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AMENOREAPRIMER
A.A.N ANANTASIKA
BATASAN
SPEROFF (2005)I. GADIS USIA 14 TH TANDA SEKS SEKUNDER (-) & BLM MENARKE
II. GADIS USIA 16 TH TANDA SEKS SEKUNDER POS TETAPI BELUM
MENARKE
UMUR
(TH)BUAH DADA
HAID JENIS
14 Ө Ө PRIMER
16 (+) Ө PRIMER
PASKA MENARCHE
3 SIKLUS ӨSEKUNDER
6 BULAN Ө
RATA-RATA UMUR GADIS SAAT MULAI PUBERTAS
-AWAL PERTUMBUHAN BUAH DADA 10,8 1,10
-RAMBUT KEMALUAN 11,0 1,21
-MENARCHE 12,9 1,20
MASHCHAK
GROUP BUAH DADA
UTERUS KETERANGAN
I Ө SENTRAL
PERIFER
II Ө RKH
TFS
III Ө Ө KEL SEKS KROMOSOM
IV EVALUASI SPT AMENORE SEKUNDER
PERTUMBUHAN BUAH DADA MERUPAKAN PETANDA
ADANYA
ESTROGEN
KLASIFIKASI SEKS SEKUNDER TANNER
TANNER STAGINGBREAST PUBIC HAIR
STAGE 1
(PREPUBERTAL)
ELEVATION OF PAPILA ONLY NO PUBIC HAIR
STAGE 2 ELEVATION OF BREAST AND PAPILA AS SMALL MOUND,
AREOLA DIAMETER ENLARGED
MEDIAN AGE:9,8 YRS
SPARSE,LONG,PIGMENTED
HAIRLY CHIEFLY ALONG LABIA
MAJORA,MEDIAN AGE 10,5 YRS
STAGE 3 FURTHER ENLARGEMENT WITHOUT SEPARATION OF BREAST AND AREOLA
MEDIAN AGE 11,2 YRS
DARK,COARSE,CURLED HAIR
SPARSELY SPREAD OVERMONS
MEDIAN AGE 11,4 YRS
STAGE 4 SECONDARY MOUND OF AREOLA AND PAPILA ABOVE THE BREAST
MEDIAN AGE 12,1 YRS
ADULT TIPE HAIR,ABUNDANT
BUT LIMITED TO THE MONS
MEDIAN AGE 12,0 YRS
STAGE 5 RECESSION OF AREOLA
TO CONTOUR OF BREAST
MEDIAN AGE 14,6 YRS
ADULT TYPE SPREAD IN
QUANTITY AND DISTRIBUTION
MEDIAN AGE 13,7 YRS
MASHCHAK
GROUP BUAH DADA
UTERUS KETERANGAN
I Ө SENTRAL
PERIFER
II Ө RKH
TFS
III Ө Ө KEL SEKS KROMOSOM
IV EVALUASI SPT AMENORE SEKUNDER
GROUP I(BUAH DADA Ө UTERUS )
PROD ESTROGNEGATIF
PX FSH SERUMTINGGIRENDAH
A. OVARIUM GAGALHIPER - HIPOG
B. HIPOTAL-PITUITARIGAGAL
HIPOG-HIPOG
A. OVARIUM GAGALHIPER-HIPOG
E ↓↓↓
KELAINAN ORGAN(OVARIUM)
KELAINAN SINTESA E (ENZYM)
A. OVARIUM GAGALHIPER-HIPOG
KEL KROMOSOM
NON ANDROGENIK-45 XO (S. TURNER)-46 ABNORMAL X DELESILENGAN PENDEK/PANJ.-MOSAIK (X/XX,X/XX/XXX,X/ XY) -46 XX/ ATAU 46 XY (MURNI GONADAL DISGENESIS) -46 XX DG DEF 17 HIDROKSILASE
ANDROGENIK **
-45 X/46 XY-45 X/46 X (Yq)-45 X (TESTISCULAR DETERMINAN POSITION)
** MESKIPUN TIDAK DITEMUKAN Y KROM
BILA ADA TANDA-TANDA HIPERANDROGEN
INDIKASI GONADEKTOMI
SINDROMA TURNER
KLINIS KEL ORGAN LAIN AUTO IMUN DISEASES
-PENDEK-WEBBING OF THE NECK-JARAK NIPLE JAUH-UDEMA KAKII & TGN-KUBITUS VALGUS-MULTIPLE PIGMENTED NEVI
-RECCURENT OTITISMEDIA-JANTUNG-GINJAL-TULI-OSTEOPOROSIS-RESIST INSULIN RINGAN
-HASHIMOTO’S THYROIDITIS-ADDISON’S DIS-ALOPECIA-VITILIGO
TERAPI SINDROMA TURNER
PERTUMBUHAN FERTILITAS
CONTINOUS DAILY LOW DOSE ANDROGEN
CESSATION OF LINEAR GROUP
ESTROGEN ON DAYS 1-25 OF EACH MONTHSPROGESTIN ON DAYS 14-25 OF EACH MONTHS
PRESENT: OOCYTE DONATION BY IVF-ET
FUTURE:CRYOPESERVATIONOF FUNCTIONAL OOCYTEOBTAINED IN INFANCY
A. OVARIUM GAGALHIPER-HIPOG
E ↓↓↓
KELAINAN ORGAN(OVARIUM)
KELAINAN SINTESA E (ENZYM)
17 HYDROXYLASE
AROMATASI
17,20 DESMOLASE
P450scc
STEROIDOGENESISCHOLESTEROL
PREGNENOLON
DHEA
17 OH PREGNENOLONE
CORTICO COST.
