Keputihan pada Perempuan

KEPUTIHAN (leukorea, white discharge, fluor albus) adalah gejala penyakit yang ditandai oleh
keluarnya cairan dari organ reproduksi, dan bukan berupa darah. Keputihan merupakan salah
satu alasan yang paling sering mengapa perempuan memeriksakan diri ke dokter, khususnya
dokter ahli kebidanan dan penyakit kandungan. Dapat dibedakan antara keputihan yang normal
dan yang tidak normal. Keputihan normal ditemukan pada :
* Bayi yang baru lahir sampai umur kira-kira 10 hari, yaitu akibat pengaruh hormon estrogen ibu
terhadap rahim dan vagina janin, saat janin masih di dalam kandungan;
* Saat mengalami haid yang pertama kali; keputihan akan hilang sendiri, akan tetapi dapat
menimbulkan keresahan pada orang tuanya;
* Perempuan dewasa apabila ia dirangsang waktu senggama, akibat pengaruh transudasi dari
dinding vagina;
* Masa subur perempuan; karena kadar hormon estrogen meningkat;
* Penderita penyakit menahun dengan kelainan jiwa neurosis.

Penyebab paling sering dari keputihan tidak normal ialah infeksi. Di sini cairan mengandung
banyak sel darah putih dan warnanya agak kekuning-kuningan sampai hijau, sering kali lebih
kental dan berbau. Organ perempuan yang dapat terkena infeksi adalah vulva, vagina, leher
rahim, dan rongga rahim. Infeksi ini dapat disebabkan oleh :
(1). Kuman (bakteri). Gonococcus, yaitu penyakit kelamin, nanah berwarna kekuningan (sel
darah putih yang mengandung kuman Neisseria gonorrhoea, pasangan dua-dua dalam
sitoplasma sel). Chlamydia trachomatis, sering menyebabkan penyakit mata trakhoma.
Gardnerella Vaginalis, yang menyebabkan peradangan vagina tak spesifik, biasanya mengisi
penuh sel-sel epitel vagina membentuk bentuk khas clue cell. Ini menghasilkan asam amino yang
akan diubah menjadi senyawa amin bau amis, berwarna ke abu-abuan. Treponema pallidum,
penyebab penyakit kelamin sifilis. Sering ditandai adanya penyakit jengger ayam di kemaluan.
(2). Jamur, dari spesies kandida. Cairannya kental, berwarna putih susu (sering berbentuk
kepala susu), gatal. Vagina kemerahan akibat radang. Penyakit jamur banyak terjadi pada
kehamilan, kencing manis, menopause, kegemukan, akseptor pil KB.
(3). Parasit, dengan penyebab keputihan terbanyak adalah Trichomonas vaginalis. Cairannya
banyak, berbuih seperti air sabun dan bau, tidak terlalu gatal, vulva kemerahan, nyeri bila
ditekan atau perih bila buang air kecil. Pada anak-anak bisa disebabkan karena parasit lain
seperti Enterobiasis, gatal sering digaruk sampai luka.
(4). Virus. ini sering disebabkan oleh Human Papilloma Virus (HPV) dan Herpes Simpleks. HPV
sering ditandai dengan kondiloma akuminata/ tumbuhan seperti jengger ayam, cairan berbau,
tanpa rasa gatal. Gambaran klinis lebih buruk bila disertai gangguan sistem kekebalan tubuh
seperti: kehamilan, pemakaian kontikosteroid jangka lama dan AIDS.

Penyebab lain dari keputihan selain infeksi adalah :

(1). Kelainan alat kelamin didapat atau bawaan. Adanya fistel vesikovaginalis atau adanya
saluran yang menghubungkan kandung kemih dan vagina atau adanya saluran yang
menghubungkan antara rektum dan vagina, akibat cedera persalinan, operasi pengangkatan
rahim, radiasi pada kanker organ reproduksi atau akibat kanker itu sendiri.
(2). Benda Asing. Terjadi akibat kotoran tanah atau biji-bijian pada anak-anak atau tertinggalnya
kondom atau benda lain yang dipakai waktu senggama, atau akibat karet pengganjal yang
digunakan untuk mencegah rahim turun.
(3). Kanker. Keputihan juga ditemukan pada tumor ganas. Sel tumbuh sangat cepat secara
abnormal dan mudah rusak, akibatnya terjadi pembusukan dan perdarahan. Cairan banyak, bau
busuk, sering disertai darah tak segar.
(4). Menopause. Pada menopause sel-sel dan vagina mengalami hambatan dalam pematangan
sel akibat tidak adanya hormon pemacu, estrogen. Vagina kering, sering timbul rasa gatal karena
tipisnya lapisan sel sehingga mudah luka dan timbul infeksi penyerta.

