DISCOVER THE MOST FREQUENT
CAUSE OF VAGINAL BLEEDING

Laila Nuranna

Division of Oncology Gynecology, Department of Obstetrics and Gynecology
Faculty of Medicine, University of Indonesia

Abstract
This topic shows the various causes of vaginal bleeding, and how common these diseases or conditions are in the general population. This is not a direct indication as to how commonly these diseases are the actual cause of Vaginal bleeding, but gives a relative idea as to how frequent these diseases are seen overall
Bleeding from the vagina may be abnormal when menstrual periods are too heavy or too light, last too long, occur too frequently, or are irregular. Any vaginal bleeding that occurs before puberty or after menopause is abnormal. Some causes are more common among certain age groups.
In children, vaginal bleeding is rare. The most common cause is injury to the vulva or vagina (sometimes due to insertion of an object, such as a toy), bleeding in children may also result from puberty that starts very early (precocious puberty).
In reproductive age, vaginal bleeding may be caused by birth control methods, such as oral contraceptives (a combination of a progestin and estrogen or a progestin alone) or an intrauterine device (IUD). Abnormal bleeding may also be caused by complications of pregnancy, such as an ectopic pregnancy, or by infections of the uterus, usually after delivery of a baby or an abortion. Other causes of bleeding include blood disorders involving abnormal clotting (such as leukemia or a low platelet count), a hydatidiform mole, endometriosis, and noncancerous growths (such as adenomyosis, fibroids, cysts, and polyps). Cancer may cause bleeding in women of reproductive age. Bleeding from the vulva is usually due to injury. Thyroid disorders can cause menstrual periods to be irregular.
In postmenopausal women, vaginal bleeding may be due to atrophic vaginitis, thinning or thickening (hyperplasia) of the lining of the uterus, or polyps in the uterus. Cancer, such as cancer of the cervix, vagina, or endometrial can also cause bleeding and should be excluded by proper diagnosis procedure.
By knowing the most frequent cause of vaginal bleeding gives a relative idea as to how frequent these diseases are seen overall, and then more important is to develop appropriate diagnosis. How to diagnose? Identify the age, the type of bleeding, during pregnant or not, is there any organ abnormality or related with hormonal imbalance.
Further procedure may support the diagnosis, identify the symptoms and the results of a physical examination (including a pelvic examination). And additional procedures may be needed. Procedures may include a Papanicolaou (Pap) test, a biopsy of the cervix, and dilation and curettage (D and C). Ultrasonography using an ultrasound device inserted through the vagina into the uterus (transvaginal ultrasonography) can determine whether the uterine lining is thickened. A biopsy of cells obtained during dilation and curettage can determine if the thickening is due to cancer.

SEE AND TREAT IN PROACTIVE-VO MODEL
OF CERVICAL CANCER PREVENTION IN DEVELOPING COUNTRY
(Indonesian Perspective)

Laila Nuranna,1 M Farid Aziz1, Santoso Cornain,2 Setyawati Budiningsih,3
Gatot Purwoto,1 Yunita Indarti,1 Budiningsih Siregar2
1Department of Obstetrics and Gynecology,
2 Department of Pathologic Anatomy,
3 Department of Community Medicine
Faculty of Medicine, University of Indonesia


Abstract
Objective: to obtain a model for the cervical cancer prevention which appropriate for country with low resource setting.

Methods: Research design is an interventional study in community setting for cervical cancer control. This study was conducted in Pademangan Sub-district, North Jakarta, in the study was conducted from 2003 to 2004. And the other study was done in Jakarta, Tasikmalaya, and Bali with 22.035 respondents from 2004 to 2006

Results:
Cervical cancer is a leading cancer in Indonesian women. Indonesia as developing country has major problem of cervical cancer because most of the cases (< 65%) were diagnosed at the advanced stage.
Screening programme based on Pap test was difficult to be applied in low resource setting, the alternative methods is Visual Inspection with Acetic Acid (VIA).We should anticipate high number cases of loss of follow up for further treatment, and the alternative is cryotherapy in one single visit or we call SEE and TREAT.
We need supporting of political will, women empowerment, community education, appropriate screening method. We combined the See and Treat and how to implement at the community in comprehensive approach, we call it PROACTIVE-VO model, which constituted a series of proactive and coordinated activity, and was consists of five pillars of area preparation, training for provider, promotion and education, see and treat by VIA and cryotherapy, and referral for invasive cases.
In Indonesia, one study in Pademangan, North Jakarta, on 6.293 respondents. It was study in community setting with model named Proactive-VO (Proactive, Coordinative with VIA, and Cryotherapy). Community counseling was performed by PKK (Pendidikan Kesejahteraan Keluarga = Family Welfare Empowerment) health cadres. And the other study was done in Jakarta, Tasikmalaya, and Bali with 22.035 respondents.
From the first study the accuracy of VIA compared with Pap test, in the case of CIN, VIA sensitivity was 92.82% with specificity of 98.97%. Kappa of 0.52. Effectivity of cryotherapy, which evaluated after 6 months, on LSIL was cured 88, 1% and on HSIL was 74.2%. Follow up at the first phase was 48.3% and at the second phase after 6 months was 65.2%
Conclusions: VIA is a good alternative screening method, and cryotherapy is a promising way to treat pracancer lesions in this low resource setting. This model is recommended for cervical cancer prevention with wider coverage to identify precancerous lesions of the cervix. The method should apply in comprehensive approach, we call it PROACTIVE-VO Model.

Key words: Cervical cancer, cancer screening, VIA, pap test, cryotherapy, see and treat, screening coverage, cervical cancer prevention model.