Postmenopause Bleeding

Definition

Postmenopausal bleeding is bleeding from the reproductive system that occurs six months or more after menstrual periods have stopped due to menopause.

Description

Menopause, the end of ovulation and menstrual periods, naturally occurs for most women age 40-55 years. The process of ending ovulation and menstruation is gradual, spanning one to two years.

Postmenopausal bleeding is bleeding that occurs after menopause has been established for at least six months. It is different from infrequent, irregular periods (oligomenorrhea) that occur around the time of menopause.

Many women experience some postmenopausal bleeding. However, postmenopausal bleeding is not normal. Because it can be a symptom of a serious medical condition, any episodes of postmenopausal bleeding should be brought to the attention of a woman’s doctor.

Women taking estrogen (called hormone replacement therapy or HRT) are more likely to experience postmenopausal bleeding. So are obese women, because fat cells transform male hormones (androgens) secreted by the adrenal gland into estrogen.

Causes and symptoms

Postmenopausal bleeding can originate in different parts of the reproductive system. Bleeding from the vagina may occur because when estrogen secretion stops, the vagina dries out and can diminish (atrophy). This is the most common cause of bleeding from the lower reproductive tract.

Lesions and cracks on the vulva may also bleed. Sometimes bleeding occurs after intercourse. Bleeding can occur with or without an associated infection.

Bleeding from the upper reproductive system can be caused by:

• hormone replacements
• endometrial cancer
• endometrial polyps
• cervical cancer
• cervical lesions
• uterine tumors
• ovarian cancer
• estrogen-secreting tumors in other parts of the body

The most common cause of postmenopausal bleeding is HRT. The estrogen in the replacement therapy eases the symptoms of menopause (like hot flashes), and decreases the risk of osteoporosis. Sometimes this supplemental estrogen stimulates the uterine lining to grow. When the lining is shed, postmenopausal bleeding occurs. Most women on HRT usually take the hormone progesterone with the estrogen, and may have monthly withdrawal bleeding. This is a normal side effect.

About 5-10% of postmenopausal bleeding is due to endometrial cancer or its precursors. Uterine hyperplasia, the abnormal growth of uterine cells, can be a precursor to cancer.

Diagnosis

Diagnosis of postmenopausal bleeding begins with the patient. The doctor will ask for a detailed history of how long postmenopausal bleeding has occurred. A woman can assist the doctor by keeping a record of the time, frequency, length, and quantity of bleeding. She should also tell the doctor about any medications she is taking, especially any estrogens or steroids.

After taking the woman’s history, the doctor does a pelvic examination and Pap test. The doctor will examine the vulva and vagina for signs of atrophy, and will feel for any sign of uterine polyps. Depending on the results of this examination, the doctor may want to do more extensive testing.

Invasive diagnostic procedures

Endometrial biopsy allows the doctor to sample small areas of the uterine lining, while cervical biopsy allows the cervix to be sampled. Tissues are then examined for any abnormalities. This is a simple office procedure.

Dilatation and curettage (D & C) is often necessary for definitive diagnosis. This is done under either general or local anesthesia. After examining the tissues collected by an endometrial biopsy or D & C, the doctor may order additional tests to determine if an estrogen-secreting tumor is present on the ovaries or in another part of the body.

Non-invasive diagnostic procedures

With concerns about the rising cost of health care, vaginal probe ultrasound is increasingly being used more than endometrial biopsy to evaluate women with postmenopausal bleeding. Vaginal ultrasound measures the thickness of the endometrium. When the endometrial stripe is less than 0.2 in (5 mm) thick, the chance of cancer is less than 1%. The disadvantage of vaginal ultrasound is that it often does not show polyps and fibroids in the uterus.

A refinement of vaginal probe ultrasound is saline infusion sonography (SIS). A salt water (saline) solution is injected into the uterus with a small tube (catheter) before the vaginal probe is inserted. The presence of liquid in the uterus helps make any structural abnormalities more distinct. These two non-invasive procedures cause less discomfort than endometrial biopsies and D & Cs, but D & C still remains the definitive test for diagnosing uterine cancer.

Treatment

It is common for women just beginning HRT to experience some bleeding. Most women who are on HRT also take progesterone with the estrogen and may have monthly withdrawal bleeding. Again, this is a normal side effect that usually does not require treatment.

Postmenopausal bleeding due to bleeding of the vagina or vulva can be treated with local application of estrogen or HRT.

When diagnosis indicates cancer, some form of surgery is required. The uterus, cervix, ovaries, and fallopian tubes may all be removed depending on the type and location of the cancer. If the problem is estrogen- or androgen-producing tumors elsewhere in the body, these must also be surgically removed. Postmenopausal bleeding that is not due to cancer and cannot be controlled by any other treatment usually requires a hysterectomy.

Prognosis

Response to treatment for postmenopausal bleeding is highly individual and is not easy to predict. The outcome depends largely on the reason for the bleeding. Many women are successfully treated with hormones. As a last resort, hysterectomy removes the source of the problem by removing the uterus. However, this operation is not without risk and the possibility of complications. The prognosis for women who have various kinds of reproductive cancer varies with the type of cancer and the stage at which the cancer is diagnosed.

Prevention

Postmenopausal bleeding is not a preventable disorder. However, maintaining a healthy weight will decrease the chances of it occurring.

Key Terms

Dilation and curettage (D & C)

A procedure performed under anesthesia during which the cervix is opened more (or dilated) and tissue lining the uterus is scraped out with a metal, spoon-shaped instrument or a suction tube. The procedure can be used to diagnose a problem or to remove growths (polyps).

Endometrial biopsy

The removal of uterine tissue samples either by suction or scraping; the cervix is not dilated. The procedure has a lower rate of diagnostic accuracy than D & C, but can be done as an office procedure under local anesthesia.

Endometrium

The tissue lining the inside of the uterus.

Fibroid tumors

Non-cancerous (benign) growths in the uterus. These growths occur in 30-40% of women over age 40, and do not need to be removed unless they are causing symptoms that interfere with a woman’s normal activities.

Osteoporosis

The excessive loss of calcium from the bones, causing the bones to become fragile and break easily. Postmenopausal women are especially vulnerable to this condition because estrogen, a hormone that protects bones against calcium loss, decreases drastically after menopause.

Bartholin’s gland cyst

Definition

A Bartholin’s gland cyst is a swollen fluid-filled lump that develops from a blockage of one of the Bartholin’s glands, which are small glands located on each side of the opening to the vagina. Bartholin’s gland cysts and abscesses are commonly found in women of reproductive age, developing in approximately 2% of all women.