Bila keputihan tidak segera diobati akan timbul penyakit radang panggul yang berlarut-larut dan
dapat menyebabkan kemandulan (infertilitas) karena kerusakan dan tersumbatnya saluran telur.
Dilaporkan juga bahwa keputihan pada kehamilan dapat menyebabkan persalinan prematur dan
kelahiran bayi dengan berat lahir rendah. Suatu keputihan yang tidak sembuh dengan
pengobatan biasa (antibiotik dan anti-jamur) harus dipikirkan keputihan tersebut disebabkan
oleh suatu penyakit keganasan seperti kanker leher rahim. Kiat menjaga kebersihan alat kelamin
luar pada perempuan
* Menjaga kebersihan alat kelamin luar pada perempuan sangat penting dalam upaya mencegah
timbulnya keputihan dan juga mencegah Penyakit Menular Seksual (PMS). Kulit daerah alat
kelamin dan sekitarnya harus diusahakan agar tetap bersih dan kering, karena kulit yang
lembab/ basah dapat menimbulkan iritasi dan memudahkan tumbuhnya jamur dan kuman
penyakit. Keadaan ini dapat dicapai dengan mengeringkan kulit dengan handuk atau tisu bila
berkeringat atau setelah buang air.
* Agar tidak terjadi infeksi dari mikroorganisme yang berasal dari anus/dubur dianjurkan untuk
cebok dari arah depan ke arah belakang.
* Terlalu sering melakukan douche (mencuci/membilas) vagina dengan larutan antiseptik dapat
merugikan, karena akan menghilangkan cairan vagina yang normal dan dapat mematikan
bakteri alamiah di dalam vagina. Keadaan ini akan lebih merangsang pengeluaran cairan vagina.
* Pemakaian deodoran, douche, bahan spermisidal, atau bahan lain yang dimasukkan ke dalam
vagina dapat mengakibatkan alergi dan iritasi pada vagina sehingga dapat juga timbul keputihan.

* Mencuci alat kelamin bagian luar cukup dengan air dan sabun mandi biasa saja.
* Pengobatan infeksi juga diberikan kepada suami, untuk menghindari fenomena ping-pong atau
kambuh-kambuhan.*

Bacaan FKUI catatan kuliah ginekologi obstetri !!!

Jika anda diduga memiliki masalah yang berhubungan dengan penyakit kewanitaan apakah itu
periode mentsruasi yang tidak teratur, masalah hormonal atau penyakit yang disebakan
hubungan seksual (STD), sebaiknya selalu periksakan ke dokter.

Ini penting untuk mengetahui gejala yang ditimbulkan dan juga untuk mendapatkan informasi
mengenai masalah kesehatan seksual yang banyak wanita hadapi, bagaimana mencegahnya dan
bagaimana melindungi diri.

Karena masih ada stigma mengenai kesehatan seksual, banyak wanita menghindari pergi ke
dokter padahal penghindaran ini dapat mempengaruhi kesehatan serius termasuk kesuburan.

Berikut beberapa penyakit umum yang wanita hadapi dan cara menjamin kesehatan kewanitaan
tetap sehat:
HPV
Human papillomavirus (HPV) adalah salah satu infeksi virus yang disebabkan oleh hubungan
seksual paling umum. Sebagian besar penyakit ini tidak begitu berbahaya tetapi jika test smear
nampak tidak normal, dokter akan menyarankan untuk test lab.

Cara untuk mengatetahui HPV adalah dengan cervical smear atau screening kesehatan seksual.
Yakinlah untuk memeriksa secara teratur setidaknya satu kali setiap tiga tahun. Berhenti
merokok karena penelitian menemukan hubungan antara merokok dan kanker vulva dan
gunakan kondom.
PID
Pelvic Inflammatory Disease (PID) mempangaruhi satu dari 10 wanita dan jika dibiarkan akan
menyebabkan ketidaksuburan. Gejala yang mungkin timbul pinggul sakit saat hubungan seks,
pendarahy ang tidak teratur atau perubahan bau pada vagina. Segera periksa ke dokter jika anda
menemukan gejala itu. Penyakit ini dapat dengan mudah disembuhkan dengan antibiotik.

Upaya pencegahan PID adalah lakukan seks yang aman dan memeriksakan secara teratur.
Kadang-kadang gejala tidak begitu jelas sampai semua terlambat.
BV
Bacterial vaginosis adalah salah satu infeksi vagina yang paling umum diantara wanita diusia
beranak. Penyakit ini sering dianggap hanya infeksi karena memiliki gejala yang sangat umum
dengan infeksi biasa.

Gejala dari ketidakseimbangan bakteri dalam vagina termasuk gatal, aroma amis dan perubahan
dalam vagina. Jangan biarkan gejala-gejala tersebut dan yakinlah untuk diperiksa dan
disembuhkan dengan baik. Jika dibiarkan, ini akan meningkat resiko berkembang menjadi PID

Gardnerella vaginalis

Overview

Bacterial vaginosis (BV) is characterized by the overgrowth of certain bacteria in the vagina,
including Gardnerella vaginalis, Gardneralla mobiluncus, and Mycoplasma hominis. It accounts
for 60% of vulvovaginal infections and causes vaginal and vulvar pain, itching, and irritation.
Young adult women, particularly those who are sexually active, are most commonly affected.
Bacterial vaginosis is grossly underdiagnosed because many women assume they have a yeast
infection and treat symptoms with over-the-counter medications.

Causes and Risk Factors

BV is caused by a change in the natural balance of bacteria in the vagina. Lacotbacillus, helpful
bacteria, metabolizes glycogen to lactic acid in the vagina and maintains normal vaginal pH,
which provides a natural defense against unhealthy bacteria proliferation. Gardnerella vaginalis
overwhelms healthy bacteria when the defense is weakened. Broad-spectrum antibiotics may
destroy healthy bacteria, disrupt the vaginas normal flora, and promote infection. Douching,
overused or retained tampons, intrauterine contraceptive devices (IUDs), diaphragms,
contraceptive sponges, and products containing nonoxynol-9 may also disrupt the balance.
Bacterial vaginosis also is associated with having multiple sex partners, a new monogamous
sexual relationship, and a history of STDs.

Signs and Symptoms

A fishy vaginal odor, itching, and irritation are common signs of BV and may be particularly
noticeable after intercourse or menses. It may be accompanied by a smooth, sticky, white or gray
discharge 4 days to 4 weeks following exposure. Elevated vaginal pH level is also a symptom.
Aboout 50% of women have Gardnerella vaginalis in their vaginal flora, but do not develop
infection. Complications BV is associated with pelvic inflammatory disease (PID), infertility,
ectopic (tubal) pregnancy, premature birth, and low birth weight in infants born to infected
mothers. Diagnosis Diagnosis is usually made by visual observation and by smell. Vaginal fluid
may be treated with a 10% solution of potassium hydroxide (KOH), which makes the
characteristic odor more pronounced. A sample is usually taken for microscopic examination to
confirm the presence of bacteria, and pH levels are checked. A pelvic examination is performed to
determine whether the cervix is producing abnormal secretions and to check for other diseases.
Most physicians recommend a full STD screening. Treatment Antibiotics such as metronidazole
and clindamycin are generally prescribed, as oral (pill) or topical (cream) treatments. When used
topically, these medications may cause side effects such as stinging, burning, and irritation.
Douching should be avoided. Sex partners may require treatment if infection recurs.

GARDNERELLA

What is gardnerella?

Gardnerella is a bacteria. Normally, it grows in small amounts in a womans vagina and rectum.
If too much gardnerella grows, it may cause a different vaginal discharge with a strange smell.
Gardnerella infections can be uncomfortable, but they are not harmful. How can you tell if you
have a gardnerella infection?

If you have a gardnerella infection, you might notice:

Women:
Discharge from your vagina that is white or grey.
Discharge from your vagina that smells like fish.
Men:
No symptoms.

How do you get tested for a gardnerella infection?

