Take Away Points Vulvovaginitis affects many women throughout their lifetime and the availability of over-the-counter treatments may lead to self-diagnosis or delays in care. The approach to treating the causes of vulvovaginitis should be comprehensive. The three most common causes of vaginitis symptoms include vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis. Effective and approved treatments recommended for vulvovaginitis should be selected based on identification of the etiology. Approach To Treatment Many women will seek medical care at some point in their lives with symptoms of vulvovaginitis. Caused by inflammation, disruption in normal bacterial flora, or infection with a new pathogen, symptoms of vulvovaginitis can include pruritis, odor, abnormal discharge, and pain. Symptoms alone are insufficient in determining the cause of vulvovaginitis, and widely available over-the-counter treatments can lead to self-diagnosis and delays in receiving proper treatment.1 With that in mind, let’s take this opportunity to review the approach to treatment for vulvovaginitis. What causes vulvovaginitis? The three most common causes of vaginitis include vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis. Other etiologies include sexually transmitted infections, autoimmune conditions, hormonal shifts, and allergic reactions. Some symptoms of these conditions may overlap, which is why the approach to vulvovaginitis must include a thorough history, a physical examination, and proper laboratory testing.1 Recurrent symptoms and/or symptoms unresponsive to treatment warrant a referral to a gynecologic specialist. Diagnosis Symptoms Physical Examination pH Microscopy Vulvovaginal Candidiasis -Thick, white vaginal discharge -Dyspareunia -Dysuria -Pruritis -Vulvar inflammation -Edema -Excoriations may be present 4.0-4.5 Saline: budding filaments KOH: hyphae or pseudohyphae Bacterial Vaginosis -Clear, white or gray vaginal discharge -Malodorous or “fishy” odor ***>50% are asymptomatic4 -Thin, homogenous vaginal discharge -Malodor -No signs of inflammation >4.5 Saline: at least 20% clue cells KOH: positive whiff test Trichomoniasis -Green-yellow, frothy vaginal discharge -Dyspareunia -Vaginal soreness -Dysuria -Vulvovaginal erythema/signs of inflammation -“Strawberry cervix” -Thin, green-yellow discharge 5.0-6.0 Saline: mixed flora and mobile trichomonads; leukocytes outnumber epithelial cells KOH: positive whiff test Vulvovaginal Candidiasis Vulvovaginal candidiasis, most commonly caused by candida albicans, may also be caused by other fungal organisms including candida krusei or candida glabrata. Vulvovaginal candidiasis accounts for approximately 20-25% of vulvovaginitis cases.4 Approved over-the-counter antifungal treatments are widely available and include several topical creams and suppositories with varying concentrations and treatment lengths. Oral and vaginal treatment options have been found to be equally efficacious in uncomplicated cases.4 The following table presents examples of available treatment options. Over-the-counter Treatment Prescription Topical Treatments Prescription Oral Treatment Clotrimazole 1% Cream, 5 grams intravaginally qhs x 7-14 days1 Tioconazole 6.5% ointment, 5 grams intravaginally x1 application1 Terconazole 80mg vaginal suppository, insert one suppository daily x 3 days1 Fluconazole 150mg tablet, take one tablet po x1 (uncomplicated)2 Fluconazole 150mg po q72h x2 doses (complicated)2 Considerations should be made when treating vulvovaginal candidiasis such as avoiding fluconazole during pregnancy especially during the first trimester, and considering use with topical “azoles” for 7 days, instead.3 Patients should be reminded that the oil-based topical treatments may weaken barrier contraceptives including condoms and diaphragms. Sex partners are typically not infected and often do not require treatment.1 Bacterial Vaginosis Bacterial vaginosis, considered a polymicrobial infection, occurs when the proliferation of anaerobic bacteria in the vagina displace Lactobacillus species. This environment is unable to support the hydrogen peroxide and normal organic