Description

The Bartholin’s glands are located in the lips of the labia that cover the vaginal opening. The glands (normally the size of a pea) provide moisture for the vulva area. A Bartholin’s gland cyst may form in the gland itself or in the duct draining the gland. A cyst normally does not cause pain, grows slowly, and may go away without treatment. It usually ranges in size from 0.4-1.2 in. (1-3 cm), although some may grow much larger.

If infected, a Bartholin’s gland cyst can form an abscess that will increase in size over several days and is very painful. In order to heal, a Bartholin’s gland cyst usually must be drained.

Causes and symptoms

A Bartholin’s gland cyst occurs if the duct becomes blocked for any reason, such as infection, injury, or chronic inflammation. Very rarely a cyst is caused by cancer, which usually occurs only in women over the age of 40. In many cases, the cause of a Bartholin’s gland cyst is unknown.

Symptoms of an uninfected Bartholin’s gland cyst include a painless jump on one side of the vulva area (most common symptom) and redness or swelling in the vulva area.

Symptoms of an abscessed Bartholin’s gland include:

• pain that occurs with walking, sitting, physical activity, or sexual intercourse
• fever and chills
• increased swelling in the vulva area over a two- to four-day period
• drainage from the cyst, normally occurring four to five days after the swelling starts

Abscesses may be caused by sexually transmitted bacteria, such as those causing chlamydial or gonococcal infections, while others are caused by bacteria normally occurring in the vagina. Over 60 types of bacteria have been found in Bartholin’s gland abscesses.

Diagnosis

A Bartholin’s gland cyst or abscess is diagnosed by a gynecological pelvic exam. If the cyst appears to be infected, a culture is often performed to identify the type of bacteria causing the abscess.

Treatment

Treatment for this condition depends on the size of the cyst, whether it is painful, and whether the cyst is infected.

If the cyst is not infected, treatment options include:

• watchful waiting by the woman and her health care professional
• soaking of the genital area with warm towel compresses
• soaking of the genital area in a sitz bath
• use of non-prescription pain medication to relieve mild discomfort

If the Bartholin’s gland is infected, there are several treatments available to treat the abscess, including:

• soaking of the genital area in a sitz bath
• treatment with antibiotics
• use of prescription or non-prescription pain medication
• incision and drainage, i.e., cutting into the cyst and draining the fluid (not usually successful, as the cyst often reoccurs)
• placement of a drain (Word catheter) in the cyst for two to four weeks so fluid can drain and prevent reoccurrence of the cyst
• marsupialization
• window operation
• use of a carbon dioxide laser to open the cyst and heat the cyst wall tissue so that the cyst cannot form a sac and reoccur
• incision and drainage, followed by treatment with silver nitrate to burn the cyst wall so the cyst cannot form a sac and reoccur
• removal of the entire Bartholin’s gland cyst, if the cyst has reoccurred several times after use of other treatment methods

During surgical treatment, the area will be numbed with a local anesthetic to reduce pain. General anesthesia may be used for treatment of an abscess, as the procedure can be painful.

In a pregnant woman, surgical treatment of cysts that are asymptomatic should be delayed until after delivery to avoid the possibility of excessive bleeding. However, if the Bartholin’s gland is infected and must be drained, antibiotics and local anesthesia are generally considered safe.

If the cyst is caused by cancer, the gland must be excised, and the woman should be under the care of a gynecologist familiar with the treatment of this type of cancer.

Alternative treatment

If a Bartholin’s gland cyst has no or mild symptoms, or has opened on its own to drain, a woman may decide to use watchful waiting, warm sitz baths, and non-prescription pain medication. If symptoms become worse or do not improve, a health care professional should then be consulted.

Infected Bartholin’s glands should be evaluated and treated by a health care professional.

Prognosis

A Bartholin’s gland cyst should respond to treatment in a few days. If an abscess requires surgery, healing may take days to weeks, depending on the size of the abscess and the type of surgical procedure used. Most of the surgical procedures, except for incision and drainage, should be effective in preventing recurring infections.

Prevention

There are few ways to prevent the formation of Bartholin’s gland cysts or abscesses. However, as a Bartholin’s gland abscess may be caused by a sexually transmitted disease, the practice of safe sex is recommended. Using good hygiene, i.e., wiping front to back after a bowel movement, is also recommended to prevent bacteria from the bowels from contaminating the vaginal area.

Key Terms

Marsupialization

Cutting out a wedge of the cyst wall and putting in stitches so the cyst cannot reoccur.

Sitz bath

A warm bath in which just the buttocks and genital area soak in water; used to reduce pain and aid healing in the genital area.

Window operation

Cutting out a large oval-shaped piece of the cyst wall and putting in stitches to create a window so the cyst cannot reoccur.

Word catheter

A small rubber catheter with an inflatable balloon tip that is inserted into a stab incision in the cyst, after the contents of the cyst have been drained.

Puerperal Infection

Definition

The term puerperal infection refers to a bacterial infection following childbirth. The infection may also be referred to as puerperal or postpartum fever. The genital tract, particularly the uterus, is the most commonly infected site. In some cases infection can spread to other points in the body. Widespread infection, or sepsis, is a rare, but potentially fatal complication.

Description

Puerperal infection affects an estimated 1-8% of new mothers in the United States. Given modern medical treatment and antibiotics, it very rarely advances to the point of threatening a woman’s life. An estimated 2-4% of new mothers who deliver vaginally suffer some form of puerperal infection, but for cesarean sections, the figure is five-10 times that high.

Deaths related to puerperal infection are very rare in the industrialized world. It is estimated three in 100,000 births result in maternal death due to infection. However, the death rate in developing nations may be 100 times higher.

Postpartum fever may arise from several causes, not necessarily infection. If the fever is related to infection, it often results from endometritis, an inflammation of the uterus. Urinary tract, breast, and wound infections are also possible, as well as septic thrombophlebitis, a blood clot-associated inflammation of veins. A woman’s susceptibility to developing an infection is related to such factors as cesarean section, extended labor, obesity, anemia, and poor prenatal nutrition.

Causes and symptoms

The primary symptom of puerperal infection is a fever at any point between birth and 10 days postpartum. A temperature of 100.4°F (38°C) on any two days during this period, or a fever of 101.6°F (38.6 °C) in the first 24 hours postpartum, is cause for suspicion. An assortment of bacterial species may cause puerperal infection. Many of these bacteria are normally found in the mother’s genital tract, but other bacteria may be introduced from the woman’s intestine and skin or from a healthcare provider.

