Irene Maria Elena, MDObstetrics and Gynecology DepartmentFK UKRIDAReproductive Health The WHO defines reproductive health as a stateof complete physical, mental and social well-being, and not merely the absence ofreproductive disease or infirmity. Reproductive health involves all of thereproductive processes, functions and systems atall stages of human life. This definition implies that people are able tohave a satisfying and safe sex life and that theyhave the capability to reproduce and the freedomto decide if, when and how often to do so. Kesehatan Reproduksi , adalah kondisi sehatmenyangkut sistem, fungsi, dan proses alatreproduksi 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 donein any patient with latent syphilis of unknown or greater than 1 yrdurationin specific situatuonsCondyloma Acuminatum, Sexuallytransmitted disease of the vulva, vagina andcervix; Etiologic agent: Human papillomavirus High risk: HPV 16 and 18; Benign: HPV 6 and11Penyakit Radang Panggul Infeksi dan peradangan pada organ-organ disaluran genital wanita bagian atas Inflamasi yang terjadi merupakan suaturangkaian kesatuan yang terdiri dari uterus(endometritis), tuba falopii (salpingitis),ovarium (ooforitis), miometrium,parametrium (parametritis), rongga pelvis(peritonitis) RPR merupakan infeksi polimikrobial danbiasanya disebabkan oleh mikroorganismeN.gonorrhoeae dan C.trachomatis Bakteri masuk melalui vagina dan serviks(kolonisasi pada endoserviks) dan menjalar kerahim lalu ke tuba falopii. Dapat juga ditemukan virus, jamur(actinomyces israeli) dan parasit(skistosomiasis) Infeksi ini jarang terjadi sebelum siklusmenstruasi pertama, setelah menopausemaupun selama kehamilan Penularan yang utama terjadi melaluihubungan seksual, tetapi bakteri juga bisamasuk ke dalam tubuh setelah prosedurkebidanan/kandungan (mis pemasangan IUD,persalinan, keguguran, aborsi dan biopsiendometrium)Organisme penyebabPenyakit Radang PanggulAerob Anaerob VirusNeisseria gonorrheae Bacteroides sp Herpes simplexChlamydia trachomatis Peptostreptococcus sp EchovirusUreaplasma urelyticum Clostridium bifermentans CoxsackieGardneralla vaginalis Fusobacterium spStrptococcus pyogenesCoagulase negativestaphylococciEscherichia coliHaemophillus influenzaeMycoplasma hominisStreptococcus pneumoniaeMycobacteriumtuberculosisInfeksi Traktus Urinarius Etiologi : E.coli (80%), Proteus, Klebsiella danPseudomonas, Enterobacter, Streptococcusfaecalis, Staphylococcus saprophyticus,Enterococcus dan Chalamydia Infeksis dari uretra (uretritis) dan kandungkencing (sistitis) Gejala : kombinasi frekuensi, urgensi, disuria,piuria, hematuria, nyeri pelvik akut ataukronik, nyeri punggung dan demamHUMAN IMMUNODEFICIENCYVIRUS HIV infection is caused by an RNA retrovirus HIV is a RNA retrovirus that attches to the CD4receptor of the target cell and integrates intothe host genome When the CD4 all count falls below 200cells/L, patients are at high risk for AquiredImmunodeficiency Syndrome (AIDS) In females: Coexisting infections may have damaged normalanatomy 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 + AssistedReproductive Technology (ART) Normal man + infected woman: IntarauterianeInsemination (IUI) Both HIV+: semen washing Anti-retrovirals, elective CS, no breastfeedingInduced Abortion Abortus dipakai untuk menunjukan ancamanatau pengeluaran hasil konsepsi sebelum janindapat hidup diluar kandungan, dan sebagaibatasan digunakan kehamilan kurang dari 20minggu atau berat anak kurang dari 500 gram. Abortus buatan (Induced Abortion) ialahpengakhiran kehamilan sebelum 20 mingguakibat tindakan (The delibrate termination ofpregnancy in a manner that ensures that theembryo or fetus will not survive) Komplikasi :- Perdarahan- Perfosi- Infeksi- SyokKontrasepsi Perencanaan Keluarga

2-4 tahun

Diafragma

MaleCondomSpermisidaCARCINOMACERVIXCERVIXthird most frequent malignancy Risk Factors:- early and frequent sexual contact- cervical viral infection particularly HPVCERVICAL INTRAEPITHELIALNEOPLASIA (CIN)

