PBL REPORT

REPRODUCTION SYSTEM
MODUL 3
“MENSTRUAL DISORDERS”

GROUP 6 ENGLISH CLASS

TUTOR :
dr. Farah Ekawati Mulyadi

Member :
Chelsa Putri Ningsih 11020160001
Sitti Rahmadani Z 11020160106
Muh. Agung Gunadi 11020160096
Mutmainna 11020160076
Nurul Ismira K 11020160066
Anastasia Nugraha 11020160056
Defina Budi 11020160036
Bambang Sukoco 11020160019
Pratiwi 11020160006
Alvi Kamal Fikri 11020150043

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
2019

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 Foreword

Thank you, we pray to the presence of God Almighty for His blessings and mercy
that we can complete this report in time. After going through the PBL process and
discussion several times.

We thank all those who have helped so that this report can be completed on time.
We also thank you to our tutors who have guided us in the PBL process to the
completion of this process. And thanks also to friends who have participated in
gathering information until the creation of this report.

In making this report, we hope to provide information and explanations about cases
and disease in Reproduction system.

We are aware that there are still many shortcomings and mistakes in making this
report. For that, we apologize, and we really hope for constructive criticism and
suggestions.

Group 6

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Scenario

A woman, 35 years old, P3A0, comes to the clinic with chief complaints
frequent spotting outside the menstrual cycle and has menorrhagia in her period.
Previous menstrual history was normal and from the history it was also known that
the patient was an IUD acceptor since 2 months ago.

Difficult Word :

1. Menstruation
Menstruation is a physiological or normal state, which is the event of expulsion
of blood, mucus and the remnants of cells which originates from the uterine
mucosa and occurs relatively regularly starting from menarche until
menopause, except during pregnancy and lactation. Duration of bleeding
menstruation varies, generally 4-6 days, but 2-9 days is still considered
physiological.1
2. P3A0
P3A0: P (Partus = number of deliveries), A (Abortion = number of abortions),
so that P3A0 is a patient who has delivered 3 times and has never had an
abortion.
3. Menoragia
Menorrhagia is bleeding that occurs in the future large amounts of menstruation
can be accompanied by clots blood even accompanied by dysmenorrhea. While
according to Prawirohardjo (2011), menorrhagia is menstrual bleeding whose
total blood count exceeds 80 ml in one cycle, and duration of more than 7 days,
the frequency of dressing can be more from 2-5 times a day.2
4. IUD
IUD (Intra Uterine Device) is a modern contraceptive device has been designed
in such a way (both shape, size, material and time active contraceptive
function), placed in the uterine cavity as an attempt contraception, blocking
fertilization, and complicating eggs implement in the uterus.3

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Key Word :

1. A woman, 35 years old, P3A0

2. Chief complaints frequent spotting outside the menstrual cycle
3. Has menorrhagia in her period
4. The patient was an IUD acceptor since 2 months ago

Questions :

1. How is physiology of menstruation ?

2. What is etiology of menstrual disorders?
3. How is pathophysiology of menstrual disorders?
4. What is the classification of menstrual disorders?
5. How is relation between IUD and the symptoms based on the scenario?
6. How is type of contraception?
7. How are steps to diagnosis menstrual disorders?
8. What is the treatment of menstrual disorders?
9. What is Islamic perspective about the scenario?

Answer :

1. Physiology of menstruation
Menstruation (menstruation) is bleeding from the uterus as a sign of
content in a functioning female body. The length of the menstrual cycle, is the
distance between the start date of past menstruation and the start of new
menstruation. The day the bleeding starts is called the first cycle day. The
normal menstrual cycle length is usually 28 days, but the variation is quite
extensive, not only among some women but also in the same woman. Also in
siblings Even twins, the cycle is always not the same. More than 90% of women
have a menstrual cycle between 24 to 35 days. The diagram below shows
variations in the duration of a woman's menstrual cycle.4,5

