STEP 7 1. Why the patient have a menstrual complaints over 15 days?

menstrual irregularities After a teen has been menstruating for a few years, her menstrual cycle typically becomes more regular. For most women, a normal menstrual cycle ranges from 21 to 35 days. However, up to 14% of women have irregular menstrual cycles or excessively heavy menstrual bleeding. Most abnormal uterine bleeding can be divided into anovulatory and ovulatory patterns.

Anovulatory: Irregular/infrequent periods with absent, minimal, or excessive(berlebih) bleeding. Ovulatory: Periods that occur at regular intervals but are characterized by excessive bleeding or a duration of greater than 7 days.

The most common menstrual irregularities include: Anovulatory Bleeding

Absent menstrual periods: When a woman does not get her period by age 16, or when she stops getting her period for at least 3 months and is not pregnant. Infrequent menstrual periods (periode jarang: Periods that occur more than 35 days apart(terpisah).

Ovulatory Bleeding

menorrhagia Heavy menstrual periods): Also called excessive(berlebih) bleeding. Although (meskipun)anovulatory bleeding and menorrhagia are sometimes grouped together, they do not have the same cause and require different diagnostic testing. Prolonged menstrual bleeding(berkepanjangan): Bleeding that exceeds 8 days in duration on a regular basis.

Dysmenorrhea : Painful periods that may include severe menstrual cramps. Additional menstrual irregularities include:

Polymenorrhea Frequent menstrual periods occurring less than 21 days apart Irregular menstrual periods with a cycle-to-cycle variation of more than 20 day Shortened menstrual bleeding of less than 2 days in duration Intermenstrual bleeding: Episodes of bleeding that occur between periods, also known as spotting

Causes menstrual irregularities Menstrual irregularities can be caused by a variety of conditions, including pregnancy, hormonal imbalances, infections, malignancies, diseases, trauma, and certain medications. Common causes of anovulatory bleeding (absent, infrequent periods, and irregular periods) include:

Adolescence(remaja) Uncontrolled diabetes

Eating disorders Hyperthyroidism or hypothyroidism Hyperprolactinemia (an abnormally high concentration in the blood of prolactin, a protein hormone) Medications, such as antiepileptics or antipsychotics Perimenopause Polycystic ovary syndrome (PCOS) Pregnancy

Common causes of ovulatory bleeding (heavy or prolonged menstrual bleeding) include2:

Structural problems, such as uterine fibroids or polyps Bleeding disorders, such as leukemia, platelet disorders, the various factor deficiencies, or von Willebrand disease Hypothyroidism Advanced (lanjutan)liver disease

Common causes of dysmenorrhea (menstrual pain) include:

Heavy menstrual flow Smoking Depression Never having given birth Endometriosis Chronic uterine infection

Additional causes of menstrual irregularity include:

Endometriosis Endocrine gland-related causes o Poorly controlled diabetes o Polycystic ovary syndrome (PCOS) o Cushing's syndrome o Thyroid dysfunction o Primary ovarian insufficiency (POI) o Late-onset congenital adrenal hyperplasia Acquired conditions o Stress-related hypothalamic dysfunction o Medications o Exercise-induced amenorrhea o Eating disorders (both anorexia and bulimia) Tumors o Ovarian o Adrenal o Prolactinomas (a noncancerous pituitary tumor that produces prolactin)

Diagnose menstrual irregularities A health care provider diagnoses menstrual irregularities using a combination of the following:

Medical history Physical examination

Blood tests Ultrasound examination Endometrial biopsya small sample of the uterus's endometrial lining is taken to be examined under a microscope Hysteroscopya diagnostic scope that allows a health care provider to examine the inside of the uterus, typically done as an outpatient procedure Saline infusion sonohysterographyultrasound imaging of the uterine cavity while it is filled with sterile saline solution Transvaginal ultrasonographyultrasound imaging of the pelvic organs including the ovaries and uterus, using an ultrasound transducer that is inserted into the vagina

Treatments for menstrual irregularities Treatment for menstrual irregularities that are due to anovulatory bleeding (absent periods, infrequent periods, and irregular periods) include:

Oral contraceptives Cyclic progestin Treatments foran underlying disorder that is causing the menstrual problem, such as counseling for an eating disorder or extreme excercise

Treatment for menstrual irregularities that are due to ovulatory bleeding (heavy or prolonged menstrual bleeding) include

Insertion of a hormone-releasing intrauterine device Use of various medications (such as those containing progestin or tranexamic acid) or nonsteroidal anti-inflammatory medications

If the cause is structural or if medical management is ineffective, then the following may be considered:

Surgical removal of polyps or uterine fibroids Uterine artery embolization, a procedure to block blood flow to the uterus Endometrial ablation, a procedure to cauterize blood vessels in the endometrial lining of the uterus Hysterectomy

Treatment for dysmenorrhea (painful periods) include:

Applying a heating pad to the abdomen Taking nonsteroidal anti-inflammatory medications Taking contraceptives, including injectable hormone therapy or birth control pills, using varied or less common treatment regimens

http://www.nichd.nih.gov/health/topics/menstruation/conditioninfo/Pages/irregularities.aspx

Menstrual Disorders There are a number of different menstrual disorders. Problems can range from heavy, painful periods to no periods at all. There are many variations in menstrual patterns, but in general women should be concerned when periods come fewer than 21 days or more than 3 months apart, or if they last more than 10 days. Such events may indicate ovulation problems or other medical conditions. Dysmenorrhea (Painful Cramps) Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs(paha). Dysmenorrhea is usually referred to as primary or secondary. Primary dysmenorrhea. Primary dysmenorrhea is cramping pain caused by menstruation. The cramps occur from contractions in the uterus and are usually more severe during heavy bleeding. Secondary dysmenorrhea. Secondary dysmenorrhea is menstrual-related pain that accompanies another medical or physical condition, such as endometriosis or uterine fibroids. Menorrhagia (Heavy Bleeding) During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood. Most women change their tampons or pads around 3 - 6 times per day. Menorrhagia is the medical term for significantly heavier periods. Menorrhagia can be caused by a number of factors. Women often overestimate the amount of blood lost during their periods. Clot formation is fairly common during heavy bleeding and is not a cause for concern. However, women should consult their doctor if any of the following occurs: Soaking through at least one pad or tampon every 1 - 2 hours for several hours Heavy periods that regularly last 10 or more days Bleeding between periods or during pregnancy. Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women, but it is still a good idea to speak with a doctor. Women who experience any post-menopausal bleeding should definitely contact their doctors.

Menorrhagia is menstrual flow that lasts longer and is heavier than normal. The bleeding occurs at regular intervals (during periods). It usually lasts more than 7 days and women lose an excessive (more than 80 mL) amount of blood. Menorrhagia is often accompanied by dysmenorrhea because passing large clots can cause painful cramping. Menorrhagia is a type of abnormal uterine bleeding. Other types of abnormal bleeding are: Metrorrhagia, also called breakthrough bleeding, refers to bleeding that occurs at irregular intervals and with variable amounts. The bleeding occurs between periods or is unrelated (tdk berhubungan)to periods. Menometrorrhagia refers to heavy and prolonged bleeding that occurs at irregular intervals. Menemetrorrhagia combines features of menorrhagia and metrorrhagia. The bleeding can occur at the time of menstruation (like menorrhagia) or in between periods (like metrorrhagia). Dysfunctional uterine bleeding (DUB) is a general term for abnormal uterine bleeding that usually refers to extra or excessive bleeding caused by hormonal problems, usually lack of ovulation (anovulation). DUB tends to occurs either when girls begin to menstruate or when women approach menopause, but it can occur at any time during a woman's reproductive life. Other types of abnormal uterine bleeding include bleeding after sex and bleeding after menopause. Causes Many different factors can trigger menstrual disorders, such as hormone imbalances, genetic factors, clotting disorders, and pelvic diseases. Causes of Dysmenorrhea (Painful Periods) Primary dysmenorrhea is caused by prostaglandins, hormone-like substances that are produced in the uterus and cause the uterine muscle to contract. Prostaglandins also play a role in the heavy bleeding that causes dysmenorrhea. Secondary dysmenorrhea can be caused by a number of medical conditions. Common causes of secondary dysmenorrhea include: Endometriosis. Endometriosis is a chronic and often progressive disease that develops when the tissue that lines the uterus (endometrium) grows onto other areas, such as the ovaries, bowels, or bladder. It often causes chronic pelvic pain.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body, causing pain and irregular bleeding. Uterine Fibroid. Fibroids are noncancerous growths that grow on the walls of the uterus. They can cause heavy bleeding during menstruation and cramping pain. Other Causes. Pelvic inflammatory disease, ovarian cysts, and ectopic pregnancy. The intrauterine device (IUD) contraceptive can also cause secondary dysmenorrhea. Causes of Menorrhagia (Heavy Bleeding) There are many possible causes for heavy bleeding:

Hormonal Imbalances. Imbalances in estrogen and progesterone levels can cause heavy bleeding. Hormonal imbalances are common around the time of menarche and menopause. Ovulation Problems. If ovulation does not occur (anovulation), the body stops producing progesterone, which can cause heavy bleeding. Uterine Fibroids. Uterine fibroids are a very common cause of heavy and prolonged bleeding. Uterine Polyps. Uterine polyps (small benign growths) and other structural problems or other abnormalities in the uterus may cause bleeding. Endometriosis and Adenomyosis. Endometriosis, a condition in which the cells that line the uterus grow outside of the uterus in other areas, such as the ovaries, can cause heavy bleeding. Adenomyosis, a related condition where endometrial tissue develops within the muscle layers of the uterus, can also cause heavy bleeding and menstrual pain. Medications and Contraceptives. Certain drugs, including anticoagulants and anti-inflammatory medications, can cause heavy bleeding. Problems linked to some birth control methods, such as birth control pills or intrauterine devices (IUDs) can cause bleeding. Bleeding Disorders. Bleeding disorders that stop blood from clotting can cause heavy menstrual bleeding. Most of these disorders have a genetic basis. Von Willebrand disease is the most common of these bleeding disorders. Cancer. Rarely, uterine, ovarian, and cervical cancer can cause excessive bleeding. Infection. Infection of the uterus or cervix can cause bleeding. Pregnancy or Miscarriage. Other Medical Conditions. Systemic lupus erythematosus, diabetes, pelvic inflammatory disorder, cirrhosis, and thyroid disorders can cause heavy bleeding. Menstrual disorders | University of Maryland Medical Center http://umm.edu/health/medical/reports/articles/menstrual-disorders#ixzz2mMZieyMb DD:

Myoma uteri

Uterine (Myoma) Fibroids Definition Uterine fibroids are noncancerous (benign) tumors that develop in the womb (uterus), a female reproductive organ.

