PERDARAHAN PER VAGINAM

PERDARAHAN PER VAGINAM

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MENORAGIA DAN POLIMENOREA

  • Dapat merupakan tanda adanya abnormalitas mekanis dalam uterus (mioma uteri atau polip endometrium)
  • Dapat disebabkan oleh anemia defisiensi zat besi
  • Dapat menyebabkan dismenoroea

Tidak perlu dilakukan tindakan khusus (hanya melakukan observasi dan penjelasan), bila :

  • Keluhan ringan dan baru berlangsung satu atau dua periode
  • Hasil pemeriksaan fisik normal
  • Hasil pemeriksaan Pap Smear normal
  • Tes kehamilan negatif
  • Hasil pemeriksaan laboratorium darah normal
  • Kemungkinan keganasan rendah

Bila pasien berusia diatas 40 tahun : BIOPSI ENDOMETRIUM

Jangan lupa menanyakan : terapi yang sedang diterima pasien. Aspirin dosis rendah sering menyebabkan terjadinya gangguan perdarahan pada pasien

           

Heavy periods and lengthy periods

  • May reflect an underlying mechanical abnormality inside the uterus (fibroids, polyps),
  • May be a cause of iron-deficiency anemia, and
  • May contribute to uncomfortable menstrual cramps.

            If the examination, Pap smear, and pregnancy test are normal, then the       chance of malignancy is very low and need not be further considered in those    under age 40 unless symptoms persist. Those over 40 should have an             endometrial biopsy.
In taking your history on these patients, it is a good idea to inquire about     medications. Aspirin, for example, even if taken in very modest amounts, can      effectively block platelet function for up to a week. By itself, I wouldn’t expect aspirin usage to cause abnormal bleeding, but if the patient has any other    coagulation issue, no matter how trivial, then the addition of aspirin to the mix could be enough to push her over the edge into a bleeding problem. If she is   taking aspirin, I would recommend both stopping the aspirin and also looking  for other coagulopathies.

Untuk mengendalikan menometroragia dan polimenorea, dapat diberikan PIL KONTRASEPSI

Pil kontrasepsi dapat mengurangi derajat menoragia dan polimenorea.

Bila pasien dalam keadaan ANEMIA , pemberian preparat zat besi dapat memperbaiki hasil pemeriksaan darah rutin.

Bila pil kontrasepsi tidak dapat menghentikan perdarahan, maka pil kontrasepsi dapat diminum terus tanpa jeda dengan konsekwensi haid tertunda.

To control heavy, lengthy periods, one good approach is to give birth control pills. The effect of the BCPs is to reduce the heaviness and duration of flow. If the patient is anemic, taking oral iron preparations will usually restore their iron and return their blood count to normal. If the BCPs fail to reduce the flow appreciably, then an alternative approach is to take the BCPs continuously, without the usual “week off.” This will postpone the menstrual period indefinitely. Even though their period may still be heavy or lengthy, the fact that they only rarely have it will have a major impact on their quality of life and anemia, if present.

Sebagai pilihan terapi lain, dapat diberikan DMPA – depot medroxyprogesteron asetat yang akan menghentikan perdarahan dan menunda datangnya haid. Harus diketahui bahwa penggunaan DMPA sering pula menyebabkan terjadinya bercak perdarahan diluar siklus haid.

Alternatively, you could start the patient on DMPA (depot medroxyprogesterone acetate) injections. This will usually disrupt the normal period and she probably won’t continue to have heavy periods. There are some significant drawbacks to this approach, however. Light spotting or bleeding are common among women taking DMPA, so you will be substituting one nuisance for another nuisance.

Bila hasil pemeriksaan USG memperlihatkan adaya polip endometriummaka harus dilakukan pengangkatan polip endometrium

If sonohysterography demonstrates an endometrial polyp, removal of the polyp will often restore a normal menstrual flow. OCPs will sometimes reduce the flow due to fibroids enough to allow the patient to tolerate these flows for extended lengths of time.

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Oligomenorea, sepanjang terjadi secara teratur dan pada saat yang tepat maka keadaan ini tidak merupakan masalah medis

Extremely light periods, so long as they occur at the right time, are not dangerous and really are not a medical problem.

