Highlights & Basics
- Vaginitis is most often caused by bacterial vaginosis; other common infectious causes include trichomoniasis and candidiasis, although noninfectious causes are also possible.
- Affects all age groups of women, particularly during their reproductive years.
- Common symptoms include discharge, pruritus, and dyspareunia.
- It is recommended to screen for sexually transmitted infections (STIs; also known as sexually transmitted diseases [STDs]) in all women with infective vaginitis.
- Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs.
Quick Reference
History & Exam
Key Factors
vaginal discharge
dysuria
discharge adherent to vaginal mucosa
Other Factors
prior episodes
pruritus
vulvodynia
vaginal dryness
dyspareunia
erythema
pale epithelium
shiny epithelium
decreased elasticity
friable epithelium
fever
vaginal bleeding
abdominal pain
strawberry cervix
Diagnostics Tests
1st Tests to Order
vaginal pH
amine "whiff" test of vaginal secretions
wet mount microscopy of vaginal secretions
Gram stain of vaginal secretions
HIV test
nucleic acid amplification test (NAAT)
venereal disease research laboratory (VDRL) test
serum rapid plasma reagin (RPR) test
Other Tests to consider
culture of vaginal secretions
polymerase chain reaction (PCR) for trichomoniasis on vaginal secretions
rapid enzyme tests of vaginal secretions
Treatment Options
acute
nonpregnant: isolated acute episode
bacterial vaginosis
trichomoniasis
uncomplicated vulvovaginal candidiasis
complicated vulvovaginal candidiasis
pregnant: isolated acute episode
bacterial vaginosis
trichomoniasis
vulvovaginal candidiasis
Definition
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Trichomonas vaginitis with copious purulent discharge emanating from the cervical os
Photomicrograph revealing bacteria adhering to vaginal epithelial cells, known as clue cells
Phase contrast wet mount micrograph of a vaginal discharge revealing the presence of Trichomonas vaginalis protozoa
Vaginal smear identifying Candida albicans using a wet mount technique
Diagnostic Approach
History
Examination and vaginal samples
- Vaginal pH >4.5
- "Whiff" test
- Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered with bacteria)
- Adherent white vaginal discharge.
Laboratory tests
Risk Factors
History & Exam
Tests
Differential Diagnosis
Gonorrhea
Differentiating Signs/Symptoms
- Pelvic or lower abdominal pain and fever may be present if ascending infection.
Differentiating Tests
- Neisseria gonorrhoeae grown on chocolate agar culture.
Chlamydia
Differentiating Signs/Symptoms
- Many are asymptomatic; intermenstrual bleeding, cervicitis, and abdominal pain may be differentiating.
Differentiating Tests
- Chlamydia trachomatis on nucleic acid amplification technique.
Cervicitis
Differentiating Signs/Symptoms
- Intermenstrual bleeding; friable cervix on physical examination; genital warts may be present if caused by human papillomavirus (HPV).
Differentiating Tests
- Cervical discharge collected for Gram stain may indicate Neisseria gonorrhoeae or Chlamydia trachomatis. Cervical cytological testing may be positive for HPV.
Lichen planus
Differentiating Signs/Symptoms
- Pruritus, intense vulvodynia, and dyspareunia are common symptoms.
- Differentiating signs may include presence of violaceous, flat-topped papules or plaques. These lesions may be present elsewhere on the body (e.g., flexor wrists and ankles).
Differentiating Tests
- Diagnosis is typically clinical.
- Histopathology may demonstrate a band-like lymphocytic infiltrate, necrotic keratinocytes, and hyperkeratosis.
Desquamative inflammatory vaginitis
Differentiating Signs/Symptoms
- Noninfectious cause of chronic inflammatory vaginitis.
- Causes purulent and copious discharge, dyspareunia, vaginal rash, vestibulo-vaginal irritation, and vaginal inflammation or erythema.
- Most common during perimenopause.
Differentiating Tests
- Elevated pH (>4.5).
- Inflammation of the vaginal walls with increased erythema and petechiae on examination.