The associated symptoms depend on the site and nature of the infection. The most typical site of infection is the genital tract. Endometritis, which affects the uterus, is the most prominent of these infections. Endometritis is much more common if a small part of the placenta has been retained in the uterus. Typically, several species of bacteria are involved and may act synergistically–that is, the bacteria’s negative effects are multiplied rather than simply added together. Synergistic action by the bacteria can result in a stubborn infection such as an abscess. The major symptoms of a genital tract infection include fever, malaise, abdominal pain, uterine tenderness, and abnormal vaginal discharge. If these symptoms do not respond to antibiotic therapy, an abscess or blood clot may be suspected.

Other causes of postpartum fever include urinary tract infections, wound infections, septic thrombophlebitis, and mastitis. Mastitis, or breast infection, is indicated by fever, malaise, achy muscles, and reddened skin on the affected breast. It is usually caused by a clogged milk duct that becomes infected. Infections of the urinary tract are indicated by fever, frequent and painful urination, and back pain. An episiotomy and a cesarean section carry the risk of a wound infection. Such infections are suggested by a fever and pus-like discharge, inflammation, and swelling at wound sites.

Diagnosis

Fever is not an automatic indicator of puerperal infection. A new mother may have a fever owing to prior illness or an illness unconnected to childbirth. However, any fever within 10 days postpartum is aggressively investigated. Physical symptoms such as pain, malaise, loss of appetite, and others point to infection.

Many doctors initiate antibiotic therapy early in the fever period to stop an infection before it advances. A pelvic examination is done and samples are taken from the genital tract to identify the bacteria involved in the infection. The pelvic examination can reveal the extent of infection and possibly the cause. Blood samples may also be taken for blood counts and to test for the presence of infectious bacteria. A urinalysis may also be ordered, especially if the symptoms are indicative of a urinary tract infection.

If the fever and other symptoms resist antibiotic therapy, an ultrasound examination or computed tomography scan (CT scan) is done to locate potential abscesses or blood clots in the pelvic region. Magnetic resonance imaging (MRI) may be useful as well, in addition to a heparin challenge test if blood clots are suspected. If a lung infection is suspected, a chest x ray may also be ordered.

Treatment

Antibiotic therapy is the backbone of puerperal infection treatment. Initial antibiotic therapy may consist of clindamycin and gentamicin, which fight a broad array of bacteria types. If the fever and other symptoms do not respond to these antibiotics, a third, such as ampicillin, is added. Other antibiotics may be used depending on the identity of the infective bacteria and the possibility of an allergic reaction to certain antibiotics.

Antibiotics taken together are effective against a wide range of bacteria, but may not be capable of clearing up the infection alone, especially if an abscess or blood clot is present. Heparin is combined with the antibiotic therapy in order to break apart blood clots. Heparin is used for five-seven days, and may be followed by warfarin for the following month. If the infection is complicated, it may be necessary to surgically drain the infected site. Infected episiotomies can be opened and allowed to drain, but abscesses and blood clots may require surgery.

Prognosis

Antibiotic therapy and other treatment measures are virtually always successful in curing puerperal infections.

Prevention

Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. With some procedures, such as cesarean section, a doctor may administer prophylactic antibiotics as a preemptive strike against infectious bacteria.

Key Terms

Abscess

A pus-filled area with definite borders.

Blood clot

A dense mat formed by certain components of the blood stream to prevent blood loss.

Cesarean section

Incision through the abdomen and uterus to facilitate delivery.

Computed tomography scan (CT scan)

Cross-sectional x rays of the body are compiled to create a three-dimensional image of the body’s internal structures.

Episiotomy

Incision of the vulva (external female genitalia) during vaginal delivery to prevent tissue tearing.

Heparin

A blood component that controls the amount of clotting. It can be used as a drug to reduce blood clot formation.

Heparin challenge test

A medical test to evaluate how readily the blood clots.

Magnetic resonance imaging (MRI)

An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.

Postpartum

Referring to the time period following childbirth.

Prophylactic

Measures taken to prevent disease.

Sepsis

The presence of viable bacteria in the blood or body tissues.

Septic

Referring to the presence of infection.

Thrombophlebitis

An inflammation of veins accompanied by the formation of blood clots.

Ultrasound examination

A medical test in which high frequency sound waves are directed at a particular internal area of the body. As the sound waves are reflected by internal structures, a computer uses the data to construct an image of the structures.

Warfarin

A drug that reduces the ability of the blood to clot.

Mastitis

Definition

Mastitis is an infection of the breast. It usually only occurs in women who are breastfeeding their babies.

Description

Breastfeeding is the act of allowing a baby to suckle at the breast to drink the mother’s milk. In the process, unaccustomed to the vigorous pull and tug of the infant’s suck, the nipples may become sore, cracked, or irritated. This creates a tiny opening in the breast, through which bacteria can enter. The presence of milk, with high sugar content, gives the bacteria an excellent source of nutrition. Under these conditions, the bacteria are able to multiply, until they are plentiful enough to cause an infection within the breast.

Mastitis usually begins more than two to four weeks after delivery of the baby. It is a relatively uncommon complication of breastfeeding mothers, occurring in only approximately 3% to 5% of nursing women.

Causes and symptoms

The most common bacteria causing mastitis is called Staphylococcus aureus. In 25-30% of people, this bacteria is present on the skin lining normal, uninfected nostrils. It is probably this bacteria, clinging to the baby’s nostrils, that is available to create infection when an opportunity (crack in the nipple) presents itself.

Usually, only one breast is involved. An area of the affected breast becomes swollen, red, hard, and painful. Other symptoms of mastitis include fever, chills, and increased heart rate.

Diagnosis

Diagnosis involves obtaining a sample of breast milk from the infected breast. The milk is cultured, allowing colonies of bacteria to grow. The causative bacteria then can be specially prepared for identification under a microscope. At the same time, tests can be performed to determine what type of antibiotic would be most effective against that particular bacteria. Sometimes, women and their physicians confuse mastitis with breast engorgement, or the tenderness and redness that appears when milk builds up in the breasts. Mastitis often can be distinguished if symptoms are accompanied by fever.

Treatment

A number of antibiotics are used to treat mastitis, including cephalexin, amoxicillin, azithromycin, dicloxacillin, and clindamycin. Breastfeeding usually should be continued, because the rate of abscess formation (an abscess is a persistent pocket of pus) in the infected breast goes up steeply among women who stop breastfeeding during a bout with mastitis. Most practitioners allow women to take acetaminophen while nursing, to relieve both fever and pain. As always, breastfeeding women need to make sure that any medication they take is also safe for the baby, since almost all drugs they take appear in the breastmilk. Warm compresses applied to the affected breast can be soothing.