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 Normal menstrual cycles in humans can be divided into two segments:
the ovarian cycle and the uterine cycle. The ovarian cycle is further divided
into the follicular phase and the luteal phase, considering that the uterine cycle
is also divided according to the proliferation and secretion phases. The ovarian
cycle is classified as: 4,5
a. Follicular phase: in this phase there is hormonal feedback which causes
follicular maturation in the middle of the cycle prepared for ovulation.
Sometime after menstruation begins, in the early follicular phase, some
follicles develop by increasing FSH influence. The increase in FSH is
caused by regression of the corpus luteum, so that steroid hormones are
reduced. With the development of the follicle, estrogen production
increases, and this suppresses FSH production. At this time LH also
increases, but its role at this level only helps make estrogen in the follicle.
The development of the follicle is after the plasma estrogen level rises. At
first estrogen rises gradually, then quickly reaches the peak. This gives
positive feedback to the cyclic center and with a sudden peak of LH (LH-
surge) release in the middle of the cycle that results in ovulation. The
elevated LH stays around 24 hours and decreases in the luteal phase. Within
a few hours after LH increases, estrogen decreases and maybe this is what

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 causes LH to decrease. Decreased estrogen may be due to morphological
changes in the follicle or it may also be due to short negative feedback from
LH to the hypothalamus. Enough LH-surge does not guarantee ovulation;
The follicle should be at a mature level so that it can be stimulated to
ovulate
b. Ovulation phase: releasing the ovum from the follicle
c. Luteal phase: Approximately 14 days. In the luteal phase, after ovulation
the granular cell cells enlarge to form a vacuole and accumulate yellow
pigment (lutein), the follicle becomes the corpus luteum. Vascularity in the
granulose layer also increases and reaches its peak on 8 ± 9 days after
ovulation. Luteinized granulose cells in the corpus luteum make a lot of
progesterone, and the luteinized theca cells also make a lot of estrogen so
that both hormones increase in the luteal phase. Starting 10 ± 12 days after
ovulation the corpus luteum regresses gradually accompanied by reduced
capillary capillaries and is followed by decreased progesterone and
estrogen secretion.
The endometrial cycle consists of 3 phases, namely: 4,5
a. Menstruation or desquamation phase
During this time the endometrium is released from the uterine wall
accompanied by bleeding. Only the thin layer that remains is called the
basale stratum, this stage lasts 4 days. With menstruation there is blood,
pieces of endometrium and mucus from the cervix. The blood does not
freeze because of the fermen that prevents blood clots and melts the pieces
of the mucous. Only if a lot of blood comes out, the fermen is insufficient
until blood clots arise in menstrual blood.
b. Intermenstruum phase or proliferative stage
In this phase the endometrium grows to ± 3.5 mm thick. This phase lasts
from day 5 to day 14 of the menstrual cycle. The proliferation phase can
be divided into 3 sub-phases, namely:
1) Early proliferation phase, the early proliferation phase takes place
between day 4 to day 9. This phase is known from the thin surface

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 epithelium and epithelial regeneration, especially from the mouth of
the gland. The glands are mostly straight, short and narrow. The shape
of this gland is characteristic of the proliferation phase; Gland cells
experience mitosis. Some preparations still show the atmosphere of the
menstrual phase, where changes in involution of cuboidal glandular
epithelium are seen. The stroma is dense and partly shows mitotic
activity, the cells are star-shaped and oval with protrusions of the
astomosis. The nucleus of the stromal cell is relatively large because
the cytoplasm is relatively small.
2) The final proliferation phase, this phase takes place on day 11 to day
14. This phase can be recognized from the surface of the uneven gland
and with lots of mitosis. The glandular epithelial nucleus forms a
pseudostratification. Stroma grows actively and densely.
c. Premenstrual phase or secretion stage
This phase starts after ovulation and lasts from the 14th day to the 28th. In
this phase the endometrium is approximately the thickness, but the shape
of the gland changes to a long, twisting and releasing sap which becomes
more and more evident. In the endometrium it has been buried with
glycogen and lime which will be needed as food for fertilized eggs. Indeed
the purpose of this change is to prepare the endometrium to receive a
fertilized egg. This phase is divided into:
1) The phase of early secretion in this phase of the endometrium is thinner
than the previous phase due to fluid loss, 4-5 mm thick.

