VAGINAL DISCHARGE

STEP 1
Adneksa
: alat alat organ panggul sekitar dari uterus atau rahim,
misalnya: ovarium, tuba fallopi dan ligementumnya
Vaginal discharge : cairan yg keluar dari vagina.
STEP 2
1. Why does she complaints over 15 days of menstruation?
2. Why does she has foul-smelling, discharge between irregular merstrual
cycle?
3. Is there any relation between her and her mother who died cause of
cervical cancer?
4. Why the patient needed to test by USG and histopathology examination?
5. What is the relation between anemic and obesity?
6. Whats the interpretation of gynecologival examination?
7. Whats the relation between the size of uterus and the abdominal pain?
8. What.s the correlation of patient irregular menstruation cycle, sometimes
ywice in a month?
9. What is the sign of she had been married and never conceived?
10.Whats the correlation between age and the problem of the patient?
11.Why did the patient had this condition since she was young?
12.Differential Diagnosis?
13.Treatment of the scenario?
14.Risk factor of this scenario?
15.Clinical examination of this scenario?
STEP 3
1. Why does she complaints over 15 days of menstruation?
Aktivitas/fisik pekerjaan berat. May cause imbalance of estrogen and
progesteron.
Psikis stress, axiety.
Normal duration of mestruation is between 3-8 hari
Menoragia, because of abnormal heavy and prolonged menstrual period
Because of the immaturity of hypothalamus, hypofisis axis, ovarium,
endometrium. Hypophisis is not in normal condition and the ovarium is not
matture
The probability of the case is leiomyoma, adenomiosis, polip
endometrium, hyperplasia endometrium, cervical cancer, malformation
artery or vein in uteri, haemostasis disturbance as like von wilebrand
disease, disturbance factor 2,5,7,9, 13. Trombositopenia and platelet
disturbance, thyroid disease, renal failure, systemic lupus eritematosous,
adenoma, prolactinomia, stress and over exercise.
Diabetic, obesity and intake of medication (antiepilectic, antipsicotic)

2. Why does she has foul-smelling, discharge between irregular menstrual

cycle?
Foul smelling caused by vagina discharge divided 2:
Physiologis
Theres mucous that produced by cervix, the color of mucous is clear and
if contaminated by air would change to white or yellow and the amount is
depends on estrogen level. The actor that caused vaginal discharge is
emotional condition, ovulation cycle, and sexuality.
Pathology
Generally happened cause theres infection from genitalia feminina.
Secrets secretion which purulent can cause by infection from gardnerela
vaginalis trichomoniasis and moniliasis bactery. Beside that, herpes
progenitalis and gonnoreae disease also can cause vanigal discharge.
If the anatomical genital condition is normal, there will be no discharge
Endometriosis: the endometrium will be thickened that will easily bleed
and bacterial will come to the bleeding and cause foul-smelling.
3. Is there any relation between her and her mother who died cause of
cervical cancer?
Jika ibu dari pasien meningal karena kanker serviks ada
bakat/potensi/kemungkinan anak juga terkena kanker karena turunan dari
genetik.
Lifestyle: tapi jika hidup sehat ada kemungkinan penurunan potensi
terkena kanker.
4. What is the correlation between obesity and sign, symptom of patient?
Obesitas banyak kolesterol transformed into estrogen estrogen
dapat memicu perumbuhan massa di uterus (leiomyoma: hormonal
response growth)
Syndrom ovarium polycistic: estrogen dari kolesterol, banyak estrogen yg
ditangkap estrogen reseptor di endometrium.
5. Whats the relation between the size of uterus and the abdominal pain?
In normal mestruation the pain only last for 1-2 days.
Kemungkinan ada massa yg terdesak saat kontraksi yg juga dapat
mendesak nervus nervus di uterus saat mens.
6. Whats the correlation of patient irregular menstruation cycle, sometimes
twice in a month, and anemic?
7. What is the sign of she had been married and never conceived?
Belum punya anak, faktor hormonal mempengaruhi, vaginal discharge
Adanya massa di uterus, ada kemungkinan hasil konsepsi tidak bisa
tertanam di endometrium.
Mass in endometrium will inhibit the zygote to implant.

