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Ovarian Cancer Screening: What you miss during gynaecology check-ups

Case scenario

Madam AK is a 40 years old engineer who came for a gynaecological check-ups due to abnormal menstruation for 3 months duration. Her mother and one of her auntie died of breast cancer many years ago. Examination findings showed Madam AK has a large left ovarian cyst and presence of some water in her abdomen suggestive of possible ovarian cancer.  Surprisingly, two months prior this visit, Madam AK has undergone a complete primary health screening which consist of full blood test and Pap test and was told that she was in good health. Does your annual primary health screening exclude all gynaecological cancer?

question-ask-women-annual-checkup-doctor-visit-health-spry

The burden of ovarian cancer

Each year, nearly a quarter of a million women around the world are diagnosed with ovarian cancer, and the disease is responsible for 140,000 deaths annually. In general population, approximately 1 in 70 women will develop ovarian cancer in her lifetime.

In Malaysia, ovarian cancer is the 5th most common cancer affecting women and the number one cause of gynaecological cancer deaths. It is estimated about 500 new cases of ovarian cancer is being diagnosed in our country every year and approximately 70% of women are diagnosed at Stage 3 or Stage 4 of the disease, with an overall five-year survival rate of only 30%.

Ovarian cancer is proven deadlier than breast cancer as statistics show that just 45% of women with ovarian cancer are likely to survive for five years, compared with 89% of women with breast cancer.

Who is likely to get ovarian cancer?

There are three categories of women with different risk level of developing ovarian cancer.

  1. Women with moderate risk i.e. risk level near the general population

This category includes women with any of the followings:

  1. A history of breast cancer diagnosed at the age of 41 or older
  2. A history of infertility and/or use of assisted reproductive therapies such as in-vitro fertilization
  • A history of endometriosis
  1. A history of hormonal replacement therapies
  2. Women with higher risk i.e. risk level 3-6 times greater than a general population.

This category of women include the followings:

  1. First degree relative (mother, sister, daughter) got ovarian cancer
  2. A personal history of breast cancer prior the age of 40.
  • A personal history of breast cancer diagnosed prior the age of 50 and have one close relatives with breast or ovarian cancer at any age
  1. Have 2 or more close relatives of breast or ovarian cancer prior to age 50
  2. Women with inherited risk of ovarian cancer i.e. risk level is more than 6 times to develop ovarian cancer
  3. Presence of a BRCA1or BRCA2 gene mutation
  4. Presence of a mismatch repair gene mutation associated with a hereditary cancer syndrome known as Hereditary Non-Polyposis Colon Cancer.

 

Ovarian cancer screening test (pap test is not designed to detect ovarian cancer)

Pap smear test is a test to detect early cervical cancer or pra-cancer.  The package of primary health screening promoted by the wellness unit in hospital often does not include full package of screening for uterus and ovarian cancer and this is the big disadvantage for women given uterine and ovarian cancer are among the most common cancer affecting women.

Thus it is recommended that for women above 40 especially of those with high risk and inherited risk, other than Pap test, additional blood test for Ca 125 and trans-vaginal scan of the pelvis should be pursued as measures of ovarian cancer screening.

  1. CA-125 measurement

CA 125 is a protein produced by more than 90 percent of advanced epithelial ovarian cancers. However, a single measurement of CA 125 has no value in diagnosing early ovarian cancer because there are many other gynaecological condition cause mild and moderately increase CA 125 level. The predictive power of CA 125 as a screening test improves if it is combined with transvaginal ultrasound finding of the ovaries.

  1. Transvaginal ultrasound of the pelvis

A number of imaging methods have been evaluated for possible use in ovarian cancer screening. Transvaginal ultrasound has consistently proven to be the most promising imaging method for routine screening of ovarian cancer.

In the largest study to date evaluating ultrasound as a screening method for ovarian cancer, 14,469 women, most of whom were at average risk for ovarian cancer, were monitored using annual transvaginal ultrasounds. Promisingly, 11 of 17 cancers detected by transvaginal ultrasound screening were diagnosed at the earliest stage of the disease, known as stage I.

 

Ovarian Cancer Screening: To do or not to do?

Ovarian cancer screening may possibly increase detection rate of ovarian cancer as well as other detection of other gynaecology condition (e.g. uterine fibroid, endometriosis and ovarian cyst) however up to date, there is no clear evidence to suggest that ovarian cancer screening with currently available methods will result in a decrease in the number of deaths from ovarian cancer. This is because CA 125 level and transvaginal imaging of enlarged ovaries do not correlate well with the stage and different type of the ovarian cancer.

Furthermore, absence of early symptom of ovarian cancer makes the prospect of detecting early and death prevention of ovarian cancer is more challenging.

Since many women routinely doing annual health check to make sure they are free from the diseases, to include a detailed gynae check up which include measurement of Ca 125 and a transvaginal ultrasound of the pelvis (to visualise the ovaries) would definitely give the women peace of mind and certainty of normal status of her reproductive organ and her health in general.

 

Written by

Dr Sharifah Halimah Jaafar M.D, M.Med O&G (UKM) AM (Mal)

Consultant Obstetrician & Gynaecology @ Regency Specialist Hospital

Women’s Health Advocates

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About Natural Birth – Benefits and Harms

A mother-to-be came to my clinic recently with a list of her childbirth wishes. She would like to experience a natural birth and she has attended a series of natural birth educational seminars organized by natural birth advocates in Kuala Lumpur.

Of late, there is an increasing demand of natural birth or gentle birth by mothers-to-be, perhaps brought about by the advocates of natural birth who actively promoting back-to-nature kind of childbirth experience. They associate natural birth with multi health benefits to the mother and the newborn however not elaborating the harmful effects.

