25530455 kuliah-menstruasi
TRANSCRIPT
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Bayu Kurniawan, dr.
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Tujuan PembelajaranTujuan Pembelajaran
Mahasiswa mampu memahami & Mahasiswa mampu memahami & menjelaskan :menjelaskan :
Siklus menstruasi normalSiklus menstruasi normal Mekanisme kerja hormonMekanisme kerja hormon Fungsi organ-organ Fungsi organ-organ
(kompartemen-kompartemen) (kompartemen-kompartemen) yang bertanggung jawab yang bertanggung jawab mengatur menstruasimengatur menstruasi
Kelainan - kelainan Kelainan - kelainan menstruasimenstruasi
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Pendahuluan (1)
Keluarnya darah secara periodik & siklik dari uterus disertai deskuamasi endometrium, sesuatu yang biasanya sangat ditunggu -tunggu oleh kebanyakan wanita dewasa
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Pendahuluan (2)
• Menarche rata-rata 12,5 tahun• Siklus Menstruasi (97%)
18 – 42 hari• Lama menstruasi rata-rata
3 – 5 hari• Jumlah perdarahan 60 – 80 cc
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Pendahuluan (3)
Kecemasan akan timbul bila “dia” tidak datang
Datang tidak sesuai harapan (terlalu banyak, terlalu sedikit, terlalu lama, terlalu pendek)
Kecemasan itu banyak dimanfaatkan oleh iklan-iklan produk pelancar menstruasi
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Poros Hormon ReproduksiPoros Hormon Reproduksi
Susunan Sentral Susunan Sentral
- Hipotalamus- Hipotalamus
- Hipofise- Hipofise Susunan PeriferSusunan Perifer
- Ovarium- Ovarium
- Endometrium- Endometrium
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S S PS S P
HTLMS
Uterus
Ovarium
PG
LINGKUNGAN
Kompartemen 4
M E N S
Kompartemen 3
Kompartemen 2
Kompartemen 1
FSH LH
Es. Pr.
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Hypothalamus
Region of brain (diencephalon) 10 grams weight Lies below third ventricle at
base of brain Important regulator of
endocrine action
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Hypothalamic Releasing Hypothalamic Releasing HormonesHormones
• Gonadotropin Releasing Gonadotropin Releasing Hormone (GnRH) Hormone (GnRH) – Stimulated by NA & Inhibited by Stimulated by NA & Inhibited by
Dopamin, Serotonin, MelatoninDopamin, Serotonin, Melatonin– Acts on lactotrophs to stimulate Acts on lactotrophs to stimulate
AP production of Follicle-AP production of Follicle-Stimulating Hormone (FSH) and Stimulating Hormone (FSH) and Luteinizing Hormone (LH)Luteinizing Hormone (LH)
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Hypothalamic Releasing Hypothalamic Releasing HormonesHormones
• Corticotropin Releasing Hormone Corticotropin Releasing Hormone (CRH)(CRH)– Acts on corticotrophsActs on corticotrophs– Stimulates AP production of Stimulates AP production of
adrenocorticotropic hormone (ACTH) adrenocorticotropic hormone (ACTH) stimulate Adrenal produce CS stimulate Adrenal produce CS
• Thyrotropin Releasing Hormone (TRH)Thyrotropin Releasing Hormone (TRH)– Acts on thyrotrophs Acts on thyrotrophs – Stimulates AP production of Thyroid Stimulates AP production of Thyroid
Stimulating Hormone (TSH) & ProlaktinStimulating Hormone (TSH) & Prolaktin
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Hypothalamic Releasing Hypothalamic Releasing HormonesHormones
• Growth Hormone Releasing Hormone Growth Hormone Releasing Hormone (GHRH = somatotropin)(GHRH = somatotropin)– Acts on somatotrophsActs on somatotrophs– Stimulates AP production of Growth Stimulates AP production of Growth
Hormone (GH)Hormone (GH)
• Growth Hormone Inhibitory Hormone Growth Hormone Inhibitory Hormone (GIH = somatostatin)(GIH = somatostatin)– Acts on somatotrophsActs on somatotrophs– Inhibits AP production of Growth Inhibits AP production of Growth
HormoneHormone
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Pituitary GlandPituitary Gland
In humans has two lobes = distinct glandsIn humans has two lobes = distinct glands Anterior (toward front of head) lobe = Anterior (toward front of head) lobe =
adenohypophysisadenohypophysis Posterior (toward back of head) lobe = Posterior (toward back of head) lobe =
neurohypophysisneurohypophysisLobes connected to hypothalamus by Lobes connected to hypothalamus by
different meansdifferent means Anterior lobe Anterior lobe connected by (portal) blood connected by (portal) blood
