Rezky Juliana PRG

Supervisor:
dr. Monika F. Farid, Sp.OG

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
ENDOMETRIOSIS
Endometriosis merupakan suatu kelainan jinak umum
yang didefinisikan sebagai keberadaan kelenjar dan stroma
endometrium di luar dari lokasi normalnya.

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
EPIDEMIOLOGI
 Insidens endometriosis yang terdiagnosis melalui pembedahan

sekitar 1,6 kasus per 1000 wanita (usia 15 – 49 tahun) per

tahunnya
 Pada wanita asimptomatik, prevalensinya sekitar 3-11%

bergantung pada populasi studi dan cara mendiagnosis.

 Prevalensinya sekitar 9-50% pada wanita infertil, 40-50% pada

wanita yang mengalami nyeri pelvis atau dismenore.

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
PATOGENESIS
Masih belum diketahui dengan jelas.
 Menstruasi retrograde

 Peran komponen imunologik dan angiogenik

 Transplatasi langsung

 Teori stem cell

 Penyebaran limfatik atau vaskular

 Metaplasia coelomic
Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
LETAK ANATOMIS
 Pelvis  Tempat lain
 Cul-de-sac anterior dan posterior  Septum rektovagina

 Peritoneum pelvis lainnya  Ureter

 Ovarium  Vesica urinaria

 Ligamen uterosacral  Pericardium

 Posterior uterus  Bekas luka pembedahan

 Permukaan posterior dari broad  Pleura

ligament
Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
ENDOMETRIOSIS LOKALISASI
MEKANISME MOLEKULAR
 Peran hormon estrogen dan progesteron

 Sistem imun

 Implantasi ektopik, proliferasi, resistensi dari apoptosis

 Inflamasi kronik

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
Mekanisme pertumbuhan adenomiosis
yang estrogen- dependent

Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
Adenomyosis
 ENDOMETRIOSIS
Pathology

• Puckered black
lesions
• White scarring
• Red polyps
• Clear blebs

White Opacification  inactive Lesion

Red-Flame Like Lesion  active Lesion
NORMAL
CUL DE SAC
CHOCOLATE CYSTS
 KLASIFIKASI
 Revised American Society for Reproductive

Medicine classification of endometriosis

Stage I (minimal) = 1-5
Stage II (mild) = 6-15
Stage III (moderate) = 16-40
Stage IV (severe) = >40
 Klasifikasi lain : ENZIAN staging system

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016.
230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams &
Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
 Stadium I ( minimal ) r-AFS GRADE I →1 - 5

KET GAMBAR , : lesi endometriosis < 1 cm

Stadium II ( mild) r-AFS GRADE II →6 - 15

: lesi endometriosis < 1 cm : 1-3 cm :deep 1-3 cm : >3 cm : >3 cm, deep
Stadium III ( moderate) r-AFS GRADE III →16-40

: lesi endometriosis < 1 cm : 1-3 cm :deep 1-3 cm : >3 cm : >3 cm, deep
Stadium IV ( severe) r-AFS GRADE IV → >40

: lesi endometriosis < 1 cm : 1-3 cm :deep 1-3 cm : >3 cm : >3 cm, deep
Stadium I/II
Stadium III
Stadium IV
Sebelum terapi Sesudah terapi
MANIFESTASI KLINIS
 Asimptomatik  Konstipasi, diare, hematokezia

 Nyeri (nyeri pelvis kronis, siklik

dinding abdomen)  Lesi traktus urinarius

 Nyeri suprapubik,, frekuensi,
 Dismenorrhea
 Dispareunia
urgensi, hematuria
 Diskezia  Lesi thoraks
 Disuria  Nyeri dada/bahu, hemoptisis,

 Subfertil, infertilitas pneumothoraks katam

 Lesi rektosigmoid
Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
DIAGNOSIS
 Pemeriksaan Fisis  Laboratorium
 Pemeriksaan spekulum  Darah lengkap
 Pemeriksaan bimanual  Ca 125
 Pemeriksaan RT  hCG
 Urinalisis
 Kultur urin
 Kultur dan swab vagina

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
 DIAGNOSIS
 Imaging
 USG transvaginal
 CT Scan
 MRI

 Laparoskopi
 Analisis Patologi

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
PENATALAKSANAAN - NYERI
Farmakologi  Agonis : Leuprolide acetate,

 NSAIDs Goserelin, Triptorelin, Nafarelin

 Antagonis : Cetrorelix, Elagolix
 Kontrasepsi hormonal kombinasi
 Aromatase inhibitor
& progestin
 Anastrozole, Letrozole
 Estrogen ; Ethinyl estradiol
 Modulator reseptor progesteron
 Progestin : DMPA, NETA, Dienogest,
LNG-IUS selektif
 Mifepristone
 Hormon seks steroid (androgen)
 Danazol, Gestrinone
 Agen GnRH

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
PENATALAKSANAAN - NYERI
Pembedahan (laparoskopi vs laparotomi)
 Pengangkatan lesi dan adhesiolysis
 Eksisi, ablasi

 Reseksi endometrioma
 Ovarian cystectomy, aspiration coupled with cyst wall ablation

 Neurektomi presakral
 Ablasi nervus uterosakral per laparoskopi
 Histerektomi
 Pengganti hormon
 Oophorektomi postoperatif
Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
PENATALAKSANAAN - INFERTILITAS
 Pembedahan (ablasi)

 Hiperstimulasi ovarium terkontrol

 Inseminasi intrauteri

 IVF

Hoffman BL, Schorge JO, Bradshaw KD, et al. Williams Gynecology. Third ed. New York: McGraw-Hill Education; 2016. 230-49 p.
Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth ed. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011. 1221-48 p.
PENANGANAN ENDOMETRIOSIS
Pilihan penanganan tergantung:
• Ringan/berat endometriosis (klasifikasi)
• Aktif/non aktif endometriosis
• Ada anak/tidak ada anak
• Tingkat rekurensi
• Usia
 ENDOMETRIOSIS
Hormonal
Indications
• Small & superficial lesions
• Recurrence after conservative surgery
• Preoperative for 6-12 wks to decrease size
• Postoperative for residual lesions
• When surgery is contraindicated or refused by the patient.
Endometriosis in Rectovaginal septum & laparotomy scars doesn’t
respond to Hormonal therapy
 ENDOMETRIOSIS
Hormonal

Produces pseudo pregnancy or pseudo menopause

• Danazol
• Progestins
• Gestrinone
• Combined oestrogen-progestogen Pills
• GnRH agonists.
Kondisi endometriosis Pengobatan

Minimal/ringan non aktif Kauter+simptomatik

Minimal/ringan aktif Kauter+MPA/Danazol

Sedang/berat non aktif Segera kauter/kistektomi

Sedang/berat aktif GnRH+Operatif

 ENDOMETRIOSIS & FERTILITAS
Endometriosis menyebabkan infertilitas:
• Oklusi tuba
• Distorsi anatomik organ pelvik
• Menghslk zat toksik: mengganggu motilitas sperma,
interaksi sperma-sel telur,transportasi embrio
ENDOMETRIOSIS

 Algoritme diagnosis dan

terapi pada wanita yang

dicurigai atau terbukti
menderita endometriosis.

Hoffman BL, Schorge JO, Bradshaw KD, et al.

Williams Gynecology. Third ed. New York:
McGraw-Hill Education; 2016. 230-49 p.
 Thank You
DEPARTEMEN OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN