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Irene Maria Elena, MD
Obstetrics and Gynecology Department
FK UKRIDA
Reproductive Health
• The WHO defines reproductive health as a state
of complete physical, mental and social well-
being, and not merely the absence of
reproductive disease or infirmity.
• Reproductive health involves all of the
reproductive processes, functions and systems at
all stages of human life.
• This definition implies that people are able to
have a satisfying and safe sex life and that they
have the capability to reproduce and the freedom
to decide if, when and how often to do so.
• Kesehatan Reproduksi , adalah kondisi sehat
menyangkut sistem, fungsi, dan proses alat
reproduksi yang dimiliki .
• NEUROSYPHILIS
No single testing technique has been able to diagnose
All adults with latent syphilis be evaluated clinically for aortitis,
neurosyphilis, gumma, iritis (CDC recommended)
Lumbar puncture for cerebrospinal fluid analysis should be done
in any patient with latent syphilis of unknown or greater than 1 yr
durationin specific situatuons
Condyloma Acuminatum, Sexually
transmitted disease of the vulva, vagina and
cervix; Etiologic agent: Human papillomavirus
• High risk: HPV 16 and 18; Benign: HPV 6 and
11
Penyakit Radang Panggul
• Infeksi dan peradangan pada organ-organ di
saluran genital wanita bagian atas
• Inflamasi yang terjadi merupakan suatu
rangkaian kesatuan yang terdiri dari uterus
(endometritis), tuba falopii (salpingitis),
ovarium (ooforitis), miometrium,
parametrium (parametritis), rongga pelvis
(peritonitis)
• RPR merupakan infeksi polimikrobial dan
biasanya disebabkan oleh mikroorganisme
N.gonorrhoeae dan C.trachomatis
• Bakteri masuk melalui vagina dan serviks
(kolonisasi pada endoserviks) dan menjalar ke
rahim lalu ke tuba falopii.
• Dapat juga ditemukan virus, jamur
(actinomyces israeli) dan parasit
(skistosomiasis)
• Infeksi ini jarang terjadi sebelum siklus
menstruasi pertama, setelah menopause
maupun selama kehamilan
• Penularan yang utama terjadi melalui
hubungan seksual, tetapi bakteri juga bisa
masuk ke dalam tubuh setelah prosedur
kebidanan/kandungan (mis pemasangan IUD,
persalinan, keguguran, aborsi dan biopsi
endometrium)
Organisme penyebab
Penyakit Radang Panggul
Aerob Anaerob Virus
Neisseria gonorrheae Bacteroides sp Herpes simplex
Chlamydia trachomatis Peptostreptococcus sp Echovirus
Ureaplasma urelyticum Clostridium bifermentans Coxsackie
Gardneralla vaginalis Fusobacterium sp
Strptococcus pyogenes
Coagulase negative
staphylococci
Escherichia coli
Haemophillus influenzae
Mycoplasma hominis
Streptococcus pneumoniae
Mycobacterium
tuberculosis
Infeksi Traktus Urinarius
• Etiologi : E.coli (80%), Proteus, Klebsiella dan
Pseudomonas, Enterobacter, Streptococcus
faecalis, Staphylococcus saprophyticus,
Enterococcus dan Chalamydia
• Infeksis dari uretra (uretritis) dan kandung
kencing (sistitis)
• Gejala : kombinasi frekuensi, urgensi, disuria,
piuria, hematuria, nyeri pelvik akut atau
kronik, nyeri punggung dan demam
HUMAN IMMUNODEFICIENCY
VIRUS
• HIV infection is caused by an RNA retrovirus
• HIV is a RNA retrovirus that attches to the CD4
receptor of the target cell and integrates into
the host genome
• When the CD4 all count falls below 200
cells/µL, patients are at high risk for Aquired
Immunodeficiency Syndrome (AIDS)
• In females: Coexisting infections may have damaged normal
anatomy and function of pelvic organs
• In males: HIV effects on semen
• Safe reproduction in couples with HIV
• Safe reproduction recommendations:
– Infected man + normal woman: semen washing + Assisted
Reproductive Technology (ART)
– Normal man + infected woman: Intarauteriane
Insemination (IUI)
– Both HIV+: semen washing
– Anti-retrovirals, elective CS, no breastfeeding
Induced Abortion
• Abortus dipakai untuk menunjukan ancaman
atau pengeluaran hasil konsepsi sebelum janin
dapat hidup diluar kandungan, dan sebagai
batasan digunakan kehamilan kurang dari 20
minggu atau berat anak kurang dari 500 gram.