I love to give my patient the best and pleasant childbirth experiences and to some extend I support natural birth however it must be carried out within the boundary of standard care, proven safe, do no harm and supported by reliable scientific evidences. Some of the childbirth wishes in the list provided are of no harm as it is within the standard care and has been proven beneficial to the mother and the baby by medical research. However some of the wishes are against the standard care, unsafe and potentially harmful to the mother and baby’s health. So, I informed my patient that some of her wishes can be fulfilled because it is proven safe and beneficial but those wishes that are  potentially harmful cannot be fulfilled.

Childbirth wishes of natural birth that are beneficial

Here are among the wishes on the childbirth wish list of the natural birth practice that are in accordance to standard care of labour and they are beneficial to the labouring mother.

  1. I wish my labour pain to start spontaneously
  2. I wish not to have any injection of analgesia and wish to cope the pain of labour with my own alternative way
  3. I wish not to be tied down to the bed for fetal monitoring and intravenous fluids
  4. I wish not to have augmentation of labour with oxytocin
  5. I wish not to have unnecessary cesarean section
  6. I wish for less disturbance and less frequent vaginal examination unless indicated
  7. I wish for the water bag to rupture spontaneously, not for artificial rupture if not indicated
  8. I wish to have my husband or companion by my side during labour and childbirth
  9. I wish not to have an episiotomy at the delivery of my baby
  10. I wish to have skin to skin contact with my baby immediately after birth
  11. I wish to initiate breastfeeding immediately after birth
  12. I wish to have my baby rooming-in with me after delivery all the time
  13. I wish to exclusively breastfeeding my baby through out the hospital stay

 

The majority of mothers are from low risk of maternal and fetal complication category.  These group mothers should be allowed to go into labour naturally and the labour progress is expected to be satisfactory without any needs of intervention to accelerate labour, use of electronic fetal monitoring or intravenous fluids for hydration. The best medical evidence has proved that electronic fetal monitoring is only beneficial to high risk pregnancy where there is an increase chance of fetal compromise. In accordance to standard care, if the labour is progressing well and as long as the baby is healthy state, there is no necessity to rupture the water bag or amniotic membranes artificially.  In fact leaving it intact until it breaks spontaneously may help with the dilatation of the cervix due to roundness and slippery nature of the membranes. However, in the event when fetal compromise is suspected, and labour does not progress as per expected, intervention will become necessary to hasten the delivery of the baby and reduce the risk of morbidity or need for longer hospitalization due to complication.

In expectant care of labour, the labouring mothers are encouraged to ambulate and walk about as it has been proven beneficial in coping with the labour pain and likely to have a shorter duration of labour as compared to those mothers who are confined to bed. To avoid and combat dehydration during labour which may interfere with the progress of labour and inefficient uterine contraction, mothers are encouraged to drink lots of water, thus there is no necessity for intravenous fluid infusion.

Labouring mothers who have companion during labour especially the presence of their spouse to offer a moral support has been shown by the medical evidence to require less analgesia and coping well with the labour and childbirth.  As a result, many hospital and labour facilities have become spouse-friendly.

There are increasing number of labouring mothers who wish to cope with the labour pain with alternative ways i.e. by hypnobirth, breathing exercise etc and do not wish to have any intervention to reduce labour pain as they are concerned about the side effects of the medication to the unborn baby. With regards to the choice of pain relief during labour, mother is free to make an informed choice about her wishes to apply her own method and free to change her mind to use other choices of analgesia.

Episiotomy is a small cut usually made on the perineum to ease the delivery of the baby head and to reduce risk of injury or extended tear to the mother’s perineum and intracranial bleeding in the event the baby popped out too sudden. However, medical evidence showed routine episiotomy to all labouring mothers brings more harm than benefits to the mother, thus it should be done only when it is deemed necessary and not routinely. For mothers who wish not to have episiotomy, it is encouraged that they do prenatal exercise and perineal massage to improve the flexibility of the perineal tissue and muscles thus reducing the risk of serious tear to the perineum during childbirth.

Skin to skin 2

Mother-infant skin to skin contact after birth

The most pleasant experience during childbirth is mother-baby skin to skin contact immediately after delivery. In many labour facilities, immediately after delivery the baby is taken away for cleaning, drying and other procedures at another place nearby. The baby would then be  shown and given to the mother after nicely wrapped up and then taken to nursery for observation. Mother-baby skin to skin contact is when the naked baby is dried & and is placed immediately after emerged from the perineum onto the bare mother’s chest, chest to chest position for a certain duration. Scientific studies have proven that mother-infant skin to skin contact immediately after birth is beneficial as it would promote mother-infant bonding, improves mild breast-milk production and increase rate of successful breastfeeding. It is also has great effects on the baby cry less and feeling safe and much more happier.  In this position, the newborn baby often automatically search for the mother’s nipple and begin to suckle the breasts.

Breast-milk production and successful breastfeeding is very much determined by the mother breastfeeding practices in the first 7 days of postnatal period. Early initiation, mother-baby rooming-in,  frequency and exclusivity of breastfeeding in the early post-partum period is proven beneficial by medical evidences and thus it is part of a standard care in most labour facilities.

Childbirth wishes of natural birth that are potentially harmful

Here are the wishes or natural birth practice that are potentially harmful and hazardous to the health of the mother and her newborn.

