3. Etiology :
Disturbance on hypothalamus - hypophysis -
ovarial - endometrial axis
o Systemic diseases
o Degenerative diseases
o Psychological disturbance
o Neoplasm / carcinoma
o Radiation
o Blood disease
o Nutritional disorders
4. The disturbance on:
• physiology of cells
• Neurotransmitter
• Neurohormonal
• receptor
How to approach the diagnosis ?
Chief complain
History of menstrual cycles
Family history of abnormality of
menstruation
Developmental disorders
History of other disease
History of medication including
contraception
Psychological disorders
- Physical examination
- Laboratory diagnostic
- USG
- Laparoscopy
- X-Ray
- CT Scan
- Colposcopy
- MRI
5. DISMENORHEA
Pain that feel just before or on menstruation
Classification :
Primary dismenorhea/functional/idhiopatic : pain that
have no pathological causes
Secondary dismenorhea
Caused by factor that could be found
6. Etiology :
Prostaglandin theory F2-a
Prostaglandin elevated the end of menstrual cycles caused
contraction of uterus →ischemia → pain.
Secondary dismenorhea
Could be caused by :
- Pelvic infection
- Endometriosis
- Myoma
- IUD
- Endometrial polyp
12. Reference
1. American Academy of Family Physicians. 2014. Diagnosis and Initial
Management of Dysmenorrhea. American Family Physician. 89(5):341-346
14. Definition of Endometriosis
• Endometriosis, a word derived from the Greek endo ‘'inside'',
metra ''uterus'' and osis ‘' disease,'' remains to some extent vague,
with the most common clinical symptoms being pelvic pain and
infertility.
• Endometriosis is a chronic estrogen-dependent chronic condition
characterized by the ectopic implantation of functional tissue
lining the uterus (endometrial glands and stroma) outside of the
uterine cavity.
(Tsamantioti, 2023)
16. Endometriosis Symptoms and sign
Suspect endometriosis in women (including young women aged 17 and under)
presenting with 1 or more of the following symptoms or signs:
• chronic pelvic pain
• period-related pain (dysmenorrhea) affecting daily activities and quality of
life
• deep pain during or after sexual intercourse
• period-related or cyclical gastrointestinal symptoms, in particular, painful
bowel movements
• period-related or cyclical urinary symptoms, in particular, blood in the urine
or pain passing urine
• infertility in association with 1 or more of the above.
(NICE, 2017)
17. Diagnosing Endometriosis
• Ultrasound
• Serum CA125 (additional, if available. >35 IU/mL may be have
endometriosis, but may be present despite a normal serum)
• MRI
• Laparoscopy consider taking biopsy to confirm the diagnosis, to
exclude malignancy.
(NICE, 2017)
23. Pharmacological Pain Management
Analgesics
• For women with endometriosis-related pain, discuss the benefits and risks of analgesics, taking into account any
comorbidities and the woman's preferences.
• Consider a short trial (for example, 3 months) of paracetamol or a non-steroidal anti-inflammatory drug (NSAID) alone or in
combination for first-line management of endometriosis-related pain.
• If a trial of paracetamol or an NSAID (alone or in combination) does not provide adequate pain relief, consider other forms
of pain management and referral for further assessment.
Neuromodulators and neuropathic pain management
• Use neuromodulators
Hormonal Treatments
• Explain to women with suspected or confirmed endometriosis that hormonal treatment for endometriosis can reduce pain
and has no permanent negative effect on subsequent fertility.
• Offer hormonal treatment (for example, the combined oral contraceptive pill or a progestogen) to women with suspected,
confirmed or recurrent endometriosis.
• If initial hormonal treatment for endometriosis is not effective, not tolerated or is contraindicated, refer the woman to a
gynaecology service, specialist endometriosis service or paediatric and adolescent gynaecology service for investigation and
treatment options.
(NICE, 2017)
24. Non-pharmacological management
• Advise women that the available evidence does not support the
use of traditional Chinese medicine or other Chinese herbal
medicines or supplements for treating endometriosis.
(NICE, 2017)
25. Surgical Management
• Laparoscopy
• Combination treatments: laparoscopy and some hormonal
treatments
• Hysterectomy in combination with surgical management : if the
woman has adenomyosis or heavy menstrual bleeding that has not
responded to other treatments
(NICE, 2017)
27. • The first-line pharmacological therapy proposed for the
management of endometriosis consists of non-steroidal anti-
inflammatory drugs, progestins, or combined hormonal contraceptives.
• As a second-line medical empiric treatment is used a three-month
trial of gonadotropin-releasing hormone (GnRH) analogs for the
suppression of the endometriosis relating symptoms.
(Tsamantioti, 2023)
28. • Kontrasepsi oral : menginduksi reaksi desidua pada jaringan endometriotic uterus. Rjimen
lanjutan: kontrasepsi oral diminum terus menerus 7 hari akan menyebabkan pendarahan,
juga dapat diresepkan untuk mencegah dismenore sekunder
• Progesteron:
• Norethindrone acetate (PO)
• depot mendroxyprogesterone acetate (DMPA) atau implant menekan pelepasan
gonadotropin dan steroidogenesis ovarium. Risiko: kehilangan mineral tulang, meski
kepadatan mineral tulang Kembali ke tingkat sebelum pengobatan setelah 12 bln
pengobatan
• Medroksiprogesteron oral : u/ pasien yg berusaha hamil karena tdk terdapat efek
kontrasepsi.
• Danazol: menekan pelonjakan LH dan FSH shg ovarium tdk menghasilkan estrogen
induksi amenore dan atrofi endometrium. ES: hipoestrogenik dan androgeniknya (jerawat,
spotting dan bleeding, hot flushes, kulit berminyak, prtumbuhan rambut pd wajah, pnurunan
libido, dan vaginitis atrofi, HDL meningkat, LDL menurun.
• GnRH agonis (cenderung untuk terapi tambahan) : gejala mirip danazol menurunkan
regulasi kelenjar hipofisis menekan LH dan FSH, ES lebih rendah daripada. danazol (efek
androgenic tdk ada)
(Luqyana & Rodiyani, 2019)
29. Reference:
• Han, E., & Kim, J. H. (2018). Endometriosis and Female Pelvic Pain. Seminars
in Reproductive Medicine, 36(02), 143 151. doi: 10.1055/s-0038-1676103
• Kuznetsov, L., Dworzynski, K., Davies, M., & Overton, C. (2017). Diagnosis and
management of endometriosis: summary of NICE guidance. BMJ, j3935. doi:
10.1136/bmj.j3935
• Luqyana & Rodiyani. 2019. Diagnosis dan Tatalaksana Terbaru Endometriosis.
Jurnal Ilmiah Mahasiswa Kedokteran Indonesia. 7(2): 67-75
• NICE. 2017. Endometriosis: diagnosis and management. National Institute for
health and care excellence guideline.
• Tsamantioti ES, Mahdy H. Endometriosis. [Updated 2023 Jan 23]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-
. Available from: https://www.ncbi.nlm.nih.gov/books/NBK567777/