CIN 1 Mild atypia Atypical changes involvelower third ofepithelium

CervixCERVICAL INTRAEPITHELIALNEOPLASIA

CIN 2 Moderate atypia Atypical changes involve1/3 2/3 of epitheliumCERVICAL INTRAEPITHELIALNEOPLASIA

CIN 3 Severe atypia Atypical changes involve>2/3 or full thickness ofthe epitheliumCERVIXTwo types of malignancy:1. Squamous cell CA 8085%2. Adenocarcinoma 15-20%Degree of Differentiation of TumorsG1 = well differentiatedG2 = intermediateG3 = undifferentiatedCERVIXVerrucous Carcinoma- a rare type of squamous cell carcinoma- warty tumors appear as large bulbous masses- rarely metastasizeAdenocarcinoma- do not appear to be affected by sexually factorsassociated with squamous cell CACERVIXAdenoma malignum- microscopically innocuous appearing tumorsconsist of well-differentiated mucinous glandthat vary in size and shape and infiltrate thestroma- deeply invasive and metastasize earlyCERVIXClear Cell Carcinoma- histologically identical to ovary- uncommon in cervix- associated with intrauterine DES exposureAdenoid Cystic Carcinoma- rare; less aggressive- resemble Basal Cell CA of skinCARCINOMA of the CERVIX

Clinical Considerations- abnormal bleeding/brownish discharge followingintercourse or douching occurring spontaneouslybetween menstrual periods- back pain- loss of appetite- weight loss- age 40-60s (median 32 years)

CervixCARCINOMA of the CERVIXStaging:- pelvic exam- general physical exam- chest radiographic exam- IVP- CT ScanNatural History and Spread- initially a locally infiltrating carcinoma that spreadsfrom cervix to the vagina and paracervical andparametrial areas

CervixCARCINOMA of the CERVIX

Forms:- ulcerated- exophytic- endophyticSpread:- lymphatic- hematogenous (lung, liver, bone)

CervixUTERUSUTERUS Most common malignancyEpidemiology:- affects women in perimenopausal andpostmenopausal years- diagnosed between 50 65 years- younger than 40 (5%)- younger than 50 (10%) Complex Atypical Hyperplasia- results from increased estrogen stimulation of theendometrium and is a precursor to endometrioidendometrial carcinomaENDOMETRIAL CARCINOMARISK FACTORSIncreases the Risk Decreases the RiskUnopposed estrogen stimulation OvulationUnopposed menopausal estrogen Progestin therapyreplacement therapy (4-8x) Combined OCPMenopause after 52 yrs (2.4x) Menopause before 49 yearsObesity (2-5x) Normal weightNulliparity (2-3x) MultiparityDiabetes (2.8x)Feminizing ovarian tumorsPolycystic ovarian syndromeTamoxifen therapy for breastcancerENDOMETRIALHYPERPLASIA Results from excess of estrogen or an excess ofestrogen relative to progestin, such as occurs withanovulationTypes:1. Simple Hyperplasia2. Complex Hyperplasia without atypia3. Complex Hyperplasia with atypiaSimple Hyperplasia

UterusComplex Hyperplasiaw/o Atypia Glands are crowded withvery little endometrialstroma and a very complexgland pattern andoutpouching formation Considered lowpremalignant potential

UterusComplex Hyperplasiaw/ Atypia

UterusENDOMETRIALHYPERPLASIANatural History- the rate at which endometrial hyperplasia progresses toendometrial carcinoma has not been accuratelydetermined Rate of Progression to Cancer- complex atypical hyperplasia 29%- simple hyperplasia 1%- complex hyperplasia w/o atypia 3%

UterusENDOMETRIAL 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)

UterusENDOMETRIAL PRIMARYCARCINOMA

UterusENDOMETRIAL PRIMARYCARCINOMAAdenosquamous Carcinoma- squamous epithelium that co-exists with glandularelements of endometrial carcinomaUterine Papillary Serous Carcinoma- highly virulent and uncommonClear Cell Carcinoma- less common (5%)- tend to develop in postmenopausal womenand carry a prognosis much worse than typicalendometrial carcinomaUterusSTAGING of ENDOMETRIALCARCINOMAStages CHARACTERISTICSStage IA Tumor limited to the endometriumIB Invasion to less than half of the myometriumIC Invasion to more than half of the myometriumStage IIA Endocervical glandular involvement onlyIIB Cervical stromal invasionStage IIIA Tumor invades serosa and/or adnexae and/or positiveperitoneal cytologyIIIB Vaginal metastases

UterusOVARYOVARIAN CARCINOMASecond most common malignancyMajor contributing factor:- detection of disease after metastatic spreadIncidence increase with age

OvaryRISKS OFOVARIAN CARCINOMAIncreases DecreasesAge BreastfeedingDiet Oral contraceptivesFamily history PregnancyIndustrialized country Tubal ligation andInfertility hysterectomy with ovarianNulliparity preservationOvulationOvulatory drugsTalc?