vesselsvessels Posterior lobe Posterior lobe connected by nervesconnected by nerves (axons) (axons)
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Anterior Pituitary (AP)Anterior Pituitary (AP)
Endocrine (hormone-secreting) gland Endocrine (hormone-secreting) gland containing several different cells typescontaining several different cells types Lactotrophs; secrete prolactinLactotrophs; secrete prolactin Gonadotrophs; secrete LH and FSHGonadotrophs; secrete LH and FSH Somatotrophs; secrete Growth hormoneSomatotrophs; secrete Growth hormone Thyrotrophs; secrete Thyroid stimulating Thyrotrophs; secrete Thyroid stimulating
hormonehormone Corticotrophs; secrete Adrenocorticotropic Corticotrophs; secrete Adrenocorticotropic
HormoneHormone Connected to hypothalamus by portal blood Connected to hypothalamus by portal blood
vesselsvessels
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Anterior Pituitary (AP)Anterior Pituitary (AP)
Follicle Stimulating HormoneFollicle Stimulating Hormone- Produksi- Produksi
Siklik, tergantung kadar hormon steroid Siklik, tergantung kadar hormon steroid sirkulasisirkulasi- Feedback negatif oleh Estrogen - Feedback negatif oleh Estrogen
Luteinizing HormoneLuteinizing Hormone- Produksi- Produksi
Siklik, tergantung kadar hormon steroid Siklik, tergantung kadar hormon steroid sirkulasisirkulasi- Estrogen rendah >> feedback negatif- Estrogen rendah >> feedback negatif- Estrogen tinggi >> feedback positif sd - Estrogen tinggi >> feedback positif sd
LH Surge >> OvulasiLH Surge >> Ovulasi
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Anterior Pituitary (AP)Anterior Pituitary (AP)Prolaktin
o Produksi dapat dirangsang TRH (hipotiroid)
o Merangsang produksi ASIo Adenoma Hipofise
Prolaktin meningkat >> Sekresi FSH - LH menurun >>
Mengganggu fungsi Ovarium
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Anterior Pituitary (AP)Anterior Pituitary (AP)Thyroid Stimulating Hormone
o Merangsang produksi thyroid di kelenjar thyroid
o Hypothyroid
TRH meningkat >>
TSH meningkat >> Prolaktin meningkat >> Sekresi FSH-LH menurun
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Posterior Pituitary
Outgrowth of the hypothalamus; composed of neural tissue
Specific neuroendocrine cells in hypothalamus have axons that project through the stalk and into the posterior pituitary
Secretes two important hormones Oxytocin (OXY) Antidiuretic hormone (ADH)
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Ovarium
Fungsi Utama
1. Fungsi Proliferatif
Sumber ovum selama fase reproduksi
2. Fungsi Sekretorik
Pembentukan & pengeluaran hormon steroid seks (estrogen, progesteron &
androgen)
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EstrogenEstrogeno Di dalam folikel, ovum dikelilingi sel granulosa (dalam) & sel teka (luar) Di dalam folikel, ovum dikelilingi sel granulosa (dalam) & sel teka (luar) o Rangsangan FSH : kolesterol (C 26), dari darah di luar folikel, sel teka membentuk Progesteron (C 21) langsung diubah menjadi Testosteron Rangsangan FSH : kolesterol (C 26), dari darah di luar folikel, sel teka membentuk Progesteron (C 21) langsung diubah menjadi Testosteron
(C 19)(C 19)o Testoteron tidak keluar sirkulasi, berdifusi ke lapisan granulosa, diubah menjadi EstrogenTestoteron tidak keluar sirkulasi, berdifusi ke lapisan granulosa, diubah menjadi Estrogeno Seiring pertumbuhan folikel, Estrogen dalam sirkulasi bertambah, feedback negatif pada hipofise sehingga pengeluaran FSH ditahanSeiring pertumbuhan folikel, Estrogen dalam sirkulasi bertambah, feedback negatif pada hipofise sehingga pengeluaran FSH ditahan
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
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EstrogenEstrogeno Sebagian besar folikel atrofi, 1 Sebagian besar folikel atrofi, 1
folikel menang memperebutkan FSH folikel menang memperebutkan FSH (reseptor lebih banyak) tumbuh (reseptor lebih banyak) tumbuh terus menjadi Folikel De Graafterus menjadi Folikel De Graaf
o Estrogen bertambah banyak, pada Estrogen bertambah banyak, pada kadar tertentu, memicu feedback kadar tertentu, memicu feedback positif sehingga hipofise positif sehingga hipofise mengeluarkan LH jumlah besar (LH mengeluarkan LH jumlah besar (LH surge)surge)
o LH surge menyebabkan pelunakan LH surge menyebabkan pelunakan dinding Folikel De Graaf, terjadilah dinding Folikel De Graaf, terjadilah Ovulasi (pecahnya folikel & Ovulasi (pecahnya folikel & keluarnya ovum)keluarnya ovum)
