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EVALUASI DAN MANAJEMEN
PERDARAHAN UTERUS ABNORMAL (AUB)PADA PERIODE PERIMENOPAUSE
S U T R I S N ODivision of Human Reproductive Endocrinology and Fertility
Department of Obstetrics and GynecologiBrawijaya University Faculty of Medicine / Saiful Anwar Hospital
Malang
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Perdarahan uterus abnormal adalah keluhan yang palingsering yang membawa wanita ke dokter umum / Obs Gyn
(Livingstone M, Fraser IS, 2002; Zinger M, 2008, Sweet MG, 2011)
PERDARAHAN UTERUS ABNORMAL (AUB) :Hampir semua wanita pernah mengalaminya ...
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!"#$%$&$ (
"#$%&$&'&( )*#$+, -.(/$0&1 2
3&(44+&( '&5% .#$+6& 7#1&5(&( %&1&0 '&1!"#$%#&'()
$#+#",+%",&) -,., /,& 0%.-,1 /,",1 8&(4 %5,#.&.7&(/1#'!,$+2" 3,+2-24(') 5'(2-24(' ,+,% (,+"24#&($
9$&,#$ :;< =+0 >#6$/% )6%&*#< ?/1 @< ABBA
C/'&( D #* &1;< E#,* "$&F* >#, G15( H.,*#* 38(#F/1< ?/1; AI< J/; K< 66; @LIMLBN< ABBO
DP##* C3 #* &1;< -0 9&0 "'8,5F5&(< @Q RIS< ABII
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Istilah yang digunakan untuk menggambarkan
Heavy Menstrual Bleeding
Menorrhagia
Hypermenorrhea
Menometrorrhagia
Dysfunctional Uterine Bleeding
Functional Uterine Hemorrhage
Excessively Heavy Menstrual Loss
Ovulatory Menorrhagia
Anovulatory MenorrhagiaFunctional Menorrhagia
Essential menorrhagia
Idiopathic Menorrhagia
Primary menorrhagia
Uncomplicated Menorrhagia
Symptomatic MenorrhagiaPersistent menorrhagia
Unexplained menorrhagia
Genuine Menorrhagia
Idiopathic Uterine Hemorrhage
Anomalou Uterine Hemorrhage
EpimenorrheaEpimenorrhagia
Polymenorrhea
Polymenorrhagia
Metropathia Hemorrhagica
CONTOH !!!
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PolypA denomyosis
L eiomyoma
Malignancy / Hyperplasia
Coagulopathy
Ovulatory disfunction
Non yet classified
Endometrium
Iatrogenic
KOMPONEN STRUKTUR KOMPONEN NON STRUKTUR
Visualisasi dgn imaging / PA
Similar !FIGO cervical cancer staging 1920
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PERDARAHAN UTERUSABNORMAL
FaktorKehamilan
dll
Kepastiankeluar dari
serviks
KomplikasiPerdarahan
AKUT KRONIS
LANGKAH-LANGKAH PENDEKATAN
RASIONAL
INVESTIGASI SISTEMATIS PALM - COEIN
TATA LAKSANA
STEP 1
STEP 2
STEP 3
STEP 4
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INVESTIGASI SISTEMATIS
P A L M C O E I N
Anamnesa
sistematis Pemeriksaanfisik
Pemeriksaan
Lab/penunjang
FaktorOvulasi
"
Hematologi" Endokrin
" Coagulopathy
hereditary
Penyakit2Obat
Pola hidup
Evaluasi Uterus
Secara TEPAT
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PERIMENOPAUSE ?
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Menopause:Tidak haidRetrospektif : 1 tahun sejak tdk haid sama sekali.
Perimenopause:Transisi sekitar menopause. Sebelum menopausesampai 1 tahun setelah menopause.
Postmenopause:
Periode setelah satu tahun menopause
Definisi : Pre-menopausePeri-menopauseMenopase
Post-menopause
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AGE
PERIMENOPAUSEREPRODUCTIVEPERIMENARCHE
Anovulatoar
Disorder of blood
coagulation
Pregn. Disorders
Medicinal
Reprod. Tractpathologies
Anovulatoar
Struktural
Malignancy
Risk factor of
malignancy
! "#$%& ()*#$+,)
! -)%#&). ()*/01
!
2,$/*3+ #*/45%#6/*
! 78)93:&
! -;
!