- Microscopy of vaginal secretions shows increased inflammatory and parabasal epithelial cell counts and abnormal vaginal flora.
- Vaginal wall biopsy shows features of acute and chronic desquamative inflammation.
Pelvic irradiation
Differentiating Signs/Symptoms
- Results from ionizing radiation-induced damage to noncancerous tissues during radiation therapy. Risks are higher in women who have been treated for cervical or ovarian cancer.
- Acute: inflammatory reaction during, immediately after, or within 3 months of radiation therapy. Causes gastrointestinal symptoms (e.g., nausea, diarrhea, abdominal cramps, urgency, bleeding).
- Chronic: develops between 6 months and 3 years, but can occur up to 30 years after treatment. Causes bowel dysmotility (e.g., urgency, malabsorption and altered feces transit). Increases risk of bowel wall stricture and perforation, adhesions, fissures, and severe bleeding.
- Latent: symptoms due to secondary malignancies (often endometrial cancer, secondary rectal or bladder tumors) years or decades after radiation therapy.
Differentiating Tests
- Diagnosis is based on a history of cervical cancer or ovarian cancer and symptoms.
- Blood tests: CBC, urea and electrolytes, LFT, glucose and calcium.
Vaginal cancer
Differentiating Signs/Symptoms
- Abnormal vaginal bleeding, odorous or blood-stained discharge, dyspareunia, persistent pelvic/vaginal pain, a lump/growth. Risk is increased in those with a history of human papillomavirus, cervical intraepithelial neoplasia, or vaginal intraepithelial neoplasia.
- More common in women over 60 years and rare in women under 40.
Differentiating Tests
- Lymphadenopathy or tumor infiltration on pelvic examination.
- Vaginal wall biopsy: positive for vaginal cancer.
Fallopian tube cancer
Differentiating Signs/Symptoms
- Rare. Palpable pelvic mass and abnormal vaginal bleeding, especially after menopause; white, clear, or pinkish discharge; abdominal pain or pressure.
Differentiating Tests
- Pelvic examination: abnormality in the shape or size of the uterus, vagina, ovaries, or fallopian tubes.
- CA125 assay: positive.
- Abdominal or transvaginal ultrasound: positive for a tumor.
- Rarely detected by pelvic examination or ultrasound unless very advanced stage.
Cervical cancer
Differentiating Signs/Symptoms
- Abnormal vaginal bleeding, dyspareunia, pain in the lower back or pelvis. Late-stage disease may present with watery or foul-smelling vaginal discharge, most likely from a necrotic mass, severe vaginal bleeding, and gastrointestinal effects.
Differentiating Tests
- Cytology: abnormal cells present.
- Colposcopy with biopsy: cervical cancer cells present in the cervical tissue.
Vaginal fistula
Differentiating Signs/Symptoms
- Can result from injury during childbirth, pelvic surgery, Crohn disease or another inflammatory bowel disease, infection, or radiation treatment. Symptoms include foul-smelling vaginal discharge, passage of gas, stool, or pus from the vagina, dyspareunia, irritation or pain in the vulva, vagina, and perineum, and recurrent urinary tract infections.
Differentiating Tests
- Pelvic examination: positive for fistula.
- Dye test: leakage from the vagina on coughing or bearing down.
- Cystoscopy: fistula identified in bladder or urethra.
- Retrograde pyelogram/CT urogram: injected dye identifies fistula.
Criteria
- Vaginal pH >4.5
- Whiff test
- Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered with bacteria)
- Adherent white vaginal discharge.
- <4 normal
- 4 to 6 intermediate
- >6 bacterial vaginosis.