A uterine myoma (also called fibroid, leiomyoma, leiomyomata, and fibromyoma) is a benign (noncancerous) tumour that grows within the muscle tissue of the uterus. There are four primary types of uterine myoma (fibroids) classified primarily by location in the uterus. The most common is the intramural uterine myoma. Subserosal - These fibroids develop in the outer portion(luar ) of the uterus and continue to grow outward. Intramural - The most common type of myoma. These develop within the uterine wall and expand making
the uterus feel larger than normal (which may cause "bulk symptoms").

Submucosal - These myoma develop just under the lining of the uterine cavity. These are the myoma that
have the most effect on heavy menstrual bleeding and the ones that can cause problems with infertility and miscarriage.

Pedunculated Myoma - Fibroids that grow on a small stalk that connects them to the inner or outer wall of
the uterus.

Fibroid Symptoms

Heavy vaginal bleeding Pelvic pressure or discomfort Bladder problems Pelvic pain Low back pain Rectal pressure Discomfort or pain with sexual intercourse

Heavy vaginal bleeding A common symptom from uterine fibroids is excessively heavy or prolonged menstrual bleeding. Not uncommonly, women describe soaking through sanitary protection in less than an hour, passing blood clots and being unable to leave the house during the heaviest day of flow. As a result, some women develop anemia, also known as a low blood count. Anemia can cause fatigue, headaches and lightheadedness.

Pelvic pressure or discomfort Women with large fibroids may have a sense of heaviness or pressure in their lower abdomen or pelvis. Often this is described as a vague sense of discomfort rather than a sharp pain. Sometimes, the enlarged uterus makes it difficult to lie face down, bend over or exercise without discomfort.

Bladder problems The most common bladder symptom is the need to urinate frequently. A woman may wake up several times during the night in order to empty her bladder. Occasionally, women experience an inability to urinate despite a full bladder. Bladder symptoms are caused by the uterine fibroids pressing against the bladder thereby reducing it's capacity for holding urine or blocking the outflow for urine to pass. It can be quite a relief when bladder problems are solved. Pelvic pain A less common symptom of fibroids is acute, severe pain. This type of pain occurs when a fibroid goes through a process called degeneration. The pain is usually localized to a specific spot and improves on it own within two to four weeks. Using a pain reliever, such as ibuprofen, can decrease the pain significantly. Chronic pelvic pain can also occur. This type of pain is usually mild but persistent and localized into a specific area. Low back pain In rare circumstances, fibroids can press against the muscles and nerves of the lower back and cause back pain. A large fibroid located on the back surface of the uterus is more likely to cause back pain than a small intramural fibroid. Because back pain is so common, it is important to look for other causes of back pain before attributing it to fibroids. Rectal pressure Fibroids can also press against the rectum and cause a sense of rectal fullness, difficulty having a bowel movement or pain with bowel movements. Sometimes, fibroids can cause hemorrhoids to develop. Discomfort or pain with sexual intercourse Fibroids can make sexual intercourse painful or uncomfortable. The pain may occur only in specific positions or during certain times of the menstrual cycle. Discomfort during intercourse is a significant issue. symptoms of uterine myoma (fibroids)

Very heavy and prolonged menstrual periods Pain in the back of the legs Pelvic pain or pressure Pain during sexual intercourse Pressure on the bladder which leads to a constant need to urinate, incontinence, or the inability to empty the bladder Pressure on the bowel which can lead to constipation and/or bloating An enlarged abdomen which may be mistaken for weight gain or pregnancy

http://www.myoma.co.uk/about-uterine-myoma.html Fibroid Treatments

Close monitoring Medical therapy Myomectomy Hysterectomy Radiofrequency Ablation Uterine Artery Embolization

MR Guided Focused Ultrasound

Close monitoring Unless fibroids are causing excessive bleeding, significant discomfort or bladder problems, a fibroid treatment is usually not necessary. A woman with fibroids should be evaluated periodically by her health care provider. The visit should include questions about fibroid symptoms and abdominal and pelvic examinations to assess uterine size. Routine pelvic ultrasounds have very little clinical benefit for women without symptoms. Fibroids are likely to increase in size each year until menopause. Changes in fibroid size should not be an indication for a fibroid procedure unless accompanied by disabling symptoms.

Medical Therapy Currently, the medical treatments available for fibroids can make symptoms better temporarily but they do not make the fibroids go away. For women with heavy bleeding, it is worth trying a medical treatment before undergoing a surgical procedure. Women with pressure symptoms caused by large fibroids will not benefit from any medicines currently available. On the horizon are several promising, new drugs that will treat the fibroids themselves not just the symptoms. Oral contraceptive pills and Progestational agents (Provera, medroxyprogesterone acetate) Women with heavy menstrual periods and fibroids are often prescribed hormonal medications to try to reduce bleeding and regulate the menstrual cycle. The medications will not cause fibroids to shrink nor will it cause them to grow at a faster rate. If the medication has not improved your bleeding after three months, consult with your doctor. Women over the age of 35 who smoke should not use oral contraceptive pills. GnRH agonists (Lupron) GnRH agonists are a class of medications that temporarily shrinks fibroids and stops heavy bleeding by blocking production of the female hormone estrogen. Lupron is the most well known of these drugs. Although Lupron can improve fibroid symptoms, it causes unpleasant, menopausal symptoms such as hot flashes and, with long-term use, leads to bone loss. Lupron should be recommended only in very specific circumstances. For example, a woman with very heavy bleeding and profound anemia will likely need a blood transfusion at the time of surgery. However, if she uses lupron for 2-3 months before surgery to make her periods temporarily stop and an iron supplement, the anemia will improve and the need for a blood transfusion will be reduced. In rare instances, a woman with huge fibroids(>10-12 cm) may be encouraged by her doctor to use lupron prior to surgery. Importantly, lupron should not be used solely for the purpose of shrinking fibroids unless surgery is planned because the fibroids will re-grow to their original size and symptoms will return as soon as the lupron is discontinued. Intrauterine Devices (IUD)

Although IUD's are typically used to prevent pregnancy, they have non-contraceptive benefits as well. An IUD that releases a small amount of hormone into the uterine cavity has been shown to decrease bleeding related to uterine fibroids. An IUD can be inserted during a routine office appointment. Ask you doctor for more information about this option.

Myomectomy Myomectomy is an operation in which fibroids are removed from within the uterus. Stitches are used to bring the walls of the uterus back together. For women with symptomatic fibroids who desire future childbearing, myomectomy is the best treatment option. Myomectomy is a very effective treatment, but fibroids can re-grow. The younger a woman is and the more fibroids present at the time of myomectomy, the more likely she is to develop fibroids in the future. Women nearing menopause are the least likely to have problems from fibroids again. A myomectomy can be performed several different ways. Depending on the size, number and location of your fibroids, you may be eligible for anabdominal myomectomy, a laparoscopic myomectomy or a hysteroscopic myomectomy. Abdominal Myomectomy

Abdominal myomectomy, also known as an "open" myomectomy, is a major surgical procedure. Patients are asleep during the operation. An incision is made through the skin on the lower abdomen ("a bikini cut"). The fibroids are removed from the wall of the uterus. The uterine muscle is sewn back together using several layers of stitches. The typical recovery involves 2 nights in the hospital and 4-6 weeks resting at home. The procedure results in a 4-inch horizontal scar near the pubic hair or "bikini" line. Blood loss during the operation may necessitate a blood transfusion. Some women store their blood before the operation in order to receive their own blood back rather than receive blood from the blood bank. About 5% of women will develop a postoperative infection that is treated with antibiotics in the hospital for as many as 5 days. About 5% of women develop a wound infection. Although the wound infection is treated at home, women must make frequent visits to the doctor's office for up to six weeks. After a myomectomy, the doctor may recommend a cesarean section (C-section) for the delivery of future pregnancies. This is done to reduce the chance that the uterus could open

apart during labor. The need for C-section will depend on how deeply the fibroids were embedded in the wall of the uterus at the time of removal. New fibroids can develop resulting in recurrent symptoms and additional procedures.