Prognosis

Prognosis for uncomplicated mastitis is excellent. About 10% of women with mastitis will end up with an abscess within the affected breast. An abscess is a collection of pus within the breast. This complication will require a surgical procedure to drain the pus.

Prevention

The most important aspect of prevention involves good handwashing to try to prevent the infant from acquiring the Staphylococcus aureus bacteria in the first place. Keeping the breast clean before breastfeeding also helps prevent infection. Keeping the breasts from becoming engorged may help prevent mastitis by preventing plugging of milk ducts.

Breast Cancer

What is cancer?

Cancer is the uncontrolled growth of cells in an organ (such as the breast, cervix, ovary or lung). Cancer cells grow together to form a mass called a tumor. Cancer is life threatening because cancer cells can invade surrounding tissue and spread through the bloodstream or lymphatic system to distant parts of the body (metastasize). Early detection before the cancer spreads provides the best chance of cure.

What is breast cancer?

Breast cancer is the most common type of cancer in women. Men can also develop breast cancer, but it is rare, accounting for less than 1 percent of all cases. Breast tumors, both benign and malignant, can develop in any part of the breast. Most tumors, however, arise from ducts that carry milk from the lobule, where milk is produced, to the nipple. About one in seven adult women in the United States develop breast cancer. If detected at an early stage when the tumor has not spread to lymph nodes, most women, about 97 percent, are cured. Early detection of breast cancer is due mainly to annual mammography screening and physical breast examinations.

The breasts are actually glands that prepare, store and dispense milk.

Each breast is divided into lobules, made up of a tight network of glands, bound together by elastic (connective) tissue that empties into ducts lined by muscle cells. Each area of the breast and each cell type respond differently to hormone changes every month. Some areas soften while other areas become more firm. Knowing this helps to explain why you may feel differences in contour and consistency.

Get to know your breasts

Each month, examine your breasts and develop a familiarity with the usual appearance and feel of your breasts. Since the breast tissue changes with monthly hormone fluctuations, you will notice changes come and go. Most breasts have some areas of “lumpiness” that are perfectly normal. If you have such an area in one breast, check the surrounding area, then the opposite breast. At the same time each month, feel for areas that are different than the surrounding breast tissue and ask yourself:

• How large is this lumpy area?
• Is there just one or more than one lump?
• Did I have this last month?
• Is there a similar lumpiness on the other breast in the same place?

In addition to lumpiness, look for the following:

• Dimpling or puckering of the skin anywhere on the breast.
• Change in skin color or texture or the presence of a rash.
• Bloody or clear fluid leaking from the nipple.
• A visible lump.

Detecting Breast Lump

Mammograms

An x-ray of the breast known as a mammogram can detect some cancers that are too small to be felt. However, sometimes lumps that can be felt are not detected in a mammogram. Women of all ages should have their breasts examined every year by a physician or trained health professional.

Much controversy has taken place about when it is best for women to begin getting regular mammograms. Based on recent research data, the National Cancer Institute recommends that:

• All women in their 40s or older who are at average risk for breast cancer should have screening mammograms every one to two years. (The American Cancer Society suggests annual mammograms.)

• All women who are at higher risk for breast cancer should ask their doctors about when and how often to schedule screening mammograms.

There are two kinds of mammography:

• Screening – x-rays that are used to look for breast changes in women who have no signs of breast cancer.

• Diagnostic – prescribed for women who have unusual breast changes, such as a lump, pain, nipple thickening or discharge, changes in breast size or shape, or who have had a suspicious screening mammogram.

Don’t simply assume that a mammogram is normal if your doctor doesn’t contact you with results. Call and ask.

Clinical Breast Exam

Because some cancers cannot be detected in mammograms, women also should have periodic breast exams by a doctor or nurse. The provider will examine your breasts while you are sitting and while you are lying down.

The provider looks for:

• Changes in the skin, such as dimpling, scaling or puckering.
• Nipple discharge or nipple inversion.
• Difference in size or shape between the two breasts.

Breast Self Examination (BSE)

Women should begin examining their breasts each month beginning around age 20. Doctors are urged to talk with their patients about the limitations of BSE. Research has shown BSE plays a small role in detecting breast cancer compared with mammograms, clinical exams and self-awareness. (Self-awareness is being familiar with how your healthy breasts feel and look like.)

The American Cancer Society (ACS) says evidence does not show monthly BSE has any advantage over annual mammograms and exams by your doctor. The ACS urges you not to substitute BSE for regular mammograms and a doctor’s exam. However, the ACS still says BSE is one way for women to know how their breasts normally feel and to notice any changes. Mammograms continue to be the gold standard in breast cancer detection and can pick up tumors several years before a lump can be felt.

The best time to do BSE is two to three days after completion of the menstrual period. Although the following information provides general guidelines, it’s best to ask your health care provider to show you how to perform BSE to be certain you are doing it correctly.

First, look in the mirror and see if you detect any lumps or thickness, swelling, puckering, dimpling, redness or soreness of the skin, as well as changes in nipple size or shape. Also squeeze the nipple to see if there is any discharge.

Standing upright with one hand behind the head, use the flats of your fingertips to gently feel the breast, making small circles around the nipple, then make larger and larger circles as you work your way around the entire breast. Change and repeat the process on the other breast. Complete the same process while lying down. Also feel the collarbone area and the armpit on each side.

Ultrasound

Ultrasound sends high-frequency sound waves into the breast, creating patterns of echoes that are converted into an image of the breast’s interior (a sonogram). Ultrasound is used to help radiologists evaluate some lumps that can be felt but are hard to see on a mammogram. It distinguishes cysts (fluid filled lesions) from solid masses in the breast. However, unlike mammography, ultrasound cannot detect small tumors. It can help with deciding the extent of breast abnormalities, especially for surgical resection.

Magnetic Resonance Imaging (MRI)

The use of MRI for detecting breast cancer is coming out of the research stage and into clinical practice and is available in selected centers. MRI uses radiowaves and magnets, a special breast coil and a computer to scan the patient to produce its images. Its usefulness in identifying tissues that are abnormally active is being studied. MRI can be helpful in deciding the extent of breast abnormalities, especially for surgical resection. It is also used along with mammography for women with dense breasts and those who are at high risk. It can help tell between a benign and cancerous lump.

Is That Lump Breast Cancer?

Not all lumps in the breast are cancerous. In fact, four-fifths of all breast lumps are not cancer. Some common benign breast changes include:

• Fibrocystic disease: Generalized breast lumpiness that may become more obvious as a woman approaches middle age and the milk-producing glandular tissue gives way to soft, fatty tissue.