8. Whats the correlation between age and the problem of the patient?
Kemungkinan dari muda pasien ini sudah ditemukan adanya massa yg
menghambat pasien untuk hamil dan terjadinya menstruasi yg lama.

9. Whats the correlation between her mother condition and the patient
condition thats not pregnant yet?
10.Why did the patient had this condition since she was young?
Aktivitas/fisik pekerjaan berat. May cause imbalance of estrogen and
progesteron.
Psikis stress, axiety.
Normal duration of mestruation is between 3-8 hari
Menoragia, because of abnormal heavy and prolonged menstrual period
Because of the immaturity of hypothalamus, hypofisis axis, ovarium,
endometrium. Hypophisis is not in normal condition and the ovarium is not
matture
The probability of the case is leiomyoma, adenomiosis, polip
endometrium, hyperplasia endometrium, cervical cancer, malformation
artery or vein in uteri, haemostasis disturbance as like von wilebrand
disease, disturbance factor 2,5,7,9, 13. Trombositopenia and platelet
disturbance, thyroid disease, renal failure, systemic lupus eritematosous,
adenoma, prolactinomia, stress and over exercise.
Diabetic, obesity and intake of medication (antiepilectic, antipsicotic)
11.Whats the interpretation of gynecologival examination?
Abnormal uterus: the size was about swans egg.
Bagaimana cara melakukan pf pembesaran uterus?
12.Why the patient needed to test by USG and histopathology examination?
To see if theres a mass or enlargement in the uterus, dan apakah ada
keganasan pd massanya
TSH
HSG : Hidrosalfingography (?)
Toxoplasma : IgM and IgG
Pap smear
13.Differential Diagnosis?
Leiomyoma
Endometriosis
Ca cervix
14.Treatment of the scenario?
High Dose Estrogen
15.Risk factor of this scenario?
Obesity
Genetic
Life style (Bad)
Hormone

16.Other clinical examination of this scenario?

TSH
HSG : Hidrosalfingography (?)
Toxoplasma : IgM and IgG
Pap smear

STEP 7
1. Why does she complaints over 15 days of menstruation?

Uterine fibroids arise from the myometrial layer of the uterine corpus or, less
commonly, the uterine cervix, and may occur singly or multiply. Fibroids may remain
within the muscular layer (intramural) or protrude outwardly to become subserosal in
location or inwardly towards the endometrial cavity, where they become known as
submucous

fibroids.

Subserosal

and

submucosal

fibroids

may

become

pedunculated. Abnormal vaginal bleeding that often accompanies the presence of

fibroids is felt to occur as a result of distortion of the endometrial lining and therefore
is seen much more commonly with submucous fibroids. For the same reason, cavity
distortion can cause recurrent second trimester loss. Uterine fibroids that obstruct
menstrual flow can cause dysmenorrhoea. Large uterine fibroids, regardless of
location, can cause mass effects on contiguous organs such as the bowel and
bladder and cause symptoms of urinary frequency, urgency, and incontinence as well
as constipation. They can outstrip their blood supply and cause acute or chronic pain
as they degenerate. Pedunculated submucous uterine fibroids can dilate the uterine
cervix and prolapse into the vagina where they can become infected.
Various mechanisms have been proposed to explain the strong association between
heavy menses and uterine fibroids. They have included ulceration over the surface of
submucous uterine fibroids, anovulation associated with uterine fibroids, increased
endometrial surface area, and interference with normal uterine contractility. To date,
none of these explanations have been conclusively validated by clinical
research. [14]
More recently, research into this area has centred on a vascular dysregulation,
thought to be mediated by a number of growth factors. It is now hypothesised that

fibroid-associated bleeding is related to dilatation of the small veins (venules) within

the myometrium and endometrium of uteri containing fibroids, thus interfering with
the haemostatic actions of platelets and fibrin plugs. [15] Nevertheless, a cause and
effect has not been established.
Leiomyomagrowthisinfluencedbyprogesteroneinteractionwithsomegrowthfactors;it
upregulates theepidermalgrowthfactor(EGF)(mitogenic)[73]andtransforminggrowth
factor (TGF)3 (bimodal action) [86] expression. On one hand, progesterone seems to
downregulateIGFIexpressionthroughPRB,whilePRAappearstoinhibitthisfunction[84].
http://bestpractice.bmj.com/bestpractice/monograph/567/basics/pathophysiology.html