DEHYD.TESTOST.
CORTISOL
D O C
TESTOSTERONE
DESOXYCORTISOL
PROGEST.
ANDROST
17 OH PROGEST
ESTRONE ESTRADIOL3 HYDRO
XY STEROID DEHYDRO
GENASE
17 OH STERO
IDDEHYDRO
GENASE
11 HYDROXYLASE
ALDOST.
CORTISON
5 REDUCTASE
21 HYDROXYLASE
11 HSD
CORTISON
17 HYDROXYLASE
DEF.17 HIDROXYLASE
CORTISONE
ACTH ↑
DEFISIENSI 17 HIDROXILASE
1. GENITALIA EKSTERNA WANITA
2. RETENSI NATRIUM DAN HIPOKALEMIA
3. HIPERTENSI
TEST ACTH
DARAH BASAL
60 MENIT
PERIKSA DARAH
COSYNTROPIN
0,25 MG IV INTERVAL
30-60 DTK
8-9 PAGI
(PUASA SEMALAM)
DEF 17 HIDROXYLASE,BILA:
-PROGESTERON ↑↑-17 HIDROKSI PROGESTERON ↑ SDKT/TETAP
BLOOD PRESSURE MEASUREMENT IN DIAGNOSISGROUP I PRIMARY AMENORHEA
SERUM FSH LEVEL
ELEVATED
HIPERGONADOTROPICHIPOGANADISME
BLOOD PRESSURE MEASUREMENT
NORMAL BLOOD PRESSURE
GONADAL DISGENESIS
KARYOTIPE
HIPERTENSION
-17 HIDROX DEF-46 XX
45,X46,X/ ABNORMAL X
MOSAICISMEPURE GONADAL DISGENESIS
45 X/ 46 XY45 X/TESTICULER
DETERMINANT POSITION
GROUP I(BUAH DADA Ө UTERUS )
PROD ESTROGNEGATIF
PX FSH SERUMTINGGIRENDAH
A. OVARIUM GAGALHIPER - HIPOG
B. HIPOTAL-PITUITARIGAGAL
HIPOG-HIPOG
CT OR MRI IN DIAGNOSIS OF GROUP I PRIMARY AMENORRHEA
SERUM FSH
LOW/NORMAL
HIPOGONADOTROPICHIPOGONADISM
CT OR MRI SELLA TURSICA
NO LESION LESION
GnRH STIMULATION TEST
NORMAL,FSH,LHRESPONSE
HIPOTHALAMICFAILURE
ABSENTRESPONSE
PITUITARYFAILURE
TEST GnRH
100 G GnRH/HR IM1 MINGGU
DRH BASAL
2X/15 MNT
100 G GnRH IV
BOLUS 30”
3O’ 60’
PX
LH
PX
FSH
KEL HIPOTHALAMUSBILA
-30’ LH ↑↑-60’ FSH ↑↑ PITUITARY BAIK
GROUP I(BUAH DADA Ө UTERUS )
PROD ESTROGNEGATIF
PX FSH SERUMTINGGIRENDAH
A. OVARIUM GAGALHIPER - HIPOG
B. HIPOTAL-PITUITARIGAGAL
HIPOG-HIPOG
PENATALAKSANAAN AMENOREA PRIMER GROUP 1
BUAH DADA -, UTERUS +, (SENTRAL/PERIFER)
FSHRENDAH/NORMAL
TINGGI
HYPER-HYPOG
PERIFER (E )
OV. GAGAL
GGN. SINTESA E
TENSI
TEST PROVOKASIACTH
PROGESTERON 17 OH PROGEST SDKT
NAIK
GGN SINTESA EDEF. 17 HYDROGENASE
CORTISONHRT
TENSI N
OV GGL
KARYOTYPING
NON ANDROGENIK ANDROGENIK
XOX/XX/XXX
X/XXXADA KOMP Y /&
TANDA ANDROGEN
GONADEKTOMIHRT