Screening
Bacterial vaginosis
Trichomonas
Treatment Approach
Bacterial vaginosis
Trichomoniasis
Vulvovaginal candidiasis
Atrophic vaginitis
Noninfective or allergic contact vaginitis
Treatment Options
nonpregnant: isolated acute episode
bacterial vaginosis
metronidazole
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
- metronidazole vaginal
(0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days
- metronidazole vaginal
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis to relieve vaginal symptoms, reduce signs of infection, and potentially to decrease the risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).[4]
- Metronidazole is the treatment of choice.[44]
- Oral and vaginal formulations have been shown to be equally effective. Choice depends on the patient compliance and preference.
intravaginal clindamycin: intravaginal cream
Primary Options
- clindamycin vaginal
(2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days
- clindamycin vaginal
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis to relieve vaginal symptoms, reduce signs of infection, and potentially to decrease the risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).[4]
- Vaginal clindamycin cream is recommended as an alternative first-line treatment option.[4]
- Women of childbearing age need to be aware that due to its oil-based formula, clindamycin cream might weaken latex condoms and diaphragms for 5 days after use.
tinidazole or secnidazole
Primary Options
- tinidazole
2 g orally once daily for 2 days; or 1 g orally once daily for 5 days
- tinidazole
- secnidazole
2 g orally as a single dose
- secnidazole
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis to relieve vaginal symptoms, reduce signs of infection, and potentially to decrease the risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).[4]
- Oral tinidazole or secnidazole may be used as an alternative second-line regimen. Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract.
clindamycin: oral preparations or intravaginal ovules
Primary Options
- clindamycin
300 mg orally twice daily for 7 days
- clindamycin
- clindamycin vaginal
100 mg ovule into the vagina once daily at night for 3 days
- clindamycin vaginal
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis to relieve vaginal symptoms, reduce signs of infection, and potentially to decrease the risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).[4]
- Oral preparations and intravaginal ovules of clindamycin may be given as second-line options.
trichomoniasis
nitroimidazole therapy
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Secondary Options
- tinidazole
2 g orally as a single dose
- tinidazole
Comments
- Treatment of trichomoniasis results in the relief of symptoms and might reduce transmission.[4] Isolation of the microorganism is not necessary prior to therapy in all cases: for example, in a symptomatic patient with previous history of trichomoniasis or a known disease in sexual partner.
- Systemic metronidazole is the treatment of choice but tinidazole is an effective alternative.[4] Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract.
- Topical treatment is not as effective. It is believed that the microorganism can colonize the urethra and associated glands and, although the topical treatment might relieve symptoms, it is better to use systemic medication for clearance.
- Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs.[4] Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.
- Retesting for T vaginalis is recommended for all sexually active women within 3 months following initial treatment.[4]
uncomplicated vulvovaginal candidiasis
antifungal therapy
Primary Options
- butoconazole vaginal
(2% sustained-release cream) insert 5 g (one applicatorful) into the vagina once daily at night as a single dose
- butoconazole vaginal
- clotrimazole vaginal
(1% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days
- clotrimazole vaginal
- miconazole vaginal
(2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days; 100 mg vaginal suppository into the vagina once daily at night for 7 days; 200 mg vaginal suppository into the vagina once daily at night for 3 days; 1200 mg vaginal suppository into the vagina once daily at night as a single dose
- miconazole vaginal
- terconazole vaginal
(0.4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (0.8% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days; 80 mg vaginal suppository into the vagina once daily at night for 3 days
- terconazole vaginal
- tioconazole vaginal
(6.5% ointment) insert 5 g (one applicatorful) into the vagina once daily at night as a single dose
- tioconazole vaginal
- nystatin vaginal
100,000 unit vaginal tablet into the vagina once daily at night for 14 days
- nystatin vaginal
- fluconazole
150 mg/dose orally as a single dose
- fluconazole
Comments
- Several agents are available orally or topically.
- Uncomplicated candidiasis refers to: Candida albicans, sporadic episodes, mild to moderate symptoms, and healthy nonpregnant women.
- This can be treated with a short-course of a topical antifungal agent.[4]
- Creams and vaginal suppositories in this regimen are oil-based and might weaken latex condoms and diaphragms.
- There is no preference between agents. Choice is based on patient compliance/comfort (between topical and oral). Cost and availability might also need to be taken into consideration.
