fek

Azwar, A, (1998). Majalah Kesehatan Masyarakat Indonesia, Siklus Pemecahan Masalah, Tahun XVII,
IAKMI, Jakarta, Hal.544-554.
----------------, (1996), Pengantar Administrasi Kesehatan , Edisi III, PT. Binarupa Aksara, Jakarta.
Departemen Kesehatan R.I., (1982). Pedoman Petugas Lapangan UPGK, Jakarta.
----------------------------------, (1990). Pedoman Stratifikasi. Departemen Kesehatan R.I., Jakarta.

Endometrial biopsy (EMB) is the most commonly used diagnostic test for DUB
(pages 17 -19). It provides an adequate sample for diagnosis of endometrial
problems in 90% to 100% of cases,15,16 but may fail to detect polyps and
leiomyomas.17 It is indicated in all women with DUB who are 35 years of age or
older, since their risk of developing malignancy is much higher.2,3 Any woman with
amenorrhea for one year or longer who experiences uterine bleeding also should
have an EMB.2 The newer slim endometrial suction currettes (Pipelle) produce
samples comparable to older, more traumatic methods but with less pain. 1,3,15,16,18
Sampling should be performed late in the cycle if possible, so it can be
determined if ovulation has taken place.3
Uterine ultrasound, especially transvaginal ultrasonography (TV-US), can
give information about suspected structural problems including fibroid
tumors.2,17,19 It is classically indicated when physical exam indicates anatomic
gynecologic abnormalities, especially of the ovaries where other methods provide
poor information.19 The endometrial stripe assessment on TV-US can provide
information about the ovulatory stage of the endometrium that has a 93%
correlation with hystological diagnosis. 19 An endometrial thickness measurement
of less than 4 to 7 mm is rarely associated with cancer, and endometrial sampling
may not be necessary in such patients.17, 20, 21
Dilatation and curettage (D&C) allows more extensive sampling of the uterine
cavity and has the advantage of being both diagnostic and therapeutic. It may be
the treatment of choice when bleeding is severe or necessitates blood
transfusions. 2 It has a higher sensitivity than endometrial biopsy, especially with
smaller in-situ lesions. It is often used when EMB is inadequate, the cervical os
is stenotic, or DUB treatment fails. 1, 3, 18 When D&C is combined with
endometrial biopsy, the detection rate approaches 100%. Fractional D&C is
usually not used in teenagers, because they rarely have endometrial cancer and
the procedure may damage the cervix or uterus. 5 It is currently required for the
staging of occult cancer. 14, 22
Hysteroscopy can be used in place of D&C for most indications, and allows for
direct visualization of the endometrial cavity with directed biopsy. Hysteroscopy
is more sensitive than fractional D&C, especially at diagnosing polyps and

submucosal leiomyomas, but it may miss endometritis. 23, 24 When combined with
EMB, it has almost 100% accuracy in diagnosing endometrial dysplasia and
cancer. 24 It may eventually become required for staging of occult cancer. Like
EMB, it often can be performed in the office setting and may be used for
treatment of DUB (see below.) 24