Manuscript for Evidence-Based Case Report
Occurrence of Carcinoma after Prolonged Exposures to Metals in Electronics
Industry: An Evidence-Based Case Report
Reynardi Larope Sutanto1
1
Medical Student, Faculty of Medicine, Universitas Indonesia, Jakarta
reynardisutanto2@gmail.com
1. Introduction
Menstrual disorders on menstruation
disturbances are variations of menstruation
which may be indicative of disease. These
disorders may include amenorrhea
(absence of menstrual periods),
dysmenorrhea, menorrhagia,
oligomenorrhea (infrequent menstrual
periods), and premenstrual syndrome.1
Menstrual disorder is believed to be
happening in increasing numbers
nowadays. Approximately 20-90% of
adolescent girls ever experienced
dysmenorrhea, 47.8% of all women
experienced premenstrual syndrome, and
12% experienced menorrhagia.
Normally, structures in the brain, such
as the hypothalamus and pituitary gland, in
coordination with the ovaries and uterus
follow a sequence of events occuring once
per month called the menstrual cycle. This
cycle is done to prepare the female body
for pregnancy. In doing this, the body is
using combination of hormones, such as
follicle-stimulating hormone (FSH),
luteinizing hormone (LH), progesterone,
and estrogen. However, disturbances in the
cycle could occur and may signal
underlying diseases which need adequate
medical interventions.2,3
There are several tests which could be
done to diagnose menstrual disorders.
These include historical anamnesis, which
seeks to find the woman’s personal and
family medical history, physical
examination primarily in the breasts and
lower abdomen, and laboratory tests such
as blood tests. In some cases, ultrasound
and magnetic resonance imaging (MRI)
could
be used to confirm several diseases. 4,5
Treatment for menstrual disorders are
judged according to its underlying
diseases. Several diseases, such as PCOS,
are chronic conditions which could not be
erased but manageable by hormonal
correction.2
Nowadays, a proper understanding on
the interaction between social determinants
of health and its biomedical outcomes have
been discovered thoroughly. Regarding
menstrual disorders, a connection between
work activity and the incidence of the
condition is thought to be quite significant.
Increasing duration of work and night
shifts are associated with menstrual
disruption. Therefore, some professions
with prolonged work and shifts are likely
to affect the outcome of reproductive
health of women.6
Flight attendants, a traditionally “pink-
collar” job, have prolonged work hours
and night shifts. Besides work hours and
night shifts, traditionally “pink-collar”
professions are associated with higher
incidence of menstrual disorders.7
Moreover, flight attendants work in
conditions with radical differences than
other professions because of the changing
external environment in high altitude.
Therefore, it is very likely that this type of
female population may have higher
probability of contracting menstrual
disorders.7,8
2. Case Illustration
 A young 27-year old woman came into Patient/Pr Interve Compa Outc
oblem ntion rison ome
the obstetric and gynecologic clinic with
complains about her menstruation cycle. Young Being a Young Mens
She has not achieved her period for more female flight female trual
population attendan of other disor
than two months and her last menses gave
t occupat ders
her immense pain and discomfort. The ions
discomforting menses only occurred since
these last two years and were increasing in Clinical Correlati
Question ve
severity. Moreover, these last menses had
Type
variable duration of cycle, ranging from 18 Study Observa
days to 40 days. She has never taken any Design tional
Studies
birth control pills and said that she practice
sexual abstinence. She comes from an 4. Methods
urban middle-class family and now works A systematic review from
as a flight attendant for an Indonesian ScienceDirect and Pubmed databases using
national flight carrier. The patient has no the keyword “("Menstruation
known relatives exhibiting metabolic Disturbances") and ("flight" OR
disorders and has an ideal body weight. "stewardess" OR "flight attendant")” were
conducted. Afterwards, inclusion criteria
Physical gynecological and obstetrical
were set to filter the results. The criteria
examinations were conducted as well as include: observational studies or higher
human chorionic gonadotropin (HCG), evidence-based level of study and studies
complete blood count (CBC) and thyroid assessing the relationship between
functions test. No signs of pregnancy were menstrual disorder and flight attendants.
found but there was an increase in Accepted studies were then assessed
testosterone concentration. An ultrasound for possible bias using STROBE
(Strengthening The Reporting of
imaging was done and several cystic
Observational Studies in Epidemiology).
formations in the ovaries were found. The outcome of the assessment could be
seen in Table 1. The whole process could
3. Clinical Question be seen in Figure 1.
Based on the illustration above, the
clinical question formulated is “Does being
a flight attendant increases the risk of
young woman having menstrual disorders?”
 5. Results
The search was conducted via
ScienceDirect and Pubmed databases.
Titles were screened for relevancy,
duplication, and availability. After a
thorough assessment of eligibility, 4
suitable articles were reviewed and
included in this literature review.
5.1 Validity

Figure 1 : Flow Diagram of Literature Searching

Radowicka M, Yang Y, et al. Lauria L, et al Iglesias R, et al

No
et al. (2013) (2013) (2006) (1980)

0 0 0 0
Title and abstract 1
1 0.5 1 1
Introduction
Background/rationale 2 0 1 1 1
Objectives 3 1 1 1 1
Methods
Study design 4 1 1 0 0
Setting 5 1 1 1 1
Participants 6 1 1 1 1
Variables 7 1 1 1 1
Data
8 1 1 1 1
sources/measurement
Bias 9 1 0 0 0
Study size 10 1 1 1 0
Quantitative variables 11 1 1 1 1
Statistical methods 12 0,8 0,6 0,8 0,8
Results
Participants 13 0,67 1 0,33 0,67
Descriptive data 14 0,67 1 0,33 0,67
Outcome data 15 1 1 1 1
Main results 16 1 1 1 1
Other analyses 17 1 1 0 1
Discussion
Key results 18 1 1 1 1
Limitations 19 1 1 1 1
 Interpretation 20 1 1 1 1
Generalisability 21 1 1 1 1
Other Information
Funding 22 Table12: STROBE critical appraisal
Total 19,14 18,1 17,14 16,14