Progesteron memungkinkan pembesaran tumor dengan cara downregulation apoptosis dari tumor. Estrogen berperan dalam pembesaran
tumor dengan meningkatkan produksi matriks ekstraseluler (Hadibroto,
2005).

a. Perdarahan abnormal
Gangguan perdarahan yang terjadi umumnya hiperminore, menoragia dan
dapat juga terjadi metroragia, Perdarahan abnormal ini yang dapat
menyebabkan anemia defesiensi besi.
Patofisiologi perdarahan uterus abnormal yang berhubungan dengan
mioma uteri masih belum diketahui dengan pasti. Beberapa penelitian
menerangkan bahwa adanya disregulasi dari beberapa faktor
pertumbuhan dan reseptor-reseptor yang mempunyai efek langsung pada
fungsi vaskuler dan angiogenesis. Perubahan-perubahan ini menyebabkan
kelainan vaskularisasi akibat disregulasi struktur vaskuler didalam uterus
yang menyebabkan terjadinya venule ectasia.

Gambar 2.2 : Representasi

vaskulernya
Universitas Sumatera Utara

gambar

uterus

normal

dan

struktur

A. Pelebaran pembuluh darah pada endometrium dan miometrium pada

uterus normal
B. Pelebaran pembuluh darah obstruksi fisik pada pembuluh darah uterus
miomatosus
(Sumber : Gross Karen L, BA)
Beberapa faktor yang menjadi penyebab perdarahan ini, antara lain
adalah :
- Permukaan endometrium yang lebih luas dari pada biasa
- Peningkatan vaskularisasi aliran vaskuler ke uterus
- Ulserasi endometrium pada mioma submukosa
- Kompresi pada pleksus venosus didalam miometrium
- Miometrium tidak dapat berkontraksi optimal karena adanya sarang
mioma di antara serabut miometrium, sehingga tidak dapat menjepit
pembuluh darah yang dilaluinya dengan baik (Prawirohardjo, 2008).
2. Why does she has foul-smelling, discharge between irregular menstrual
cycle?

The vaginal discharge can become chronic and foul-smelling, due to fibroid
expulsion, and surgical evacuation of the uterus may be required.
http://www.gponline.com/clinical-review-uterine-fibroids/article/1115934
3. Is there any relation between her and her mother who died cause of
cervical cancer?
4. What is the correlation between obesity and sign, symptom of patient?

Astudyfoundthattheriskofmyomasincreased21%witheach10 kgincrease
in body weight and with increasing body mass index [21]. Shikora et al.
reportedsimilarresultsinwomenwithgreaterthan30%bodyfat[22].The
adipose tissue converts adrenal and ovarian androgens into estrogens,
whereas several mechanisms associated with obesity lead to decreased
synthesis of sex hormone binding globulin. Consequently, the increase of
biologicallyavailableestrogenscouldberesponsibleforincreasingmyoma
prevalenceand/orgrowthinoverweightandobesewomen.Furthermore,
NairandAlHendyevaluatedtheassociationbetweenobesityrelatedchronic
inflammationandinitiation,aswellastheprogressionofuterineleiomyomaby
usinganin vitromodelwithrepresentativecelllinesofadipocytesandhuman
uterineleiomyomacells.Theydemonstratedthatcocultureofadipocytesand
uterine leiomyoma cells results in an increased proliferation of leiomyoma
cells,andtheyhavealsodemonstratedthatTNFtreatmentincreaseshuman

uterine leiomyoma cells proliferation in a concentrationdependent manner

[23].
Estrogensareabletoregulatetheexpressionofgrowthfactorsbyactivatingsome
signaling pathways. Estrogens upregulate plateletderived growth factor (PDGF)
expression in leiomyoma cells, while they downregulate activin and myostatin in
human myometrial explants. In addition, estrogens also downregulate epidermal
growth factor (EGF) expression but upregulate the expression of EGFR in both
myometriumandleiomyomacells.Theseestrogenactionsareaccomplishedthrough
the rapidactivation ofdifferent kinds ofkinases;someofthem [75]result tobe
increasedinbothimmortalizeduterinesmoothmuscleandleiomyomacelllinesunder
estrogenstimulation.Inaddition,Parkandcolleagues reportedthatestrogensmay
also stimulate the proliferation of leiomyoma cells by activating ATPsensitive
potassiumchannels[76].
http://www.hindawi.com/journals/ogi/2013/173184/