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2) The phase of endometrial advanced secretion in this phase is 5-6 mm
thick. In this phase there is an increase in the phase of early secretion,
with endometrium very much containing blood vessels that bend and
are rich in glycogen. This phase is ideal for nutrition and development
of the ovum. Cytoplasm of stromal cells increases. Stromal cells
become decidual cells in the event of pregnancy. Changes due to
hormonal influences in the uterus.

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2. Etiology of menstrual disorders
a. State of pelvic pathology
Surface lesions in the genital tract:6
1) Mioma uteri, adenomiosi
2) Polip Endometrium
3) Hiperplasi endometrium
4) Adenokarsionoma endometrium, sarcoma
5) Infection of the cervix, endometrium and uterus
6) Ca cervikx and polip
7) Trauma

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 Deep Lesions

1) Adenimiosis difus, mioma uteri, hipertrofi myometrium

2) Endometriosis
3) Venous artery malformations in the uterus
b. Systemic medical illness
1) Hemostatic disorders, von Willebrand's disease, disorders of factors
II, V, VII, VIII, IX, XIII, thrombocytopenia, disorders of platelets
2) Thyroid disease, liver, kidney failure, adrenal gland dysfunction, SLE
3) Pituitary hypothalamic disorders: adenoma, prolactinoma, stress,
excessive exercise

3. Pathophysiology of menstrual disorders

Menorrhagia is a bleeding that occurs during menstruation with a large
amount can be accompanied by blood clots even accompanied by
dysmenorrhea. Menorrhagia is menstrual bleeding in which the total blood
count exceeds 80 ml in one cycle, and the duration is more than 7 days, for the
frequency of dressing pads can be more than 2-5 times a day. The cause of
menorrhagia is greatly affected by conditions in the uterus. Related to fibrin
and platelets which affect the blood clotting process. This can occur if there is
a blood clotting disorder, for example in von Willebrands disease and
thrombocytopenia. It can also be caused by the presence of polyps, myomas,
and endometrial hyperplasia. The condition that most often causes menorrhagia
due to uterine myoma. The rest of the three events can be caused by
endocrinological disorders. Other diseases that may cause abnormal bleeding
are kidney disorders or abnormalities in the liver. If menorrhagia persists it can
also be caused by the use of a uterine contraception (IUD). Based on these
causes, Menorrhagia occurs due to uterine myomas, endometrial polyps and or
endometrial hyperplasia causing disruption of uterine muscle contractility, and
wider endometrial surface so that blood vessels enlarge and are at risk of
necrosis so that bleeding will occur.7,8

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 Changes in the menstrual cycle generally occur in respondents who use
IUD contraception. This cycle change occurred in the first 3 months and will
decline after the next 3 months. Changes in the cycle that occurred occurred
due to damage to proteins due to several enzymes. In addition, these enzymes
also cause the destruction of blood clots that accumulate in the endometrium.
According to the research of Zannah et al. (2011), that after installing IUD
contraception there were 3 respondents from several respondents experiencing
changes in the menstrual cycle in the form of longer menstrual periods each
month, such as menstrual periods which were only around 4 to 5 days to 7
days.7,8

4. Classification of menstrual disorders

Menstrual disorders and the cycle during reproduction can be classified into:9
a. Menstrual cycle disorders
1) Polymoreorea
Menstrual cycle is shorter than normal, ie less than 21 days, bleeding is
more or less the same as normal menstruation. The causes are hormonal
disorders, ovarian congestion due to inflammation, endometriosis, and
others. In hormonal disorders ovulation disorders cause short luteal
period. Diagnosis and treatment require other hormonal and laboratory
tests.
2) Oligomenorea
Menstrual cycle is longer than normal, which is more than 35 days, with
less bleeding. Generally in this case the patient's health is not disturbed
and fertility is quite good.
3) Amenorrhoea
Circumstances where there is no menstruation for a minimum of 3
consecutive months. Amenorrhea is divided into 2, namely primary and
secondary amenorrhoea. Primary amenorrhoea is a condition in which
a woman aged 18 years or older has never menstruated, generally
associated with congenital and genetic abnormalities. Secondary