Oligomenorea sering terjadi diantara pasien yang minum pil kontrasepsi dosis rendah.

Idealnya adalah, pil kontrasepsi melakukan blokade peranan ovarium dalam memproduksi hormon dan ovulasi. Akseptor pil kontrasepsi ini akan menghasilkan hormon sendiri sedemikian rupa agar status tubuhnya tidak terganggun namun tanpa menghasilkan ovulasi. Akibat jangka panjangnya adalah terjadinya penumpukan estrogen dalam sirkulasi yang sedikit lebih rendah dibandingkan wanita yang non akseptor pil kontrasepsi. Inilah sebabnya mengapa pada akseptor pil kontrasepsi sering memperlihatkan adanya haid dengan jumlah lebih sedikit, dismenorea yang menjadi lebih ringan dan lebih singkat dibandingkan sebelumnya.

This condition is most often seen among women taking low dose birth control pills. Ideally, the birth control pills will block the normal ovarian functions of production of hormones and ovulation. Then, they provide their own hormones to restore the woman to a more or less normal status, but without ovulation. Usually, the result of this exchange is that the cumulative circulating estrogen levels are little lower than if the woman were not taking BCPs. It is this feature of reduced estrogen levels that results in lighter, shorter periods with fewer cramps that we see among women taking BCPs.

Akan tetapi, kadar estrogen pada sejumlah wanita sudah sedemikian rendah sebelum mereka minum pil kontrasepsi. Pada wanita ini, haid berlangsung dengan jumlah yang sedmakin lama semakin sedikit atau bahkan berhenti sama sekali.

In some women, however, the estrogen levels are significantly lower than before they started taking the BCPs. In this case, they will notice their menstrual periods getting lighter and lighter and possibly even disappearing altogether.

Keadaan ini tidak berdampak pada status fertilitas selanjutnya dan pola haid akan pulih secara sempurna segera setelah penggunaan pil kontrasepsi dihentikan.

Bila perdarahan haid berhenti sama sekali, maka kemungkinan kehamilan harus disingkirkan dan selanjutnya terdapat 3 pilihan :

  1. Mengganti jenis pil kontrasepsi
  2. Tambahkan sedikit estrogen perooral
  3. Memberikan penjelasan pada pasien mengenai penyebab berhentinya haid saat minum pil kontrasepsi.

————
Bila pasien mengalami terlambat haid, pertama kali singkirkan kemungkinan kehamilan.

Bila tes kehamilan [negatif] dan pasien bukan akseptor pil kontrasepsi maka lakukan observasi saja.

Peristiwa terlambat haid seringkali mengkhawatirkan pasien

Bila selama 3 bulan berturut-turut tidak datAng haid maka yang dilakukan oleh dokter adalah :

  1. Aliran darah haid di normalisir dengan pil kontrasepsi atau Depoprovera.

Depoprovera berfungsi dengan baik bila fungsi ovarium tidak terlampau     tertekan dan tidak berfungsi dengan baik pada sejumlah wanita yang produksi  estrogen nya rendah sehingga “priming” endometrium tak terjadi.

  1.  Pil kontrasepsi umumnya bekerja dengan baik tanpa memandang derjaat  depresi fungsi ovarium.
  2. Periksa kelainan kelenjar Tiroid dengan pemeriksaan TSH
  3. Periksa kadar prolaktin serum
  4. Periksa kemungkinan terjadinya kegagalan ovarium prematur dengan memeriksan kadar FSH

If the patient remains without a period for an extended length of time (3 months or more), then the following are often done:

  • Normal menstrual flows are re-established with either BCPs, or oral Provera. Provera works well if ovarian function is not deeply depressed, but will not work for some women, notably those whose estrogen production is so low that virtually no endometrial priming is happening. BCPs will usually work regardless of the degree of ovarian suppression.
  •   These patients should be tested for thyroid malfunction with a TSH.
  •   These patients are frequently tested for prolactin disorders with a serum prolactin
  •   Finally, these patients may be tested for premature ovarian failure with an FSH.

Menometroragia adalah terjadinya haid dengan siklus yang “unpredictable” dan terjadi lebih dari satu kali dalam satu bulan.

Irregular Periods means menstrual periods coming at unpredictable intervals, rather than the normal once-a-month cycles.