  1. I wish to deliver my baby in a squatting position on the floor or assume any position that I feel comfortable.
  2. I wish not to have injection uterotonic (Oxytocin/Sytometrine) after delivery of the baby
  3. I wish to have the placenta detached and come out spontaneously itself without assistance
  4. I wish to have a delayed umbilical cord clamping until the pulsation of the cord has subsided
  5. I wish to have the cord and the placenta left alone with the baby until it dried up and detached itself from the baby umbilicus (lotus practice)
  6. I wish my baby not to be given injection Vitamin K and other immunization after delivery
Delivering in half squatting position

Delivering in half squatting position

Delivering baby in squatting position is perhaps the best position for childbirth. This is because the upright position of the mother, vertical axis of the uterus and the effect of gravity are perhaps improve bearing forces and facilitate descend of the fetus down to birth canal without much resistance.  However if the mother is squatting and bearing down on the floor, there is a danger that the baby head might hit the floor first as a result of sudden expulsion from birth canal due to uncontrolled bearing force and unprotected perineum. In the case of cord around the baby’s neck or shoulder dystocia (stuck shoulder) after the baby’s head had popped, the baby would be in great danger as it might not be readily identified when the mother is in squatting position.

Upon delivery of the baby, all delivering mothers are at risk of postpartum haemorhage. Injection of uterotonic drug like sytometrine or pitocin to the mother immediately after the baby has delivered is a standard care of childbirth to prevent postpartum haemorrhage. If it is omitted, the care can be considered substandard or negligent on the part of the caregiver should complication arises as a result of the omission. It has been proven by scientific evidence that injection syntometrine is beneficial to reduce postpartum blood loss and it used has reduced almost 50% of maternal death due to postpartum haemorrhage worldwide.

Spontaneous expulsion of the placenta may happen 10 -15 minutes after childbirth as the uterus contracted and the shearing effect bring about detachment of the placental surface from the surface of the uterus. If let alone the placenta can come out by itself.  However, it is not going to be easy and uncomplicated for everybody. There is a danger of excessive blood loss if the expulsion takes a longer time. There may be a complication where the placenta is firmly adherent and retained in the uterus requiring manual removal of the placenta. There may also be a danger of postpartum haemorrhage and uterine atony in the event of accumulation of blood in the uterine cavity inflating the womb but not revealed as the detached placenta is obstructing the cervical os. There will be a danger of serious postpartum haemorrhage due to outpouring of the blood with coagulation failure after the placenta is expelled out. Controlled cord traction (CCT) is a standard care applied after sign of placental separation is seen and the doctor or midwife would pull the cord with another hand pushing the uterus upward to give counter traction to reduce risk of the postpartum haemorhage.  CCT has been proven beneficial by medical evidence to reduce danger of postpartum haemohage.

Delaying the cord clamping after birth of the baby has been proven beneficial to the baby especially the premature baby by scientific medical evidence recently. It has been shown that delayed clamping of the cord for about 6-8 seconds allows extra 100 – 200 ml of blood from the placenta return to the baby circulation and this extra volume of blood improves baby haemoglobin level and stabilize blood pressure but it increase the risk of neonatal jaundice. Although it is proven beneficial but it cannot be taken out of context by the natural birth advocates. The recommendation is only to delay around 6-8 seconds and not longer or indefinitely because there is greater harms if it is clamped too late. This is because the blood from baby circulation may reverse back to the placenta when the pressure in the placental end drop shortly after it complete detachment from the uterus. As the pressure in the umbilical cord drop and the blood flow slowing down, there will be formation of thrombus or micro blood clot which might escape into the baby circulation causing embolism.

There is a belief by certain group of natural birth that the detached placenta should be left with the newborn until it dried by itself as placenta is seen as a companion to the baby. This belief is very tribal and has no scientific basis to it. A detached placenta is a dead tissue and thus it will naturally undergo a decay process. As it is a tissue that filled with blood and nutrient, it is a fertile ground for bacterial growth. Thus exposing the baby longer with a non functioning placenta put the baby at greater risk of infection and shock due to sepsis which often fatal.

Injection Vitamin K to the newborn immediately after birth is a standard care as a prophylaxis to prevent incident of haemorrhagic disease of newborn. This is the condition where there is a sudden bleeding in the baby’s brain soon after birth up to 24 hours of life due to vitamin K deficiency. Newborn infants are at risk of developing vitamin K deficiency, and this coagulation abnormality leads to serious bleeding. Transplacental transfer of vitamin K is very limited during pregnancy, and the storage of vitamin K in neonatal liver is also limited. This makes the newborn infant uniquely vulnerable to hemorrhagic disorders unless  vitamin K is given for prevention of bleeding immediately after birth.  A mother who refuse injection Vitamin K to be given to her newborn is irresponsible and it is considered substandard care amounting to negligent in the part of care-giver if injection vitamin K is not given to the newborn should this unfortunate event occur to the baby.

Message to natural birth advocates

Most of the natural birth practices and wishes are not a new trend or new flavor of childbirth but are already imparted in the standard care of labour & childbirth in modern practice where it benefits are supported by scientific medical evidence.  Childbirth, although a natural process but not all are without complication. Maternal and neonatal death are a national issue and the rate of maternal and neonatal mortality is a reflection of the standard & quality health care of a country.  Thus, while the mother wishes is to have a special experience of natural birth but the care-giver has a duty to ensure the safety of both mother and her baby under their care. The quality care of childbirth has to be delivered according to the guidelines of standard care which are supported by medical evidence, not by perception and belief of the mother,

Mothers who have list of natural childbirth wishes to discuss with their doctor or care-giver of their wishes before they come in labour to make sure those wishes can be carried out without compromising the quality and standard care.

Authored by,

Dr Sharifah Halimah Jaafar

Consultant O&G

Regency Specialist Hospital


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Bagaimana endometriosis menjejas potensi saya untuk hamil?