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 amenorrhea is a condition where a person has had a period, but then
does not get menstruation, usually refers to nutritional disorders,
metabolic disorders, tumors, infectious diseases, and others. There are
also physiological amenorrhoea, namely the period before puberty,
pregnancy, lactation, and after menopause.
b. Volume and duration of menstrual disorders
1) Hipermenorea (menoragia) Is menstrual bleeding that is more than
normal, or longer than 8 days. The cause of this abnormality is in
conditions in the uterus. Usually associated with the presence of uterine
myoma with a wider endometrial surface and contractility disorders,
endometrial polyps, endometrial decay disorders, and so on. Therapy
for this disorder is therapy in the main cause.
2) Hypomenorrhea It is menstrual bleeding that is shorter and or less than
normal. The cause is found in the constitution of the sufferer, the
condition of the uterus, endocrine disorders, etc. Hypomenorrhoea
therapy is psychological in order to calm the sufferer, unless other real
causes have been found . This condition does not affect fertility.
c. Other menstrual disorders
1) Dysmenorrhea
Definition of dysmenorrhea is a gynecological disorder in the form of
menstrual pain, which is generally in the form of cramps and is
concentrated in the lower abdomen. This cramping is often
accompanied by low back pain, nausea, vomiting, headache or diarrhea.
The term dysmenorrhea is only used if the pain occurs so great, because
almost all women experience discomfort in the lower abdomen before
and during menstruation. It is said that if the pain that occurs this forces
the sufferer to rest and leave the activity for several hours or days.
Dysmenorrhea is divided into two, namely:
a) Primary dysmenorrhoea is menstrual pain associated with the
ovulation cycle and is the result of contraction of the myometrium
without the identification of pathological abnormalities. Primary

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 dysmenorrhea usually occurs 12-24 months after menarche, when
the ovulation cycle has formed.
b) Secondary dysmenorrhoea Refers to menstrual pain associated with
pelvic abnormalities, such as endometriosis, adenomyosis, uterine
myoma and others. Therefore, secondary dysmenorrhoea is
generally associated with other gynecologic symptoms such as
dysuria, dyspareunia, abnormal bleeding or infertility.

5. Relation between IUD and symproms in scenario

a. Menorrhagia
IUD insertion causes a heightened concentration of plasminogen activators
in endometrium, and this enzyme resulting in increased fibrinolytic
activity, and prevents blood clotting, bleeding arise as a result of more.10,11
b. Blood spotting between menstrual cycles
Spotting is the presence of blood spots between two menstrual period or
inter-menstrual. Spotting can occur in the use of IUD because of
mechanical irritation of the lining of the uterus and a consequent increase
proteolytik activity (fibrinolytic) of the fluid of the uterus and
endometrium.10,11

6. Type of contraception
Contraception types are divided in to Hormonal & Non Hormonal :12
a. Non hormonal :
1) Contraception Without Using Drugs or Tools :
a) Coitus Interruptus
b) Postcoital Douche
c) Prolonged Lactation
d) Rhythm Method
2) Simple Contraception For Men :
a) Condom
3) Simple Contraception For Women :

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 a) Pessarium
In General Pessarium can be divided in to diaphragm vaginal dan
cervical cap.
b. Hormonal Contraception :
1) Contraceptive Pill, Consist Of :
a) Combination Contraceptive Pill
b) Sequential Pill
c) Mini-pill (Continous Low-dose Progesterone Pill, atau Prostagen
Only Pill)
d) Postcoital Contraception (Morning After Pill)
e) menorea Pascapil (Post Pill Amenorrhoea)
2) Injection Contraception (Depo Provera), consist of :
a) Injections every 3 Months (Depo Provera)
b) Injections every Months (Monthly Injectable)
3) Intra Uterine Device (IUD)

7. Step to diagnosis menstrual disorders

a. Anamnesis
Consist of : 13-17
1) Main complaint
Current complains of patient
2) General disease history
Whether the patient ever suffered disease by weight, tuberculosis,
heart, kidney, abnormality blood, Diabetus mellitus and abnormality
soul.
Non surgical history gynecologic like strumektomi, mammektomi,
appendectomy, and others.
3) Obstetric history
Please note history gestation previously, if ever encountered
miscarriage, Parturition spontaneously normal or parturition to the
action, and how the circumstances of his son. Is there infection