Laparoscopic Myomectomy

Only certain fibroids can be removed by laparoscopy. If the fibroids are large, numerous or deeply embedded in the uterus, then an abdominal myomectomy may be necessary. Laparoscopy is performed in the operating room with the patient asleep. Four 1-cm incisions (cuts) are made in the lower abdomen: one at the navel (belly button), one below the "bikini" line (near the pubic hair), and one near each hip. The abdominal cavity is filled with carbon dioxide gas. A thin, lighted telescope is placed through an incision so the doctors can see the ovaries, fallopian tubes and uterus. Long instruments, inserted through the other incisions, are used to remove the fibroids. The uterine muscle is sewn back together. At the end of the procedure, the gas is released and the skin incisions are closed. Small scars remain in the skin. The typical recovery involves 1 night in the hospital and 2-4 weeks resting at home. Sometimes during the operation, it is necessary to switch from a laparoscopic myomectomy to an abdominal myomectomy. Complications from laparoscopy include injuries to internal organs and bleeding. Also, the uterus may be less strong after surgery. Therefore, women planning to become pregnant in the future, are usually encouraged to have an open, abdominal myomectomy. New fibroids can grow resulting in recurrent symptoms and additional procedures.

Hysteroscopic Myomectomy

Only women with submucosal fibroids are eligible for this type of myomectomy. Fibroids located within the uterine wall cannot be removed with this technique. Hysteroscopic myomectomy is an out-patient surgical procedure. Patients go home after several hours of observation in the recovery room. The operation is usually performed with patients asleep. Women lie are their backs with their feet held in gynecology stirrups. A speculum is placed in the vagina. A long, slender "telescope" is placed through the cervix into the uterine cavity. Fluid is introduced into the uterine cavity to lift apart the walls. Instruments passed through the hysteroscope are used to shave off the submucosal fibroids. There can be cramping and light bleeding after the procedure. The typical recovery involves 1 to 4 days of resting at home. There are no scars on the skin after the procedure.

Hysterectomy Hysterectomy is a major surgical procedure in which the uterus (womb) is removed. Many women choose hysterectomy to definitively resolve their fibroid symptoms. After hysterectomy, menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow. A woman can no longer become pregnant after a hysterectomy. There are several different surgical approaches. A vaginal hysterectomyinvolves removing the uterus through an incision in the vagina. Anabdominal hysterectomy is performed through an incision on the lower abdomen. A laparoscopic hysterectomy is accomplished through four tiny incisions on the abdomen. The type of hysterectomy will depend on the size of the uterus and several other factors. The ovaries are not necessarily removed during a hysterectomy. Women should discuss the pros and cons of ovarian removal with their physicians. Vaginal Hysterectomy

A vaginal hysterectomy is performed by removing the uterus through the vagina rather than through an incision (cut) on the abdomen. To be eligible for a vaginal hysterectomy, the uterus cannot be too large. The surgery is usually performed with the patient asleep. Most women stay 2 nights in the hospital. The recovery involves significant pain for 24 hours and mild pain for 10 days. Full recovery usually takes 4 weeks. After a vaginal hysterectomy, there are no scars on the skin. Complications from the surgery include bleeding, infections and an injury to the intestines or bladder.

Abdominal Hysterectomy

An abdominal hysterectomy is performed by removing the uterus through a horizontal incision (cut) on the lower abdomen ("a bikini cut"). If the uterus is very large or if there is a scar from an earlier operation, it may be necessary to make a vertical incision on the lower abdomen. A total abdominal hysterectomy means removing the uterus and the cervix (the lowest part of the uterus). Women who have had abnormal pap smears or cervical dysplasia are usually encouraged to have their cervix removed at the time of hysterectomy. A subtotal or supra-cervical hysterectomy means removing only the upper part of the uterus. It is possible that women who retain their cervix will have less bladder leakage and vaginal relaxation later in life. However, it has not been scientifically Total Abdominal Hysterectomy proven to improve these outcomes. Women who have had a supra-cervical hysterectomy will continue to need periodic pap smears. In addition, some women will have monthly spotting or light bleeding if endometrial glands are still embedded in the cervical tissue. An abdominal hysterectomy requires general anesthesia The usual hospital stay is 3 days. The procedure results in a 4 inch horizontal scar Supra-cervical Hysterectomy near the pubic hair or "bikini" line. The typical recovery involves 6 weeks resting at home. Some women experience a complication that requires a longer recovery time. About 5% of women develop a post-operative infection that is treated with antibiotics in the hospital for as many as 5 days. About 5% of women develop a wound infection that is treated at home but requires frequent visits to the doctor's office for wound care for up to six weeks. Other complications include bleeding, infection and injury to the intestines or bladder.

Laparoscopic Hysterectomy(angkat rahim)

Laparoscopic hysterectomy is a new procedure in which the uterus is removed through very small incisions on the lower abdomen. The cervix, or lower portion of the uterus, remains in place. Women with large fibroids may not be candidates. If the uterus is large then an abdominal hysterectomy may be necessary. Laparoscopy is performed in the operating room with the patient asleep. Four 1-cm incisions (cuts) are made in the lower abdomen: one at the navel (belly button), one below the "bikini" line (near the pubic hair), and one near each hip. The abdominal cavity is filled with carbon dioxide gas. A thin, lighted telescope is placed through an incision so the doctors can see the ovaries, fallopian tubes and uterus. Long instruments, inserted through the other incisions, are used to remove the uterus. A special instrument is used to

cut the uterus into smaller segments for removal through the small incisions. At the end of the procedure, the gas is released and the skin incisions are closed. Small scars remain in the skin. The typical recovery involves 1 night in the hospital and 2-4 weeks resting at home. Sometimes during the operation, it is necessary to switch from a laparoscopic hysterectomy to an abdominal hysterectomy. Complications from laparoscopy include injuries to internal organs and bleeding.

http://coe.ucsf.edu/coe/fibroid/treatments.html

What differential of phyisical exam of myoma Fibroid Diagnosis

Doctor's visit Ultrasonography Sonohysterography Magnetic resonance imaging (MRI) Hysteroscopy

Doctor's visit Usually fibroids are found by your doctor/gynecologist during a routine physical examination. A pelvic examination allows a physician to feel the size and shape of the uterus. If the uterus is enlarged or irregularly shaped, then fibroids may be present. Alternatively, a women may notice new symptoms, which she then tells her doctor about. After a doctor examines you and thinks that you may have fibroids, there are several tests that can be done to confirm the diagnosis. The first examination performed is usually an ultrasound. The other tests are more specialized and are only performed if needed to guide treatment options. Below is a brief description each type of exam.

Ultrasonography Ultrasound is a safe and reliable way to assess the uterus and ovaries and to look for fibroids. Sound waves are used to create a picture of the uterus and ovaries. No radiation is used during this exam. The procedure can take between 30-60 minutes to perform. The initial portion of the exam is performed with the transducer on the abdomen. Conducting gel is placed on the skin and feels wet and cool. It is often necessary to have a full bladder to better see the pelvic structures. The transducer is moved around to allow the technologist to take pictures of the uterus and ovaries.

The second portion of the exam is performed by looking internally. You will need to empty your bladder first. A special ultrasound probe will then be placed in the vagina. It is usually not painful and is inserted like a tampon. Close up pictures can then be taken of the uterus, endometrium (the lining of the uterus) and ovaries. Sonohysterography This is also an ultrasound procedure which uses no radiation. This exam helps to better visualize the inside of the uterus and endometrium. Submucosal fibroids and polyps can easily be identified by this method. The exam takes approximately half an hour. It is often performed right after a period ends. The patient is positioned similar to a gynecology exam and the area is cleaned with special soap. A small catheter is inserted through the cervix and a small balloon is inflated to hold it in place. Sterile saline is injected into the uterus and ultrasound pictures are obtained. During the procedure you may experience some cramps similar to menstrual cramps. These cramps can last for a short time after the study and are a normal sensation.

Sonohystogram long view of the uterus

Sonohystogram cross section view of the uterus

Magnetic resonance imaging (MRI) It is more expensive than ultrasound but gives the doctors a reproducible, detailed picture of how many fibroids there are, how big they are and exactly where they are located. Not all women with fibroids need an MRI. All patients that are being evaluated for a uterine artery embolization will get an MRI. MRI stands for magnetic resonance imaging. No radiation is used during this study. Pictures are obtained using a large special magnet. The exam takes approximately 45-60 minutes during which time you are asked to remain still. Before the study begins an i.v. is placed in the arm. You then lie down on a bed. The big magnet is shaped like a "donut" through which this moving bed passes. The machine makes loud clunking and tapping noises. The technologist will give you ear plugs to put in your ears during the study to dull the sound of the machine. Contrast material is then injected through the i.v. and more pictures are taken of the pelvic area.

MRI sagital view of the pelvis http://coe.ucsf.edu/coe/fibroid/diagnosis.html#top Ca cervix

An MRI axial or cross sectional scan

Cervical cancer is a disease in which malignant (cancer) cells form in the tissues of the cervix. The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal).

Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which cells that are not normal begin to appear in thecervical tissue. Later, cancer cells start to grow and spread more deeply into the cervix and to surrounding areas. Cervical cancer in children is rare. For more information, see the PDQ summary on Unusual Cancers of Childhood. Human papillomavirus (HPV) infection is the major risk factor for cervical cancer. Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Infection of the cervix with human papillomavirus (HPV) is almost always the cause of cervical cancer. Not all women with HPV infection, however, will develop cervical cancer. Women who do not regularly have tests to detect HPV or abnormal cells in the cervix are at increased risk of cervical cancer. Other possible risk factors include the following:

Giving birth to many children. Having many sexual partners. Having first sexual intercourse at a young age. Smoking cigarettes. Using oral contraceptives ("the Pill"). Having a weakened immune system. There are usually no noticeable signs or symptoms of early cervical cancer but it can be detected early with regular check-ups.