Puan A, 32 tahun,  telah berkahwin selama 6 tahun tetapi gagal untuk hamil kehamilan. Beliau hanya mengalami sakit haid yang biasa dan kitaran haidnya adalah normal. Tiga tahun lalu dia telah menjalani prosedur laparoskopi dilakukan untuk mencari punca kemandulan dan dia diberitahu bahawa dia mempunyai Gred 2 endometriosis. Dia telah mendapatkan rawatan kesuburan dengan pil kesuburan dan telah mencuba pelbagai percubaan inseminasi dalam rahim (IUI) oleh doktor tetapi semua adalah sia-sia. Satu lagi doktor mencadangkan beliau menjalani persenyawaan invitro (IVF) untuk meningkatkan peluang dia mengandung.

Dalam amalan saya, saya sering melihat banyak lagi kes-kes seperti Puan A yang gagal untuk hamil walaupun telah menjalani banyak rawatan akibat endometriosis walaupun ia hanya Gred 1 atau Gred 2. Semua gred endometriosis boleh menjejaskan potensi kesuburan wanita.

mild endometriosis

Lesi endometriosis awal yang selalu gagal dikesan semasa laparoskopi


Dalam tajuk sebelum ini kita telah belajar tentang bagaimana saya mendapatkan endometriosis, dan anda telah belajar tentang grading endometriosis, membolehkan kita memahami bagaimana endometriosis memberi kesan kepada kesuburan wanita.

Semua gred endometriosis sama ada ringan atau teruk boleh menjejaskan peluang anda untuk hamil. Terdapat banyak faktor tentang endometriosis yang menghalang proses pembiakan semula jadi dan ia juga memberi kesan terhadap hasil rawatan kesuburan termasuk IVF. Di antara semua sebab-sebab kemandulan wanita yang menjalani IVF, mereka yang menderitai endometriosis mempunyai kadar kehamilan jauh lebih rendah daripada yang lain. Mengapa? Berikut adalah sebabnya.

1Persekitaran peritoneal yang tidak kondusif : Endometriosis menghasilkan atau merembeskan cecair inflamasi  yang mengandungi bahan cytokines, proteins dan sel darah putih pembunuh ke dalam rongga peritoneal dan pada permukaan ovari dan rahim. Cecair ini toksik dan beracun kepada sperma, oocytes dan juga sel sel embryo yag baru tersenyaawa. Walaupun tiub fallopio tidak rosak dan berfungsi tetapi ramai pesakit endometriosis ringan masih tidak gagal hamil dengan cara semula jadi, kaedah IUI atau IVF.

2. Tiub fallopian terlekat dan rosakDalam usaha untuk hamil secara semula jadi atau melalui IUI, tiub fallopian mesti berfungsi dengan baik dan tidak tersumbat bagi membenarkan sperma untuk menyeberang dari rahim ke ovari mana oosit berada. Tindak balas inflamatori sering menyebabkan pembentukan lekatan pada tiub menyebabkan ia tertampal ke tisu sekitar, terlipat dan rosak.

3.
Endometrioma (Chocolate cyst): Pembentukan sista coklat di ovari, menyebabkan banyak kerosakan kepada folikel yang tersimpan dalam tisu ovari. Semakin besar sista tersebut, lebih banyak ia memberi kesan kepada rizab ovari. Selalunya doktor akan mencadangkan pembedahan untuk membuang sista coklat sebelum rawatan kesuburan sedang dijalankan untuk meningkatkan peluang kehamilan tetapi ini perlu dilakukan dengan pertimbangan berhati-hati untuk meminimumkan kerosakan dan kehilangan tisu ovari dan folikel.
adenomyosis

adenomyosis


4.
Pembentukan Adenomyosis: Terdapat satu lagi varian endometriosis iaitu Adenomyosis. Tidak seperti endometriosis yang berada diluar rahim,  dalam kes adenomyosis, tisu endometrium berhijrah dan ditanam di dalam otot rahim dan ia bertindak balas dengan hormon estrogen, berdarah secara mikro setiap bulan, menjalani tindak balas inflamasi  dan akhirnya menhasilkan fibrosis dan parut otot rahim. Rahim menjadi bengkak dan keras kerana Adenomyosis. Ini sering menyebabkan kesakitan pesakit yang teruk tempoh, hubungan seks yang menyakitkan dan pendarahan haid yang berat. Rahim keras akibat Adenomyosis memberi kesan kepada perjalanan sperma ke destinasi dan implantasi embrio untuk terus hidup.

5.  Fibroid rahim wujud bersama-sama: Hampir 10% daripada wanita yang mempunyai endometriosis juga mempunyai fibroid rahim pada masa yang sama. Ini kerana endometriosis dan fibroid adalah kedua-duanya adalah pemyakiy yang bergantung kepada hormon estrogen semulajadi wanita untuk terus kekal dan aktif.
Oleh:
Dr Sharifah Halimah Jaafar
Consultant O&G
Regency Specialist Hospital


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How endometriosis affects my fertility

Puan A, 32 yrs old has been married for 6 years but failed to conceive a pregnancy. She has minimal period pain but otherwise a normal and regular period. Three years ago she has had a laparoscopy procedure done to find a cause of her infertility and she was told that she has Grade 2 endometriosis. She has undergone many cycle of fertility treatment with fertility pills and has tried many attempt of intrauterine insemination (IUI) by her regular doctor but all are futile. Another doctor has recommended her to undergo invitro fertilization (IVF) to improve her chance of pregnancy.

In my practice, I often see many more cases like Puan A who failed to conceive despite all attempt due to endometriosis eventhough it is only a Grade 1 or Grade 2 endometriosis. All grades of endometriosis affect a woman fertility potential.

mild endometriosis

Grade 1 or mild endometriosis lesion which is often missed at laparoscopy

In the previous write up we have learned about how I get endometriosis, and you have learned about the grade of endometriosis, now lets us understand how endometriosis affects my fertility.