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 childbed and history curettage which can be a source of infection
pelvis and infertility.
4) Gynecologic history
History disease/abnormality gynecologic and treatment, especially
surgery ever experienced.
5) Menstruation history
Please note history menarche, the menstrual cycle regular or not,
many blood out going, duration menstruation, Accompanied by a
sense painful or not, and menopause, need to be asked menstruation
The last still normal,
6) Contraception history: History of use contraception whether the
patient using contraception naturally with or without tools,
hormonal, non-hormonal and contraception steady.
7) Family history
Needs to be asked whether family. No patients who have disease
severe or chronic.
b. Physical examination
Examination Common include: 13-17
1) The general impression; does seem sick, What is consciousness, if
pale, complained pain in the area abdominal.
2) Vital signs examination; check blood pressure, pulse, And
temperature.
3) Abdominal examination
a) Inspection: that attention to form, enlargement (leading to
gestation, tumoror ascites), movement breathing, Skin
conditions (thick, shiny, wrinkled, striae, Pigmentation).
b) Palpation
Before examination, Bladder and rectum should be empty. To
find great tumor, High fundus, surface tumor, The movement
fetus, mark fluid free, whether on palpation feels sick.

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 c) Percussion: To hear gas ingut, Determines enlargement tumor,
there fluid free in the cavity abdominal and feelings sick diketok
time.
d) Auscultation: Examination noisygut, motion fetus or fetal heart
rate
4) Breast examination: is of significant importance with respect to
diagnostic abnormality endocrine, gestation and carcinoma
mammary
5) Genitalia Externa Examination, consisting of:
a) Inspection vulva : Spending fluid or blood of burrows coitus, No
injury in the vulva, is there growth genital wart, Bartholin's Cyst,
abscess Bartholin and fibroma on the labia, note the shape and
color, are there abnormalityon rerineum and anus,
b) Palpation vulva: Palpable tumor, bumpor swelling of Bartholin's
glands.
6) Inspekulo Examination, consisting of:
a) Examination vagina : Is there ulceration, swelling or fluid in
vagina, is there bumpon vagina,
b) Examination porsio uteri : Any injury, whether covered by fluid/
Mucus, bloody and therea bnormality,
c) Taking fluid derived from ulcers vagina and porsio uteri.
Examination bacteriological, examination mild and examination
cytology.
7) Vaginal Toucher to determine :
a) Uterus: How to position nuterus, Great, movements, and
consistency uterus, Is there any painful time examination.
b) Adnexal (left-right areauterus) : Examination This is done by
moving the finger which resides in the lateral fornix and the
hands are on the outside move side ways uterine,

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 c) The posterior fornix (douglas pouch) : Examination is to
determine whether therepus (infection) And whether the fornix
stand out due bleeding The abdominal cavity.
8) Rectal Examination: Examination rectal performed on woman
which have not been coitus, on the abnormality such as congenital
atresia himenalis or vaginalis, hymen rigidus and vaginismus. The
trick: the index finger inserted into the rectum, the outside hand is
placed on sympisis.
9) Rectovaginal Examination: Examination rectovaginal used on
process-process left behind and right ofuterine (Parametrial) like
infiltrates and tumor, The trick: the index finger inserted into vagina
while the middle finger into the rectum.

Supporting examination: 13-17

1) Laboratory examination
Complete blood tests must be performed on all women who experience
menorrhagia. This examination must be carried out in parallel with the
treatment of menorrhagia given. Examination of coagulation disorders
must be considered in women with menorrhagia since menarche and
have a personal or family history of coagulation disorders. Serum
ferritin examination should not be carried out routinely in women with
abnormal uterine bleeding. Thyroid hormone testing should only be
done if there are signs and symptoms of thyroid disease.
2) PAP smear
The possibility of uterine myoma, polyps, endometrial hyperplasia
or malignancy should be excluded.
3) USG
Pelvic USG, both abdominal (suprapubic) and transvaginal, Doppler
ultrasonography provides additional information that is useful for
identifying abnormalities of the endometrium and myometrium.
Hysteroscopy or hysterosonography can be used as a second-line

17
 procedure if an ultrasound examination shows an intrauterine
abnormality or if medical treatment fails after 3-6 months. In patients
with risk factors for endometrial cancer should be combined with a
directed biopsy.