Early cervical cancer may not cause noticeable signs or symptoms. Women should have regular check-ups, including tests to check for HPV or abnormal cells in the cervix. The prognosis (chance ofrecovery) is better when the cancer is found early. Signs and symptoms of cervical cancer include vaginal bleeding and pelvic pain. These and other signs and symptoms may be caused by cervical cancer or by other conditions. Check with your doctor if you have any of the following:

Vaginal bleeding. Unusual vaginal discharge. Pelvic pain. Pain during sexual intercourse. Tests that examine the cervix are used to detect (find) and diagnose cervical cancer. The following procedures may be used:

Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patients health habits and past illnesses and treatments will also be taken. Pelvic exam : An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.

Pelvic exam. A doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and presses on the lower abdomen with the other hand. This is done to feel the size, shape, and position of the uterus and ovaries. The vagina, cervix, fallopian tubes, and rectum are also checked.

Pap test: A procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells

are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap smear.

Pap test. A speculum is inserted into the vagina to widen it. Then, a brush is inserted into the vagina to collect cells from the cervix. The cells are checked under a microscope for signs of disease.

Human papillomavirus (HPV) test : A laboratory test used to check DNA or RNA for certain types of HPV infection. Cells are collected from the cervix and DNA or RNA from the cells is checked to find out if an infection is caused by a type of human papillomavirus that is linked to cervical cancer. This test may be done using the sample of cells removed during a Pap test. This test may also be done if the results of a Pap test show certain abnormal cervical cells. Endocervical curettage : A procedure to collect cells or tissue from the cervical canal using acurette (spoon-shaped instrument). Tissue samples may be taken and checked under a microscope for signs of cancer. This procedure is sometimes done at the same time as acolposcopy. Colposcopy : A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette (spoonshaped instrument) and checked under a microscope for signs of disease. Biopsy : If abnormal cells are found in a Pap test, the doctor may do a biopsy. A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue is usually done in the doctors office. A woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped sample of cervical tissue). Certain factors affect prognosis (chance of recovery) and treatment options. The prognosis (chance of recovery) depends on the following:

The patient's age and general health. Whether or not the patient has a certain type of human papillomavirus. The stage of the cancer (whether it affects part of the cervix, involves the whole cervix, or has spread to the lymph nodes or other places in the body). The type of cervical cancer.

The size of the tumor. Treatment options depend on the following:

The stage of the cancer. The size of the tumor. The patient's desire to have children. The patients age. Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the stage of the pregnancy. For cervical cancer found early or for cancer found during the last trimester of pregnancy, treatment may be delayed until after the baby is born. Stages of Cervical Cancer After cervical cancer has been diagnosed, tests are done to find out if cancer cells have spread within the cervix or to other parts of the body. The process used to find out if cancer has spread within the cervix or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-raymachine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scannerrotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called asonogram. Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. Cystoscopy : A procedure to look inside the bladder and urethra to check for abnormal areas. Acystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. Laparoscopy : A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples to be checked under a microscope for signs of disease.

Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at the same time. Pretreatment surgical staging is usually done only as part of a clinical trial. The results of these tests are viewed together with the results of the original tumor biopsy to determine the cervical cancer stage. There are three ways that cancer spreads in the body. Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas. Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body. Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body. Cancer may spread from where it began to other parts of the body. When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body. Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body. The metastatic tumor is the same type of cancer as the primary tumor. For example, if cervical cancer spreads to the lung, the cancer cells in the lung are actually cervical cancer cells. The disease is metastatic cervical cancer, not lung cancer. The following stages are used for cervical cancer: Carcinoma in Situ (Stage 0) In carcinoma in situ (stage 0), abnormal cells are found in the innermost lining of the cervix. These

Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil eraser is about 5 mm. Stage I In stage I, cancer is found in the cervix only. Stage I is divided into stages IA and IB, based on the amount of cancer that is found.

Stage IA:

Stage IA1 and IA2 cervical cancer. A very small amount of cancer that can only be seen with a microscope is found in the tissues of the cervix. In stage IA1, the cancer is not more than 3 millimeters deep and not more than 7 millimeters wide. In stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not more than 7 millimeters wide. A very small amount of cancer that can only be seen with a microscope is found in the tissues of the cervix. Stage IA is divided into stages IA1 and IA2, based on the size of the tumor.
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In stage IA1, the cancer is not more than 3 millimeters deep and not more than 7 millimeters wide. In stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not more than 7 millimeters wide. Stage IB is divided into stages IB1 and IB2.

Stage IB1 and IB2 cervical cancer. In stage IB1, the cancer can only be seen with a microscopic and is more than 5 mm deep or more than 7 mm wide OR the cancer can be seen without a microscope and is 4 cm or smaller. In stage IB2, the cancer is larger than 4 cm.
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In stage IB1: the cancer can only be seen with a microscope and is more than 5 millimeters deep and more than 7 millimeters wide; or the cancer can be seen without a microscope and is 4 centimeters or smaller. In stage IB2, the cancer can be seen without a microscope and is larger than 4 centimeters. Stage II

Stage II cervical cancer. Cancer has spread beyond the cervix but not to the pelvic wall or to the lower third of the vagina. In stages IIA1 and IIA2, cancer has spread beyond the cervix to the vagina. In stage IIA1, the tumor can be seen without a microscope and is 4 centimeters or smaller. In stage IIA2, the tumor can be seen without a microscope and is larger than 4 centimeters. In stage IIB, cancer has spread beyond the cervix to the tissues around the uterus.

In stage II, cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of the body between the hips) or to the lower third of the vagina. Stage II is divided into stages IIA and IIB, based on how far the cancer has spread.

Stage IIA: Cancer has spread beyond the cervix to the upper two thirds of the vagina but not totissues around the uterus. Stage IIA is divided into stages IIA1 and IIA2, based on the size of thetumor. In stage IIA1, the tumor can be seen without a microscope and is 4 centimeters or smaller. In stage IIA2, the tumor can be seen without a microscope and is larger than 4 centimeters. Stage IIB: Cancer has spread beyond the cervix to the tissues around the uterus. Stage III In stage III, cancer has spread to the lower third of the vagina, and/or to the pelvic wall, and/or has caused kidney problems. Stage III is divided into stages IIIA and IIIB, based on how far the cancer has spread.

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Stage IIIA:

Stage IIIA cervical cancer. Cancer has spread to the lower third of the vagina but not to the pelvic wall. Cancer has spread to the lower third of the vagina but not to the pelvic wall.

Stage IIIB:

Stage IIIB cervical cancer. Cancer has spread to the pelvic wall; and/or the tumor has become large enough to block the ureters (the tubes that connect the kidneys to the bladder). The drawing shows the ureter on the right blocked by the cancer. This blockage can cause the kidney to enlarge or stop working.

Cancer has spread to the pelvic wall; and/or the tumor has become large enough to block the ureters (the tubes that connect the kidneysto the bladder). This blockage can cause the kidneys to enlarge or stop working. Stage IV In stage IV, cancer has spread to the bladder, rectum, or other parts of the body. Stage IV is divided into stages IVA and IVB, based on where the cancer is found.

Stage IVA: Enlarge

Stage IVA cervical cancer. Cancer has spread to nearby organs, such as the bladder or rectum. Cancer has spread to nearby organs, such as the bladder or rectum.

Stage IVB:

Stage IVB cervical cancer. Cancer has spread to parts of the body away from the cervix, such as the liver, intestines, lungs, or bones. Cancer has spread to other parts of the body, such as the liver, lungs, bones, or distant lymph nodes. Recurrent Cervical Cancer Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the cervix or in other parts of the body. Treatment Option Overview
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There are different types of treatment for patients with cervical cancer. Three types of standard treatment are used: Surgery Radiation therapy Chemotherapy New types of treatment are being tested in clinical trials. Patients may want to think about taking part in a clinical trial. Patients can enter clinical trials before, during, or after starting their cancer treatment. Follow-up tests may be needed. There are different types of treatment for patients with cervical cancer. Different types of treatment are available for patients with cervical cancer. Some treatments arestandard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on

new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment. Three types of standard treatment are used: Surgery Surgery (removing the cancer in an operation) is sometimes used to treat cervical cancer. The following surgical procedures may be used:

Conization: A procedure to remove a cone-shaped piece of tissue from the cervix and cervicalcanal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy. Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a totalabdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.

Hysterectomy. The uterus is surgically removed with or without other organs or tissues. In a total hysterectomy, the uterus and cervix are removed. In a total hysterectomy with salpingooophorectomy, (a) the uterus plus one (unilateral) ovary and fallopian tube are removed; or (b) the uterus plus both (bilateral) ovaries and fallopian tubes are removed. In a radical hysterectomy, the uterus, cervix, both ovaries, both fallopian tubes, and nearby tissue are removed. These procedures are done using a low transverse incision or a vertical incision.

Radical hysterectomy: Surgery to remove the uterus, cervix, part of the vagina, and a wide area of ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodesmay also be removed.