• Cyclic breast changes: Associated with changes during the menstrual cycle due to extra fluid collecting in the breast cycle. Lumps usually go away by the end of the menstrual period.

• Cysts: Fluid-filled sacs that often enlarge and become tender just before the menstrual period. This is diagnosed with ultrasound and is usually treated by observation or by fine needle aspiration.

• Fibroadenomas: Solid, round tumors made up of tissue. They feel rubbery and can be moved around easily. Although they sometimes can be diagnosed with fine needle aspiration, most surgeons believe that it is a good idea to remove fibroadenomas to make sure they are benign.

• Fat Necrosis: Round, firm lumps formed by damaged and disintegrating fatty tissues, typically occurring in obese women with very large breasts.

• Sclerosing adenosis: Excessive growth of tissues in the breast’s lobules, frequently causing breast pain. Without a biopsy, adenosis can be difficult to distinguish from cancer.

The only certain way to learn whether a breast lump or abnormality is cancerous is by having a biopsy.

In this procedure, a surgeon removes some of the suspicious breast tissue that is examined under a microscope by a pathologist. There are different forms of biopsy. The doctor determines which technique is best, depending on the nature and location of the lump and the woman’s overall health status.

Biopsy Methods

• Fine needle aspiration: Uses a very thin needle and syringe to remove either fluid from a cyst or clusters of cells from a solid mass. It can be the first diagnostic technique, depending on the availability of the expert cytologist.

• Excisional biopsy: Generally used for lumps smaller than an inch in diameter, it removes the entire suspicious area along with a small margin of normal tissue. Usually performed in an outpatient department of a hospital with the use of local anesthesia.

• Incisional biopsy: Slices a portion of the tumor for the pathologist to examine. Generally used for larger tumors with the use of local anesthesia.

• Core needle biopsy: Uses a somewhat larger needle with a special cutting edge to remove a small core of tissue. This technique may not work well for lumps that are very hard or very small.

• Localization biopsy: Uses mammography or ultrasound to locate and a needle or wire to localize the tissue for biopsy (core, excision or FNA). Often used for deeper, non-palpable lumps.

• Stereotactic localization biopsy: Uses a 3-D X-ray to guide the needle or wire to localize the tissue for biopsy (core, excision or FNA), with a computer plotting the exact position of the suspicious area.

The Pathologist/Cytologist

The pathologist is a specialist who examines cells or tissues under a microscope, looking for abnormal cell shapes and unusual growth patterns. It is important to have a pathologist who is experienced in diagnosing breast cancer evaluate your biopsy slides.

Bring someone along to share the conversation with your doctor and use a tape recorder when you are learning about your biopsy results. If the diagnosis is cancer, you may be too upset to fully take in important information your doctor gives you. Another set of eyes and ears can help. Use the tape recorder to recall and review vital information with family and/or friends if the diagnosis is cancer.

If there is any question about the results of your biopsy, you will want to make sure your biopsy slides have been reviewed by more than one pathologist (second opinion).

Understanding Breast Cancer Staging

t is not uncommon for a woman to hear the word “cancer” and then to completely block out anything the doctor may say after that. No woman can ever be truly prepared to hear that she has cancer.

No matter what type of breast cancer you have, the effect it has on you depends on a number of factors, including your general health. But one of the most important things you can do for yourself is to find others who have already gone through the anxiety of breast cancer to help you through the fear and worry. Now is not the time to withdraw. Learn all you can about breast cancer – knowledge is power.

Understanding the stages of breast cancer

Breast cancer usually is diagnosed as falling into one of five stages. How your cancer is staged and your treatment choices will depend on:

• How small or large your tumor’s size is and where it is found in your breast
• If cancer is found in the lymph nodes in your armpit
• If cancer is found in other parts of your body

Here are some terms sometimes used to describe cancer:

• Malignant: the biopsy revealed the presence of cancer cells
• In situ or noninvasive: a very early cancer or precancer that has not spread beyond the breast
• Invasive: cancer has spread to surrounding tissue in the breast and may have spread to the lymph nodes in the armpit or to other parts of the body
• Metastasized: the cancer has spread to other parts of the body, such as the bones, lungs, liver or brain

Staging of breast cancer

Stage 0

Very early breast cancer or pre-invasive cancer that has not spread within or outside the breast.

Stage I

Tumor smaller than 2 centimeters (cm) (1 inch). No cancer is found in lymph nodes in the armpit, or outside the breast.

Stage II

Tumor smaller than 2 cm (1 inch). Cancer is found in the lymph nodes in the armpit.

or

Tumor between 2 cm and 5 cm (1 and 2 inches). Cancer may or may not be found in the lymph nodes in the armpit.

or

Tumor larger than 5 cm (2 inches). Cancer is not found in the lymph nodes in the armpit.

Stage III

Tumor smaller than 5 cm (2 inches), with cancer also in the lymph nodes that are stuck together.

or

Tumor larger than 5 cm (2 inches) or cancer is attached to other parts of the breast area including the chest wall, ribs and muscles.

or

Inflammatory breast cancer. In this rare type of cancer, the skin of the breast is red and swollen.

Stage IV

Tumor has spread to other parts of the body, such as the bones, lungs, liver or brain.

Prognosis

Once your doctor has determined the type and stage of breast cancer, your chance of recovery will depend on many factors, including:

• The type and stage of cancer
• How fast and how aggressively the cancer is growing
• How much the breast cancer cells depend on female hormones for growth, measured by hormone receptor tests; tumors that are hormone-dependent (estrogen/progesterone receptor positive) can be treated by hormonal therapy
• Your age and menopausal status
• Your general state of health
• Your mental health and ability to cope with problems

It will be difficult to accept your diagnosis at first, but over time, that may change. A positive attitude and the support of friends and family will not only help you through this ordeal, but may even contribute to your recovery, experts say.

Making decisions

Treatments for breast cancer vary, depending on an individual’s situation. In the past, doctors used to perform biopsies and remove breasts all in the same operation. This rarely happens today. Women need time to absorb biopsy results, learn about their options and perhaps get a second opinion. The advantage of a FNA (fine needle aspiration) gives the patient time to assess her surgical options.

Gone are the days when doctors firmly told patients what was best. Today, patients bear more and more responsibility for speaking with a variety of medical experts, gathering as much information as possible and choosing from several treatment options.

When your doctor tells you that you have breast cancer, you feel overwhelmed with emotions and miss important information. Be sure to bring someone with you and a tape recorder so you can review what your doctor has told you about your disease.

