Disfunctional Uterine
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DISFUNCTIONAL UTERINE BLEEDING
Oleh :Joko Purwito ( 9910144 )
Pembimbing :Dr Aloysius S,SpOG
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Pendahuluhan
Gangguan haid
DUBPerdarahan masif/tidak teratur ygtidak disebabkan kelainan anatomi (mioma, lesi, atau tumor yang lain)
WANITA
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FISIOLOGI SIKLUS HAID
Haid Keluarnya darah dari vagina, yang berasal dari uterus secara periodik dan siklis.
HIpothalamus
Hipofise
Ovarium
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Normal Abnormal
Durasi 4-6 hari < 2 atau > 7 hari
Volume 30 ml Lebih dari 80 ml
Interval 24-35 hari
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KLASIFIKASI DUB
DUB
Anovulatoar (90%) Ovulatoar(10%, usia reproduktif)
Postmenarche, 20% Perimenopause, 50%
Imaturitas aksis HPO Menurunnya
fungsi ovarium
Defek fase luteal
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Perdarahan abnormal siklus anovulatorik
<< progesterone & >> estrogen akibat tidak terbentuknya korpus luteum aktif karena tidak terjadinya ovulasi
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– Rangsangan estrogen tidak dinetralisir oleh progesteron endometrium menebal
– Endometrium strukturnya rapuh, tumbuh tak teratur
– Menars: 2-3 tahun sesudah menars (80%) – Beberapa tahun menjelang menopause, 8-10
siklusnya dalam setahun– Wanita dengan kontrasepsi hormonal/HRT,
sakit atau stres
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Perdarahan abnormal siklus ovulatorik
ketidakseimbangan hormonal
- Umur korpus luteum yg memendek atau memanjang
- Isufisiensi atau persistensi korpus luteum
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• Dapat terjadi pada fase luteal
• Pemakai kontrasepsi progesteron
• Gangguan regenerasi sel oleh estrogen menyebabkan perdarahan tak teratur
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DUB siklus ovulatoar dibedakan dalam 3 jenis :
• Perdarahan pada pertengahan siklus• Perdarahan akibat gangguan pelepasan
endometrium• Perdarahan bercak (spotting) prahaid dan
pascahaid
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Siklus Ovulatoar Siklus Anovulatoar
1. Perubahan jumlah perdarahan & siklus:
– Menorrhagia
– Lamanya perdarahan >>
2. Gejala premenstruasi
3. Dismenorrhoe
4. Mittleschmertz
5. Perubahan mukus serviks
6. Kurva temperatur bifasik
7. Hasil positif penggunaan alat prediktor LH
1. Perubahan jumlah perdarahan & siklus:
Kadar unopposed estrogen:
spotting & frekuensinya jarang
Kadar unopposed estrogen:
withdrawal masif & siklus >>
2. Tanpa gejala premenstruasi
3. Tidak terdapat perubahan mukus serviks
4. Kurva temperatur monofasik
5. Hasil negatif penggunaan alat prediktor LH
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Patofisiologi DUB :
1. Faktor hormon steroid :
- Estrogen Breakthrough Bleeding
- Estrogen Withdrawal Bleeding
- Progesterone Breaktrough Bleeding
- Progesterone Withdrawal Bleeding
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2. Prostaglandin Endometrium
3. Lisosom Endometrium ( teori enzim )
4. Regenerasi & Epitelialisasi Jaringan Endometrium
Patofisiologi DUB :Patofisiologi DUB :
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Perdarahan Bercak Estrogen (Estrogen Breakthrough Bleeding)
• X ovulasi corpus luteum X progesteron • Estrogen lamban X umpan balik negatif FSH & LH
, X lonjakan LH rangsangan estrogen terhadap endometrium berlangsung lama & terus menerus hiperplasia endometrium
• Estrogen mencapai nilai ambang mendatar/turun tidak mampu mepertahankan endometrium gangguan vaskularisasi nekrosis & perdarahan
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Perdarahan Lucut Estrogen (Estrogen Withdrawal Bleeding)
• Kadar estrogen inadekuat tidak mampu memicu lonjakan LH ovulasi tidak terjadi
• Penurunan FSH diikuti penurunan estrogen yang mendadak terkelupasnya endometrium secara tidak sempurna & berkepanjangan
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•Perdarahan Bercak Progesteron (Progesterone Breakthrough Bleeding)
Terganggunya keseimbangan progesteron terhadap estrogen
•Perdarahan Lucut Progesteron (Progesterone Withdrawal Bleeding)
Penurunan mendadak progesteron iskemia endometrium fase proliferasi nekrosis deskuamasi lapisan endometrium