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Progesteron Ovulasi : darah kaya kolesterol masuk ke lapisan
granulosa, atas rangsangan LH membuat progesteron (sirkulasi)
Folikel >> Korpus Luteum >> Produksi Progesteron 14 hari setelah ovulasi, pembuahan (-), Korpus
Luteum regresi & Progesteron mendadak hilang dari sirkulasi
a t a u Pembuahan (+), hasil konsepsi (sinsitiotrofoblas)
memproduksi HCG (Human Chorionic Gonadotrophin), menjaga Korpus Luteum terus memproduksi Progesteron & Estrogen
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Normal Menstrual Hormone Cycle
0 14 28
Estradiol
Progesterone
LH
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EndometriumEndometrium
o Fase Menstruasi / DeskuamasiFase Menstruasi / Deskuamasio Fase RegenerasiFase Regenerasio Fase ProliferasiFase Proliferasi
- Early proliferation phase- Early proliferation phase- Midproliferation phase- Midproliferation phase- Late proliferation phase- Late proliferation phase
o Fase SekresiFase Sekresi- Sekresi dini- Sekresi dini- Sekresi lanjut- Sekresi lanjut
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Early Phase of Menstrual CycleEarly Phase of Menstrual Cycle
Menstruation = shedding of uterine lining Menstruation = shedding of uterine lining that occurs when progesterone levels fallthat occurs when progesterone levels fall First day of bleeding = day 1 of cycleFirst day of bleeding = day 1 of cycle Bleeding occurs @ 5 daysBleeding occurs @ 5 days
FSH stimulates follicles to develop and FSH stimulates follicles to develop and secrete estrogensecrete estrogen Follicular phase of cycle, with respect to the ovaryFollicular phase of cycle, with respect to the ovary
Estrogen stimulates proliferation of uterine Estrogen stimulates proliferation of uterine lining (ENDOMETRIUM)lining (ENDOMETRIUM) Proliferative phase of cycle, with respect to uterusProliferative phase of cycle, with respect to uterus
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Mid-Cycle Menstrual EventsMid-Cycle Menstrual Events Estrogen effect at hypothalamus goes from Estrogen effect at hypothalamus goes from
inhibitory to stimulatoryinhibitory to stimulatory Instead of turning down GnRH secretion from Instead of turning down GnRH secretion from
hypothalamus, estrogen turns it uphypothalamus, estrogen turns it up• Increases LH secretion from pituitaryIncreases LH secretion from pituitary• Results in LH surgeResults in LH surge
LH surge triggers ovulationLH surge triggers ovulation Egg is released (ovulatory phase of cycle)Egg is released (ovulatory phase of cycle) Follicle forms corpus luteumFollicle forms corpus luteum
• Converts from estrogen-secreting structure to Converts from estrogen-secreting structure to progesterone-secreting structureprogesterone-secreting structure
• Progesterone causes development and secretory activity Progesterone causes development and secretory activity of glands in uterine liningof glands in uterine lining
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Late Phase of Menstrual CycleLate Phase of Menstrual Cycle
Progesterone stimulates glandular Progesterone stimulates glandular activity in endometrium of uterusactivity in endometrium of uterus Secretory phase with respect to uterusSecretory phase with respect to uterus Luteal phase with respect to ovaryLuteal phase with respect to ovary
In the absence of pregnancyIn the absence of pregnancy CL regresses; progesterone and estrogen CL regresses; progesterone and estrogen
levels falllevels fall Blood supply to endometrium diminishesBlood supply to endometrium diminishes Endometrial tissues are shed = mensesEndometrial tissues are shed = menses
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Regularity of Menstrual CycleRegularity of Menstrual Cycle
Follicular phaseFollicular phase–Preceding ovulationPreceding ovulation
–More variable phaseMore variable phase
Luteal phaseLuteal phase–Follows ovulationFollows ovulation
–Least variable phase; always @ Least variable phase; always @ 14 days14 days
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Konsep Menstruasi (1)
Hipotesis : Faktor Hormonal Faktor Enzym Faktor Vaskuler Faktor Prostaglandin
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Konsep Menstruasi (2)
• Faktor Hormonal- Fase Luteal :
14 hari setelah ovulasi >> Pembuahan (-) >> Korpus Luteum regresi, Progesteron sirkulasi menurun- Sebab ???