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ALUR TATA LAKSANA AUB - HIFERI
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BOBOTNYA
DI PROSESDIAGNOSTIK
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! " # $ % & '
-A 5:#(# B "6/%/=3 !"#$%&'( *+,%-#, .(,,/-#0 1!*.2
Diagnostic
Exploration of endocervical canalSuspected endometrial polyps
Suspected submucous leiomyomas
Evaluation of endometrial lining
Focal pathologically suspect lesions (endometrial ca)
Misplaced foreign bodiesUterine anomalies
Intrauterine adhesions
Evaluation of uterotubal junctions
Evaluasi uterus : endometrium miometrium
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Leioioma uteri, Malignancy / Hyperplasia
Polip endometrium, Adenomiosis
PERDARAHAN UTERUS ABNORMAL
KOMPONEN STRUKTUR
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Evaluasi struktur uterus dan rongga uterus
345
634
784
494
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HSG
TVS
SISOHS
MRI
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HSG : x - ray
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TVS
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! " # $ % & '
-A 5:#(# B "6/%/=3 !"#$%&'( *+,%-#, .(,,/-#0 1!*.2
Diagnostic
Exploration of endocervical canalSuspected endometrial polyps
Suspected submucous leiomyomas
Evaluation of endometrial lining
Focal pathologically suspect lesions (endometrial ca)
Misplaced foreign bodiesUterine anomalies
Intrauterine adhesions
Evaluation of uterotubal junctions
Evaluasi uterus : endometrium miometrium
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?@C D
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TVS COLOR DOPLER
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TVS COLOR DOPLER 3D
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WINDOW
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S I S
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CEC FC#%3*) E*G593/* C/*/,&9:)$/=$#0,&H
E*96%#93 +#3$#* 9#%3*) #:#5 8#,#* I/*:$#9 I)
.#%#( +#45( 5:)$3 .#* :58# G#%/03 .33I56
0)()$3I9##* 9/*/=$#J1 E96%#, %#3* KC/*/,&9:)$/=$#0,&L
M&9:)$/9/*/=$#0,&L 9#%3*) 3*G593/*
9/*/,&9:)$/=$#0,& FCECHL #*. ,&9:)$/9#%03*=/D+/*:$#9:D9/*/=$#0,& FM&2/C&H
N/%.9:)3* OPL P$)) OQL P)*9/* 2PL ): #%L RSST1
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Parsons AK, 2001
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TUJUAN PEMERIKSAAN
)#*&+$,- .//0
Melihat kelainan di :
Canalis servicalis
Otot polos uterus (myometrium)Endometrium
Cavum uteri
Tuba Fallopi
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TVS
CEC
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CEC D
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CEC U 9)+$):/$& )*./():$35(
! :;-+? !*.@
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M30)$0%#93# )*./():$35(
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CEC D >/%30
C#=3V#% CEC W 0/%&09 .)*=#* "Q *= 6039
FR U X ((HC#=3V#% ?@C "Q /G TR ((1
Y XZD&)#$D/%. [3:, ()*/$$,#=3#K
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SIS
COLOR DOPLER
POLIP
Y \\ &)#$ /%.
]3:, Y^P
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;&/(# 958(5I/#9#
38 years old woman with AUB
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MYOMA UTERI SUBMUCOUS
TVS
SIS
3 D
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SINEKIACAV.UTERI
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! " # $ % & '
-A 5:#(# B "6/%/=3 !"#$%&'( *+,%-#, .(,,/-#0 1!*.2
Diagnostic
Exploration of endocervical canal
Suspected endometrial polyps
Suspected submucous leiomyomas
Evaluation of endometrial lining
Focal pathologically suspect lesions (endometrial ca)
Misplaced foreign bodies
Uterine anomalies
Intrauterine adhesions
Evaluation of uterotubal junctions
Evaluasi uterus : endometrium miometrium
VISUAL!!TERAPI!.. ++++++++++
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Dokter!!!!.
Visual langsungSasaran target tepat
Mengurangi Error
Target biopsi jelas
Jaringan biopsi representatif
Manfaat TERAPI
?
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Melihat endocervix
Melihat uterine cavity
Melihat endometriumMelihat tubal osteium
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MYOMA UTERI SUBMUCOUS
TVS
SIS
OHS
W -
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Uterus dan serviks reguler, ostia bebas
AUB - O
Polip korpus kecil di cornua tuba kiri, kavum
reguler, ostia tuba bebas bilateral
Myoma submukosa Uterus septus (septum kecil dengan panjang 5
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Adhesi intrauterin grade 1 (ruptur akibat sheathhisteroskop
Hiperplasia endometrium
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Myoma submukosaMyoma submukosa dengan pembuluhDarah yang besar besar.
Uterus subseptus hiperplasia
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Polip corpus fibrosa besar di dinding posterior Polip corpus
Ny M, 36 th
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WHICH ONE
THE BEST
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C)*936J:#9 .#* 90)93J93:#9 CEC
;).3+#$) C)$43+) Y.43#9/$& C/((3:)L T___
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TVS - OHS
Shalev J et al, 2000
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Salim R et al, 2004
AB 494 < 634
P b di TVS SIS d OHS d k AUB
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Perbandingan TVS, SIS dan OHS pada kasus AUBpada usia reproduksi
Kelekci S, 2005
Fertility Sterility, 2005
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Sardo et al, 2008
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Akurasi Diagnosis untuk Evaluasi Kelainan di Uterus
Grup Dx Benar (%) Dx Salah (%)
HSG 60 40SIS 54 46
OHS 72 28
Brown SE et al, 2000
Evaluasi Uterine Cavity dengan MRI TVS HSE (SIS) dan Hysteroscopy
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Evaluasi Uterine Cavity dengan MRI, TVS, HSE (SIS), dan Hysteroscopy
Dueholm M et al, 2001
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Safety: TVS, SIS dan OHS aman, komplikasi jarang,cocok untuk AUB pada perimenopase.
Effectiveness: SIS lebih efektif dari TVS untuk mendeteksi
beberapa kelainan intrakaviter.
SIS dan OHS mempunyai kemampuan yang samadalam hal sensitifitas, spesifisitas, PPV dan NPV
Cost-Effectiveness : SIS lebih murah daripada OHS.
Namun kemampuan OHS lebih dalam hal
kemampuan sebagai terapi.Rekomendasi: TVS dan SIS bisa menjadi prosedur yang baik
dalam mengevaluasi perdarahan perimenopause
T KE HOME M SS GE
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SELALUSEHAT
SAMPAIUSIA
MENOPAUSE
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THANK YOU
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