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DIAGNOSIS DUB
• Anamnesis
• Pemeriksaan Fisik
• Pemeriksaan Penunjang
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• Pola menstruasi
• Riwayat menstruasi selama setahun
• Kenaikan/penurunan berat badan
• Kelainan makan
• Pemakaian hormonal
• Stress
• Excersice berlebihan
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Umum :
• Keadaan umum penderita• Sebab lain yg mungkin berhubungan dgn perdarahan
Ginekologis :
Kelainan genitalia interna perlu dicari, seperti erosi, radang, tumor atau keganasan, dan infeksi
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• LABORATORIUM
• BIOPSI
• USG
• SONOHISTEROGRAFI
• HISTEROSKOPI
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• Tes kehamilan
• Hitung darah lengkap
• Serum progesteron > 3 ng/ml ovulasi baru saja terjadi
• TSH
• Kelainan koagulasi
• Tes fungsi hati/ginjal
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• Riwayat perdarahan abnormal yang meragukan
• Adanya hiperplasia/keganasan
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• Membedakan kelainan anatomis
• Ketebalan endometrium biopsi– < 5 mm tidak perlu biopsi – > 12 mm meski kecurigaan klinis/adanya
penyakit adalah rendah
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sindroma
post ligasi
tuba
Tumor
fungsional
ovarium
Penyakit
adrenal
Hormon
eksogen
Gagal
ginjal
kronikPenyakit
tiroid Obat-obatan
Terapi
antikoagulan
Penyakit hati
Kelainan anatomis servikal
Koagulopati
Kelainan kehamilan
Kelainan anatomis
DIAGNOSISBANDING
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•Tujuan:
– Memperbaiki keadaan umum
– Menghentikan perdarahan
– Mengembalikan fungsi hormon reproduksi
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• Pertimbangan Penatalaksanaan: – Umur, status, fertilitas– Berat, jenis, & lama perdarahan
Jenis Terapi• Medikamentosa
• Operatif
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Perbaikan keadaan umum:
• Syok atasi dengan resusitasi cairan
• Hb < 8gr% transfusi darah
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Penghentian perdarahan : pemakaian hormon steroid
- Estrogen- Progestin- Androgen
GnRH analog Inhibitor Prostaglandin Antifibrinolitik Levonorgestrel IUD
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1. Dilatase dan Kuretase – Tujuan diagnostik (> 35 tahun/perimenopause)
– Hemodinamik tidak stabil resusitasi cairan + D & C
– Mekanisme? peluruhan lapisan basal endometrium proses normal (penghentian perdarahan: mekanisme pembekuan, vasokonstriksi arteriol basalis, & reepitelialisasi)
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2. Ablasi Endometrium
• Kontraindikasi pembedahan & efektif sebagai pilihan lain
• Tujuan: menginduksi amenorrhoe
• Kelebihan: X pengangkatan uterus, waktu pemulihan <<, komplikasi <<
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Ablasi Endometrium
Teknik:
- Transcervical Resection of The Endometrium (TCRE)
- Endometrial Laser Ablation (ELA)
- Thermal Balloon Ablation of The Endometrium (TBEA)
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Kriteria penderita pada ablasi endometrium:
• Menorrhagia, perdarahan > 8 hari, anemia
• Besar uterus < 12 minggu kehamilan & panjang cavum uteri < 12 cm
• X kanker/prakanker endometrium/cervical
• Lewat usia reproduktif
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3. Histerektomi
– Terapi menorrhagia – Tingkat kepuasan – Morbiditas 40%
– Mortalitas 10 pasien per 10.000 operasi
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• Episode tunggal, postmenarche lebih baik
• Induksi ovulasi kesembuhan 80%
• Rekurensi: D & C (30-40%), ablasi (25%), histerektomi kepuasan (morbiditas 40%)
• Komplikasi: anemia (30%), infertilitas (45-55%), keganasan (1-2%)
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• DUB perdarahan masif/iregular, X kelainan anatomik
• DUB ovulatoar: postmenarche & sebelum perimenopause defek corpus luteum
• DUB anovulatoar: pubertas, wanita tua, obese, PCOS
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• Diagnosis: anamnesis, pemeriksaan fisik, pemeriksaan penunjang
• Terapi: medikamentosa dan operatif
• Prognosis: usia, episode, pengobatan
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