- If a male sexual partner presents with symptoms (e.g., irritation), these may be managed with topical agents.[4]
complicated vulvovaginal candidiasis
antifungal therapy
Primary Options
- fluconazole
150 mg orally every 3 days for a total of 3 doses
- fluconazole
Comments
- Several agents are available orally or topically.
- Complicated candidiasis refers to: nonalbicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.
- Treatment for complicated disease should be initiated with a short course of antifungal therapy, followed by maintenance therapy.[4]
- There is no preference between agents; choice is based on patient compliance/comfort (between topical and oral), and additional considerations might be cost and availability.
- Topical azole antifungals are recommended for 7-14 days. Many of these agents are available over the counter, and any of the options recommended for uncomplicated vulvovaginal candidiasis can be used.
- Vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sexual partners is not recommended, but should be considered in women who have recurrent infection.
pregnant: isolated acute episode
bacterial vaginosis
intravaginal or oral metronidazole
Primary Options
- metronidazole vaginal
(0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days
- metronidazole vaginal
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis.[4] Although bacterial vaginosis is known to increase the risk of certain pregnancy and neonatal complications, the only established benefits of treatment in pregnant women are relief of vaginal symptoms, reduced signs of infection, and potentially a decreased risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).
- Oral and vaginal formulations of metronidazole have been shown to be equally effective. Choice depends on patient compliance and preference.
intravaginal or oral clindamycin
Primary Options
- clindamycin vaginal
(2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days
- clindamycin vaginal
Secondary Options
- clindamycin vaginal
100 mg ovule into the vagina once daily at night for 3 days
- clindamycin vaginal
- clindamycin
300 mg orally twice daily for 7 days
- clindamycin
Comments
- Treatment is indicated in all symptomatic women with bacterial vaginosis.[4] Although bacterial vaginosis is known to increase the risk of certain pregnancy and neonatal complications, the only established benefits of treatment in pregnant women are relief of vaginal symptoms, reduced signs of infection, and potentially a decreased risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).
- Symptomatic pregnant women can be treated with either of the oral or vaginal regimens recommended for nonpregnant women.[4]
trichomoniasis
metronidazole
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Comments
- Topical treatment is not as effective. It is believed that the microorganism can colonize the urethra and associated glands and, although the topical treatment might relieve symptoms, it is better to use systemic medication for clearance.
- In pregnancy, delaying use is recommended until after the first trimester.
- Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs.[4]
- Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.
vulvovaginal candidiasis
topical antifungal therapy
Primary Options
- clotrimazole vaginal
(1% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days
- clotrimazole vaginal
- miconazole vaginal
(2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days
- miconazole vaginal
Comments
- Topical azole antifungal therapies are recommended for use in pregnant women.[4]
- Vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sexual partners is not recommended, but should be considered in women who have recurrent infection. If a male sexual partner presents with symptoms (e.g., irritation), these may be managed with topical agents.[4]
atrophic vaginitis
estrogen therapy
Primary Options
- estradiol vaginal
(50-100 micrograms/24 hours) insert ring into vagina and change every 3 months as required; place the ring into the posterior vaginal fornix; it is to remain in place continuously for 3 months
- estradiol vaginal
- estrogens, conjugated vaginal
(0.625 mg/g) insert 0.5 to 2 g into the vagina once daily at night for 1-2 weeks
- estrogens, conjugated vaginal
Comments
- Administration may be symptomatic, continuous, or cyclic (3 weeks on and 1 week off).
- The ring should be removed after 3 months and, if appropriate, replaced by a new ring. The need to continue treatment should be assessed at 3- to 6-month intervals.
irritant or allergic vaginitis
irritant avoidance ± emollients
Comments
- Preventive measures are the mainstay of treatment. Avoiding causative agents, such as feminine hygiene products, latex condoms/diaphragms, douching, and irritants such as strong soaps or bubble baths, can help prevent vaginitis. Hormone-free vaginal creams and gels, often called emollients, are available without prescription and are commonly used to restore vaginal pH and to relieve vaginal irritation and pruritus, and to increase vaginal moisture.