Bila haid yang terjadi jumlahnya normal dan berlangsung selama kurang dari 7 hari, maka keadaan ini tidak terlalu berbahaya dan cukup mendapatkan observasi saja.

Bila karakter iregularitas sedemikian parah, maka sebaiknya segera diatasi dengan pil kontrasepsi dosis rendah sampai akhirnya haid hanya terjadi satu kali dalam satu bulan.

If the flows, whenever they come, are normal in character and length, this is not a dangerous condition and no treatment or evaluation is required. If the patient finds the irregular character of her periods to be troublesome, then starting low dose BCPs will be very effective in giving her quite normal, once-a-month menstrual flows.

Bila aliran haid tidak konsisten (kadang deras dan kadang sedikit) dan sepertinya bukan merupakan peristiwa haid yang normal (siklus anovulatoir). Pada kondisi ini regulasi haid harus dilakukan denga menggunakan pil kontrasepsu. Perdarahan anovulatoar yang sulit diatasi dan disertai dengan hirsuitisme serta hiperplasia endometrium umumnya disebabkan oleh defisiensi hormon progesteron.

If the flows, whenever they come, are not consistent; are sometimes heavy, are sometimes light, are sometimes only spotting, then they are likely not true menstrual cycles, but are anovulatory bleeding (which is uterine bleeding occurring in the absence of ovulation). This condition should be treated with re-establishment of normal, regular periods, usually with BCPs. Unresolved anovulatory bleeding may, over many months to years, lead to cosmetic problems (unwanted hair growth due to relative excess of male hormones) and uterine lining problems (endometrial hyperplasia due to a lack of the protective hormone progesterone).

Pasien dengan oligomenorea khususnya yang disertai dengan obesitas – jerawat serta terlihatnya sejumlah folikel dalam ovarium melalui pemeriksaan ultrasonografi adalah pasien dengan sindroma ovarium polikistik. Keadaan ini sering diatasi dengan pemberian pil kontrasepsi dan methformin.

Patients with infrequent periods, particularly if associated with overweight status, acne, and multiple follicles on the ovary when visualized with ultrasound, usually have “polycystic ovary syndrome.” This condition may be effectively treated with OCPs, but also can respond well to the use of Metformin.

Pasien hipotiroid juga mengalami gangguan haid dan skrining dengan TSH untuk mencari kelainan tiroid sering sangat membantu.

Patients with hypothyroidism may also have this type of menstrual cycle, and screening for thyroid disease with a TSH is helpful.
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Polimenorea atau metroragia

Seorang wanita dengan keluhan sering mendapatkan haid ( haid terjadi lebih sering ) dengan interval kurang dari 26 hari sering memperlihatkan adanya sejumlah faktor predisposisi :

  • Bila perdarahan masih mengikuti suatu siklus, maka diperkirakan bahwa hal ini disebabkan oleh “defek fase luteal” atau produksi progesteron oarium yang tidak memadai.
  • Bila perdarahan tidak konsisten maka diperkirakan bahwa hal ini disebabkan pleh kegagalan ovulasi atau perdarahan anovulatoir
  • Bila siklus terjadi benar-benar normal dan haid terjadi setiap bulan. Perdarahan terjadi diantara siklus haid maka hal ini mungkin disebabkan oleh faktor mekanis seperti mioma uteri atau polip endometrium

Too Frequent Periods
Periods that are too frequent (more often than every 26 days, “metrorrhagia”) can be related to several predisposing factors:
• If the periods are otherwise normal, then a short “luteal phase” or insufficient ovarian production of progesterone may be responsible.
• If the periods are inconsistent, then failure to ovulate and the resulting anovulatory bleeding may be responsible.
• If the periods are actually normal and once a month, but there are episodes of bleeding in between the periods, then mechanical factors such as fibroids or polyps may be responsible.

Wanita dengan hipertiroid secara klasik memperlihatkan terjadi menoragia.

Women with hyperthyroidism are classically described as experiencing frequent, heavy periods., In real life, they rarely show that pattern, but we usually screen these patients for thyroid disease anyway.
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Perdarahan terus menerus

Penderita perdarahan terus menerus untuk waktu yang lama (berminggu-minggu) umumnya disebabkan oleh gangguan pada lapisan endometrium.