8. Treatment of menstrual disorders

a. Abnormal Uterine Bleeding
a.1 Menoragia
Menorrhagia is more than 80 ml of bleeding or changing pads more
than 6 times per day with a regular cycle. Calculation of blood count is
often not in accordance with the amount of bleeding coming out.
Menorrhagia can be treated without endometrial biopsy. Because the
regular cycle is rarely a sign of malignancy. However, if the bleeding is
more than 7 days or treatment with medication fails, further examination
uses ultrasound transvagina and endometrial biopsy are highly
recommended. Physiological examination of blood clots should be done.18
Medical treatment for menorrhagia can be done as below, namely:
1) Combination of estrogen progestin
The procedure for treatment is appropriate for the treatment of irregular
bleeding
2) Progestin
Given if there are contraindications to the use of estrogen. The
procedure for treatment is in accordance with the treatment of irregular
bleeding.

3) NSAIDs (nonsteroidal anti-inflammatory drugs)

4) The intrauterine contraceptive (IUD) contains Levonorgestrel
The Levonorgestrel IUD is proven to be effective and efficient
compared to hysterectomy in menorrhagia.
Non-hormonal Therapy

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 Medical treatment is given if no pathology is found in the pelvis. The
medical goals are to reduce the amount of blood coming out, reduce the risk
of anemia, and improve the quality of life. Medical non-hormones that can
be used for abnormal uterine bleeding are as follows: 18
Nonsteroidal Antiinflammatory Drugs (NSAIDs)
There are 5 groups of NSAIDs based on their chemical composition,
namely (1) Salicylate (aspirin), (2) Analog of indoleasetic acid
(indomethacin), (3) Derivatives of aryl proponic acid (ibuprofen), (4)
Fenamat (mefenamic acid), (5) Coxibs (celecoxib). The first four groups
worked by inhibiting cyclooxygenase-1 (COX-1) and the last group worked
to inhibit cyclooxygenase-2 (COX-2).
Mefenamic acid is given at a dose of 250-500 mg 2-4 times a day.
Ibuprofen is given at a dose of 600 - 1,200 mg per day. NSAIDs can improve
endometrial hemostasis and can reduce menstrual blood counts 20 - 5O%.
The general side effect is that it can cause gastrointestinal complaints and is
a complication in women with peptic ulcer.
Antifibrinolysis
The endometrium has a fibrinolytic system. In women with
menoragia complaints found levels of plasminogen activator in the
endometrium are more high from normal. Plasminogen activator inhibitors
or antifibrinolysis drugs can be used to treat menorrhagia.
Tranexamic acid works to inhibit plasminogen reversibly and if
given during menstruation can reduce the amount of bleeding 40 - 5O%.
The side effects of tranexamic acid are gastro intestinal and thromboembolic
complaints which appear to be not significantly different from the incidence
in the normal population.
Treatment with Surgical Therapy
The main factor that influences the choice of treatment of abnormal
uterine bleeding is whether the patient has used the medical treatment of
choice of drugs with little cure or no improvement in complaints at all. If

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 this happens, the sufferer will refuse to return to medical treatment, so that
surgical therapy becomes the choice.
Hysterectomy - is the main surgical procedure performed on the
failure of medical equipment. The rate of success against bleeding reaches
100%. The number of satisfaction is quite high reaching 95 "/" after 3 years
postoperatively. However, complications can still occur in the form of
infection bleeding, and surgical wound healing problems. At present,
minimally invasive surgical procedures have been developed by ablation to
reduce endometrial thickness. This method is thought to be easier to do, and
fewer complications. However, of course there still needs to be evidence by
further evaluation. Some surgical procedures currently used in the treatment
of abnormal uterine bleeding are endometrial ablation, transcervical
resection, hysteroscopic operatile myomectomy, hysterectomy, and
occlusion or uterine artery embolism.
First treatment of Abnormal Uterine Bleeding
The first treatment is determined by hemodynamic conditions. If the
hemodynamic condition is unstable, it will immediately be admitted to the
hospital for general repair treatment. If the hemodynamic condition is
stable, immediate treatment is taken to stop the bleeding as shown below.
a.2 Acute and Heavy Bledding
Acute bleeding and many often occur in 3 conditions, namely in
adolescents with impaired coagulopathy, adults with uterine myomas, and
in the use of anticoanabetic drugs. Treated in 2 ways, namely curettage and
medical dilatation. In full, both methods are explained as below: 18
1) Dilation and curettage
Not absolutely done, only if there is a suspicion of malignancy and
failure with medical therapy. Abnormal uterine bleeding with a risk of
malignancy, ie if age> 35 years, obesity, and chronic anore cycle.
2) Medical management
There are several types of hormone drugs that can be used to treat
abnormal uterine bleeding.