nonpregnant: persistent or recurrent symptoms
bacterial vaginosis
metronidazole
Primary Options
- metronidazole vaginal
(0.75% gel) apply to the vagina twice a week for 4-6 months
- metronidazole vaginal
Comments
trichomoniasis
nitroimidazole therapy
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Secondary Options
- metronidazole
2 g orally once daily for 7 days
- metronidazole
- tinidazole
2 g orally once daily for 7 days
- tinidazole
Comments
- If multidose therapy with metronidazole or treatment with a single dose of tinidazole for 7 days is unsuccessful (and reinfection is excluded), it is recommended to treat the patient and her partner(s) with metronidazole or tinidazole 2 g once daily for 7 days.[4] Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract. If treatment is unsuccessful after the woman has been reexposed to an untreated partner, multidose therapy with metronidazole should be repeated.
- Topical treatment is not as effective. It is believed that the microorganism can colonize the urethra and associated glands and, although the topical treatment might relieve symptoms, it is better to use systemic medication for clearance.
- Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs. Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.
complicated vulvovaginal candidiasis
antifungal therapy
Primary Options
- fluconazole
150 mg orally once weekly for 6 months
- fluconazole
Comments
- Several agents are available orally or topically.
- Complicated candidiasis refers to: nonalbicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.
- Treatment for complicated disease may involve longer duration of initial oral or topical treatment, followed by maintenance therapy for 6 months.[56]
- There is no preference between agents; choice is based on patient compliance/comfort (between topical and oral), and additional considerations might be cost and availability.
- Topical azole antifungals are recommended for 7-14 days. Many of these agents are available over the counter, and any of the options recommended for uncomplicated vulvovaginal candidiasis can be used.
pregnant: persistent or recurrent symptoms
bacterial vaginosis
metronidazole
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Comments
- If, after a short course of metronidazole, treatment is unsuccessful, high-dose metronidazole for 7 days is recommended.
trichomoniasis
metronidazole
Primary Options
- metronidazole
500 mg orally twice daily for 7 days
- metronidazole
Comments
- If, after a single high dose of metronidazole, treatment is unsuccessful, high-dose metronidazole for 7 days is recommended.
- Topical treatment is not as effective. It is believed that the microorganism can colonize the urethra and associated glands and, although the topical treatment might relieve symptoms, it is better to use systemic medication for clearance.
- Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs.[4] Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.
complicated vulvovaginal candidiasis
topical antifungal therapy and consultation with an infectious disease specialist
Comments
- Complicated candidiasis refers to: nonalbicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.
- Consultation with an infectious disease specialist might be required to discuss further culture and sensitivity testing.
- Pregnant women are treated only with topical azoles, for no longer than 7 days.[4] Many of these agents are available over the counter, and any of the options recommended for uncomplicated vulvovaginal candidiasis can be used.
- Vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sexual partners should be considered in women who have recurrent infection. If a male sexual partner presents with symptoms (e.g., irritation), these may be managed with topical agents.[4]
Emerging Tx
Vitamin C vaginal tablets
Ospemifene
Ibrexafungerp
Oteseconazole
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
- Follow-up is not recommended if symptoms resolve. Recurrence of bacterial vaginosis is not unusual and women should be advised to return for additional therapy if symptoms recur.
- A treatment regimen different from the original regimen may be used to treat recurrent disease.
- Retesting is recommended for all sexually active women within 3 months of initial treatment. This is because of a high rate of reinfection.[4]
- Women should be instructed to follow up if symptoms persist or recur within 2 months of onset of initial symptoms.