AWAS KEL ORGAN LAIN
AUTOIMUN
GGN PERTBHNSEKS SEKUNDER FERTILITAS
ANDROGEN (TB)
SP. PERTUMBHNOPTIMAL (3 BLN TUMBUH
LAGI)HRT
OOSIT DONORIVF
SENTRAL(PITUITARI- HYPOTAL)
CT SCAN
KEL + KEL -
HIPOTAL +
TEST PROVOKASI
GnRHCC
-
PITUITARI
PROLAKTINOMA
BROMOKRIPTIN BEDAH
LAIN
COMPLETE DIAGNOSTIC EVALUTION OF WOMEN WITH GROUP I PRIMARY AMENORRHEA
SERUM FSHLEVEL
LOW OR NORMAL ELEVATED
HYPERGONADOTROPICHYPOGONADISM
CT OR MRI, PROLAKTINTSH
HYPOGONADOTROPICHYPOGONADISM
BLOOD PRESSURE
NO LESION
HYPERTENSIONNORMAL BLOOD
PRESSURE
LESION
17HYDROXDEFICIENCY
46, XX
GYNADALDYSGENESIS
KARYOTYPINGGnRH STIMULATION TEST
NORMAL FSH, LH
RESPONSE
HYPOTHALAMIC FAILURE
ABSENT
RESPONSE
PITUITARI FAILURE
45,X46,X/ABNORMAL XMOSAICISMPURE GONADAL, 45,X/ 46 XY45,X/45,Xi (Yq)
45,X TESTICULAR
DETERMINANT
POSITION
MASHCHAK
GROUP BUAH DADA
UTERUS KETERANGAN
I Ө SENTRAL
PERIFER
II Ө RKH
TFS
III Ө Ө KEL SEKS KROMOSOM
IV EVALUASI SPT AMENORE SEKUNDER
GUP II AMENOREA
(BUAH DADA POS,UTERUS NEG)
RKH TFS
ESTROGPOS
GGANPERTUMB
ORGANREPROD
RKH : MAYER ROKITANSKY KUSTER HAUSER SYNDROME
TFS : TESTISCULAR FEMINIZATION SYNDROME
KLASIFIKASI KELAINAN PERTUMBUHAN DUKTUS MULLER
I. AGENESIS (RKH)II. GANGGUAN FUSI VERTIKAL
A. OBSTRUKSIB. NON OBSTRUKSI
III. GANGGUAN FUSI LATERALA. OBSTRUKSI
B. NON OBSTRUKSI
RKH
DASARNYA GENOTIPE WANITAAGENESIS DUKTUS MULLER
(OVARIUM NORMAL)
KLINIS
•H – P – O BAIK OVULASI POS
•TESTOSTERON “N” WANITA
•GANGGUAN PADA GENITALIA : VAGINA DAN UTERUS
GUP II AMENOREA
(BUAH DADA POS,UTERUS NEG)
RKH TFS
ESTROGPOS
GGANPERTUMB
ORGANREPROD
RKH : MAYER ROKITANSKY KUSTER HAUSER SYNDROME
TFS : TESTISCULAR FEMINIZATION SYNDROME
NORMAL DEVELOPMENT OF INTERNAL AND EXTERNAL GENITAL
UNDIFFERENTIATED GONAD
KARYOTIPEXYXX OVARIAN
DEVELOPMENT
TESTICULAR
DEVELOPMENT
MISTESTOST. AND DEHYDROTEST
WOLFIAN DUCT REGRESION
+
MULLERIAN DEVELOPMENT OF OVIDUCTS AND UTERUS
+
FEMALE EXTERNAL GENITALT DHT
WOLFIAN OV.
DEV.
DEV. OF MALE EXT
GENITAL
SEMINAL VES. AND PROSTAT
LAB SCROTAL FUSION+ PHALLIC DEV.
MULLERIAN DUCT.
