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Contraception o These doesn’t protect against STD


 Hormonal
Terdapat dalam bentuk oral, injeksi, trasdermal 2. Cancer cervix!
patch, dan transvaginal ring Risk factor, staging, definition, causes, pathophysiology!
o Estrogen + Progestin Contraceptive: combination Cervical cancer risk factors include:
oral contraceptive (COCs) yang paling sering a. Human Papilloma Virus Infection
digunakan utk hormonal contrasepsi. HPV is the most important risk factor for cervical
o MOA: suppresi GnRH di hypotalamus utk prevent cancer, it is a group of more than 150 related viruses,
sekresi FSH dan LH. Progestin prevent ovulation some of which causes papillomas, more commonly
by suppressing LH and menebalkan mukus serviks known as warts. HPV infect cells on the surface of the
sehingga sperma tidak bisa masuk. Estrogen skin contact, not the blood or internal organs. t. About
prevent ovulation by suppressing FSH release, 2/3 of all cervical cancer are caused by HPV 16 and
stabilize endometrium yang dapat prevent 18.
intermenstrual bleeding. b. Smoking
o Method: pills, transdermal patch, vaginal ring, Tobacco by-products have been found in the cervical
injection(progestin), intrauterine device(progestine) mucus of women who smoke. These substances are
o Administration: minum daily (21-81 days) dan stop believed to damage the DNA of cervix cells and
minum sekitar 4-7day “pill-free interval). Biasanya contribute to the development of cervical cancer.
saat pill free interval ada bleeding. Start minum Smoking also makes the immune system less effective
COCs on first day of menstrual cycle. Minum in fighting HPV infections.
selalu di jam yg sama. c. Immunosuppression
o Side effect: nausea (treat with milk), vomit, HIV puts women at higher risk for HPV infections.
stomach cramps, bloating, diare, Another group of women are those taking drugs to
 Intrauterine device (IUD) suppress immune response, such as those with
o Shape like T, works by stopping sperm from autoimmune disease or organ transplant.
reaching and fertilizing eggs. d. Chlamydia Infection
o 5 types: liletta, kyleena, mirena, skyla : release It is spread by sexual contact and can cause pelvic
small amount of progestine ke tubuh, dan bisa inflammation, leading to infertility. Women with
mengurangi heavy periods. Yg kelima: Paragard or chlamydia infection often asymptomatic and are at
copper T: hormone free, copper yg trigger immune higher risk of developing cervical cancer.
system to prevent pregnancy, tp bisa menyebabkan e. Diet low in fruits and vegetable: increased risk.
heavy period. f. Being overweight: more likely to develop
o Chance of pregnancy: <1% adenocarcinoma of the cervix.
o Benefits: last longer, ga ribet, safe terutama utk g. Long term use of oral contraceptives
breastfeeding Risk of cervical cancer goes up along the longer a
o Not suitable: STD, pregnant, cancer cervic, woman takes OCs, and goes back down again after the
unexplained vaginal bleeding. Klo alergi copper jg OCs are stopped. Cervical cancer risk was doubled in
no women who took birth control pills longer than 5
o Last: 3,5,10 thn years, but returned to normal after 10 years stopped.
 Barrier methods h. IUD use
o Male condoms: failure rate: ¾ org per 100 couple Women who had ever used IUD had a lower risk, and
(yrs of exposure). Makin baru pertama pake makin also seen even in women who had IUD for less than a
high risk of failure. Bisa buat prevent infection year, and protective effect remained after the IUDs
:STD were removed.
o Female condoms: terdapat polyurethane sheath i. Having multiple full-term pregnancies
with one flexible polyurethane ring at each end. Women who had 3 or more full-term pregnancies
Pregnancy risk is higher than male condom have an increased risk of developing cervical cancer.
o Spermicides: a physical barrier to sperm j. Being younger than 17 at first full-term pregnancy
penetration. Almost 2 times more likely to get cervical cancer
 Fertility awareness – based method later in life.
o Harus tau kapan lg fertile, no sex on fertile phase k. Poverty
o Types: standard days method, calendar rhythm Low-income women do not have access to adequate
method, temperature rhythm method,cervical health care services including Pap test, means they
mucus rhythm method, smptothermal method, may not get screened or treated for cervical pre-
 Emergency contraception cancers.
o COC, progestin – only method, copper iud, and l. Diethylstilbestrol (DES)
mifepristone It is a hormonal drgs that was given to some women
o Contoh: levonorgestrel, norgestrel to prevent miscarriage between 1940 and 1971.
