1.
Contraception
 Hormonal
Terdapat dalam bentuk oral, injeksi, trasdermal
patch, dan transvaginal ring
o Estrogen + Progestin Contraceptive: combination
oral contraceptive (COCs) yang paling sering
digunakan utk hormonal contrasepsi.
o MOA: suppresi GnRH di hypotalamus utk prevent
sekresi FSH dan LH. Progestin prevent ovulation
by suppressing LH and menebalkan mukus serviks
sehingga sperma tidak bisa masuk. Estrogen
prevent ovulation by suppressing FSH release,
stabilize endometrium yang dapat prevent
intermenstrual bleeding.
o Method: pills, transdermal patch, vaginal ring,
injection(progestin), intrauterine device(progestine)
o Administration: minum daily (21-81 days) dan stop
minum sekitar 4-7day “pill-free interval). Biasanya
saat pill free interval ada bleeding. Start minum
COCs on first day of menstrual cycle. Minum
selalu di jam yg sama.
o Side effect: nausea (treat with milk), vomit,
stomach cramps, bloating, diare,
 Intrauterine device (IUD)
o Shape like T, works by stopping sperm from
reaching and fertilizing eggs.
o 5 types: liletta, kyleena, mirena, skyla : release
small amount of progestine ke tubuh, dan bisa
mengurangi heavy periods. Yg kelima: Paragard or
copper T: hormone free, copper yg trigger immune
system to prevent pregnancy, tp bisa menyebabkan
heavy period.
o Chance of pregnancy: <1%
o Benefits: last longer, ga ribet, safe terutama utk
breastfeeding
o Not suitable: STD, pregnant, cancer cervic,
unexplained vaginal bleeding. Klo alergi copper jg
no
o Last: 3,5,10 thn
 Barrier methods
o Male condoms: failure rate: ¾ org per 100 couple
(yrs of exposure). Makin baru pertama pake makin
high risk of failure. Bisa buat prevent infection
:STD
o Female condoms: terdapat polyurethane sheath
with one flexible polyurethane ring at each end.
Pregnancy risk is higher than male condom
o Spermicides: a physical barrier to sperm
penetration.
 Fertility awareness – based method
o Harus tau kapan lg fertile, no sex on fertile phase
o Types: standard days method, calendar rhythm
method, temperature rhythm method,cervical
mucus rhythm method, smptothermal method,
 Emergency contraception
o COC, progestin – only method, copper iud, and
mifepristone
o Contoh: levonorgestrel, norgestrel
 Lactation:
o Breastfeeding: unlikely to ovulate for the first 10
weeks
 Permanent:
o Vasectomy: male sterilization, cut or ties or block
the vas deferens. Hormone ga terganggu, tetap bisa
ereksi.
o Tubal ligation: cut or tied or clamp the fallopian tube
o These doesn’t protect against STD
2. Cancer cervix!
Risk factor, staging, definition, causes, pathophysiology!
Cervical cancer risk factors include:
a. Human Papilloma Virus Infection
HPV is the most important risk factor for cervical
cancer, it is a group of more than 150 related viruses,
some of which causes papillomas, more commonly
known as warts. HPV infect cells on the surface of the
skin contact, not the blood or internal organs. t. About
2/3 of all cervical cancer are caused by HPV 16 and
18.
b. Smoking
Tobacco by-products have been found in the cervical
mucus of women who smoke. These substances are
believed to damage the DNA of cervix cells and
contribute to the development of cervical cancer.
Smoking also makes the immune system less effective
in fighting HPV infections.
c. Immunosuppression
HIV puts women at higher risk for HPV infections.
Another group of women are those taking drugs to
suppress immune response, such as those with
autoimmune disease or organ transplant.
d. Chlamydia Infection
It is spread by sexual contact and can cause pelvic
inflammation, leading to infertility. Women with
chlamydia infection often asymptomatic and are at
higher risk of developing cervical cancer.
e. Diet low in fruits and vegetable: increased risk.
f. Being overweight: more likely to develop
adenocarcinoma of the cervix.
g. Long term use of oral contraceptives
Risk of cervical cancer goes up along the longer a
woman takes OCs, and goes back down again after the
OCs are stopped. Cervical cancer risk was doubled in
women who took birth control pills longer than 5
years, but returned to normal after 10 years stopped.
h. IUD use
Women who had ever used IUD had a lower risk, and
also seen even in women who had IUD for less than a
year, and protective effect remained after the IUDs
were removed.
i. Having multiple full-term pregnancies
Women who had 3 or more full-term pregnancies
have an increased risk of developing cervical cancer.
j. Being younger than 17 at first full-term pregnancy
Almost 2 times more likely to get cervical cancer
later in life.
k. Poverty
Low-income women do not have access to adequate
health care services including Pap test, means they
may not get screened or treated for cervical pre-
cancers.
l. Diethylstilbestrol (DES)
It is a hormonal drgs that was given to some women
to prevent miscarriage between 1940 and 1971.