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The choice of medication is listed below:

Combination of estrogen progestin

Acute and large hemorrhages will usually improve if treated with a

combination of estrogen and progesterone in the form of contraceptive pills.
The dosage starts with 2 x 1 tablet for 5-7 days and after the bleeding occurs,
followed by 1 x 1 tablet for 3-5 cycles. Can also be given with a tapering
dose of 4 x 1 tablet for 4 days, lowered the dose to 3 x 1 tablet for 3 days,
2x I lablet for 2 days, 1 x 1 tablet for 3 weeks then stop without medication
for 1 week, followed by the pill 1 x 1 tablet combination for 3 cycles.

The use of combined contraceptive pills will reduce the number of

menstrual blood to 60 '/ "and the pathophysiology of the condition of
anowlation will be corrected so that acute and many bleeding will be cured.

Estrogen
Estrogen therapy can be given in 2 forms, intra-venous or oral, but
inrra vein preparations are difficult to obtain in Indonesia. The
administration of high-dose oral estrogen is effective enough to treat
abnormal uterine bleeding, namely conjugated estrogen with a dose of 1.25
mg or 17 beta estradiol 2 mg every 6 hours for 24 hours. After bleeding
stops, followed by the administration of combined contraceptive pills.
Nausea can occur with estrogen therapy.
Progestin
Progestin is given for 14 days then stops without medication for 14
days, repeated for 3 months. Usually progestins are given if there are
contraindications to estrogen. Currently there are several oral progestrin
preparations that can be used, namely Medroksi progesterone acerate
(MPA) with a dose of 2 x 10 mg, Norethisterone acetate dose 2 x 5 mg,
Didrogesterone dose 2 x 10 mg and Norme- gestrol acetate dose 2 x 5 mg .
In choosing the type of progestin, a strong dose must be taken to stop
abnormal uterine bleeding. Progestins are anti-estrogen which will stimulate

21
 the activity of the enzyme 17 beta hydroxy steroid dehydrogenase and
sulfotranferase to convert estradiol to estron. Pro gestin will prevent the
occurrence of hyperplasia endometrium.
a.3 Irregular Bledding
Irregular bleeding can be in the form of metroragia, menometroragia,
oligomenorrhea, prolonged bleeding that has occurred in a matter of weeks
or months and various other forms of bleeding patterns. The form of the
bleeding pattern above is combined because it has relatively the same
handling. Irregular bleeding involves many types of bleeding patterns and
certainly has a variety of causes. Metroragia, menometroragia,
oligomenorrhea, prolonged bleeding, etc. are forms of bleeding that can
occur. Before starting with hormone therapy, systemic causes should be
evaluated first, as done below: 18
1) Check TSH: evaluation of hypothyroid disease and hyperthyroidism
should be done early
2) Check prolactin: if there is oligomenorrhea or hypomenorrhea
3) Perform a PAP smear: if bleeding occurs after intercourse
If you suspect or there is a risk of endometrial malignancy: Perform
endometrial biopsy and consider conducting an examination with
transvaginal ultrasound. If there are limitations to conducting an evaluation
as mentioned above, it can immediately carry out treatment as below,
namely:
1) Combination of estrogen progestin
Give combination dose 1 x 1 tablet contraceptive a day, given cyclic for
3 months.
2) Progestin
If there are contraindications to the use of combination contraceptive
pills, pro-gestin can be given for example: MPA 10 mg 1 x tablet per
day. Treatment was carried out for 14 days and stopped for 14 days.
Progestin treatment is repeated for 3 months.