 Lactation: Women whose mother took DES develop clear-cell
o Breastfeeding: unlikely to ovulate for the first 10 adenocarcinoma of the vagina or cervix more often.
weeks Average age of women when they are diagnosed with
DES-related clear-cell adenocarcinoma is 19 years.
 Permanent:
m. Having a family history of cervical cancer
o Vasectomy: male sterilization, cut or ties or block
Cervical cancer may run in some families, can
the vas deferens. Hormone ga terganggu, tetap bisa
increase the risk up to 3 times than no one in the
ereksi.
family had it.
o Tubal ligation: cut or tied or clamp the fallopian tube
Etiology  Major risk factors in HPV infections are: evidence in humans
 Sex at a young age
Inadequate
 Multiple sexual partners
epidemiological
 Promiscuous male partners 3 6,11 evidence and absence of
 History of sexually transmitted diseases carcinogenic potential in
Pathophysiology mechanistic studies
HPV infection must be present for cervical cancer to HPV =
occur. On average, only 5% of HPV infections will human
result in development of CIN grade 2 or 3 lesions within papillomavir
3 years of infection and only 40% of CIN 3 lesions us.
progress to invasive cervical cancer with 30 years.
The following factors have been postulated to influence Management
the development of CIN 3 lesions: Immunization
 Type and duration of viral infection. Evidence suggests that HPV vaccines prevent HPV
 Host conditions that compromise immunity. infection. The following 2 HPV vaccines are approved
 Environmental factors. by the FDA:
 Lack of access to routine cytology screening.  Gardasil (Merck, Whitehouse Station, NJ): This
quadrivalent vaccine is approved for girls and
Genetic susceptibility women 9-26 years of age to prevent cervical cancer
Genetic changes in several classes have been linked to (and also genital warts and anal cancer) caused by
cervical cancer. TNF is involved in initiating the cell HPV types 6, 11, 16, and 18; it is also approved for
commitment to apoptosis, and the genes TNFa-8, TNFa- males 9-26 years of age
572, TNFa-857, TNFa-863, and TNFG-308A have been
associated with a higher incidence of cervical cancer.  Cervarix (GlaxoSmithKline, Research Triangle
Polymorphism in Tp53 (involved in apoptosis and gene Park, NC): This bivalent vaccine is approved for
repair) associated with increased rate of HPV infection girls and women 9-25 years of age to prevent
progressing to cervical cancer. cervical cancer caused by HPV types 16 and 18
HLA genes anomalies are associated with an increased
risk. The chemokine receptor-2 (CCR2) gene on The Advisory Committee on Immunization Practices
chromosome 3p21 and the Fas gene in chromosome (ACIP) recommendations for vaccination are as follows:
10q24.1 perhaps by disrupting the immune response to  Routine vaccination of females aged 11-12 years of
HPV. The CASP8 gene (also known as FLICE or age with 3 doses of either HPV2 or HPV4
MCH5) has a polymorphism in the promoter region that
has been associated with a decreased risk of cervical  Routine vaccination with HPV4 for boys aged 11-
cancer. 12 years of age, as well as males aged 13-21 years
Epigenetic modifications may also be involved in of age who have not been vaccinated previously
cervical cancer. Methylation is the best understood and  Vaccination with HPV4 in males aged 9-26 years
probably the most common mechanism of epigenetic of age for prevention of genital warts; routine use
DNA modelling in cancer. not recommended
Human papillomavirus
Cancer study found that more than 90% of all cervical Follow up for cervical cancer patients
cancer worldwide are caused by 8 HPV types: 16, 18, Follow up of cervical cancer patients include:
31, 33, 35, 45, 52, and 58. Three types (16, 18, and 45)
cause 94% of cervical adenocarcinomas. o Being examined by your doctor
o Brushing a sample of cells from the cervix or
colposcopy
HPV Alpha Evidence for Cervical
Types o Blood tests
Group Cancer Causation
o X-rays
Most carcinogenic HPV o CT scans or MRI scans
1 16 type, known to cause o Liver ultrasound scans
cancer at several sites
The patients will be asked about how they are feeling and
18,31,33,35,
any side effects from treatment. Also ask the patient if they
39,45,51,52, Sufficient evidence
had any new symptoms or are worried about anything.
56,58, 59
After the treatment take a sample of cells taken from the
Limited evidence in cervix using a small brush or colposcopy repeated once a
2A 68 humans and strong year. If the patient had their womb removed, doctor may
mechanistic evidence suggest taking a sample of cells from the top of the vagina if
26,53,66,67,70,73,8 Limited evidence in you have unusual symptoms this is called vaginal vault test.