All grade of endometriosis whether or not mild or severe affect your chance to conceive a pregnancy. There are many factors about endometriosis that obstruct natural reproductive process and it also affect the result of fertility treatment including IVF.

Among all causes of infertility in patient who undergoing for IVF, those with endometriosis has much lower pregnancy rate than the others. Why? Here are the reasons.

  1. Hostile peritoneal environment: Endometriosis produces or secretes  inflammatory fluids which contained inflammatory mediators into the peritoneal cavity and on the surface of the ovaries and uterus.  This fluid is toxic and poisonous to the sperms, the oocytes as well as to the new embryo.  Eventhough the fallopian tubes are not damaged and functioning but many patients with mild endometriosis still could not conceive through natural means or by IUI and IVF.
  2. Blocked and non functioning fallopian tubes.  In order to conceive naturally or through IUI, a woman must has a functioning, mobile and patent fallopian tubes to enable sperms to cross over from the uterus to the ovaries where the oocytes are. The inflammatory reaction brought by the inflammatory fluids often results in adhesion formation that the tubes become plastered to the surrounding tissues, distorted and kinked, thus making it lost its function.
  3. Endometrioma (Chocolate cyst): The formation of chocolate cyst in the ovary, causes much damage to the follicles stored in the ovarian tissues due to tissue tension by the growing cyst and by inflammatory products released into the ovary. The more bigger the cyst, the more it affect the ovarian reserves. Often the doctor would suggest surgery to remove the chocolate cyst first before the treatment of fertility is being carried out to improve chances of pregnancy however this has to done with a very careful consideration to minimize the damage and lost of healthy ovarian tissues.

    adenomyosis

    Adenomyosis

  4. Formation of Adenomyosis: There is another variant of endometriosis i.e adenomyosis.  Unlike the endometriosis, in adenomyosis, endometrium tissues migrated and implanted in the muscle of the uterus which responding to the estrogen hormone. It bleeds microscopically every month and undergoing inflammatory reaction to finally cause fibrosis and scarring of the uterine muscle. The uterus becomes swollen and hardened due to scar tissue. This often cause severe period pain, painful sexual intercourse and heavy menstrual bleeding. Hardened uterus due to adenomyosis affects the course of sperms to swim to its destination and implantation of the embryo and its survival.
  5. Coexisting uterine fibroid: Almost 10% of the women who have endometriosis also has co-existing uterine fibroid.  This is because the endometriosis and uterine fibroid are both estrogen dependent disorders that depending on hormone oestrogen to support it existence.


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Kenapa saya boleh dapat endometriosis?

“Dr, kenapa saya boleh dapat endometriosis?” tanya Puan M, 26 tahun yang nyata pasrah kerana mengalami sakit senggugut yang teruk sejak belasan tahun dan masih belum hamil walaupun sudah 5 tahun berumahtangga. Tiga tahun lepas beliau pernah menjalani pembedahan akibat chocolate cyst pada ovari. Sakit senggugut yang dialaminya hilang seketika sehingga 1 tahun lepas dimana sakit senggugutnya menyerang semula dan beliau juga berasa sakit bila berhubungan intim bersama suaminya.

Bila pesakit saya bertanya soalan cepu emas seperti ini, jantung saya terasa berhenti seketika untuk mencari ayat ayat yang sesuai untuk menjawab soalan supaya pesakit tidak menjadi lebih runsing dan keliru. Saya melihat terus kedalam mata Puan M yang mula berair lalu memegang tangannya dengan erat..”Dr memahami penderitaan puan, tapi sukar untuk kita tentukan mengapa sesetengah wanita boleh mendapat penyakit ini, ada banyak lagi maklumat tentang penyakit yang kita belum tahu dan masih dalam penyiasatan saintifik”.

endometriosis 1Mengikut literature perubatan, hampir 10% wanita terbelenggu oleh sakit endometriosis. Jika sakit kanser boleh mengancam nyawa, sakit endometriosis mengancam kualiti hidup wanita kerana ia melumpuhkan sistem pembiakan dam menyebabkan sakit pelvis kronik seperti senggugut, sakit semasa berhubungan seks, sakit belakang dan juga kadang kadang sakit semasa membuang air besar. Ada wanita kadang kadang menjadi takut bila masa haidnya telah hampir kerana sakit senggugut yang amat teruk sekali. Ada yang sampai menjejas keharmonian rumahtangga kerana gagal hamil.

Apakah itu Endometriosis?

Picture1Endometriosis adalah satu penyakit dimana sel sel atau tisu lapisan didinding dalam rahim yang dipanggil endometrium, terlepas keluar ke bahagian luar rahim, melekat dan terus hidup di permukaan luar rahim, ovari, peritoneum, serta organ berdekatan seperti usus dan juga pundi kencing. Sel sel endometrium ini seperti juga ditempat asal mempunyai reseptor estrogen dan progesteron, akan diransang oleh hormon setiap bulan untuk menebal dan mengalami pendarahan mikro di permukaan organ. Ini menyebabkan reaksi inflamatori kronik terus berlaku dikawasan implantasi berkenaan menghasilkan pembentukan salur darah mikro kapilari baru, pengeluaran cecair inflamatori dan terjadi lengketan dan lekatan serta tisu tisu parut yang lebih dalam di bahagian yang terjejas.

