: hidung, pharing:

perdarahan

• tulang: osteokondritis tl

panjang

• anemia hemolitik

• hepatosplenomegali

• SSP

146

(119)

Sifilis

kongenital

lanjut: > 2 th

Keratitis interstisialis, Bilateral gigi hutschinson Gigi Mulberry Gangguan

saraf pusat VIII – tuli

Neurosifilis Sklerosis –

sabre 147

(120)

Diagnosis: klinis + lab

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

(121)



_{Lakukan pemeriksaan serologi tiap 3 bln pd tahun I}



_{Ulang serologi setiap 6 bln pd tahun II}



_{* Amati kembali pada tahun ke 3}

(122)

Kondiloma Akuminata

 Termasuk dalam STD  Pria = Wanita

 Penularan : kontak kulit

langsung

 Etiologi : Human Papilloma

Virus (HPV) tipe 6,11,16,18, 30, 31, dsb  Virus DNA  Keluarga Papova 150 •

Predileksi :

– Pria : perineum, sekitar anus, sulkus koronarius, glans penis, muara uretra eksterna, korpus penis

– Wanita : vulva, introitus vagina, porsio uteri (<<), disertai fluor albus, pada wanita hamil pertumbuhan lebih cepat

•

Vegetasi bertangkai,

merah-hitam, papilomatosa

•

Giant condyloma (Buschke)

(123)

Terapi

 Sebagai first line bisa dipilih podofilin atau TCA

 Podofilin

 Tingtur podofilin 25%, 0,3 cc, dapat diulang setelah 3 hari

 Gejala toksisitas : mual, muntah, nyeri abdomen, gangguan pernafasan, supresi

sumsum tulang, trimbositopenia, leukopenia

 Teratogenik : kematian fetus

 Tidak Dapat untuk mengobati condiloma acuminata yang lokasinya berada pada

vagina dan cerviks (risiko chemical burn)

 Asam trikloroasetat 50% :  Dioleskan seminggu sekali

 Efek samping : ulkus, sehingga perlu hati hati dalam pemberian  Dapat diberikan pada ibu hamil dan lesi internal

 5-Fluorourasil 1-5% cr :

 Berbentuk gel, lebih baik digabung dengan epinefrin

(124)



Elektrokauterisasi

 Hanya untuk kondiloma acuminata yang berada di labia / kulit  Beresiko terjadinya jaringan parut



Bedah beku/cryotherapy (N2, N2O cair)



Bedah skalpel



lebih baik pada kondiloma yang besar

dan menutupi jalan lahir



Laser karbondioksida

 Lebih cepat sembuh, sedikit jaringan parut dibandingkan

elektrokauterisasi



Interferon

 Injeksi IM atau intralesi atau topikal (cr)

 Dosis : 4-6mU IM 3 kali seminggu, 6 mg atau 1-5mU IM, 6 mg

(125)

Kondiloma akuminata vs kondiloma lata

Kondiloma akuminata



Etiologi : HPV virus

Kondiloma lata



Etiologi : triponema

palidum (sifilis

sekunder)

153

(126)

Kista dan Abses Bartholini



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

(127)

Patologi



Abses Bartholini merupakan

polymikrobal infeksi



Neisseria gonorrhoeaea

yang paling umum



Jika tidak inflamasi



asimtomatik



Simtom: nyeri vulva,

dispareunia, kesulitan

berjalan/olah raga

Isolates from Bartholin's Gland

Abscesses

Aerobic organisms

Neisseria gonorrhoeae

Staphylococcus aureus

Streptococcus faecalis

Escherichia coli

Pseudomonas aeruginos

Chlamydia trachomatis

Anaerobic organisms

Bacteroides fragilis

Clostridium perfringens

Peptostreptococcus

species

Fusobacterium species

155

(128)

Penatalaksanaan



Asimtomatik



tidak perlu terapi



Incisi dan drainase



tx cepat & mudah



kemungkinan rekuren



WORD CATHETER



MARSUPIALIZATION



INCISI & DRAINASE

(129)

WORD CATHETER



Pembuatan 5 mm incisi pada

kista atau abses



Masukkan kateter Word dan

dikembangkan dengan 2-3 ml

saline



_{selama 3-4 minggu}



Jika tidak ada bukti infeksi



(130)

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

(131)

Incisi dan drainase



Dilakukan pada pasien yang tidak respon pada

terapi konservatif



_{tidak ada infeksi aktif}

159

•

Pemasangan balon kateter Word (Kambuh 3-17%)

•

Marsupialisasi (Kambuh 10-24%)

•

Eksisi



risiko perdarahan

(132)

Patofisiologi



GO



cepat menjadi abses



keluar lewat

duktus



_{tersumbat: abses membesar}



Radang bisa berulang (68-75%)



Jika menahun



terbentuk kista

(133)

INFEKSI KONGENITAL

(134)

Teratogen: TORCH

162

(135)

(136)

(137)

165

_{TOXOPLASMOSIS}

In pregnancy, the most

common mechanisms of

acquiring infection:

1. consuming raw or very

undercooked meats or

contaminated water,

2. exposure to soil

(gardening without

gloves) or

(138)

(139)

(140)

(141)

(142)

172

Amniocentesis should not be offered at less than 18 weeks’ gestation

because of the high rate of false-positive results.

Spiramycin: fetal prophylaxis

Pyrimethamine _folic

acid antagonist. Should not be used in the first trimester because it is potentially teratogenic. Folinic acid: to counteract bone marrow depression by pyrimethamine