Also, be sure to find others who have already gone through the anxiety of breast cancer to help you through the fear and worry. Now is not the time to withdraw.

Treatment

There are several treatment options. Often, more than one treatment is used.

• Surgery: taking out the cancer in an operation.

• Radiation therapy: using high-dose X-rays to kill cancer cells or keep them from dividing and growing.

• Chemotherapy: using anti-cancer drugs to kill or stop the growth of cancer cells.

• Hormonal therapy: using hormones to stop cancer cells from growing.

• Biological therapy (immunotherapy): using the immune system to fight cancer or to lessen the side effects that may be caused by some cancer treatments. Many biological therapies are being tested in clinical trials. See below for more information

Types of surgery

• Lumpectomy: A surgeon removes the breast cancer, a little normal breast tissue around the lump, and some lymph nodes under the arm. The surgeon is trying to totally remove the cancer, altering the breast as little as possible. Lumpectomy is usually accompanied by radiation therapy to destroy any remaining cancer cells.

• Total mastectomy: The surgeon removes the entire breast. Some lymph nodes under the arm may be removed also.

• Partial mastectomy: This surgery conserves as much as the breast as possible. Some breast tissue is removed, as well as the lining over the chest muscles below the tumor and usually some of the lymph nodes under the arm. Radiation therapy usually follows.

• Modified radical mastectomy: The surgeon removes the breast, some of the lymph nodes under the arm, the lining over the chest muscles and sometimes part of the chest wall muscles.

• Radical mastectomy: The surgeon removes the breast, chest muscles and all the lymph nodes under the arm. The standard operation for many years, it is used now only rarely when the cancer has spread to the chest muscles. There is no survival advantage if one has local therapy (lumpectomy or partial mastectomy plus radiation treatment versus modified radical mastectomy).

• A sentinel node biopsy: This is a technique that helps determine if a cancer has spread (metastasized), or is contained locally.

Radiation therapy

High-energy X-rays are used to destroy cancer cells that might still be present in the breast tissue. Doctors sometimes use radiation therapy following a lumpectomy or mastectomy, before or, rarely, instead of surgery and/or in conjunction with chemotherapy. Possible problems: feeling more tired than usual; skin reactions such as itching, redness, soreness, peeling, darkening, or shininess, and decreased sensation, and in some cases problems swallowing. Radiation does NOT cause hair loss, vomiting, or diarrhea. Depending on their risk analysis, women over 70 years of age may not require radiation therapy after surgery.

Chemotherapy

Even when a lump is small, cells may have broken off and spread outside the breast. Doctors can use chemotherapy to destroy them, using either a single drug or a combination of drugs.

The drugs often are injected into the bloodstream through an intravenous needle that is inserted into a vein, but sometimes they are administered as a pill. Adjuvant treatment to reduce the risk of cancer recurrence usually ranges from three to six months. Possible problems: hair loss, loss of appetite, nausea, vomiting, diarrhea, constipation, fatigue, infections, bleeding, weight change, mouth sores and throat soreness, infertility, early menopause, weakening of the heart, reduced ovarian function, damage to ovaries, secondary cancers such as leukemia.

These drugs are also used when the risk for recurrence is high such as having an aggressive (high risk) pathology of your cancer, if the cancer spread to your lymph nodes, and negative estrogen/progestin receptors.

You can learn more about chemotherapy by contacting NCI’s 1-800-4-CANCER (1-800-422-6237) and requesting the following booklets: Helping Yourself During Chemotherapy, Chemotherapy and You, and Eating Hints for Cancer Patients.

Hormonal therapy

If lab tests show that your tumor relied on your natural hormones to grow, any remaining cancer cells may continue to be stimulated by your body’s hormones. Hormonal therapy can prevent your body’s hormones from reaching any remaining cancer cells.

Tamoxifen is one of the most common drugs used for hormonal therapy, taken daily as a pill. Estrogen stimulates the growth of tumors. Tamoxifen combats the resulting stimulation of estrogen receptor positive tumors. Although benefits are generally considered to far outweigh risks, you should be aware that tamoxifen use can increase risks for cancer of the uterus and, rarely, blood clots for patients also undergoing chemotherapy.

Possible problems: hot flashes, nausea, vaginal spotting, increased fertility. Less common side effects include depression, vaginal itching, bleeding or discharge, loss of appetite, eye problems, headache and weight gain.

Arimidex® (aromatase inhibitors) is a drug that may improve survival for women with breast cancer up to 50 percent. Unlike tamoxifen, it prevents estrogen production. It is only effective for postmenopausal women. In a clinical trial, women who were given Arimidex had a 17 percent reduction in the recurrence of the disease. In addition, women who took Arimidex experienced fewer side effects than women who were treated with tamoxifen. Armidex can be used for premenopausal women by giving them Lurpon or Zolodex to stop ovarian function. Femora® and Aromasin®, other aromatase inhibitors, appear to be equivalent to Arimidex and may be superior to tamoxifen for adjuvant and first line therapy.

Biological therapy

Antibodies are proteins made by the body’s own natural immune system that are directed against foreign and infectious agents, called antigens. Monoclonal antibodies engineered through biotechnology are produced as therapeutic drugs to provide specific anti-tumor action within the human body. Herceptin® (trastuzumab) is a monoclonal antibody approved in 1998 by the Food and Drug Administration for the treatment of metastatic breast cancer. It inhibits cancer cell division and growth. Recently, it has been found to improve survival as an adjuvant treatment in patients with HER2-positive breast cancer after surgery.

New treatments designed to repair, stimulate or increase the body’s natural ability to fight breast cancer currently are being investigated in clinical trials worldwide. Some of these experimental immunotherapies utilize, and, in others, boost substances produced naturally by the body’s own cells. Cancer vaccines are being evaluated in clinical trials. Clinical trials adding Avastin® (bevacizumab) to chemotherapy and other VEGFs (vascular endothelial growth factor) have shown promise.

Catcinoma Cervix / Cervix Cancer

The cervix is the smooth organ that forms the entrance to a woman’s uterus. Cancer of the cervix has no symptoms. That’s why the only way to detect it is through a Pap smear, a standard life-saving screen that is performed as part of a woman’s yearly pelvic examination.

Every year, nearly 600,000 American women are diagnosed with cervical dysplasia; 9,710 women are diagnosed with cases of invasive cervical cancer. Early detection of abnormal changes can save lives. Unfortunately, of those women who die of cervical cancer today, 80 percent have not had a Pap smear in five years or more. Cervical cancer, even though falling 2 percent per year, is still the second most common cause of cancer deaths in women. Ironically, it is one of the most preventable and curable by “early identification” of cervical intra-epithelial neoplasia (CIN) and micro-invasive disease.