REGRESSION
XY
NORMAL TIDAK NORMAL(GGN PERTUMBUHAN)
TFS
GENOTIPE: LAKIPENOTPE: WANITA
PERBEDAAN RKH DAN TFSPEMERIKSAAN RKH TFS
KARYOTIPING 46 XX 46 XY
HEREDITER ? MATERNAL X LINKED
RECESSIVE 25% ANAK
TERKENA 25% CARIER
RAMBUT SEKS “N” WANITA NEG/SEDIKIT
TESTOSTERON “N” WANITA “N” / ↑ WANITA
KELAINAN LAIN SERING JARANG
KEGANASAN GONAD NORMAL 5% KEMUNGKINAN GANAS
DIFFERENTATION OF THE CONGENITAL ABSENCE OF THE UTERUS FROM THE ANDROGEN INSENSITIVITY SYNDROME
SERUM TESTOSTERONE & OBSERVATION OF PUBIC AND
AXILARY HAIR
NORMAL MALE TESTOSLEVEL AND ABSENT PUBIC
AND AXILARY HAIR
NORMAL FEMALE TESTOSTERON LEVEL AND NORMAL PUBLIC
AND AXILARY HAIR
ANDROGEN INSENSITIVITY(TESTICULAR FEMINIZATION)CONGENITAL ABSENT OF UTERUS
CONFIRM WITH KARYOTIPECONFIRM OVULATION WITH A BBT OR WEEKLY SERUM PROGESTERONE X 4
TERAPI AMENOREA GRUP IIBUAH DADA (+) UTERUS (-)
RKH TFS
BEDAH : VAGINA TIRUAN
GONADEKTOMI(PASCA PUBERTAS)
HRT
PENATALAKSANAAN AMENOREA PRIMER GRUP II, BUAH DADA +, UTERUS -, (RKH, TFS)
TESTOSTERON
TINGGI/ N, LAKI2
RENDAH/ N, WANITA
RKH
TANDA OVULASI KLINIS/ PMS
BBT
USG
VAGINA TIRUAN
AWAS KEL. BAWAAN LAIN
TFS
-+
GONADEKTOMI(PASCA PUBERTAS ) HRT
MASHCHAK
GROUP BUAH DADA
UTERUS KETERANGAN
I Ө SENTRAL
PERIFER
II Ө RKH
TFS
III Ө Ө KEL SEKS KROMOSOM
IV EVALUASI SPT AMENORE SEKUNDER
EVALUATION OF WOMEN WITH GROUP III
PRIMARY AMENORRHEA
KARYOTIPE (46, XY)
ENZYMEDEFICIENCY AGONADISME
GROUP III AMENORE PRIMER
(BUAH DADA & UTERUS (-) )
A. GANGGUAN ENZIM
DEFISIENSI DARI:
- 17, 20 – DESMOLASE *
- 17 - HIDROKSILASE *
B. TESTICULAR AGONADISM
* KARYOTIPING XY GONADEKTOMI
CHOLESTEROL
5 ANDROSTENEDIONE
17 HYDROXYPROGESTERONE
PROGEST
517 ANDROSTENEDIOL
517 HYDRPREGNOL
5 DEHYDEPIANDROS
TESTOSTERONE
ESTRONE
DEOXYCORTISOL
DEOXYCORTICOST
ESTRADIOL
CORTISOL
CORTICOST18 hydroksiCORTICOST
5 PRENENOLONE
ALDOS
SEX STERO
ID
MIN
ERA
LO C
OR
TICO
ST
GLU
CO
CO
RTIC
OST
2 HYDROXYLASE
3 HYDROXY DEHYDROGENASE
17 OH STEROID OXYREDUCTASE
17,20 DESMOLASE
17 HYDROXYLASE
20.21 DESMOLASE18 OXYDASE .
18 HYDROXYLASE11 HYDROXYLASE
GROUP III AMENORE PRIMER
(BUAH DADA & UTERUS (-) )
A. GANGGUAN ENZIM
DEFISIENSI DARI:
- 17, 20 – DESMOLASE *
- 17 - HIDROKSILASE *
B. TESTICULAR AGONADISM
* KARYOTIPING XY GONADEKTOMI
AMENORE PRIMER GRUP III
AGONADISM
TEORITIS
JAR. TESTISKULAR ADA PADA AWAL PERTUMBUHAN EMBRIO
SISTEM DUCTUS MULLER TERTEKAN
TAPI,SETELAH ITU JAR. TESTISKULAR MENGHILANG
VANISHING TESTESSYNDROME
THERAPI AMENORE PRIMER GRUP III
(BUAH DADA & UTERUS NEGATIF)
-GONADEKTOMI-HRT
GRUP IV AMENOREA PRIMER
(BUAH DADA & UTERUS +)
EVALUASI
SAMA DENGAN AMENORE SEKUNDER