Satu studi prospektif dijalankan dan dijumpai kemungkinan risiko

menderita mioma uteri adalah setinggi 21% untuk setiap kenaikan
10kg berat badan dan dengan peningkatan indeks massa tubuh.
Temuan yang sama juga turut dilaporkan untuk wanita dengan 30%
kelebihan lemak tubuh. Ini terjadi kerana obesitas menyebabkan
pemingkatan konversi androgen adrenal kepada estrone dan
menurunkan hormon sex-binding globulin. Hasilnya menyebabkan
peningkatan estrogen secara biologikal yang bisa menerangkan
mengapa terjadi peningkatan prevalensi mioma uteri dan
pertumbuhannya (Parker, 2007).
Syndrom ovarium polycistic: estrogen dari kolesterol, banyak estrogen yg
ditangkap estrogen reseptor di endometrium.
5. Whats the relation between the size of uterus and the abdominal pain?

Rasa Nyeri
Rasa nyeri bukanlah gejala yang khas tetapi dapat timbul karena
gangguan sirkulasi darah pada sarang mioma, yang disertai
nekrosis setempat dan peradangan. Pada pengeluaran mioma
submukosa yang akan dilahirkan, pada pertumbuhannya yang
menyempitkan kanalis servikalis dapat menyebabkan dismenore.
The pathogenesis of pain associated with these lesions is also a mystery. Some
authors have suggested that pain could result from local pressure by the tumor on
cutaneous nerves. However, the histologic findings do not show that prominent nerve
fibers are associated with these tumors. Others have theorized that specific

infiltrating cells may play a role; one study of 24 angioleiomyomas revealed that
painful tumors had fewer mast cells than asymptomatic ones. Yet others have
suggested that muscle contraction may be pivotal in the induction of pain.
The excitation of the arrector pili muscle occurs via the sympathetic nervous system.
Norepinephrine, secreted by postganglionic nerve fibers, activates the alphareceptors of the muscle. Muscle contraction ensues; this is triggered by the influx of
ions, most specifically calcium. Understanding this basic physiologic process may be
relevant to the medical treatment of symptomatic leiomyomas.
http://emedicine.medscape.com/article/1057733-overview#aw2aab6b2b2
6. Whats the correlation of patient irregular menstruation cycle, sometimes
twice in a month, and anemic?
7. What is the sign of she had been married and never conceived?

8. Whats the correlation between age and the problem of the patient?

9. Whats the correlation between her mother condition and the patient
condition thats not pregnant yet?

Wanita dengan garis keturunan tingkat pertama dengan penderita

mioma uteri mempunyai peningkatan 2,5 kali kemungkinan risiko
untuk menderita mioma uteri dibanding dengan wanita tanpa garis
keturunan penderita mioma uteri. Penderita mioma yang
mempunyai riwayat keluarga penderita mioma uteri mempunyai 2
kali lipat kekuatan ekspresi dari VEGF- (a myoma-related growth
factor) dibandingkan dengan penderita mioma yang tidak
mempunyai riwayat keluarga penderita mioma uteri (Parker, 2007).
10.Why did the patient had this condition since she was young?
11.Whats the interpretation of gynecologival examination?
Bagaimana cara melakukan pf pembesaran uterus?

12.Why the patient needed to test by USG and histopathology examination?

HSG : Hidrosalfingography (?)
Leiomyomas are smooth muscle tumors that are generally well differentiated. The
characteristic smooth muscle nuclei are elongated with blunt ends, and they are often
described as cigar or eel shaped. When these fibers are cut in cross-section, perinuclear
vacuolization may be appreciated. With electron microscopy, the smooth muscle cells of a
leiomyoma appear normal.

http://emedicine.medscape.com/article/1057733-workup#a0723
13.Differential Diagnosis?
14.Treatment of the scenario?
15.Risk factor of this scenario?
16.Other clinical examination of this scenario?
HSG : Hidrosalfingography (?)