OvaryCLASSIFICATION OFOVARIAN CARCINOMACLASS FREQUENCYEpithelial Stromal 65Germ Cell 20 25Sex Cord-Stromal 6Lipid Cell < 0.1Gonadoblastoma < 0.1Soft tissue tumorsUnclassified tumorsSecondary (metastatic)Tumor-like conditions

OvaryWHO Classification of OvarianNeoplasmCLASSIFICATION OFOVARIAN CARCINOMAEpithelial 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 youngwomen teens

OvaryCLASSIFICATION OFOVARIAN CARCINOMA Sex Cord-Stromal Tumors- 3rd most common- contain elements that recapitulate the constituents of theovary 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 gonadsparticulary when Y chromosome is present

OvaryCLASSIFICATION OFOVARIAN CARCINOMASoft Tissue Tumor- not specific to the ovary- hemangioma or lipomaUnclassified- Small Cell CA highly virulent affecting young womenSecondary Metastatic TumorsTumor-like conditions

OvarySerous Cystadenocarcinoma

OvaryMucinous Cystadenocarcinoma

OvaryEndometriod Tumors

IIC Tumor either IIA or IIB, but w/ tumor on surface of one or bothovaries, or w/ capsule ruptures, or if w/ ascitesStage IIIA Tumor grossly limited to the pelvis w/ negative nodes but w/microscopic seeding to the abdominal peritoneal surfaceIIIB Tumor of one or both ovaries w/ histologically confirmedimplants of abdominal peritoneal surfaces, none exceeding 2cm, nodes are negativeIIIC Abdominal implants greater than 2 cm and/or positiveretroperitoneal or inguinal nodesStage IVA Parenchymal liver metastasisTeratoma Mature Teratoma (Dermoid) Most common type of ovarianteratoma/ovarian neoplasms; and mostcommon neoplasm diagnosed duringpregnancy Composed of fully/well differentiated maturetissues from 3 germs cell layers, usuallyectodermal (skin, hair, sebaceous glands, glia)but also mesodermal and endodermalderivatives Occuring in woman ages 20-30 years Complications: torsion, rupture, infection,malignant transformation (2%)Teratoma Immature Teratoma The malignant counterpart of mature cysticteratoma 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 prognosticimportance and guidelines for chemotherapy They are usually unilateral, although thecontralateral may contain a mature teratoma These tumors often secrete fetoprotein(AFP)Torsion Cyst Adnexal torsion may be suspected in thewoman with an adnexal mass whoexperiences the sudden onset of pelvic pain Torsion of the adnexae can involve the ovary,tube, and ancillary structures, eitherseparately or together Commonly associated with a cystic neoplasm Symptoms include :Abdominal pain and tenderness, that usuallyare sudden in onset and result from occlusionof the vascular supply to the twisted organRuptured Cyst A ruptured ovarian cyst is a commonphenomenon, with presentation ranging fromno symptoms to symptoms mimicking anacute abdomen Each month, a mature ovarian follicleruptures, releasing an ovum so the process offertilization can begin Occasionally, these follicles may bleed into theovary, causing cortical stretch and pain, or atthe rupture site following ovulation Similarly, a corpus luteum cyst may bleedsubsequent to ovulation or in early pregnancy. As blood accumulates in the peritoneal cavity,abdominal pain and signs of intravascularvolume depletion may arise. The etiology of this increased bleeding isunknown, although abdominal trauma andanticoagulation treatments may increase therisk. Nonphysiologic cysts, such as cystadenomasand mature cystic teratomas (dermoid cysts),may, in rare cases, rupture and causesymptoms a diffuse chemical peritonitis can accompanyrupture of a dermoid cyst, presumably fromspillage of sebaceous fluidTorsion and Ruptured Cyst These symptoms :- severe or sharp pelvic pain- fever- faintness or dizziness- rapid breathingcan indicate a ruptured cyst or an ovariantorsion. Both complications can have seriousconsequences 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 (HimpunanOnkologi Ginekologi indonesia)THANK YOU

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Human Reproduction | Ovarian Cancer | Carcinoma