• Faktor EnzymFase Proliferasi : Enzym hidrolitik dalam endometrium (estrogen) >> Fase Luteal : Pembuahan (-) >> Regresi Endometrium + Perdarahan
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Konsep Menstruasi (3)• Faktor Vaskuler
Fase Proliferasi : Pembentukan Sistem Vaskuler berlekuk-lekuk >> Regresi Endometrium >> Bendungan Vaskuler >> Nekrosis + Perdarahan
• Faktor Prostaglandin- Endometrium : Prostaglandin E2 / F2- Disintegrasi endometrium :Prostaglandin dilepas & menyebabkan kontraksi miometrium (membatasi perdarahan menstruasi)
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Kelainan Menstruasi (1) Kelainan banyaknya & lamanya perdarahan
- Hipermenorea atau menoragia - Hipomenorea
Kelainan siklus- Polimenorea - Oligomenorea- Amenorea
Perdarahan di luar haid- Metroragia
Gangguan Lain- Premenstrual tension- Mastodimia- Mittelschmerz- Dismenorea
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Kelainan Menstruasi (2)
Sistemik Organik Fungsional
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Disfunctional Uterine Disfunctional Uterine BleedingBleeding
• Faktor HormonalFaktor Hormonal- - Rangsangan terus-menerus Estrogen / Rangsangan terus-menerus Estrogen /
ProgesteronProgesteronA T A UA T A U
-- Penurunan mendadak Estrogen / Penurunan mendadak Estrogen / ProgesteronProgesteron
• Menstruasi NormalMenstruasi Normal : P : Progesterone Withdrawl rogesterone Withdrawl BleedingBleeding
• -- Semua wanita usia reproduksiSemua wanita usia reproduksi-- Tersering awal & akhir fungsi ovariumTersering awal & akhir fungsi ovarium-- 2/3 berusia di atas 40 tahun2/3 berusia di atas 40 tahun-- 3% di bawah 20 tahun3% di bawah 20 tahun-- Pubertas ???Pubertas ???
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Disfunctional Uterine Disfunctional Uterine BleedingBleeding
•Estrogen Withdrawal BleedingEstrogen Withdrawal Bleeding •Estrogen Breaktrough BleedingEstrogen Breaktrough Bleeding •Progesterone Breaktrough Progesterone Breaktrough
BleedingBleeding •Progesterone Withdrawal Progesterone Withdrawal
BleedingBleeding
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AMENOREA AMENOREA
Klasifikasi :Klasifikasi :Amenorea Primer Amenorea Primer
Amenorea SekunderAmenorea Sekunder Penyebab : Penyebab :
- - Bermacam – macam Bermacam – macam - - Dibagi berdasarkan gangguan di Dibagi berdasarkan gangguan di tiap2 tiap2 kompartemenkompartemen
Amenorea Primer : umumnya kelainan Amenorea Primer : umumnya kelainan gonad (kelainan bawaan)gonad (kelainan bawaan)
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AMENOREAAMENOREAKompartemen 1 (Uterus / Kompartemen 1 (Uterus /
Endometrium)Endometrium) Aplasia & Hipoplasia uteriAplasia & Hipoplasia uteri Sindroma AshermanSindroma Asherman Endometritis tuberculosaEndometritis tuberculosa HisterektomiHisterektomi
Kompartemen 2 (Ovarium)Kompartemen 2 (Ovarium) Kelainan kongenital:Kelainan kongenital:
Disgenesis ovarium (Sindroma Turner)Disgenesis ovarium (Sindroma Turner) Sindroma Testicular Feminization Sindroma Testicular Feminization
Menopause prematurMenopause prematur Operasi, radiasi & radang ovariumOperasi, radiasi & radang ovarium Tumor sel granulosea, Sel teka, Sel hilus, dsbTumor sel granulosea, Sel teka, Sel hilus, dsb