5.2
5.3 Importance menstrual disorders could be found in
The importance of the study flight attendant profession. The studies
included in this report is attributed to attribute this primarily to the differences
the strong connection exhibited by in work hours, higher night shifts, and
every study between the occupation of change in altitude and thus environment.
the women as flight attendants and the Iglesias et al (1980) conducted a study
rate of menstrual disorders. All of the of 200 airline stewardesses. The study
studies, conducted in multiple found that 39% of them underwent
Yang Iglesias menstrual disorders, primarily manifesting
Laurie
Paramete Randowicka et al et al as changes in the cycle and 38% got
et al
r et al (2013) (2013 (1980) dysmenorrhea. However, it also found that
(2006)
) 11% of them who had previous menstrual
Is my disorders got healed after becoming
patient so airline stewardesses. The age of the study
different to coupled with the lower critical assessment
those in
is the major limitation for this study
the study Yes Yes Yes Yes
that the result.1–9
result Lauria et al (2006) found that out of
cannot 3036 flight attendants, 74% of which were
apply? currently working, menstrual irregularities
Is the could be found more likely in the
condition currently working flight attendants
similar to Yes Yes Yes No compared to the retirees (20.6% vs 10.4%,
my p = 0.02). Moreover, fertility problems
setting? could be seen at 20.6% of the
Did the respondents.8
study use Yang et al (2013) found that menstrual
valid
Yes Yes Yes Yes disorders, such as abnormal cycles and
methods to
address the dysmenorrhea, was significantly higher in
question? flight attendants compared to non-flight
countries from different years point to attendants (30.55% vs 13.40%).
a connection between the occupation Accordingly, the fertility rate (36.59% vs
and the clinical outcome. 43.95%) was lower and the spontaneus
abortion rate was significantly higher
5.4 Applicability (6,80% vs 2.97%).
Table 2: Applicability of the study Finally, Radowicka et al (2013) found
that the occurrence of menstrual disorder
in flight attendants is 21%. Menstrual
6. Discussion disorders are more likely to be found in
As stated before, all of the studies point women working more than 5 years or 14
to similar conclusion that is an increase in routes per week even if the correlation is
 not too significant (p>0.05). Significant
correlations were found between years of
work as flight attendant and incidence of
throid diseases, cervical erotions, and
dysmenorrhea.10
7. Conclusion
Based on the studies assessed, it can be
concluded that women working as female
flight attendants are more likely to have
menstrual disorders primarily because of
the change in environment of work.
However, further research is needed to
find more direct evidence or correlation
between other professions with similar
problmes, such as female pilots, and
promising treatment and management for
women working as a flight attendant or
other fields relating to the sky and
differing altitudes.
8. References
1. Langevin SM, McClean MD, Michaud
DS, Eliot M, Nelson HH, Kelsey KT.
Occupational dust exposure and head and
neck squamous cell carcinoma risk in a
population-based case-control study
conducted in the greater Boston area.
Cancer Med. 2013 Dec;2(6):978–86.
2. Shrestha D, Liu S, Hammond SK,
LaValley MP, Weiner DE, Eisen EA, et al.
Risk of renal cell carcinoma following
exposure to metalworking fluids among
autoworkers. Occup Environ Med. 2016
Oct;73(10):656–62.
3. Boffetta P, Fontana L, Stewart P, Zaridze
D, Szeszenia-Dabrowska N, Janout V, et
al. Occupational exposure to arsenic,
cadmium, chromium, lead and nickel, and
renal cell carcinoma: a case-control study
from Central and Eastern Europe. Occup
Environ Med. 2011 Oct;68(10):723–8.
4. Tripodi D, Ferron C, Malard O, de
Montreuil CB, Planche L, Sebille-Rivain
V, et al. Relevance of both individual risk
factors and occupational exposure in
cancer survival studies: the example of
intestinal type sinonasal adenocarcinoma.
Laryngoscope. 2011 Sep;121(9):2011–8.
5. Pesch B, Casjens S, Stricker I, Westerwick
D, Taeger D, Rabstein S, et al. NOTCH1,
HIF1A and other cancer-related proteins in
lung tissue from uranium miners--variation
by occupational exposure and subtype of
lung cancer. PLoS ONE.
2012;7(9):e45305.
6. Heltoft KN, Slagor RM, Agner T, Bonde
JP. Metal arc welding and the risk of skin
cancer. Int Arch Occup Environ Health.
2017 Nov;90(8):873–81.
7. Khlifi R, Olmedo P, Gil F, Hammami B,
Chakroun A, Rebai A, et al. Arsenic,
cadmium, chromium and nickel in
cancerous and healthy tissues from
patients with head and neck cancer. Sci
Total Environ. 2013 May 1;452–453:58–
67.
8. Huang S-H, Wu I-C, Wu D-C, Wu C-C,
Yang J-F, Chen Y-K, et al. Occupational
risks of esophageal cancer in Taiwanese
men. Kaohsiung J Med Sci. 2012
Dec;28(12):654–9.
9. Chang C-H, Liu C-S, Liu H-J, Huang C-P,
Huang C-Y, Hsu H-T, et al. Association
between levels of urinary heavy metals
and increased risk of urothelial carcinoma.
Int J Urol. 2016 Mar;23(3):233–9.