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REFERAT

KISTA
ENDOMETRIOSIS

Preseptor:
S. Ranny Yulia Effendi
dr. Jerry Indrawan,
130611012
Sp.OG

Bagian/SMF Obstetri dan Ginekologi


Fakultas Kedokteran Universitas
Malikussaleh
Rumah Sakit Umum Cut Meutia
5/23/2018 Aceh Utara 1
2018
PENDAHULUAN
Definisi
Risk factor & Protective factor
Patofisiologi
• Menurut topografinya endometriosis dapat
digolongkan, yaitu sebagai berikut:
– Endometriosis Interna
• Endometriosis didalam miometrium (uterus)/di dalam
uterus  adenomiosis
• Letaknya didalam tuba  adenomiosis ismika nodosa,
hematosalping.
– Endometriosis Eksterna
Endometriosis di luar uterus “true endometriosis”,
letaknya:
- di dinding belakang uterus,
- dibagian luar tuba
- di ovarium (di pelvio-peritonium dan di cavum
Douglasi, rekto-sigmoid, kandung kencing, umbilikus
sampai pada kulit dan paru paru-paru).
• Endometriosis dapat dikelompokkan menjadi 3 kategori berdasarkan
lokasi dan tipe lesi,yaitu:
• Ovarian Endometrial Cysts (Endometrioma)
terbentuk akibat invaginasi dari korteks ovarium setelah penimbunan debris menstruasi
dari perdarahan jaringan endometriosis.
Kista endometrium bisa besar (>3cm) dan multilokus, dan bisa tampak seperti kista coklat
karena penimbunan darah dan debris ke dalam rongga kista.

• Deep Nodular Endometriosis


jaringan ektopik menginfiltrasi septum rektovaginal atau struktur fibromuskuler pelvis
seperti uterosakral dan ligamentum utero-ovarium.
Nodul-nodul dibentuk oleh hiperplasia otot polos dan jaringan fibrosis di sekitar jaringan
yang menginfiltrasi.
Jaringan endometriosis akan tertutup sebagai nodul, dan tidak ada perdarahan secara
klinis

• Peritoneal endometriosis
Pada awalnya lesi di peritoneum akan banyak tumbuh vaskularisasi sehingga menimbulkan
perdarahan saat menstruasi.
Lesi yang aktif akan menyebabkan timbulnya perdarahan kronik rekuren dan reaksi
inflamasi sehingga tumbuh jaringan fibrosis dan sembuh.
Lesi berwarna merah dapat berubah menjadi lesi hitam tipikal dan setelah itu lesi akan
berubah menjadi lesi putih yang miskin vaskularisasi dan ditemukan debris glandular.
Manifestasi klinik
Sites of endometriosis
• Pelvic – Lungs & thorax
– Ovary – Urinary tract
– Cul de sac • Less common sites
– Uterosacrals – Cervix
– Posterior surface of uterus – Hernial sacs
– Posterior broad ligament – Umblicus
– Rectovaginal septum – Laparotomy/episiotomy
sites
– Tubes and round ligaments
– Tubal stumps after
• Extrapelvic sites sterilization
– Intestines (rectosigmoid,
cecum, terminal ileum,
• Rarest
proximal colon, appendix) – Extremities
Diagnosis
• Anamnesis
• Pemeriksaan fisik
• Pemeriksaan penunjang

LAPAROSKOPI  GOLD STANDAR


Laparoscopic photographs
Ovarian endometrioma: chocolate cyst

Ovarian endometrioma: “kissing ovaries”

Peritoneal endometriosis

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Pemeriksaan fisik
1. Inspeksi vagina dg spekulum
2. Dilanjutkan dengan:
- Pemeriksaan bimanual menilai ukuran, posisi,
mobilitas uterus
- Palpasi rectovagina  mempalpasi ligamentum
sakrouterina dan septum rektovagina (unutk
mencari ada atau tidaknya nodul endometriosis)

*saat haid  meningkatkan peluang mendeteksi


nodul endometriosis dan menilai nyeri
Pemeriksaan penunjang (*khas)
• USG (abdominal/transvaginal)
 Pemeriksaan penunjang lini pertama
 Tetapi tidak baik untuk mendeteksi endometriosis di peritoneal

• MRI
 Baik untuk mendiagnosis endometrium ektopik (peritoneal)

• Lab  pemeriksaan marker biokimia


 IL-6 (membedakan wanita dengan atau tanpa endometriosis)
 IL-6 dan TNF-α (penanda yang baik untuk diagnosis endometriosis gejala
ringan-sedang)
 CA125, Hs-CRP dan VEGF (meningkat pada kasus yang sudah lama terjadi,
sehingga tidak dapat digunakan untuk mendiagnosis kasus baru
endometriosis)
Biopsi

• A:kista endometriotik  kista coklat tdd darah


yang mengalami degenerasi
• B: stroma endometrium ttd:
- sel-sel stroma gemuk (khas perubahan desidual)
- Bagian tengah tampak banyak magrofag yg
mengandung hemosiderin
Diagnosis Banding
Dibedakan berdasarkan:
1. Ginekologi
2. Non ginekologi
Klasifikasi
• AFSASRMmerevisi lagi sistem klasifikasinya, yang dikenal
dengan sistem skoring revised-AFS (r-AFS)

• Menurut ASRM, Endometriosisdiklasifikasikan kedalam 4


derajat keparahan tergantung pada lokasi, luas, kedalaman
implantasi dari sel endometriosis, adanya perlengketan, dan
ukuran dari endometrioma ovarium.