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AMENOREAAMENOREAKompartemen 3 (Hipofise)Kompartemen 3 (Hipofise)
Sindrom Sheehan (HPP Sindrom Sheehan (HPP shock shock hipofise hipofise atrofi ok kekurangaan darah)atrofi ok kekurangaan darah)
Tumor-tumor hipofiseTumor-tumor hipofiseKompartemen 4 Kompartemen 4
(Hipotalamus & SSP)(Hipotalamus & SSP) Sindrom amenore galaktore PCOSindrom amenore galaktore PCO Amenorea hipotalamikAmenorea hipotalamik Anoreksia nervosaAnoreksia nervosa Psikosis, dsbPsikosis, dsb
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AMENOREAAMENOREAGangguan organ endokrin lainGangguan organ endokrin lain
Sindroma Cushing, Addison Sindroma Cushing, Addison (Kel.Suprarenalis)(Kel.Suprarenalis)
Hipo / hipertiroidiHipo / hipertiroidi Diabetes MellitusDiabetes Mellitus
Lain-lainLain-lain Penyakit sistemikPenyakit sistemik Gangguan giziGangguan gizi ObesitasObesitas
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AMENOREAAMENOREA• AnamnesaAnamnesa
Lamanya amenore (primer/sekunder), Lamanya amenore (primer/sekunder), keadaan emosional, gangguan keadaan emosional, gangguan metabolik lainmetabolik lain
• Pemerikasaan FisikPemerikasaan Fisik
Tanda seks sekunder, keadaan gizi, Tanda seks sekunder, keadaan gizi, postur tubuh, hirsutisme, galaktorea, postur tubuh, hirsutisme, galaktorea, dsbdsb
• Pemeriksaan GinekologiPemeriksaan Ginekologi
Keadaan organ-organ genitaliaKeadaan organ-organ genitalia
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AMENOREAAMENOREA• Tes HormonalTes Hormonal
Progestin selama 5–7 hari : Progestin selama 5–7 hari : Perdarahan withdrawal (+) fungsi pertumbuhan folikel Perdarahan withdrawal (+) fungsi pertumbuhan folikel cukup baik, cukup baik, hanya tidak terjadi ovulasihanya tidak terjadi ovulasi
Perdahan withdrawl (-) estrogen rendah, fungsi ovarium Perdahan withdrawl (-) estrogen rendah, fungsi ovarium jelek jelek Estrogen selama 25 hari (hari ke 16 ditambah preparat Estrogen selama 25 hari (hari ke 16 ditambah preparat progestin) progestin) Perdarahan withdrawal (-) kerusakan ada di Perdarahan withdrawal (-) kerusakan ada di kompartemen 1kompartemen 1
Perdarahan withdrawl (+) kerusakan ada di Perdarahan withdrawl (+) kerusakan ada di kompartemen 2, 3 & 4 kompartemen 2, 3 & 4 Pemeriksaan FSH / LH Pemeriksaan FSH / LH kadar tinggi (rangsangan hipofise kadar tinggi (rangsangan hipofise ada, tetapi ada, tetapi ovarium tidak bereaksi, artinya ovarium tidak bereaksi, artinya kerusakan di kerusakan di ovarium) ovarium)
kadar rendah (kerusakan di kadar rendah (kerusakan di hipofise ke atas, hipofise ke atas, pemeriksaan foto sela pemeriksaan foto sela tursika) tursika)
• Sebelum melakukan tes estrogen-progesteron, dilakukan Sebelum melakukan tes estrogen-progesteron, dilakukan dahulu pemeriksaan Prolaktin & TSH dahulu pemeriksaan Prolaktin & TSH
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AMENOREAAMENOREA
• Pemeriksaan Tambahan Pemeriksaan Tambahan
Pemeriksaan kromosom, Pemeriksaan kromosom, laparoskopi, tes luas visus, kerokan laparoskopi, tes luas visus, kerokan endometrium, dsbendometrium, dsb
DiagnosaDiagnosa
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