A doctor or nurse can test you by looking at the discharge from your vagina or by taking a swab
from your vagina. Men are not usually tested for gardnerella infections.
How is a gardnerella infection treated?

Gardnerella in your vagina is not harmful. You only need to treat a gardnerella infection if the
symptoms are bothering you. Women can be treated with prescription drugs such as flagyl or
clindamycin. The infection can be treated by taking a medication by mouth, or by inserting a
medicated cream into the vagina. Lactobacillus (the bacteria found in yogurt) can help control
the symptoms. You can put one or two yogurt capsules in your vagina before bedtime for one
week. You can buy these lactobacillus yogurt capsules at the health food store. You should keep
them in the fridge. Men are not usually treated for gardnerella.

Do you need a follow-up test?

If you feel better, you dont need another test.
How do you prevent a gardnerella infection?
Always wipe yourself from front to back after going to the bathroom
Do not use deodorant tampons or pads, perfumed soaps, bath oils, or feminine hygiene sprays.
Wear cotton underwear during the day. Its better not to wear underwear when you sleep.
Wear loose fitting pants.
Avoid douching.
Change out of your wet bathing suit or sweaty exercise clothes as soon as possible.

Bacterial Vaginosis (Gardnerella Vaginitis)

What Is It?

Bacterial vaginosis is a gynecological condition caused by a change in the type of bacteria found
in the vagina. Under normal circumstances, bacteria belonging mostly to the Lactobacillus family
live harmlessly in the vagina and produce chemicals that keep the vaginal environment mildly
acidic. In bacterial vaginosis, these normal Lactobacillus bacteria are replaced by other types of
bacteria that normally are present in smaller concentrations in the vagina. This shift in bacterial
population away from Lactobacillus results in bacterial vaginosis. Scientists do not fully
understand the reason behind the change in concentration of vaginal bacteria that causes
bacterial vaginosis. Risk factors that seem to increase the likelihood of bacterial vaginosis include
a history of multiple sex partners, a sexual relationship with a new partner, the use of vaginal
contraceptive product that contains the chemical nonoxynol-9 and frequent vaginal douching.
Bacterial vaginosis is the most common cause of abnormal vaginal odor and discharge. For most
women, bacterial vaginosis is simply a nuisance, and the goal of treatment is to relieve
symptoms. Bacterial vaginosis commonly is diagnosed during pregnancy. Bacterial vaginosis has
been implicated as a risk factor for premature labor and delivery, premature rupture of
membranes and postpartum uterine infections. This is why pregnant women may be checked for
bacterial vaginosis even when they have no symptoms.

Symptoms
Up to 50 percent of women diagnosed with bacterial vaginosis do not have symptoms. In others,
it causes an unpleasant vaginal odor and a white vaginal discharge. For some women, these
symptoms are especially bothersome during or after intercourse. The white discharge seen in
bacterial vaginosis tends to have a thinner consistency than the "cheesy," thick discharge seen in
vaginal yeast (Candida) infections. Significant irritation of the vulva or pain with intercourse is
uncommon with bacterial vaginosis. So if you have these symptoms, your doctor will check for
other possible causes.

Diagnosis

In addition to asking you to describe the vaginal odor and discharge, your doctor will ask you
about your menstrual history (last menstrual period), number of sex partners, previous vaginal or
urinary-tract infections, history of sexually transmitted infection and pelvic infection, methods of
contraception and pregnancy history, and personal-hygiene issues such as douching history and
your use of feminine deodorants, tightly fitting undergarments and tampons. Your doctor also
may ask if you have any other diseases, such as diabetes, or if you have used antibiotics recently.

Your doctor can diagnose bacterial vaginosis based on the results of a gynecological examination
and laboratory tests of your vaginal fluid. There is no perfect test, but if you have three of the
following four criteria, there is a 98-percent chance that you have bacterial vaginosis:
White, thin, coating on your vaginal walls during the pelvic exam
pH test of your vaginal discharge that shows low acidity (pH greater than 4.5)
Fishy odor when a sample of your vaginal discharge is combined with a drop of potassium
hydroxide on a glass slide (the "whiff test")
Clue cells (vaginal skin cells that are coated with bacteria) visible on microscopic exam of your
vaginal fluid

Your doctor also may order other laboratory tests to rule out other causes of vaginal discharge.