What is a Pap test?

A Pap test or Pap smear, named after the doctor (George Papanicolaou) responsible for initiating the procedure, is the main way doctors check to see if a woman has developed abnormal cells on the coating (the very top layer of cells) of her cervix. The test is quick, simple, and painless, and shows the presence of an infection, inflammation, abnormal cells, or cancer. The doctor collects a sample and the lab pathologist (cytology lab) analyzes the “smear” under a microscope.

The Pap test may reveal abnormal cell growth, or dysplasia (precancerous cell changes), in the area of the cervix. Abnormal cells look different microscopically from normal cells in that their nuclei show certain specific changes, and that they divide more quickly than normal cells.

How is a Pap test done?

A Pap test is done during an internal pelvic examination. During a Pap test, the doctor uses a tiny wooden spoon to painlessly scrape some cells from the surface of the cervix and smear these cells onto a small glass slide, which will be stained with a special dye that identifies abnormal cells.

For accurate results, a Pap smear should be done when a woman is not menstruating. Additionally, she should avoid douching, using vaginal medicines, spermicidal birth control foams, and other creams or jellies because these substances may wash away or hide abnormal cells. If that should happen, her doctor might mistakenly believe that the woman’s Pap test is normal.

Current guidelines from the National Cancer Institute recommend that all women who are or have been sexually active, or are 18 years of age or older, should have regular Pap tests and pelvic exams.

Why are Pap tests so important?

• A Pap test can catch early signs of cancer before the disease spreads deeper into the cervix and before the cancer spreads to other parts of the body.

• About 50 million Pap tests are performed every year in the United States, with up to 7 percent of the women tested having some type of abnormal results.

• Between 60 percent and 80 percent of American women who are diagnosed with invasive cancer (cancer that spreads) each year, did not have a Pap smear in the earlier year, according to doctors at the Memorial Sloan-Kettering Cancer Center in New York City.

What is the link between the human papilloma virus and cervical cancer?

Research published in the British Journal of Obstetrics and Gynecology reveals that DNA from the human papilloma virus (HPV) is present in almost all invasive cervical cancers. Therefore, having a yearly Pap test, which screens for HPV, is crucial in detecting cervical cancer. Researchers have also discovered “compelling evidence” that persistent HPV infection is the “pivotal step” in the development of cervical cancer. In addition, there are high-risk types of HPVs: numbers 16 and 18 are “definite” carcinogens in humans and HPV 16 is the most common high-risk type. In fact, there are studies that show a greater odds ratio for “the association between HPV and cervical carcinoma than for smoking and lung cancer.”

How is cervical cancer diagnosed?

When a Pap test uncovers abnormalities, a diagnosis of cervical dysplasia is made, and the dysplasia is classified according to a system. Cervical dysplasia, also called cervical intraepithelial neoplasia (CIN), is rated as mild, moderate, or severe. Cervical dysplasia sometimes, but not always, evolves into cervical cancer. A Pap test can catch early signs of cancer before the disease spreads deeper into the cervix and before the cancer spreads to other parts of the body.

Abnormal cells are classified as atypical squamous cells of undetermined significance (ASCUS). Other abnormal cells that are mild but more definite are called low-grade squamous intraepithelial lesions (LSIL). How to handle these mild abnormalities is controversial; some physicians take a “wait-and-see” attitude. That’s because often the cell abnormalities clear up without treatment. So a more conservative physician recommends follow-up Pap tests at three or six months. Others suggest a more aggressive approach: colposcopy, a procedure that allows a physician to use a special microscope to provide closer examination of the cervix, and/or biopsy.

During the procedure the doctor may take tissue samples (a cervical biopsy) from the area. If still more tissue is needed, the patient undergoes a cold cone biopsy. The patient is put in the hospital under general anesthesia and a large tissue sample is taken. The cone biopsy often removes all the cancerous tissue. The reason for all these tests is to accurately match a patient’s medical condition with the most effective therapies available.

What are the signs of cancer of the cervix?

Signs and symptoms of cervical cancer usually don’t appear until precancerous cervical cells become cancerous and invade nearby tissue. Because precancerous changes in the cervix do not cause pain or abnormal bleeding, there are usually no signs that would make a woman suspect that she had precancerous cells in her reproductive organs.

The most common symptom of cervical cancer is abnormal bleeding. This could include:

• Any spotting or bleeding that occurs between normal periods, after sexual intercourse, douching, or during an internal pelvic examination
• Menstrual bleeding that lasts longer and is heavier than usual
• Increased vaginal discharges
• Painful intercourse
• Bleeding after menopause

Risk factors for cervical cancer

Fortunately, cervical cancer is a slow-growing disease. Therefore, a yearly Pap smear will flag any abnormal changes in the cervix that need to be checked out to determine their exact cause, amount, behavior, and type. A physician will decide whether other risk factors warrant further testing. African-American, Hispanic, Native-American women, and women over age 65 are at increased risk because of their general lack of access to good medical care.

Other risk factors for cervical cancer and dysplasia are:

• Starting sexual intercourse at an early age (16 or younger)
• Having multiple sexual partners
• Smoking cigarettes or passive smoking
• Having a history of gynecological cancer
• Using oral contraceptives for five years or more
• Having a diet that is low in vitamin A
• Having a history of sexually transmitted disease, especially HPV infection
• Having the HIV (human immunodeficiency infection), which causes AIDS
• Having been exposed to the drug known as DES (diethylstilbestrol), which had been used by the medical community between 1938 and 1971 to prevent miscarriages

In the journal Nature, some startling statistics in a Swedish study revealed that sometimes, there is a genetic link between women who had cervical cancer and their biological relatives. Over 126,000 relatives of over 71,000 cases of women with cervical cancer helped determine the conclusion of that study.

What is cervical cancer staging?

Cancer “staging” means determining the amount of a cancer a person has, especially when the disease has spread from one spot to another. It is very important to know the exact “grade” or amount of cancer a patient has developed, to plan the best treatment for her. Tissue removed during a cervical biopsy will be staged as follows:

• Stage I: Cancer has not spread to nearby locations in the body.
• Stage II: A small amount of cancer (only visible using a microscope) has spread. The cancer has extended beyond the cervix but not to the pelvic sidewall or the vagina.
• Stage III: A large amount of cancer is deep in the cervix. The cancer extends to the pelvic sidewall, involves the lower third of the vagina or obstructs one or both ureters.
• Stage IV: The cancer spreads to distant organs beyond the pelvis or involves the pelvis or involves the bladder or rectum.
• Stage IVA: The five-year survival rate is between 20 percent to 30 percent
• Stage IVB: It is unusual to survive five years.