Modified radical hysterectomy: Surgery to remove the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs. Nearby lymph nodes may also be removed. In this type of surgery, not as many tissues and/or organs are removed as in a radical hysterectomy. Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes. Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation. Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such ascarcinoma in situ. This type of treatment is also called cryotherapy. Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor. Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer. Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiationtherapy uses a machine outside the body to send radiation toward the cancer. Internal radiationtherapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stageof the cancer being treated. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into avein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. See Drugs Approved to Treat Cervical Cancer for more information. New types of treatment are being tested in clinical trials. Information about clinical trials is available from the NCI Web site. Patients may want to think about taking part in a clinical trial. For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment. Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward. Patients can enter clinical trials before, during, or after starting their cancer treatment. Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment. Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials. Follow-up tests may be needed. Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging. Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups. Treatment Options by Stage

Carcinoma in Situ (Stage 0) Treatment of carcinoma in situ (stage 0) may include the following:

Loop electrosurgical excision procedure (LEEP). Laser surgery. Conization. Cryosurgery. Total hysterectomy for women who cannot or no longer want to have children. Internal radiation therapy for women who cannot have surgery. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage 0 cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IA Cervical Cancer Treatment of stage IA cervical cancer may include the following:

Total hysterectomy with or without bilateral salpingo-oophorectomy. Conization. Modified radical hysterectomy and removal of lymph nodes. Internal radiation therapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IA cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IB Cervical Cancer Treatment of stage IB cervical cancer may include the following:

A combination of internal radiation therapy and external radiation therapy. Radical hysterectomy and removal of lymph nodes. Radical hysterectomy and removal of lymph nodes followed by radiation therapy pluschemotherapy. Radiation therapy plus chemotherapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IB cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IIA Cervical Cancer Treatment of stage IIA cervical cancer may include the following:

A combination of internal radiation therapy and external radiation therapy plus chemotherapy. Radical hysterectomy and removal of lymph nodes. Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IIA cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IIB Cervical Cancer Treatment of stage IIB cervical cancer may include internal and external radiation therapy combined with chemotherapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IIB cervical cancer. For more specific results, refine the search by using other search

features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage III Cervical Cancer Treatment of stage III cervical cancer may include internal and external radiation therapy combined withchemotherapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage III cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IVA Cervical Cancer Treatment of stage IVA cervical cancer may include internal and external radiation therapy combined with chemotherapy. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IVA cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Stage IVB Cervical Cancer Treatment of stage IVB cervical cancer may include the following:

Radiation therapy as palliative therapy to relieve symptoms caused by the cancer and improvequality of life. Chemotherapy. Clinical trials of new anticancer drugs or drug combinations. Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withstage IVB cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. Treatment Options for Recurrent Cervical Cancer Treatment of recurrent cervical cancer may include the following:

Pelvic exenteration followed by radiation therapy combined with chemotherapy. Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life. Clinical trials of new anticancer drugs or drug combinations.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withrecurrent cervical cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site. http://www.cancer.gov/cancertopics/pdq/treatment/cervical/Patient/page4/AllPages Cervical Cancer

Cervical cancer is the third most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries. Etiology With rare exceptions, cervical cancer results from genital infection with HPV, which is a known human carcinogen. Although HPV infections can be transmitted via nonsexual routes, the majority result from sexual contact. Consequently, major risk factors identified in epidemiologic studies are as follows:

Sex at a young age Multiple sexual partners Promiscuous male partners History of sexually transmitted diseases HIV infection is associated with a 5-fold increase in the risk of cervical cancer, presumably because of an impaired immune response to HPV infection. Exposure to diethylstilbestrol in utero has been associated with an increased risk of CIN grade 2 or higher.

Signs and symptoms The most common finding in patients with cervical cancer is an abnormal Papanicolaou (Pap) test result. Because many women are screened routinely, the most common finding is an abnormal Papanicolaou (Pap) test result. Typically, these patients are asymptomatic. Clinically, the first symptom of cervical cancer is abnormal vaginal bleeding, usually postcoital. Vaginal discomfort, malodorous discharge, and dysuria are not uncommon. The tumor grows by extending along the epithelial surfaces, both squamous and glandular, upward to the endometrial cavity, throughout the vaginal epithelium, and laterally to the pelvic wall. It can invade the bladder and rectum directly, leading to constipation, hematuria, fistula, and ureteral obstruction, with or without hydroureter or hydronephrosis. The triad of leg edema, pain, and hydronephrosis suggests pelvic wall involvement. The common sites for distant metastasis include extrapelvic lymph nodes, liver, lung, and bone.

Physical symptoms of cervical cancer may include the following:

Abnormal vaginal bleeding Vaginal discomfort Malodorous discharge Dysuria Pathophysiology Human papillomavirus (HPV) infection must be present for cervical cancer to occur. HPV infection occurs in a high percentage of sexually active women. However, approximately 90% of HPV infections clear on their own within months to a few years and with no sequelae, although cytology reports in the 2 years following infection may show a low-grade squamous intraepithelial lesion. On average, only 5% of HPV infections will result in the development of CIN grade 2 or 3 lesions (the recognized cervical cancer precursor) within 3 years of infection. Only 20% of CIN 3 lesions progress to invasive cervical cancer within 5 years, and only 40% of CIN 3 lesions progress to invasive cervical cancer with 30 years. Because only a small proportion of HPV infections progress to cancer, other factors must be involved in the process of carcinogenesis. The following factors have been postulated to influence the development of CIN 3 lesions:

The type and duration of viral infection, with high-risk HPV type and persistent infection predicting a higher risk for progression; low-risk HPV types do not cause cervical cancer Host conditions that compromise immunity (eg, poor nutritional status, immunocompromise, and HIV infection) Environmental factors (eg, smoking and vitamin deficiencies) Lack of access to routine cytology screening In addition, various gynecologic factors significantly increase the risk of HPV infection. These include early age of first intercourse and higher number of sexual partners. Although use of oral contraceptives for 5 years or longer has been associated with an increased risk of cervical cancer, the increased risk may reflect a higher risk for HPV infection among sexually active women. However, a possible direct interaction between oral contraceptives and HPV infection has not been disproved. Genetic susceptibility Genetic susceptibility to cervical cancers caused by HPV infection has been identified via studies of twins and other first-degree relatives, as well as genome-wide association studies. Women who have an affected first-degree biologic relative have a 2-fold relative risk of developing a cervical tumor compared with women who have a nonbiologic first-degree relative with a cervical tumor. Genetic susceptibility accounts for fewer than 1% of cervical cancers. Genetic changes in several classes of genes have been linked to cervical cancer. Tumor necrosis factor (TNF) is involved in initiating the cell commitment to apoptosis, and the genes TNFa-8, TNFa572, TNFa-857, TNFa-863, and TNF G-308A have been associated with a higher incidence of cervical cancer. Polymorphisms in another gene involved in apoptosis and gene repair, Tp53, have been associated with an increased rate of HPV infection progressing to cervical cancer. Human leukocyte antigen (HLA) genes are involved in various ways. Some HLA gene anomalies are associated with an increased risk of HPV infection progressing to cancer, others with a protective effect. The chemokine receptor-2 (CCR2) gene on chromosome 3p21 and the Fas gene on chromosome 10q24.1may also influence genetic susceptibility to cervical cancer, perhaps by disrupting the immune response to HPV. The CASP8 gene (also known as FLICE or MCH5) has a

polymorphism in the promoter region that has been associated with a decreased risk of cervical cancer. Epigenetic modifications may also be involved in cervical cancer. Methylation is the best understood and probably the most common mechanism of epigenetic DNA modeling in cancer. Aberrant DNA methylation patterns have been associated with the development of cervical cancer and may harbor important clues for developing treatment. Human papillomavirus HPV comprises a heterogeneous group of viruses that contain closed circular double-stranded DNA. The viral genome encodes 6 early open reading frame proteins (ie, E1, E2, E3, E4, E6, and E7), which function as regulatory proteins, and 2 late open reading frame proteins (ie, L1 and L2), which make up the viral capsid. To date, more than 115 different genotypes of HPV have been identified and cloned. A large multinational cervical cancer study found that more than 90% of all cervical cancers worldwide are caused by 8 HPV types: 16, 18, 31, 33, 35, 45, 52, and 58. Three types16, 18, and 45cause 94% of cervical adenocarcinomas. HVP type 16 may pose a risk of cancer that is an order of magnitude higher than that posed by other high-risk HPV types. The World Health Organization (WHO) International Agency for Research on Cancer Monograph Working Group has grouped HPV types of the mucosotropic alpha genus according to the evidence supporting their association with cervical cancer (see Table 1, below). Table 1. Human Papillomavirus Types Associated With Cervical Cancer HPV Alpha Types Group 1 16 18,31,33,35,39,45,51,52,56,58, 59 2A 2B 68 26,53,66,67,70,73,82 30,34,69,85,97 3 6,11 Evidence for Cervical Cancer Causation Most carcinogenic HPV type, known to cause cancer at several sites Sufficient evidence Limited evidence in humans and strong mechanistic evidence Limited evidence in humans Classified by phylogenetic analogy to HPV types with sufficient or limited evidence in humans Inadequate epidemiological evidence and absence of carcinogenic potential in mechanistic studies

HPV = human papillomavirus. Table 2. Cervical Cancer Staging: Primary Tumor (T) TNM Stage TX T0 Tis FIGO Stage 0 Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ

T1 T1a

I IA

Cervical carcinoma confined to uterus (extension to corpus should be disregarded) Invasive carcinoma diagnosed only by microscopy. All macroscopically visible lesionseven with superficial invasionare T1b/1B. Stromal invasion with a maximal depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less. Vascular space involvement, venous or lymphatic, does not affect classification. Measured stromal invasion 3 mm or less in depth and 7 mm or less in lateral spread Measured stromal invasion more than 3 mm but not more than 5 mm with a horizontal spread 7 mm or less Clinically visible lesion confined to the cervix or microscopic lesion greater than IA2 Clinically visible lesion 4 cm or less in greatest dimension Clinically visible lesion more than 4 cm Cervical carcinoma extends beyond the cervix but not to the pelvic sidewall or to the lower third of vagina Tumor without parametrial invasion Tumor with parametrial invasion Tumor extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney Tumor involves lower third of vagina; no extension to pelvic sidewall Tumor extends to pelvic sidewall and/or causes hydronephrosis or nonfunctioning kidney Cervical carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the bladder mucosa or rectal mucosa. Bullous edema does not qualify as a criteria for stage IV disease. Spread to mucosa of adjacent organs (bladder, rectum, or both) Distant metastasis

T1a1 T1a2 T1b T1b1

IA1 IA2 IB IB1 IB2

T2 T2a T2b T3 T3a T3b -

II IIA IIB III IIIA IIIB IV

T4 M1

IVA IVB

Diagnosis Human papillomavirus (HPV) infection must be present for cervical cancer to occur. Complete evaluation starts with Papanicolaou (Pap) testing. Screening recommendations Current screening recommendations for specific age groups, based on guidelines from the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), the American Society for Clinical Pathology (ASCP), the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG), are as follows :

< 21 years: No screening recommended 21-29 years: Cytology (Pap smear) alone every 3 years 30-65 years: Human papillomavirus (HPV) and cytology cotesting every 5 years (preferred) or cytology alone every 3 years (acceptable)

>65 years: No screening recommended if adequate prior screening has been negative and high risk is not present Complete evaluation starts with Papanicolaou (Pap) testing. Positive results should prompt colposcopy and biopsies with further workup of cervical intraepithelial neoplasia (CIN), including excisional procedures. If pathologic evaluation after loop electrosurgical excision or conization suggests invasive cancer with positive margins, the patient should be referred to a gynecologic oncologist. Patients with suspicious or grossly abnormal cervical lesions on physical examination should undergo biopsy regardless of the cytologic findings. Once the diagnosis is established, a complete blood count (CBC) and serum chemistries for renal and hepatic function should be ordered to look for abnormalities from possible metastatic disease, and imaging studies should be performed for staging purposes. In the International Federation of Gynecology and Obstetrics (Federation Internationale de Gynecologie et dObstetrique *FIGO+) guidelines for staging, procedures are limited to the following :

Colposcopy Biopsy Conization of cervix Cystoscopy Proctosigmoidoscopy Chest x-ray Cystoscopy and proctoscopy should be performed in patients with a bulky primary tumor to help rule out local invasion of the bladder and the colon. Barium enema studies can be used to evaluate extrinsic rectal compression from the cervical mass. In the United States, more complex radiologic imaging studies are often done to guide the choice of therapeutic options. These may include computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET), as well as surgical staging. Management Immunization Evidence suggests that HPV vaccines prevent HPV infection.The following 2 HPV vaccines are approved by the FDA:

Gardasil (Merck, Whitehouse Station, NJ): This quadrivalent vaccine is approved for girls and women 9-26 years of age to prevent cervical cancer (and also genital warts and anal cancer) caused by HPV types 6, 11, 16, and 18; it is also approved for males 9-26 years of age Cervarix (GlaxoSmithKline, Research Triangle Park, NC): This bivalent vaccine is approved for girls and women 9-25 years of age to prevent cervical cancer caused by HPV types 16 and 18 The Advisory Committee on Immunization Practices (ACIP) recommendations for vaccination are as follows:

Routine vaccination of females aged 11-12 years of age with 3 doses of either HPV2 or HPV4 Routine vaccination with HPV4 for boys aged 11-12 years of age, as well as males aged 13-21 years of age who have not been vaccinated previously Vaccination with HPV4 in males aged 9-26 years of age for prevention of genital warts; routine use not recommended Stage-based treatment The treatment of cervical cancer varies with the stage of the disease, as follows:

Stage 0: Carcinoma in situ (stage 0) is treated with local ablative or excisional measures such as cryosurgery, laser ablation, and loop excision; surgical removal is preferred Stage IA1: The treatment of choice for stage IA1 disease is surgery; total hysterectomy, radical hysterectomy, and conization are accepted procedures Stage IA2, IB, or IIA: Combined external beam radiation with brachytherapy and radical hysterectomy with bilateral pelvic lymphadenectomy for patients with stage IB or IIA disease; radical vaginal trachelectomy with pelvic lymph node dissection is appropriate for fertility preservation in women with stage IA2 disease and those with stage IB1 disease whose lesions are 2 cm or smaller Stage IIB, III, or IVA: Cisplatin-based chemotherapy with radiation is the standard of care Stage IVB and recurrent cancer: Individualized therapy is used on a palliative basis; radiation therapy is used alone for control of bleeding and pain; systemic chemotherapy is used for disseminated disease Prognosis The prognosis in patients with cervical cancer depends on the disease stage. In general, the 5-year survival rates are as follows:

Stage I - Greater than 90% Stage II - 60-80% Stage III - Approximately 50% Stage IV - Less than 30% The ACS estimates that 4220 women will die of cervical cancer in the United States in 2012. This represents 1.3% of all cancer deaths and 6.5% of deaths from gynecologic cancers. http://emedicine.medscape.com/article/253513-overview#showall Polip endometrium Definition Uterine polyps are growths attached to the inner wall of the uterus that extend into the uterine cavity. Overgrowth of cells in the lining of the uterus (endometrium) leads to the formation of uterine polyps, also known as endometrial polyps. These polyps are usually noncancerous (benign), although some can be cancerous or can eventually turn into cancer (precancerous polyps). The sizes of uterine polyps range from a few millimeters no larger than a sesame seed to several centimeters golf ball sized or larger. They attach to the uterine wall by a large base or a thin stalk. Symptoms Signs of uterine polyps include:

Irregular menstrual bleeding for example, having frequent, unpredictable periods of variable length and heaviness Bleeding between menstrual periods Excessively heavy menstrual periods

Vaginal bleeding after menopause Infertility Some women may experience only light bleeding or spotting or may even be symptom-free. Causes Although the exact cause of uterine polyps is unknown, hormonal factors appear to play a role. Uterine polyps are estrogen-sensitive, meaning that they respond to estrogen in the same way that the lining of your uterus does growing in response to circulating estrogen. Risk factors Risk factors for developing uterine polyps include:

Peri- or postmenopausal age High blood pressure (hypertension) Obesity Tamoxifen, a drug therapy for breast cancer Tests and diagnosis

Transvaginal ultrasound. A slender, wand-like device placed in your vagina sends out sound waves and creates an image of your uterus, including its interior. A related procedure, known as hysterosonography, involves having salt water (saline) injected into your uterus through a small tube threaded through your vagina and cervix. The saline expands your uterine cavity, which gives the doctor a clearer view of the inside of your uterus.

Hysteroscopy. Doctors may perform a procedure called hysteroscopy to diagnose and treat uterine polyps. In a hysteroscopy, your doctor inserts a thin, flexible, lighted telescope (hysteroscope) through your vagina and cervix into your uterus. Hysteroscopy allows your doctor to examine the inside of your uterus and remove any polyps that are found. This eliminates the need for a follow-up procedure.

Curettage. During curettage, your doctor uses a long metal instrument with a loop on the end to scrape the inside walls of your uterus. This may be done to collect a specimen for lab testing or to remove a polyp. Your doctor may perform curettage with the assistance of a hysteroscope, which lets your doctor view the inside of your uterus before and after the procedure. Treatments and drugs

Watchful waiting. Small polyps without symptoms (asymptomatic) may resolve on their own. Treatment is unnecessary unless you're at risk of uterine cancer. Medication. Certain hormonal medications, including progestins and gonadotropin-releasing hormone agonists, may shrink a uterine polyp and lessen symptoms. But taking such medications is usually a short-term solution at best symptoms typically recur once you stop taking the medicine. Curettage. Your doctor uses a long metal instrument with a loop on the end to scrape the inside walls of your uterus. This may be done to collect a specimen for lab testing or to remove a polyp. Your doctor may perform curettage with the assistance of a hysteroscope, which allows your doctor to view the inside of your uterus before and after the procedure. Surgical removal. During hysteroscopy, instruments inserted through the hysteroscope the device your doctor uses to see inside your uterus make it possible to remove polyps once they're identified. The removed polyp may be sent to a lab for microscopic examination. Complications Uterine polyps may be associated with infertility. If you have uterine polyps and you experience infertility, removal of the polyps might allow you to become pregnant. Uterine polyps also may present an increased risk of miscarriage in women who undergo in vitro fertilization (IVF). If you're considering IVF treatment and you have uterine polyps, your doctor may recommend polyp removal before embryo transfer.