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 If medical treatment fails, it should be considered to be referred to a
place of treatment with more complete facilities. Transvaginal ultrasound
examination or sonohysterographic saline infusion was performed to detect
uterine myoma and endometrial polyps. Medical failure can be a
consideration for performing surgical procedures, such as endometrial
ablation, hysteroscopic resection, and histectomy.
In certain circumstances minor variations in irregular bleeding occur
which do not require evaluation as explained above. Irregular bleeding that
occurs in 2 years after menarche is usually due to anorulation due to
immaturity of the hypothalamic-pituitary-ovarian axis. Menstruation does
not come with long intervals often occurring in the perimenopausal period.
In such circumstances counseling is very necessary, but if needed can be
given a combination of estrogen progesterone.
b. Dysfunctional Uterine Bledding
Uterine dysfunction bleeding is abnormal uterine bleeding that
occurs without a state of pelvic pathology, certain systemic disease, or
pregnancy. Uterine dysfunction bleeding can occur in a cycle or cycle,
which is caused by a malfunctioning of the hypothalamic-pituitary-ovarian-
endometrial shaft mechanism. 18
Treatment of Uterine Disfunction Bleeding
Handling of Uterine dysfunction bleeding is carried out to achieve
two interrelated goals, namely the first to restore growth and development
of abnormal endometrium which results in anor.'r.riasi state and secondly
makes menstruation -vang regular, cyclic with normal volume and amount.
Both of these objectives can be achieved by how to stop bleeding and
regulate menstruation to be normal again.
Menstrual Regulations To Be Normal Back
As for abnormal uterine bleeding, the first treatment is determined
based on hemodynamic conditions. If hemodynamics is unstable,
immediately enter the hospital for general repair treatment. If stable
hemodynamic treatment to stop bleeding is carried out such as procedures

23
 for abnormal uterine bleeding with acute and many forms of bleeding.
Medicine used is a combination of estrogen and progestin or progestin and
estrogen.
Regulating Menstruation After Cessation of Bleeding Depends on
Two Things, namely Age and Parity.
Adolescents, can be given medicine:
1) Combination of estrogen progesterone (combination contraceptive
pill)
2) Cyclic progestin, for example MPA dose of 10 mg per day for 14 days,
14 days later without medication. Both treatments are repeated for 3
months.
Reproductive age
1) If multiparous parity: give hormonal contraception as above
2) If you have infertility and want to get pregnant: give an induction of
omlation
Age of Perimenopause
1) Give low-dose combination contraceptive pills or DMPA injections

Side effects that may occur after an IUD installer are changes in the menstrual
cycle (common in the first 3 months and will decrease after 3 months), longer and
more menstrual periods, bleeding (spotting) between menstruation, menstruation
more painful, and feeling pain and spasms during 3 to 5 days after installation. Until
now the mechanism of the IUD has not been known with certainty, now the most
opinion is that the IUD in the uterine cavity causes an endometrial inflammatory
reaction accompanied by the designation of leukocytes which can destroy the
blastocyst or sperm. If vaginal and irregular bleeding occurs, then confirm and
confirm the presence of pelvic infection and ectopic pregnancy. If there are no
pathological abnormalities, ongoing bleeding and severe bleeding, do counseling
and monitoring. Give ibuprofen (800 mg, 3 times a day for 1 week) to reduce
bleeding and give iron tablets (1 tablet daily for 1-3 months). The IUD allows to be
released if the client wants. If the client has used an IUD for more than 3 bulls and

24
is known to suffer from anemia (Hb <7gr%), it is advisable to remove the IUD and
help choose another appropriate method.19-22

9. Islamic perspective
Q.S. Al-Baqarah (2) : 222

And they asked you (Muhammad) about menstruation. Say, "it is something
dirty." Therefore stay away from your wife during menstruation; and don't
approach them before they are holy. If they have been holy, mix them
according to what Allah has commanded you. Really, Allah likes people who
repent and like people to purify themselves.

25
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16. Perkins R B, Hall J E, Martin K A, 1999. Neuroendocrine Abnormalities in
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Pustaka Sarwono Prawirohardjo. 168-173.
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SARWONO PRAWIROHARDJO

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