The survival rate (living for five years or more after treatment) for women with stage I cancer is good: 80 percent to 85 percent. For women with stage IV cervical cancer, survival is less than 12 percent.

How is cancer of the cervix treated?

Cancer of the cervix is treated differently from other types of cancer in the body, and it may be treated differently from other types of cancer found in the female reproductive tract, such as the ovaries and uterus. Every cancer treatment will depend on the size, amount, and type of cancer a patient has developed. The most common cervical cancer treatments may include:

• Some type of surgery.

• Radiation therapy.

• A combination of surgery and radiation.

• Chemotherapy for advanced stage disease.

• Laser surgery (a thin beam of light aimed at the abnormal cells) may be used to destroy abnormal cells, as well as those cells that have already turned into cervical precancer cells.

• Surgery (cutting out abnormal cells) is used to remove cancerous cells that have already spread outside the cervix.

• Hysterectomy (removal of the uterus, or the uterus and cervix) is used to treat patients whose cancer has spread from the cervix to other reproductive organs.

• Combined radiation therapy and chemotherapy (cisplatin) is a powerful treatment that is used for patients whose cervical cancer has spread to other reproductive organs, and possibly to other places in the body.

• Chemotherapy (5-FU with platinum) can enhance the value of radiotherapy for specific indications.

Preventing cancer of the cervix

Yearly pelvic examinations to identify and treat precancerous conditions remain the most effective ways to prevent cervical cancer. A woman should think preventively by avoiding partners with high-risk sexual histories and insisting on the use of a condom.

The good news is that scientists have developed a vaccine that can potentially prevent cancer of the cervix associated with HPV 16 and 18. The FDA recently approved this vaccine in June 2006 for use in young women ages 9 to 26.

Menyusun Latar Belakang Revisi

Trus apa saja yang harus ditulis dalam latar belakang ?

Secara sederhana latar belakang terdiri dari Fakta, Teori dan Opini, yaitu

1. Fakta berisi data-data pendukung permasalahan anda
2. Teori berisi singkatan teori yang mendukung permasalahan anda
3. Opini berisi tentang pendapat anda yang berisi komen terhadap fakta dan teori sebelumnya

Akan tetapi agar lebih komplit sebaiknya latar belakang diisi dengan Introduksi, Justifikasi, Kronologi Masalah dan Konsep Solusi, yaitu :

1. Introduksi isinya apa yang anda permasalahkan, biasanya definisi-definisi dari apa yang tercantum dari tulisan anda
2. Justifikasi isinya data-data yang mendukung permasalahan anda
3. Kronologi masalah berisi tentang bagaimana permasalahan bisa terjadi secara teoritis.
4. Konsep solusi berisi bagaimana kira-kira permasalahan diselesaikan

Apa beda kedua model latar belakang diatas ?

Pada model FTO, pembaca tidak tahu maksud pada awal paragraf latar belakang (fakta) dan baru tahu setelah membaca opini anda, sedangkan model kedua pembaca sudah anda arahkan dengan memberikan introduksi diawal paragraf.

Trus latar belakang yang baik itu bagaimana ?

Taruhlah anda menggunakan model penulisan latar belakang FTO, pada saat anda menuliskan teori, maka yang seharusnya anda tulis disana merupakan miniatur dari tinjauan pustaka… artinya dari sana sebenarnya kerangka konseptual penelitian sudah dapat dibayangkan.

Demikian halnya jika anda menggunakan model justifikasi dkk, pada saat anda menulis kronologi masalah disana sudah tergambar kerangka konsep penelitian.

Trus bagaimana cara menyusun tinjauan pustaka ? …. bersambung pada penyusunan daftar pustaka

Menyusun Latar Belakang

Upps sebelum menuju ke latar belakang, saatnya mengisi formulir pengajuan judul..,

Judul apa yang akan anda pilih? apakah ada pengaruh judul terhadap isi laporan?

Dalam memilih judul ada beberapa hal yang harus anda ketahui, menurut pengalaman saya, dalam menulis judul anda sudah harus tujuan penelitian dan bagaimana tujuan dijawab dengan analisa datanya berarti anda juga sudah harus tahu tentang skala datanya.

Coba anda lihat dua judul yang hampir sama berikut ini :

Judul 1

”Hubungan pengetahuan dengan perilaku ibu dalam penggunaan garam beryodium”

Judul 2

”Pengaruh pengetahuan ibu terhadap perilaku ibu dalam penggunaan garam beryodium”

Apa bedanya ??

Secara teoritis hubungan bersifat reversible atau dapat dibalik dan tetap memberikan arti yang sama, misalnya judul 1 kita balik menjadi :

”Hubungan perilaku dengan pengetahuan ibu dalam penggunaan garam beryodium”

Artinya tetap sama…sama halnya hubungan paku dengan palu atau hubungan palu dengan paku jawabannya tetap sama yaitu paku untuk dipukul palu atau palu untuk memukul paku.

Sedangkan jika kita balik judul yang kedua :

Pengaruh perilaku terhadap pengetahuan ibu dalam penggunaan garam beryodium

Artinya akan berbeda, sebagai contoh pengaruh paku terhadap tembok berbeda dengan pengaruh tembok terhadap paku, kalo paku terhadap tembok jawabannya paku membuat tembok berlubang sedangkan kalau tembok terhadap paku, misalnya..membuat paku bengkok

Trus apa beda pengaruh dengan hubungan ?

Kalo hubungan diselesaikan secara asosiatif dan pengaruh dapat diselesaikan dengan asosiatif maupun komparatif tergantung desain penelitiannya !!

Jadi sebelum menentukan judul, coba anda baca seri ngoceh tentang penelitian ini sampai selesai baru anda tentukan apa judul anda … bersambung pada menyusun latar belakang

Sekarang bagaimana dengan menyusun latar belakang… ada dua macam cara dalam menyusun latar belakang… deduksi dan induksi

Deduksi, deduksi lebih enak dipergunakan untuk penelitian yang sifatnya studi kelayakan….misalnya studi kelayakan sebuah kebijakan paling enak latar belakangnya melihat kondisi mikronya (misalnya kondisi ekonomi rakyat) kemudian baru makro (kondisi ekonomi negara).

Induksi, dipergunakan untuk penelitian kausal atau sebab akibat misalnya pengaruh paku terhadap tembok, ya yang diteliti kondisi paku dan tembok secara umum baru dibahas paku dan tembok yang akan diteliti.

Bersambung pada lanjutan menyusun latar belakang revisi