Prevention

Doctors are not exactly sure why bacterial vaginosis develops. Because it occurs more commonly
in people who are sexually active, bacterial vaginosis is considered by some to be sexually
transmitted. However, bacterial vaginosis also occurs in people who either are not sexually active
or have been in long-term monogamous relationships. Treatment of male sex partners doesn't
necessarily prevent re-infections in women who have had bacterial vaginosis. Scientists currently
have no explanation for why some women have problems with recurrent infection, but in some
cases treating the male partner may be helpful. According to experts, having bacterial vaginosis
may make it easier for you to be infected with HIV if your sexual partner has HIV. If you already
have HIV, then the presence of bacterial vaginosis may increase the chance that you will spread
HIV to your sexual partner.

Treatment

Doctors commonly treat bacterial vaginosis using medications. Options include metronidazole
(MetroGel-Vaginal) or clindamycin (Cleocin). Either can be taken by mouth or applied as a
vaginal cream or gel. However, oral preparations are the preferred treatment. The U.S. Centers
for Disease Control and Prevention currently recommends that all pregnant women with
symptoms should be treated with oral medications because they are safe and work better than
vaginal preparations. Pregnant women who are at high risk of preterm labor and delivery should
be tested for bacterial vaginosis and receive treatment even if symptoms are absent. Routinely
screening all women for bacterial vaginosis is not recommended. However, women who undergo
certain hospital or office-based surgical procedures may be treated if infection is identified.
Bacterial vaginosis has been associated with uterine, pelvic, and vaginal-cuff infection in women
who have had certain procedures such as endometrial biopsy, hysterosalpingogram (utero-
tubogram), IUD insertion, dilation and curettage (D&C), hysterectomy and Caesarean section.
Currently, doctors do not recommend any routine treatment for the male sex partners of women
who have bacterial vaginosis.

When To Call A Professional

Call your doctor whenever you notice any abnormal vaginal odor or discharge, especially if you
are pregnant.

Prognosis

Studies show that a seven-day treatment with oral metronidazole or a five-day treatment with
metronidazole vaginal gel is equally effective in non-pregnant women, and clindamycin vaginal
cream is slightly less effective than either preparation of metronidazole. Repeat episodes of
bacterial vaginosis occur, but they often improve with re-treatment.

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Keadaan normal vagina

- flora dominan aerobik, produksi lactobacillus

- pH normal asam (< 4.5)
- sekresi normal konsistensi "flokuler" kental, tidak encer, tidak lengket
- jumlah sekresi sedikit, seolah tersembunyi di forniks posterior

Keputihan (leucorrhea / fluor albus)

Adanya cairan yang keluar dari vagina.

Ciri keputihan normal :

- warna keputihan jernih
- tidak berbau
- tidak meninggalkan noda pada pakaian dalam
- tidak lama
- meningkat pada masa sesaat sebelum / sesudah haid
- meningkat saat ovulasi (dapat sebagai tanda deteksi)
- meningkat selama kehamilan
- meningkat setelah sanggama
- meningkat akibat pengaruh hormonal
- terdapat komunitas flora normal vagina

(Candida albicans dalam keadaan normal ditemukan pada 30-50% vagina dan serviks).

Keputihan alami :
- bayi wanita baru lahir
- anak wanita pada awal pubertas / menarche
- wanita dewasa : masa subur, kehamilan, akseptor KB
- menopause : vaginitis senilis

Radang vulva / vagina berdasarkan penyebab

Bacterial vaginosis (BV)

Disebut juga vaginitis nonspesifik, vaginitis gardnerella

Dipengaruhi proses alkalinisasi vagina, misalnya sanggama sering, pemakaian obat pencuci
vagina (vaginal douche).

Peningkatan faktor risiko BV :

- penyakit radang panggul
- pascaaborsi
- sitologi abnormal
- kehamilan
- ketuban pecah dini, korioamnionitis
- endometritis pasca sectio cesarea

Diagnosis BV : 1) sekret berbau amis, 2) sekret warna abu-abu keruh, 3) pH > 4.5

Terapi BV :
- metronidazol 2 x 500mg oral (7 hari) atau dosis tunggal 2 g oral.
- klindamisin krim 2% aplikasi intravaginal malam hari selama 7 hari