2B Cervical cells can be very difficult to interpret after
2 humans
radiotherapy, so the patient will not continue to have regular
Classified by
tests as part of the cervical screening programme. Using
phylogenetic
30,34,69,85, speculum at appointments to make sure there are no
analogy to HPV
97 problems.
types with
Follow up is 3 to 4 month checkups to start with. Then if all
sufficient or limited
is well at a year after treatment they will change to 6
monthly for 2 years. And then yearly for another 3 years. cytology, making sure to rotate it at least 360o for the
The most appropriate follow-up strategy has not been spatula and 5 rotations for the broom.
clearly stated. Clinical with gynaecological examination 7. For thin prep the spatula and brush are to be swirled
including PAP smear are usually performed every 3 months vigorously in the vial 10 times to release the specimen
for the first 2 years, every 6 months for the next 3 years and and then discarded.
yearly thereafter. SCC dosage in squamous cell carcinoma 8. When conventional cytology is to be performed, the
may be useful in patients’ follow-up if initially increased. specimens are smeared on a glass slide and
PET/CT might have a role in early local recurrence and subsequently sprayed with fixative or placed in 90%
metastasis detection. alcohol solution.
Hasil menurut klasifikasi Papanicolaou
3. PAP Smear  Kelas I = negatif (tidak ditemukan sel-sel ganas)
The mainstay of cervical cancer screening for the last 60+  Kelas II = ada sel-sel atipik, tp tidak mencurigakan
years has been the Papanicolaou test. The Papanicolaou test,  Kelas III = ada sel-sel atipik, curiga keganasan
also known as the Pap test or the Pap smear, was developed  Kelas IV = ada kemungkinan tumor ganas
in the 1940s by Georgios Papanikolaou. It involves  Kelas V = jelas tumor ganas
exfoliating cells from the transformation zone of the cervix
to enable examination of these cells microscopically for Normalnya endocervix dibatasi glandular cells, sementara
detection of cancerous or precancerous lesions. ectocervix dibatasi squamous cells.
Screening recommedations: Jika ada abnormalitas pada squamous cells, namanya CIN
a. <21 years: no screening recommended. (cervical intra-epithelial neoplasia), jika ada
b. 21 – 29 years: cytology (pap smear) alone every 3 abnormalitas pada glandular cells, namanya CGIN
years. (cervical glandular intra-epithelial neoplasia)
c. 30 – 65 years: HPV and cytology contesting every 5 4. Adnexal mass: Adnexa refers to the area connecting to the
years (preferred) or cytology alone every 3 years uterus, such as the fallopian tubes and ovaries. When a mass
(acceptable) occurs in this region, it is referred to an adnexal mass. Most
d. >65 years: no screening recommended if adequate adnexal masses develop in the ovary.
prior screening has been negative and high risk is not Cause: ovarian cyst, benign ovarian tumors, ovarian cancer,
present ectopic pregnancy
Diagnose: pelvic exam, usg
Preparation:
 The patient is not menstruating 5. Endometrial cancer
 Avoid vaginal intercourse, douching, use of tampons, Happens pada woman after menopause
use of medicinal vaginal cream or contraceptive cream - RF: menarche early, late menopause, obese, dm,
for 24 – 48 hrs hipertensi
 Pre-existing cervicitis should be treated prior to - Symp: abnormal vaginal bleeding or discharge, painful
cervical screening urination, enlarged uterus, dyspareunia, weight loss
 Should proceed in the presence of bleeding or - Diagnosis: CBC, urine test, pelvic exam , pap smears,
cervicitis, as these symptoms may be related to cervical transvaginal ultrasound, biopsy – ct scan, mri
dyslasia or neoplasm, which may be detected with - Treatment: hysterectomy with bilateral salpingo-
cervical screening oophorectomy
Procedure:
1. Prepare the equipments: examination
light, examination table with foot
supports, metal or plastic speculum,
examination gloves, cervical spatula
and cytobrush, liquid-based cytology
or glass slide and fixative.
2. Patient in lithotomy position.
3. Metal or plastic speculum is placed
in the vagina, lukewarm water may
be used to lubricate and warm the
speculum.
4. Transformation zone of the cervix is
the region where squamous
epithelium replaces glandular
epithelium and HPV has a
predilection for this region.
5. Discharge covering the cervix may
be removed carefully using a large
swab, ensuring that the cervix is
minimally traumatized.
6. Cervical broom or cervical spatula is
applied to the surface of the cervix
and turned in a single direction to
achieve an adequate sample for