• yakni:
- Stadium I (minimal) : 1-5
- Stadium II (ringan) : 6-15
- Stadium III (sedang) : 16-40
- Stadium IV (berat) : >40
Walaupun tidak ada perubahan staging dari
klasifikasi tahun 1985 sistem klasifikasi tahun
1996 memberikan deskripsi morfologi lesi
endometriosis, yakni putih, merah, dan hitam.
TATALAKSANA
Treatment goals
• To alleviate pains
• To delay recurrence as long as possible
• To help patients get pregnant
Treatment Options
• Medical Therapy
– NSAIDs and Cox2 inhibitors
– COCs
– Progestogens
– Anti progestins
– GnRH agonists and antagonists
 Aromatase inhibitors
 Selective Estrogen Receptor Modulators
• Selective Progesteron Receptor Modulators

• Surgical Treatment
– Conservative Surgery
– Definitive Surgery
Treatment options
• Thoughts before deciding the treatment
– Symptoms
• Pain or infertility or both
– Patient characteristics
• Age
• Severity of disease
• Severity of pain
• Prior treatment history
• Reproductive needs
• Other wishes
Some rough guidelines
• First-line medical treatment: patients with mild
symptoms or adolascent girls
• Medical treatment: Patients with endometriosis who
wish to get pregnant
• Fertility-preserving surgery: Young patients with
severe endometriosis who wishes to have children
• Ovary-preserving surgery+medication: young patients
with severe endometriosis who does not wish to have
children
• Radical surgery: Older patients with severe
endometriosis who do not wish to have children
Treatment options
• Surgery
– Laparoscopy or laparotomy
– Radical or conservative
• Non-surgical treatment (medication)
– First-line medication
– Progestins
– Gonadotropin-releasing hormone (GnRH) agonists
– Danazol (androgenic)
– Oral contraceptives
– Controlled ovarian hyperstimulation (fertility
treatment)
Surgery
-Indications -Pros
Medical treatment ineffective Proven efficacy
Size of the adnexal mass > 5 -Cons
cm Invasive
Wishing to get pregnant Costly
-Purposes Certain risks
Accurate diagnosis Due to high recurrence risk
Removal of endometriotic (~50% 5 yrs), 2nd surgery may
lesions as much as possible be needed
Removal of adhesion and Increases the risk of
restoration of normal damaging ovaries, and the
anatomy risk of premature ovarian
failure
Medical treatment:
Expectant treatment
• Use NSAIDs
– Asprin
– Other analgesics such as ibuproten
– Selective COX-2 inhibitors
– Little impact, if any, on endometriotic lesions
• Follow-up
Medical treatment
• Principles (for current treatment modalities)
– To suppress ovarian estrogen production (GnRH-a and
danazol) necessary for the development and maintenance of
ectopic endometrium
– To induce a pseudo-pregnency (progestins and OC), which
suppresses ovulation and estrogen production
– With reduced estrogen production, endometriotic lesions
may shrink in size or may be eliminated
• All are short-term; recurrence after termination
• All have various side-effects
• ~10% simply do not respond to pregestin therapy
Progestin treatment
• Based on a serendipitous finding that pregnancy relieves the
sysmptoms of endometriosis
• Mechanism of action (MOA)
• Suppresses ovulation
• Suppress the growth of endometriotic lesions
• Reduce inflammation
• Progestins
– Oral
• Norethisterone acetate
• Cyproterone acetate
• Dienogest
– Intramuscular route
• Medroxiprogesterone acetate
– Intrauterine route
• Levonorgestrel-releasing IUD
• Side-effects
– Spotting, hot-flashes, breakthrough bleeding
GnRH agonists treatment
• MOA
– Negative feedback control of ovarian estrogen production
• Method of administration
– Injection
• Side-effects
– Hot-flashes
– loss of libido
– vaginal dryness,
– decreased bone density
• Quite expensive
Danazol treatment
• Danazol is a modified androgen
• 2.5-3.5% of activity of methyl testosterone
• MOA
– Antagonizes estrogen at the tissue level
• Blocks estrogen receptor sites
– Suppresses ovulation (and thus estrogen production)
• Alters pulsatile GnRH release patterns
• Side-effects: weight gain, acne, hirsutism, …
• Decreased use after GnRHa introduction
Treatment with oral contractives
• MOA
– Suppresses ovulation
– Induces a psudopregnancy state
• Not approved by the USFDA yet
• Often used as an “empirical” treatment (w/o a firm Dx)
• Pros
– Low cost
– Easy
– Addition to contraception
• Cons
– Not good for women who wish to get pregnant
Other medical treatment
• Traditional Chinese medicine
– A recent review indicates that evidence is not
there due to poor quality
• Mifepristone (RU486)
– Inadequate evidence
KOMPLIKASI
TERIMAKASIH

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