acids that normally thrive within the vaginal flora.4 Identified organisms commonly associated with bacterial vaginosis include: Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma, Prevotella species, and Mobiluncus species.1,4 Bacterial vaginosis accounts for an estimated 40-50% of cases presenting with symptoms related to vaginal discharge.5 Diagnosis of bacterial vaginosis is made on the basis of Positive Amsel’s Criteria, where an individual must have at least three out of the four criteria: (1) thin, white, yellow homogenous discharge; (2) clue cells on wet mount microscopy; (3) a vaginal pH of >4.5; and (4) positive whiff test, or release of a fishy odor when 10% potassium hydroxide (KOH) is added to wet mount.3 The Bacterial Vaginosis in Adults/Adolescents: 2015 CDC STD Guidelines recommend the following regimens for the treatment of bacterial vaginosis.2 Metronidazole 500 mg PO bid x7 days Metronidazole gel 0.75%, insert 5 grams intravaginally qd x 5 days Clindamycin 2% cream, insert 5 grams intravaginally qhs x 7 days For those unable to complete the first-line treatments, alternative regimens have been identified.1 Patients should be counseled on the avoidance of alcohol during and up to 72 hours after completing treatment with metronidazole.1 While the routine treatment of sexual partners is not recommended, women should refrain from sexual intercourse during the treatment course of bacterial vaginosis.1 Bacterial vaginosis may affect up to 20% of pregnant women. Despite its high incidence, the U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening as there is conflicting evidence of its impact on the risk of preterm delivery.7 Treating bacterial vaginosis is paramount as it lowers vulnerability to trichomoniasis, C. trachomatis, N. gonorrhoeae, HIV, and HSVII.1 Additionally, testing for sexually transmitted infection, including HIV, is recommended in the standard management of patients with bacterial vaginosis. Trichomoniasis Trichomoniasis is a protozoal infection caused by trichomonas vaginalis (T. vaginalis) and is the most common nonviral sexually transmitted infection in the world.6 Its incidence increases one’s chance of acquiring HIV by 2-3 fold.1 The treatment recommended for trichomoniasis is a single-dose nitroimidazole. Either metronidazole 2 grams orally in a single dose or tinidazole 2 grams orally in a single dose are preferred but if these are not tolerated or if the individual is pregnant, metronidazole may be given as 500 mg twice daily for 7 days.1 Again, patients should be counseled on the avoidance of alcohol during and up to 72 hours after treatment completion. Sexual partners should be treated and sexual intercourse avoided until both sexual partners have completed treatment. Follow-up testing is recommended for all women 3 months following the initial treatment.1 For more information: The American College of Obstetricians and Gynecologists (ACOG) – “Vaginitis” CDC 2015 Sexually Transmitted Diseases Treatment Guidelines – “Diseases Characterized by Vaginal Discharge” Paladine HL, Desai UA. Vaginitis: Diagnosis and Treatment. Am Fam Physician. 2018;97(5):321-329. References: Diseases Characterized by Vaginal Discharge – 2015 STD Treatment Guidelines. (2015, June 4). https://www.cdc.gov/std/tg2015/vaginal-discharge.htm. Bacterial Vaginosis in Adults/Adolescents: 2015 CDC STD Guidelines | epocrates Guideline Synopsis. Colonna, C. (2020, July 13). Amsel Criteria. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK542319/. Paladine HL, Desai UA. Vaginitis: Diagnosis and Treatment. Am Fam Physician. 2018;97(5):321-329. Sobel, J. D. (2020, May 26). Bacterial vaginosis: Treatment. (R. L. Barbieri & K. Eckler, Eds.). https://www.uptodate.com/contents/bacterial-vaginosis-treatment?search=bacterial vaginosis&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1. Sobel, J. D. (2020, June 30). Trichomoniasis. (R. L. Barbieri & K. Eckler, Eds.). https://www.uptodate.com/contents/trichomoniasis?search=trichomoniasis&source=search_result&selectedTitle=1~87&usage_type=default&display_rank=1. Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83(7):807-815.