• Abortus buatan (Induced Abortion) ialah
pengakhiran kehamilan sebelum 20 minggu
akibat tindakan (The delibrate termination of
pregnancy in a manner that ensures that the
embryo or fetus will not survive)
• Komplikasi :
- Perdarahan
- Perfosi
- Infeksi
- Syok
Kontrasepsi
• Perencanaan Keluarga
2-4 tahun
Diafragma
Male
Condom
Spermisida
CARCINOMA
CERVIX
CERVIX
third most frequent malignancy
Risk Factors:
- early and frequent sexual contact
- cervical viral infection particularly HPV
CERVICAL INTRAEPITHELIAL
NEOPLASIA (CIN)
CIN 1
Mild atypia
Atypical changes involve
lower third of
epithelium
Cervix
CERVICAL INTRAEPITHELIAL
NEOPLASIA
CIN 2
Moderate atypia
Atypical changes involve
1/3 – 2/3 of epithelium
CERVICAL INTRAEPITHELIAL
NEOPLASIA
CIN 3
Severe atypia
Atypical changes involve
>2/3 or full thickness of
the epithelium
CERVIX
Two types of malignancy:
1. Squamous cell CA – 80–85%
2. Adenocarcinoma – 15-20%
Degree of Differentiation of Tumors
G1 = well differentiated
G2 = intermediate
G3 = undifferentiated
CERVIX
Verrucous Carcinoma
- a rare type of squamous cell carcinoma
- warty tumors appear as large bulbous masses
- rarely metastasize
Adenocarcinoma
- do not appear to be affected by sexually factors
associated with squamous cell CA
CERVIX
Adenoma malignum
- microscopically innocuous appearing tumors
consist of well-differentiated mucinous gland
that vary in size and shape and infiltrate the
stroma
- deeply invasive and metastasize early
CERVIX
Clear Cell Carcinoma
- histologically identical to ovary
- uncommon in cervix
- associated with intrauterine DES exposure
Adenoid Cystic Carcinoma
- rare; less aggressive
- resemble Basal Cell CA of skin
CARCINOMA of the CERVIX
Clinical Considerations
- abnormal bleeding/brownish discharge following
intercourse or douching occurring spontaneously
between menstrual periods
- back pain
- loss of appetite
- weight loss
- age 40-60s (median 32 years)
Cervix
CARCINOMA of the CERVIX
Staging:
- pelvic exam
- general physical exam
- chest radiographic exam
- IVP
- CT Scan
Natural History and Spread
- initially a locally infiltrating carcinoma that spreads
from cervix to the vagina and paracervical and
parametrial areas
Cervix
CARCINOMA of the CERVIX
Forms:
- ulcerated
- exophytic
- endophytic
Spread:
- lymphatic
- hematogenous (lung, liver, bone)
Cervix
UTERUS
UTERUS
Most common malignancy
Epidemiology:
- affects women in perimenopausal and
postmenopausal years
- diagnosed between 50 – 65 years
- younger than 40 (5%)
- younger than 50 (10%)
Complex Atypical Hyperplasia
- results from increased estrogen stimulation of the
endometrium and is a precursor to endometrioid
endometrial carcinoma
ENDOMETRIAL CARCINOMA
RISK FACTORS
Increases the Risk Decreases the Risk
Unopposed estrogen stimulation Ovulation
Unopposed menopausal estrogen Progestin therapy
replacement therapy (4-8x) Combined OCP
Menopause after 52 yrs (2.4x) Menopause before 49 years
Obesity (2-5x) Normal weight
Nulliparity (2-3x) Multiparity
Diabetes (2.8x)
Feminizing ovarian tumors
Polycystic ovarian syndrome
Tamoxifen therapy for breast
cancer
ENDOMETRIAL
HYPERPLASIA
Results from excess of estrogen or an excess of
estrogen relative to progestin, such as occurs with
anovulation
Types:
1. Simple Hyperplasia
2. Complex Hyperplasia without atypia
3. Complex Hyperplasia with atypia
Simple Hyperplasia
Uterus
Complex Hyperplasia
w/o Atypia
Glands are crowded with
very little endometrial
stroma and a very complex
gland pattern and