Jika sel endometrium ter implan di permukaan ovari, ia akan terbenam ke dalam dan secara perlahan ia akan berdarah setiap bulan dan akhirnya menjadi chocolate cyst atau endometrioma yang boleh merosakkan tisu dan folikel (telur) simpanan di dalam ovari. Salur falopian juga boleh terlekat pada tisu sekelilingnya. Faktor faktor ini dan ceair inflamatori yang terhasil menjejaskan peluang wanita untuk hamil.

adhesios

Lengketan

Lengketan yang terhasil menyebabkan lekatan organ sekeliling seperti usus besar pada dinding belakang rahim dan juga ovari dan pengumpulan tisu tisu parut boleh memerangkap saraf saraf pudendal di bahagian belakang pelvis, septum vagina-rektum dan ligamen utero-sacral. Iritasi oleh cecair inflamatori, perdarahan mikro dan parutan menyebabkan kesakitan semasa haid dan selepas, berhubunga seks dan kadang kadang sepanjang masa.

Bagaimana sel sel  endometrium boleh terlepas keluar dari dalam rahim atau tumbuh di luar kawasan?

Ini juga adalah soalan yang sukar dijawap kerana sehingga kini kita masih tidak tahu sebab yang sebenar. Ada banyak teori teori yang dikemukakan untuk menjelaskannya.  Antara teori yang mudah diterima oleh doktor ialah teori “retrograde menstruation” atau pembalikan haid.

Pelvic_Endometriosis

Retrograde menstruation

“Retrograde menstruation’ini ialah satu keadaan dimana darah haid tumpah atau keluar kebelakang rahim setiap bulan melalui salur fallopian membawa bersamanya sel sel endometrium. Ini selalunya terjadi jika darah haid turun tidak lancar akibat sempit pintu rahim, atau posisi dan struktur rahim yang luarbiasa.  Ada terdapat beberapa keadaan yang menyebabkan terjadi retrograde menstruation, antaranya seperti berikut:

  1. Mullerian abnormality (e.g Bicornuate uterus, vaginal septum etc)
  2. Imperforated hymen
  3. Cervical stenosis (akibat jangkitan atau parut)
  4. Retroverted uterus (rahim terbalik)

Walaubagaimanapun, ada terdapat baanyak kajian yang membuktikan retrograde menstruation dan endometriosis boleh berlaku pada wanita yang mempunyai rahim yang normal.

Gred Endometriosis – Adakah ia penting untuk diketahui?

Gred 1 - Vesicle atau blister jernih

Grade 1 – Vesicle atau blister jernih

Jika anda mengalami endometriosis, apakah gred anda? Endometriosis boleh di gredkan dengan tepat mengikut klassifikasi American Fertility Society (AFS) melalui prosedur laparoskopi. Ada terdapat 4 gred endometriosis i.e Gred 1, Gred 2, Gred 3, dan Gred 4. Gred ini dapat memberi sedikit maklumat tentang jangkamasa kita telah mengalami endometriosis dan ia juga berhubung kait dengan prognosis kesuburan.  Walaubagaimana pun ia tidak berkait dengan keterukan simptom yang dialami oleh seseorang pesakit endometriosis.  Ada terdapat wanita yang mengalami sakit senggugut yang teruk tetapi hanya punyai Gred 1 endometriosis dan wanita yang punyai Gred 4 endometriosis tetapi tiada apa apa simptom.

endometriosis grade 4

Gred 1-2 – Blister yang mula berdarah

endometriosis grade 43

Grade 4 – pelvic adhesion

Bilakah saya mula menghidapi endometriosis?

Soalan ini selalu ditanya oleh pihak insuran sebelum ia bersetuju untuk menangung kos perubatan pesakit. Ada terdapat insuran company yang tidak mahu melindungi sakit endometriosis keran beranggapa ia telah ada sejak azali lagi sebelum polisi insuran dibeli.

Satu daripada soalan yang wajib dijawab oleh doktor dalam borang insuran semasa pesakit masuk ke hospital untk pembedahan cocholate cyst ialah “Pada pendapat doktor, sejak bilakah sakit ini telah bermula?” Saya harus berhati hati semasa menjawab soalan ini kerana sebenarnya amat sukar untuk kita tentukan dengan yakin 100% akan titik permulaan penyakit ini. Ia bergantung kepada gred endometriosis yang dihidapi sekarang dan sejarah penyakit yang sama dimasa lepas.

Ada terdapat banyak kajian saintifik yang telah membuktikan bahawa penyakit endometriosis bermula semasa zaman remaja. Majoriti dari remaja ini mempunyai Gred 1 endometriosis 1 yang sukar di diagnosakan pada zaman usia remaja, oleh itu tidak dapat dikesan dan dirawat sehingga akhirnya bertahun kemudian sampai ke Gred 3 dan 4 di usia matang. Ada segelintir remaja yang didapati mengalami Gred 3-4 endometriosis kesemuanya dari golongan yang punyai rahim yang tidak normal sejak lahir akibat ketaknormalan Mullerian atau imperforated hymen.

Kajian (Reese 1996) juga menunjukkan hampir 70 % remaja yang mengadu sakit senggugut yang kronik, didapati mengalami endometriosis apabila dilaparoskopi dan majoriti mempunyai rahim yang normal. Jika endometriosis dapat dikesan dan dirawat pada peringkat awal, simptom dan progres endometriosis mumgkin boleh dikawal dan potensi kesuburan atau fertilitinya dimasa depan dapat dilindungi. Tapi ini selalunya tidak terjadi.