http://www.mayoclinic.com/health/uterine-polyps/DS00699

2. Why did the patient release of large amounts of blood? Dysfunctional uterine bleeding Anovulatory Perimenarchealimmature hypothalamic-pituitary-ovarian axis Perimenopausalinsensitive ovarian follicles Endocrinopathiessee systemic causes Drugshypothalamic depressants, steroids Ovulatory Organic lesions Pregnancy-associated causesimplantation spotting, abortion, ectopic pregnancy, gestational trophoblastic disease, postabortal or postpartum infection Anatomic uterine lesions Neoplasmleiomyoma, polyp, endometrial hyperplasia, cancer Atrophic endometrium Infectionsexually transmitted disease, tuberculosis Mechanical causesintrauterine device, perforation Arteriovenous malformation Partial outflow obstructioncongenital mllerian defect, Asherman syndrome Anatomic nonuterine lesions Ovarian lesionshormonally functional neoplasm Fallopian tube lesionssalpingitis, cancer Cervical and vaginal lesionscancer, polyp, infection, atrophic vaginitis, foreign body, trauma Systemic abnormalities Exogenous hormone administrationsex steroids, corticosteroids Coagulopathies Hepatic failure Chronic renal failure Endocrinopathieshypothyroidism, hyperthyroidism, adrenal disorders, hypothalamic-pituitary disorders, polycystic ovarian syndrome, obesity Sumber : Rukmono Siswishanto SMF/Bagian Obstetri & Ginekologi RS Sardjito/ Fakultas Kedokteran UGM , Yogyakarta 2. Why did yhe patient feels weak? Anemia Menorrhagia is the most common cause of anemia (reduction in red blood cells) in premenopausal women. A blood loss of more than 80mL (around three tablespoons) per menstrual cycle can eventually lead to anemia. Most cases of anemia are mild. Nevertheless, even mild anemia can reduce oxygen transport in the blood, causing fatigue and a diminished physical capacity. Moderateto-severe anemia can cause shortness of breath, rapid heart rate, lightheadedness, headaches, diabetes mellitus,

ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur in prolonged and severe anemia that is not treated. 3. Why the patient accompanied by severe abdominal pain? Because endocrine factor: obes have relation of estrogen, estrogen can stimuly uterus contraction. Obes with prostaglandin: Disminorhea primer: only happend in ovulatory cycles. Onset singkat. Disminorhea sekunder: still pain even without there are no ovulation. Etiology: intrauterin; myoma, polip endometrium, IUD, infection, tumor jinak di vagina atau uterus. Extrauterin; endometriosis, inflamation, adhetion, cytogenic, syndroma congestif pelvis 4. Why there are foul smelling vaginal discharge between menstrual cycles? VAGINAL DISCHARGE Heavy periods with smelly discharge: You periods seem to be getting heavier by the month, there is bleeding in between periods, particularly after sexual intercourse. There is a heavy, foul smelling discharge. These may be signs of early stages of cervical cancer, a condition called cervical dysplasia. Ask your doctor to perform aPap smear test. Fishy discharge Gray, fishy smelling vaginal discharge that is worse after having sex or washing with soap. There may also be itchiness or irritation in and around the vulva and vagina. You may have bacterial vaginosis, see vaginitis. Gray/greenish discharge as well as itchiness around the vagina or vulva. There may be a burning sensation when urinating and discomfort during sex. You could havetrichomoniasis, a type of vaginitis which is sexually transmitted. Ask your doctor to perform an STD test. Trichomonas is treated with antibiotics; your partner will also need to be tested. Thick white discharge which looks like cottage cheese, may smell yeasty like bread. Usually accompanied by itching and a burning sensation when urinating. The vulva can also look swollen and sore. See: yeast infection symptoms (Candida). Bleeding between periods with abnormal vaginal discharges. Discharge may be watery, pinkish, foul smelling or blood tinged. The vulva may be persistently itchy (pruritus). Rule out: vaginal cancer symptoms. Bleeding between periods or heavier periods than normal with increased vaginal discharge. There may be a burning feeling in the vagina and urethra which could be mistaken for a urinary tract infection (cystitis). There may also be irritation around the anus and a need to urinate frequently. These are symptoms of gonorrhea, a sexually transmitted disease.

Greenish discharge

Cottage cheese discharge Watery discharge

Increased vaginal discharge

Discharge with burning pain

Unusual vaginal discharge, burning pain when urinating, lower abdominal pain and a frequent need to urinate; these are all signs of a sexually transmitted disease calledchlamydia. Sometimes there may be no symptoms. Ask your doctor for a chlamydia screening. Treatment consists of antibiotics with a follow up test a few weeks later. Your partner will also need to be tested.

http://www.womens-health-advice.com/reproductive-disorders.html

To confirm: -pap smear: Pap smear The Pap smear is a screening test for cervical cancer. Cells scraped from the opening of the cervix are examined under a microscope. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina. Who should have a Pap smear? Pregnancy does not prevent a woman from having a Pap smear. Pap smears can be safely done during pregnancy. Pap smear testing is not indicated for women who have had a hysterectomy(with removal of the cervix) for benign conditions. Women who have had a hysterectomy in which the cervix is not removed, called subtotal hysterectomy, should continue screening following the same guidelines as women who have not had a hysterectomy. The screening guidelines of several key medical organizations are summarized in the table below. Organization When to start Pap smear testing Frequency of Pap smear testing At what age to stop having Pap smears

American Cancer Society 2004

3 years after vaginal intercourse, no later than age 21

Yearly with exceptions: 1. Total hysterectomy for benign disease every 2 years if liquid-based kit 2. > 70 years old with at least three every 2-3 years if normal Pap smear three normal tests results and no in a row in abnormal Pap women >30 years results in the last old 10 years

1. Recommend against doing Pap Within 3 years At least every 3 years smears in women United States Preventative ofonset of sexual (no evidence that every older than 65 years Services Task Force 2003 activity or age 21, year is better than of age, if adequate whichever comes first every 3 years) screening with normal results and otherwise not at

risk for cervical cancer. 2. Recommend against doing Pap smears in women who have had a total hysterectomy for benign disease. Difficult to set an upper Yearly until age 30 age limityears. Beginning at age postmenopausal 3 years after first sexual American College 30, if three normal women screened intercourse or age 21, ofObstetrics andGynecology annual Pap results, can within the prior 2-3 whichever comes first. do a Pap alone every 2- years have a very low 3 years risk of developing abnormal Pap smears.

Which women are at increased risk for having an abnormal Pap smear? A number of risk factors have been identified for the development of cervical cancer and precancerous changes in the cervix.

HPV: The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. (See below for details). About 95%-100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women. Smoking: One common risk factor forpremalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold. Weakened immune system: Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix.

Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk. Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age. How is a Pap smear done? A woman should have a Pap smear when she is not menstruating. The best time for screening is between 10 and 20 days after the first day of her menstrual period. For about two days before testing, a woman should avoid douchingor using spermicidal foams, creams, or jellies or vaginal medicines (except as directed by a physician). These agents may wash away or hide any abnormal cervical cells. A Pap smear can be done in a doctor's office, a clinic, or a hospital by either a physician or other specially trained health care professional, such as aphysician assistant, a nurse practitioner, or a nurse midwife.

With the woman positioned on her back, the clinician will often first examine the outside of the patient's genital and rectal areas, including the urethra (the opening where urine leaves the body), to assure that they look normal. A speculum is then inserted into the vaginal area (the birth canal). (A speculum is an instrument that allows the vagina and the cervix to be viewed and examined.) A cotton swab is sometimes used to clear away mucus that might interfere with an optimal sample. A small brush called a cervical brush is then inserted into the opening of the cervix (the cervical os) and twirled around to collect a sample of cells. Because this sample comes from inside the cervix, is called the endocervical sample ("endo" meaning inside). A second sample is also collected as part of the Pap smear and is called the ectocervical sample ("ecto" meaning outside). These cells are collected from a scraping of the area surrounding, but not entering, the cervical os. Both the endocervical and the ectocervical samples are gently smeared on a glass slide and a fixative (a preservative) is used to prepare the cells on the slide for laboratory evaluation.

A bimanual (both hands) pelvic exam usually follows the collection of the two samples for the Pap smear. The bimanual examination involves the physician or health care practitioner inserting two fingers of one hand inside the vaginal canal while feeling the ovaries and uterus with the other hand on top of the abdomen (belly). The results of the Pap smear are usually available within two to three weeks. At the end of Pap smear testing, each woman should ask how she should expect to be informed about the results of her Pap smear. If a woman has not learned of her results after a month, she should contact her health care practitioner's office.

How the Test is Performed You lie on a table and place your feet in stirrups. The doctor or nurse gently places an instrument called a speculum into the vagina to open it slightly. This allows the doctor or nurse to see inside the vagina and cervix. Cells are gently scraped from the cervix area. The sample of cells is sent to a lab for examination. How to Prepare for the Test Tell your doctor or nurse about all the medicines you are taking. Some birth control pills that contain estrogen or progestin may interfere with test results. Also tell your doctor or nurse if you:

Have had an abnormal Pap smear Might be pregnant

Do not do the following for 24 hours before the test:

Douche (douching should never be done) Have intercourse Take a bath Use tampons

Avoid scheduling your Pap smear while you have your period (are menstruating). Blood may make the Pap smear results less accurate. If you are having unexpected bleeding, do not cancel your exam. Your doctor will determine if the Pap smear can still be done. Empty your bladder just before the test. How the Test Will Feel A Pap smear may cause some discomfort, similar to menstrual cramps. You may also feel some pressure during the exam. You may bleed a little bit after the test. Why the Test is Performed The Pap smear is a screening test for cervical cancer. Most cervical cancers can be detected early if a woman has routine Pap smears. Screening should start at age 21. After the first test:

You should have a Pap smear ever 3 years to check for cervical cancer. If you are over age 30 and you also have HPV testing done and both the Pap smear and HPV test are normal, you can be tested every 5 years. (HPV is the human papillomavirus, the virus that causes genital warts and cervical cancer.)