Complications
Citations
Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.[Abstract][Full Text]
American College of Obstetricians and Gynecologists. Vaginitis in nonpregnant patients: ACOG practice bulletin, number 215. Obstet Gynecol. 2020 Jan;135(1):e1-e17.[Abstract]
1. Ness RB, Hillier SL, Richter HE, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol. 2002 Oct;100(4):765-72.[Abstract][Full Text]
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23. World Health Organization. WHO guideline on self-care interventions for health and well-being, 2022 revision. Geneva: World Health Organization; 2022.[Abstract][Full Text]
24. National Institute for Health and Care Excellence. Reducing sexually transmitted infections. June 2022 [internet publication].[Full Text]
25. Centers for Disease Control and Prevention. Vaginal candidiasis. Oct 2021 [internet publication]. [Full Text]
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27. British Association for Sexual Health and HIV. UK national guideline for the management of bacterial vaginosis. 2012 [internet publication].[Full Text]
28. Sturdee DW, Panay N; International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010 Dec;13(6):509-22.[Abstract][Full Text]
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32. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991 Feb;29(2):297-301.[Abstract][Full Text]
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Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Evidence-based guidelines for the prevention, diagnosis and management of STIs, including recommendations for bacterial vaginosis, trichomoniasis and candidiasis.Published by
Centers for Disease Control and Prevention
Published
2021
Summary
Evidence-based recommendations on screening for vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.Published by
Society of Obstetricians and Gynaecologists of Canada
Published
2015
Summary
The guideline covers the presentation and clinical findings of bacterial vaginosis, trichomoniasis, and candidiasis, and outlines the differential diagnoses. Recommendations are made for investigations based on currently available evidence.Published by
International Union Against Sexually Transmitted Infections; World Health Organization
Published
2018
Summary
The guideline provides recommendations on the diagnosis and management of Trichomonas vaginalis infection.Published by
British Association for Sexual Health and HIV
Published
2021
Summary
The guideline provides recommendations on the diagnosis and management of bacterial vaginosis at first presentation as well as recurrence.Published by
British Association for Sexual Health and HIV
Published
2012
Summary
The guideline provides recommendations on the diagnosis and management of vulvovaginal candidiasis.Published by
British Association for Sexual Health and HIV
Published
2020
Summary
The guideline covers the diagnosis and treatment of common causes of vaginitis in nonpregnant women.Published by
American College of Obstetricians and Gynecologists
Published
2020 (reaffirmed 2022)
Treatment
Summary
Evidence-based guidelines for the prevention, diagnosis and management of STIs, including recommendations for bacterial vaginosis, trichomoniasis and candidiasis.Published by
Centers for Disease Control and Prevention
Published
2021
Summary
Recommendations on the management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.Published by
Society of Obstetricians and Gynaecologists of Canada
Published
2015
Summary
Recommendations for management of bacterial vaginosis, trichomoniasis, and candidiasis based on currently available evidence, including the management of persistent and recurrent infections.Published by
International Union Against Sexually Transmitted Infections; World Health Organization
Published
2018
Summary
Recommendations for management of postmenopausal vaginal atrophy including assessment, diagnosis, and treatment.Published by
International Menopause Society
Published
2010
Summary
The guideline provides recommendations on the diagnosis and management of Trichomonas vaginalis infection.Published by
British Association for Sexual Health and HIV
Published
2021
Summary
The guideline provides recommendations on the diagnosis and management of bacterial vaginosis at first presentation, as well as recurrence.Published by
British Association for Sexual Health and HIV
Published
2012
Summary
The guideline provides recommendations on the diagnosis and management of vulvovaginal candidiasis.Published by
British Association for Sexual Health and HIV
Published
2020
Summary
The guideline covers the diagnosis and treatment of common causes of vaginitis in nonpregnant women.Published by
American College of Obstetricians and Gynecologists
Published
2020 (reaffirmed 2022)
Credits
Patient Instructions
- Diet: Lactobacillus acidophilus supplements in the diet may help to prevent vaginitis.[21]
- Activity: abstinence from douching and sexual activity is recommended until completion of treatment. If the patient remains sexually active, advise use of condoms as a precaution; some of the topical treatments are oil-based and can break condoms (e.g., clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use). Check with condom manufacturer.
- Pregnant women: topical clindamycin preparations should not be used in the second half of pregnancy.
- Encourage continued sexual activity as it may help postpone worsening atrophy.
- Avoiding causative agents, such as feminine hygiene products, latex condoms/diaphragms, douching, and irritants such as strong soaps or bubble baths, can help prevent vaginitis.