Masalahnya ialah kita dan masyarakat telah beranggapan bahawa simptom senggugut yang dialami semasa usia remaja adalah normal dan akan hilang bila telah melahirkan anak. Kita selalu mendengar ibu ibu dan cikgu cikgu serta doktor juga memberitahu kita sebegitu dan meng’normal’kan simptom sakit senggugut sebagai perkara yang biasa dan tidak perlu mendapat perhatian dan rawatan. Namun sebenarnya bukan semua remaja yang mengalami sakit senggugut disebabkan proses fisiologikal, ada sebilangan dari mereka yang mengalami sakit endometriosis dan perlu mendapat rawatan supaya ia tidak merosakkan potensi organ pembiakannya dimasa depan seperti kes Puan M.

Bolehkan endometriosis dikesan melalui ujian darah?

Ujian darah tumour marker Ca125 secara sendiri tidak dapat mengesahkan penyakit endometriosis tetapi bagi wanita yang mempunyai simptom seperti sakit senggugut, ia boleh memberi panduan untuk siasatan selanjutnya. Adalah sukar untuk mengesan penyakit endometriosis Gred 1, kerana sehingga kini tiada ujian mudah yang boleh dibuat untuk megesannya diperingkat awal.

Chocolate cyst (Endometrioma)

Endometriosis lebih mudah dikesan diperingkat lewat. Jika paras Ca125 didapati tinggi dan ujian imbasan ultraasound menunjukkan adanya chocolate cyst, kemungkinan wanita itu mengalami endometriosis hampir 99% tepat.

Sehingga hari ini hanya ada satu cara yang dapat mengesan endometriosis diperingkat awal iaitu dengan melihat terus kedalam abdomen dan pelvis menggunakan laparoskopi.

Take Home Message

Endometriosis adalah sakit kronik dan berulang yang selalunya dikesan apabila organ pembiakan pesakit telah lumpuh, tidak dapat hamil dan mengalami kesakitan pelvis yang telah menjejaskan kualiti hidup. Jika dikesan di peringkat awal ia boleh di rawat dan di kawal dan potensi reproduktif di masa depan dpat dilindungi. Bukan semua remaja yang mengalami sakit senggugut adalah proses fisiologikal.  Remaja yang mengalami sakit senggugut yang teruk dan berterusan sehingga selepas period harus diberi perhatian dan dibawa berjumpa doktor untuk siasatan lanjut.

Ikuti posting yang seterusnya minggu depan …”Dr, bolehkah saya hamil, saya ada endometriosis”

Oleh,

Dr Sharifah Halimah Jaafar

Pakar Perunding Perbidanan & Sakit Puan

Regency Specialist Hospital

http://www.drsharifah.com.my


3 Comments

Emergency Contraception

Tahukah anda bagaimana menggunakan emergency contraception?

unplanned pregnancy

Jika anda telah melakukan hubungan sex tanpa sebarang pelindung atau tanpa menggunakan kaedah kaedah pencegahan kehamilan sedangkan anda belum bersedia untuk hamil, anda boleh menggunakan  emergency contraception.

Ia lebih baik daripada anda hamil tidak terancang dan kemudiannya ingin menggugurkan kandungan atau lebih teruk lagi membuang bayi yang baru lahir.  Namun begitu jika anda belum bersedia untuk hamil adalah lebih ideal anda menggunakan kaedah perancangan keluarga yang lebih tetap seperti Pill pencegah hamil, suntikan Depo Provera, IUCD hormone atau copper based atau menggunakan kondom. Bagi pasangan yang telah berumah tangga dan megadakan hubungan intim lebih kerap, kaedah emergency contraception bukan kaedah yang sesuai untuk mencegah kehamilan.  Bagi golongan muda yang membuat pilihan melakukan hubungan sex sebelum berkahwin adalah satu pilihan yang bijak jika anda menggunakan kondom untuk mencegah kahamilan tak terancang.

Bilakah  emergency contraception diperlukan?

  • Selepas hubungan sex tak terlindung, tidak menggunakan sebarang kaedah pencegah hamil
  • Bila terjadi insiden “contraceptive failure” semasa hubungan sex seperti berikut:
    • Kondom pecah atau tertanggal semas sex
    • terlupa mengambil pill perancang 3 hari berturut turut
    • gagal withdrawal – buang keluar
  • Pasangan yang jarang melakukan hubungan sex (sekali sekala)
  • Mangsa rogol
  • Melakukan sex rambang tanpa pelindungan (one nite stand)

Terdapat pelbagai jenis emergency contraception

  1. After morning Pill – Postinor (boleh didapati di farmasi)
  2. Oral contraceptive pills (OCP) – (Dose tinggi- Yuzpe regime)
  3. Alat dalam rahim (IUCD)

Cara pengambilan

emergency-contraception-300x300

Postinor atau lebih dikenali sebagai äfter morning pills” boleh di dapatkan di mana mana farmasi. Ia ialah pill hormone progestogen (levanogestrel). Ia boleh diambil terus senyak 1.5mg i.e 2 biji selepas sex dalam jangkamasa 120 jam (5 hari).  Ia juga boleh di ambil 0.75mg (1 biji) 2 kali dalam masa 12 jam setiap biji.

postinor

Postinor boleh menghalang kehamilan dengan melambatkan atau mencegah proses ovulasi dan menebalkan cervical mucus serta mengurangkan kebolehan sperma untuk mensenyawakan telur. Postinor tidak dapat menghalang kehamilan jika proses implantasi telah berlaku dan ia tidak dapat meyebabkan keguguran.

Keberkesanan: Dengan regimen ini hampir 52-94% kehamilan dapat dicegah.

Adakah ia selamat? Postinor adalah selamat digunakan dan jika kehamilan gagal dicegah, ia tidak boleh menyebabkan keguguran atau kecederaan pada bayi. Antara kesan sampingnya ialah rasa mual, dan kadang kadang muntah.