outpouching formation
Considered low
premalignant potential
Uterus
Complex Hyperplasia
w/ Atypia
Uterus
ENDOMETRIAL
HYPERPLASIA
Natural History
- the rate at which endometrial hyperplasia progresses to
endometrial carcinoma has not been accurately
determined
Rate of Progression to Cancer
- complex atypical hyperplasia – 29%
- simple hyperplasia – 1%
- complex hyperplasia w/o atypia – 3%
Uterus
ENDOMETRIAL CARCINOMA
Symptoms:
- postmenopausal and perimenopausal bleeding
Diagnosis:
- endometrial sampling
- Fractional D&C
- Pap smear – detect endometrial CA (50%)
Histologic Types:
G1 = well differentiated (<6% solid components)
G2 = intermediate (6-50% solid components)
G3 = poorly intermediate (>50% solid components)
Uterus
ENDOMETRIAL PRIMARY
CARCINOMA
Uterus
ENDOMETRIAL PRIMARY
CARCINOMA
Adenosquamous Carcinoma
- squamous epithelium that co-exists with glandular
elements of endometrial carcinoma
Uterine Papillary Serous Carcinoma
- highly virulent and uncommon
Clear Cell Carcinoma
- less common (5%)
- tend to develop in postmenopausal women
and carry a prognosis much worse than typical
endometrial carcinoma
Uterus
STAGING of ENDOMETRIAL
CARCINOMA
Stages CHARACTERISTICS
Stage IA Tumor limited to the endometrium
IB Invasion to less than half of the myometrium
IC Invasion to more than half of the myometrium
Stage IIA Endocervical glandular involvement only
IIB Cervical stromal invasion
Stage IIIA Tumor invades serosa and/or adnexae and/or positive
peritoneal cytology
IIIB Vaginal metastases
Uterus
OVARY
OVARIAN CARCINOMA
Second most common malignancy
Major contributing factor:
- detection of disease after metastatic spread
Incidence increase with age
Ovary
RISKS OF
OVARIAN CARCINOMA
Increases Decreases
Age Breastfeeding
Diet Oral contraceptives
Family history Pregnancy
Industrialized country Tubal ligation and
Infertility hysterectomy with ovarian
Nulliparity preservation
Ovulation
Ovulatory drugs
Talc?
Ovary
CLASSIFICATION OF
OVARIAN CARCINOMA
CLASS FREQUENCY
Epithelial Stromal 65
Germ Cell 20 – 25
Sex Cord-Stromal 6
Lipid Cell < 0.1
Gonadoblastoma < 0.1
Soft tissue tumors
Unclassified tumors
Secondary (metastatic)
Tumor-like conditions
Ovary
WHO Classification of Ovarian
Neoplasm
CLASSIFICATION OF
OVARIAN CARCINOMA
Epithelial Stromal Tumors
- most frequent
- arise from coelomic epithelium
Germ Cell Tumor
- second most common
- most common in young women
- composed of extraembryonic elements or 3 embryonic layers
(ectoderm, mesoderm or endoderm)
- main cause of ovarian malignancy particularly in young
women – teens
Ovary
CLASSIFICATION OF
OVARIAN CARCINOMA
Sex Cord-Stromal Tumors
- 3rd most common
- contain elements that recapitulate the constituents of the
ovary and testis
- secrete sex steroid hormones or may be hormonally inactive
Lipid Cell Tumor
- extremely rare; histologically resemble the adrenal gland
Gonadoblastoma
- consists of germ cell and sex-cord stromal elements
- occur in individuals with dysgenetic gonads
particulary when Y chromosome is present
Ovary
CLASSIFICATION OF
OVARIAN CARCINOMA
Soft Tissue Tumor
- not specific to the ovary
- hemangioma or lipoma
Unclassified
- Small Cell CA – highly virulent affecting young women
Secondary Metastatic Tumors
Tumor-like conditions
Ovary
Serous Cystadenocarcinoma
Ovary
Mucinous Cystadenocarcinoma
Ovary
Endometriod Tumors
IIC Tumor either IIA or IIB, but w/ tumor on surface of one or both
ovaries, or w/ capsule ruptures, or if w/ ascites