Women whose mother took DES develop clear-cell
adenocarcinoma of the vagina or cervix more often.
Average age of women when they are diagnosed with
DES-related clear-cell adenocarcinoma is 19 years.
m. Having a family history of cervical cancer
Cervical cancer may run in some families, can
increase the risk up to 3 times than no one in the
family had it.
 Etiology  Major risk factors in HPV infections are:
 Sex at a young age
 Multiple sexual partners
 Promiscuous male partners
 History of sexually transmitted diseases
Pathophysiology
HPV infection must be present for cervical cancer to
occur. On average, only 5% of HPV infections will
result in development of CIN grade 2 or 3 lesions within
3 years of infection and only 40% of CIN 3 lesions
progress to invasive cervical cancer with 30 years.
The following factors have been postulated to influence
the development of CIN 3 lesions:
 Type and duration of viral infection.
 Host conditions that compromise immunity.
 Environmental factors.
 Lack of access to routine cytology screening.
Genetic susceptibility
Genetic changes in several classes have been linked to
cervical cancer. TNF is involved in initiating the cell
commitment to apoptosis, and the genes TNFa-8, TNFa-
572, TNFa-857, TNFa-863, and TNFG-308A have been
associated with a higher incidence of cervical cancer.
Polymorphism in Tp53 (involved in apoptosis and gene
repair) associated with increased rate of HPV infection
progressing to cervical cancer.
HLA genes anomalies are associated with an increased
risk. The chemokine receptor-2 (CCR2) gene on
chromosome 3p21 and the Fas gene in chromosome
10q24.1 perhaps by disrupting the immune response to
HPV. The CASP8 gene (also known as FLICE or
MCH5) has a polymorphism in the promoter region that
has been associated with a decreased risk of cervical
cancer.
Epigenetic modifications may also be involved in
cervical cancer. Methylation is the best understood and
probably the most common mechanism of epigenetic
DNA modelling in cancer.
Human papillomavirus
Cancer study found that more than 90% of all cervical
cancer worldwide are caused by 8 HPV types: 16, 18,
31, 33, 35, 45, 52, and 58. Three types (16, 18, and 45)
cause 94% of cervical adenocarcinomas.
HPV Alpha Evidence for Cervical
Types
Group Cancer Causation
Most carcinogenic HPV
1 16 type, known to cause
cancer at several sites
18,31,33,35,
39,45,51,52, Sufficient evidence
56,58, 59
Limited evidence in
2A 68 humans and strong
mechanistic evidence
26,53,66,67,70,73,8 Limited evidence in
2B
2 humans
Classified by
phylogenetic
30,34,69,85,
analogy to HPV
97
types with
sufficient or limited
evidence in humans
Inadequate
epidemiological
3 6,11 evidence and absence of
carcinogenic potential in
mechanistic studies
HPV =
human
papillomavir
us.
Management
Immunization
Evidence suggests that HPV vaccines prevent HPV
infection. The following 2 HPV vaccines are approved
by the FDA:
 Gardasil (Merck, Whitehouse Station, NJ): This
quadrivalent vaccine is approved for girls and
women 9-26 years of age to prevent cervical cancer
(and also genital warts and anal cancer) caused by
HPV types 6, 11, 16, and 18; it is also approved for
males 9-26 years of age
 Cervarix (GlaxoSmithKline, Research Triangle
Park, NC): This bivalent vaccine is approved for
girls and women 9-25 years of age to prevent
cervical cancer caused by HPV types 16 and 18
The Advisory Committee on Immunization Practices
(ACIP) recommendations for vaccination are as follows:
 Routine vaccination of females aged 11-12 years of
age with 3 doses of either HPV2 or HPV4
 Routine vaccination with HPV4 for boys aged 11-
12 years of age, as well as males aged 13-21 years
of age who have not been vaccinated previously
 Vaccination with HPV4 in males aged 9-26 years
of age for prevention of genital warts; routine use
not recommended
Follow up for cervical cancer patients
Follow up of cervical cancer patients include:
o Being examined by your doctor
o Brushing a sample of cells from the cervix or
colposcopy
o Blood tests
o X-rays
o CT scans or MRI scans
o Liver ultrasound scans
The patients will be asked about how they are feeling and
any side effects from treatment. Also ask the patient if they
had any new symptoms or are worried about anything.
After the treatment take a sample of cells taken from the
cervix using a small brush or colposcopy repeated once a
year. If the patient had their womb removed, doctor may
suggest taking a sample of cells from the top of the vagina if
you have unusual symptoms this is called vaginal vault test.
Cervical cells can be very difficult to interpret after
radiotherapy, so the patient will not continue to have regular
tests as part of the cervical screening programme. Using
speculum at appointments to make sure there are no
problems.
Follow up is 3 to 4 month checkups to start with. Then if all
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