Dalam keadaan normal, cedera pada endometrium segera mengalami perbaikan. Pada seorang wanita yang mengalami perdarahan selama beberapa minggu dandisertai dengan dsmnorea umumnya mengalami gangguan pembuatan lapisan endometrium. Sangat sedikit endometrium yang tersisa dan pasien mengalami kesulitan dalam restorasi endometrium sehingga harus dibantu. Keadaan ini sering terjadi pada masa menarche dan pasien dapat mengalami anemia

Constant Bleeding
Women who experience significant daily bleeding for a very long time (weeks) sometimes develop another kind of problem unique to this circumstance, denuding of the uterine lining.

Normally, small breaks or tears in the uterine lining are promptly repaired. For women who have been bleeding for weeks, with the accompanying uterine cramping, the uterine lining becomes very nearly completely lost. There is so little endometrium left that the woman will have difficulty achieving repair and restoration of the normal lining without external assistance. A common example of this situation would be a teenager who has been bleeding for many weeks but who, through embarrassment, has not sought medical attention. On arrival, she continues to bleed small amounts of bright red blood. She is profoundly anemic, with a hemoglobin of 7.0 or less.

Pasien ini tidak memberikan respon dengan terapi pil kontrasepsi dengan kadar estrogen rendah dan progestin tinggi. Pada pasien terjadi daerah perdarahan didalam lapisan dalam uterus.

Pasien ini memerlukan estrogen murni untuk stimulasi endometrium secara efektif (linoral atau premarin) 3 dd 2 – 5 mg

Selain itu, pasien diminta untuk tirah baring selama 24 – 48 jam.

NSAID’s ( asam mefenamat ) dapat membantu untuk menghentikan perdarahan.

Setelah perdarahan berkurang, lanjutkan pemberian estrogen dengan dosis lebih rendah sampai berhenti secara sempurna. Kemudian berikan progestin (provera) selama 5 – 10 hari. Progestin diperlukan oleh karena endometroium yang terbentuk sangat rapuh dan mudah berdarah.

Progestin memberikan dukungan struktural pada endometrium sehingga tidak rapuh dan berdarah.

These patients don’t respond to simple BCP treatment because the BCPs are so weak in estrogen and so strong in progestin that the uterine lining barely has a chance to grow and cover up the denuded, bleeding areas inside the uterus.

These patients need strong doses of plain estrogen, to effectively stimulate the remaining uterine lining, causing it to proliferate. Premarin, 2.5 to 5 mg PO per day, or IV will provide this strong stimulus to the uterine lining and if combined with bedrest, will usually slow or stop the bleeding significantly within 24to 48 hours. The estrogen is stimulating the uterine lining to grow lush and thick. Once the bleeding has slowed, continue the estrogen for several days, but at somewhat lower dosages (1.25 to 2.5 mg per day) until the bleeding completely stops. Then, add a progestin, such as Provera 5-10 mg PO per day for 5-10 days. A progestin is necessary at this point because the lush, thick uterine lining is also very fragile and easily broken. Progesterone provides a structural support to the uterine lining, making it less likely to tear or break.

Setelah endometrium cukup tebal maka dia akan dapat mengelupas (luruh) secara normal.

Menghentikan terapi akan mencetuskan terjadinya haid dalam waktu 3 hari kedepan. Endometrium akan pulih kembali dan diharapkan akan mengalami siklus haid yang normal.

Once a normal, thick, well-supported lining has been re-established, first with estrogen, then with the addition of progesterone, it will need to be shed, just like a normal lining is shed once a month. Stopping all medication will trigger a normal menstrual flow about 3 days later. The lining will have been restored and the vicious cycle of bleeding leading to more endometrial loss leading to more bleeding will be broken. Future periods may then be normal, although many physicians will start BCPs at this point to prevent recurrence of the constant bleeding episode.

About Bambang Widjanarko

Obstetrician and Gynecologist ; Staf pengajar di Fakultas Kedokteran & Kesehatan UMJ ; Kepala Departemen Obstetri Ginekologi FKK UMJ ; Ahli Kebidanan & Ilmu Penyakit Kandungan di RS Islam Jakarta Utara.

Posted on 17/05/2012, in Uncategorized. Bookmark the permalink. Leave a comment.

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