Stage IIIA Tumor grossly limited to the pelvis w/ negative nodes but w/
microscopic seeding to the abdominal peritoneal surface
IIIB Tumor of one or both ovaries w/ histologically confirmed
implants of abdominal peritoneal surfaces, none exceeding 2
cm, nodes are negative
IIIC Abdominal implants greater than 2 cm and/or positive
retroperitoneal or inguinal nodes
Stage IVA Parenchymal liver metastasis
Teratoma
• Mature Teratoma (Dermoid)
• Most common type of ovarian
teratoma/ovarian neoplasms; and most
common neoplasm diagnosed during
pregnancy
• Composed of fully/well differentiated mature
tissues from 3 germs cell layers, usually
ectodermal (skin, hair, sebaceous glands, glia)
but also mesodermal and endodermal
derivatives
• Occuring in woman ages 20-30 years
• Complications: torsion, rupture, infection,
malignant transformation (2%)
Teratoma
• Immature Teratoma
• The malignant counterpart of mature cystic
teratoma or dermoid
• 2nd most common germ cell malignancy
• Proliferation of meiotic germ cell
• Neural elements that makes it malignant
• The amount of undifferentiated neural tissues
(immature neural tissue present) is prognostic
importance and guidelines for chemotherapy
• They are usually unilateral, although the
contralateral may contain a mature teratoma
• These tumors often secrete ά fetoprotein
(AFP)
Torsion Cyst
• Adnexal torsion may be suspected in the
woman with an adnexal mass who
experiences the sudden onset of pelvic pain
• Torsion of the adnexae can involve the ovary,
tube, and ancillary structures, either
separately or together
• Commonly associated with a cystic neoplasm
• Symptoms include :
Abdominal pain and tenderness, that usually
are sudden in onset and result from occlusion
of the vascular supply to the twisted organ
Ruptured Cyst
• A ruptured ovarian cyst is a common
phenomenon, with presentation ranging from
no symptoms to symptoms mimicking an
acute abdomen
• Each month, a mature ovarian follicle
ruptures, releasing an ovum so the process of
fertilization can begin
• Occasionally, these follicles may bleed into the
ovary, causing cortical stretch and pain, or at
the rupture site following ovulation
• Similarly, a corpus luteum cyst may bleed
subsequent to ovulation or in early pregnancy.
• As blood accumulates in the peritoneal cavity,
abdominal pain and signs of intravascular
volume depletion may arise.
• The etiology of this increased bleeding is
unknown, although abdominal trauma and
anticoagulation treatments may increase the
risk.
• Nonphysiologic cysts, such as cystadenomas
and mature cystic teratomas (dermoid cysts),
may, in rare cases, rupture and cause
symptoms
• a diffuse chemical peritonitis can accompany
rupture of a dermoid cyst, presumably from
spillage of sebaceous fluid
Torsion and Ruptured Cyst
• These symptoms :
- severe or sharp pelvic pain
- fever
- faintness or dizziness
- rapid breathing
can indicate a ruptured cyst or an ovarian
torsion. Both complications can have serious
consequences if not treated early.
• Williams obstetrics
• Williams gynecologic
• Clinical gynecologic oncology (De Saia)
• Medscape
• Current obstetrics and Gynecology Ed 11
• WHO : Introduction to Reproductive Health and The Environtment
• Panduan penatalaksanaan infeksi pada traktus genitalis dan urinarius
• Buku ajar kependudukan dan pelayanan KB
• At a glance sistem Reproduksi Ed 2
• Panduan pelayanan klinik Kanker Ginekologi Ed 3-2013 (Himpunan
Onkologi Ginekologi indonesia)
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