After age 65 to 70: Most women can stop having Pap smears as long as they have had three negative tests within the past 10 years.

You may not need to have a Pap smear if you have had a total hysterectomy (uterus and cervix removed) and have not had an abnormal Pap smear, cervical cancer, or other pelvic cancer. Discuss this with your doctor. Normal Results A normal result means there are no abnormal cells present. Talk to your doctor about the meaning of your specific test results. What Abnormal Results Mean Abnormal results are grouped as follows: ASCUS or AGUS

This result means there are atypical cells of uncertain significance The changes may be due to HPV They may also mean there are changes that may lead to cancer

LSIL (low-grade dysplasia) or HSIL (high-grade dysplasia):

This means precancerous changes are likely to be present The risk of cervical cancer is greater with HSIL

Carcinoma in situ (CIS):

This result usually means the abnormal changes are likely to lead to cervical cancer

Atypical squamous cells (ASC):

Abnormal changes have been found and may be HSIL

Atypical glandular cells (AGC):

Cell changes that may lead to cancer are seen in the upper part of the cervical canal or inside the uterus

When a Pap smear shows abnormal changes, further testing or follow-up is needed. The next step depends on the results of the Pap smear, your previous history of Pap smears, and risk factors you may have for cervical cancer. Follow-up testing may include:

Colposcopy-directed biopsy An HPV test to check for the presence of the HPV virus types most likely to cause cancer

For minor cell changes, doctors usually recommend having another Pap smear in 6 to 12 months. Considerations The Pap smear test is not 100% accurate. Cervical cancer may be missed in a small number of cases. Most of the time, cervical cancer develops very slowly and follow-up Pap smears should identify changes in time for treatment.

http://www.nlm.nih.gov/medlineplus/ency/article/003911.htm Biopsy A biopsy is the removal of a small piece of tissue for laboratory examination. How the Test is Performed There are several different types of biopsies. A needle biopsy is called a percutaneous biopsy. It removes tissue using a hollow tube called a syringe. The needle is passed several times through the tissue being examined. The surgeon uses the needle to remove the tissue sample. Needle biopsies are often done using CT scan or ultrasound. These imaging tools help guide the surgeon to the right area. An open biopsy is surgery that uses local or general anesthesia. This means you are relaxed (sedated) or asleep and pain-free during the procedure. It is done in a hospital operating room. The surgeon makes a cut into the affected area, and the tissue is removed. Closed biopsy uses a much smaller surgical cut than open biopsy. A small cut is made so that a camera-like instrument can be inserted. This instrument helps guide the surgeon to the right place to take the sample. How to Prepare for the Test Before scheduling the biopsy, tell your doctor and nurse about any medicines you are taking, including herbs and supplements. You may be asked to stop taking some for a while, particularly those that can make you bleed. Such medications include aspirin, Coumadin (warfarin), and nonsteroidal anti-inflammatory medications (NSAIDs). Never stop or change your medications without first talking to your health care provider. How the Test Will Feel In a needle biopsy, you will feel a small sharp pinch at the site of the biopsy. In an open or closed biopsy, local or general anesthesia is often used to make it pain-free. Why the Test is Performed A biopsy is most often done to examine tissue for disease. Normal Results The tissue removed is normal. What Abnormal Results Mean An abnormal biopsy means that the tissue or cells have an unusual structure, shape, size, or condition. This may mean you have a disease, such as cancer, but it depends on your biopsy. Risks

Bleeding Infection

http://www.nlm.nih.gov/medlineplus/ency/article/003416.htm -IVA: inspeksi visual asam asetat (sekret diambiltetesi as.asetatamati, tampak ???)indikasi, cara kerja dr masing2 px Early detection of cervical cancer with vinegar method is called IVA (Inspection Visual with Acetic Acid). This method has been introduced since 1925 by Hans Hinselman from Germany, but only applied around the year 2005. Early detection of cervical cancer by applying vinegar to 3-5 percent in the mouth of the womb (cervix) is not to be done by a doctor, but can be practiced by trained personnel such as midwives in health centers. And in about 60 seconds already can be seen if there are abnormalities, namely the appearance of white plaques on the cervix. These white plaques may be aware as pre-cancerous sores. Early detection of cervical cancer is in addition to easy and cheap, also has a very high accuracy in detecting precancerous lesions or sores, which reached 90 percent. World Health Organization (WHO) has examined the application of IVA in India, Thailand, and Zimbabwe. Its effectiveness was not lower than the Pap smear. Cervical cancer is caused by infection with HPV (Human Papilloma Virus) can indeed be called a silent killer because it does not cause symptoms in the initial state. If the condition is advanced before a person can feel symptoms such as frequent pain in the pelvic area, pain during copulate, bleeding arise, etc. Actually, cervical cancer is preventable by HPV vaccination can provide protection for nine years. Indeed, this vaccine can only be accessed by certain circles because of the cost is expensive. Secondary prevention of cervical cancer can be done, among other methods of early detection using VIA or pap smears. WHO recommends, ideally women aged 25-60 years doing cervical examination every three years. In addition to the same performance with other tests and the results can be immediately known, IVA also offers other advantages, that is practical, requiring only simple tools, and affordable. Preparation before IVA test, detection of cervical cancer by applying vinegar, among others, is not menstruating, not pregnant, and not having sexual intercourse within 24 hours before the examination. 5. What the relation of history family with this symptom? 6. What is the relation between physical exam with anemic and obese condition? Blood is a multifaceted body fluid and the medium through which essential nutrients are delivered to tissues throughout the body. On average, the adult human body contains more than 5 liters of blood. Blood flows freely through the veins and arteries because it is over halfliquid plasma; the remainder of blood volume consists mostly of solid cells and cell fragments, which are suspended in the plasma (ASH 2011; Merck 2006; Alberts 2002; MedlinePlus 2012a; Dean 2005).

Red blood cells, or erythrocytes, contain hemoglobin, an iron-containing protein responsible for transporting oxygen from the lungs to tissues (Merck 2006). Erythrocytes are continuously produced in bone marrow and survive about 120 days (MedlinePlus 2012a; Lledo-Garcia 2012; Dean 2005). Having an abnormally low number of erythrocytes or low hemoglobin is known as anemia (Merck 2006).

ANEMIA Menorrhagia is the most common cause of anemia (reduction in red blood cells) in premenopausal women. A blood loss of more than 80mL (around three tablespoons) per menstrual cycle can eventually lead to anemia. Most cases of anemia are mild. Nevertheless, even mild anemia can reduce oxygen transport in the blood, causing fatigue and a diminished physical capacity. Moderateto-severe anemia can cause shortness of breath, rapid heart rate, lightheadedness, headaches, ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur in prolonged and severe anemia that is not treated. http://health.nytimes.com/health/guides/symptoms/menstrual-periods-heavy-prolonged-orirregular/print.html Obesity : obesity can make hormone estrogen and progesteron in body imbalance,because fatty contains androsterediol change to estradiol and make hormone estrogen increaed than progesteron,and if endometrium expose estrogen can make hiperplasi and make abdominal pain caused press the organns parametrium. . if estrogen decreased it can make descuamate stratum fungsional in endometrium. But usually unfollow ovulation. having too much estrogen and not enough progesterone. Women who have mentioned hormone imbalance over time may be more likely to get endometrial cancer after age 50. This hormone imbalance can happen if a woman:

Is obese. Fat cells make extra estrogen, but the body doesn't make extra progesterone to balance it out. Takes estrogen without taking a progestin - Estrogen only hormone replacement therapy (HRT). Has polycystic ovary syndrome (PCOS) and chronic anovulation, which causes hormone imbalance.

In general estrogens are responsible for the lining of the uterus (endometrium) grow thicker. Progesterone "opposes" estrogen - progesterone level goes up then drops at the end of each menstrual cycle, making the thick endometrium layer shed away. This is what we know as menstrual bleeding. When there is too much estrogen in the body, progesterone can't do its job. The endometrium gets thicker and thicker. If the lining builds up and stays that way, then cancer cells can start to grow. Over time, the endometrium cells can become cancerous. http://www.women-health-info.com/272-Endometrial-cancer.html 7. What is the relation of history g0p0a0 with foul smeling vaginal discharge? 8. What is the relation between size and uterus position with foul smelling vaginal discharge? 9. Why the patient need to do USG and hystopatology exam?

ULTRASOUND Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. Imaging can help diagnose fibroids, endometriosis, or structural abnormalities of the reproductive organs. Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and finding obstructions in the urinary tract. It uses sound waves to produce an image of the organs. Ultrasound carries no risk and causes very little discomfort. http://health.nytimes.com/health/guides/symptoms/menstrual-periods-heavy-prolonged-orirregular/print.html Histopathology is the microscopic examination of biological tissues to observe the appearance of diseased cells and tissues in very fine detail. The main use of histopathology is in clinical medicine where it typically involves the examination of a biopsy (i.e. a surgically removed sample or specimen taken from a patient for the purposes of detailed study) by a specialist physician called a pathologist. http://www.ivy-rose.co.uk/HumanBody/Histology/What-is-Histopathology.php 10. What the relation 32 years old with her symptoms?