Oral contraceptive Pills (OCP): Jika farmasi di tempat anda tidak mempunyai Postinor (After Morning Pills), anda boleh menggunakan pil perancang keluarga (Mercilon, Gynera, Marvelon, etc). Oleh kerana dose progestogen bagi setiap pil perancang adalah rendah, untuk mendapat kesan pencegahan kehamilan, anda harus mengambil 5-6 biji pills dalam masa 12 jam selepas hubungan sex.  Kesan nya adalah sama seperti pill Postinor

pills

Alat Dalam Rahim (copper based IUCD): Jika anda tidak mahu mengambil ubat hormon atau hubungan sex itu telah berlaku lebih approx 5 hari, IUCD boleh digunakan sebagai langkah pencegahan dari hamil.

iud

WHO telah mencadangkan copper-bearing IUD, sebagai emergency contraceptive, dimasukkan dalam masa lima hari selepas hubungan sex tak terlindung. Ia adalah satu kaedah yang ideal untuk wanita yang ingin meneruskan pemakaian IUCD sebagai langkah pencegahan kehamilan sebelum dia bersedia untuk hamil.

Copper-bearing IUD mencegah persenyawaan daripada berlaku dengan menyebabkan perubahan chemical didalam persekitaran rahim dan menyebabkan kegagalan proses implantasi daripada berlaku. Ia 99% berkesan untuk mencegah kehamilan.

Kalau tak bersedia untuk hamil, gunakan lah kaedah kaedah pencegahan.  Janganlah sampai datang ke klinik doktor dan berkata “Dr, tolonglah saya. Saya dah hamil lagi, anak saya masih kecil, saya belum bersedia. Boleh tak cuci?”

Yang remaja pula, jika boleh tunggu, tangguhkan lah dulu hubungan sex sehingga selepas berkahwin. Tetapi jika telah berlaku kemalangan sex atau memilih untuk meneruskannya..pastikan lah anda menggunakan kaedah kaedah pencegahan kehamilan.

Oleh,

Dr Sharifah Halimah Jaafar


4 Comments

‘Douche’ Vagina: Adakah ia amalan yang selamat?

woman-in-bathroom

Apakah douching faraj ?

Perkataan ”douche” ialah perkataan Peranchis yang bermaksud ‘cuci’ ‘atau ‘rendam’. Ia ialah satu cara untuk mencuci vagina atau faraj, selalunya dengan campuran air dan cuka. Douches ada dijual di farmasi dan pasarraya mengandungi antiseptik dan pewangian. Ada terdapat pelbagai jenis dan brand douches vagina di pasaran.

Vaginal-Douche-Bottles

Kenapa sesetengah wanita gemar mengamalkan douching vagina?

Sesetengah wanita mengamalkan douching kerana mereka ingin merasa lebih bersih. Ada yang membuat douching sesekali sekala bila ada turun discharge atau keputihan yang luarbiasa atau bila mereka berasa gatal di bahagian alat sulit yang disangkakan kerana tidak cukup bersih. Walaubagaimanapun, hasil kajian scientifik tidak menunjukkan atau menyokong amalan ini.

Apakah kesan kesan buruk amalan douching vagina?

Secara umum, risiko amalan douching vagian/faraj lebih tinggi dari kebaikannya jika ada. Wanita yang selalu melakukan douching faraj berisiko untuk mendapat masalah masalah seperti berikut:

  1. Jangkitan faraj (bacterial vaginosis). Douching boleh mengganggu keseimbangan bacteria atau flora flora semulajadi yang melindungi vagina. Perubahan ini menyebabkan flora yang baik seperti lactobasillus mengurang dan bacteria yang tidak friendly menjadi kumpulan yang dominan di dalam vagina dan mengubah persekitarannya. Ia akan menyebabkan vagina mengeluarkan cecair atau lendiran yang luar biasa dan berbau busuk dan hanyir seperti bau ikan. Bacteria vaginosis juga boleh meningkatkan risiko ‘pre term labour’bagi ibu yang sedang hamil.  Dari pangalaman saya sebagai pakar gynae, ramai wanita yang mengalami masalah turun keputihan atau yang luar biasa, adalah sering dari kalangan mereka yang mengamalkan douching kerana ingin menjaga kebersihan vagina.
  2. Penyakit infamatori pelvis (PID). PID ialah infeksi pada rahim, tiub fallopian dan ovary.  Kajian menunjukkan wanita yang mengamalkan douching faraj 75% lebih berisiko untuk mendapat PID.
  3. Komplikasi Kehamilan. Wanita yang gemar melakukan douching faraj lebih dari sekali seminggu lebih sukar untuk hamil dan 76% berisiko mendapat kemilan luar rahim (ectopic pregnancy) jika hamil.
  4. Kanser pangkal rahim. Amalan douching sekurang kurangnya sekali seminggu juga dikaitkan dengan kemungkinan meningkat peluang untuk mendapat kanser pangkal rahim.

Bagaimanakah cara yang betul untuk menjaga kesihatan atau kebersihan vagina.

Sebenarnya vagina mempunyai sistem pembersihan semula jadi.  Flora flora seperti lactobasilus yang hidup didalam vagina mengeluarkan antiseptik semula jadi (HCL) dan menjadikan vagina lebih berasid, pH lebih rendah. Oleh itu, kita tidak perlu untuk membersih dalaman vagina dengan kerap.  Jika anda rasa perlu untuk mencuci dalaman vagina, memadai gunakan air paip yang bersih tanpa menggunakan agen pencuci seperti sabun, pewangi dan sebagainya. Anda hanya perlu menjaga kebersihan bahagian luar vagina selepas membuang air besar atau air kecil dan juga semasa haid.

Oleh:

SHJ

Dr Sharifah Halimah Jaafar