Resident Editor: Nadine Pardee, MD

Faculty Editor: Alison Huang, MD

Background

• More than 90% of vaginitis symptoms are caused by bacterial vaginosis, vulvovaginal candidiasis, or trichomoniasis
• Other, less common, causes of vulvovaginal symptoms include chemical irritation, atrophic vaginitis, douches, foreign bodies, allergic hypersensitivity, lichen planus (painful or pruritic flat hyperkeratotic lesions)

Normal vaginal physiology

• Normal vaginal pH 4.0-4.5 in premenopausal women; 4.7 in postmenopausal women.
• Normal vaginal discharge: clear to white, thick or thin, mostly odorless. Volume may wax and wane physiologically or in response to OCPs or other medications. Infrequent irritation or pruritus are common, but pain or burning are abnormal.
• Factors that alter vaginal environment: menses, antibiotics, oral contraceptive pills (OCPs), STIs, sexual intercourse, stress, vaginal medications, pregnancy, HIV, diabetes, smoking.

Signs and Symptoms

• Vaginal soreness and dryness, pruritus, burning, abnormal discharge, dyspareunia, occasional spotting, dysuria, and foul smelling odor
• Symptoms depend on etiology (see below)

Evaluation

• History – ask about pruritus, burning, abnormal discharge, dyspareunia, concurrent pelvic pain, fevers, new sexual partners, dysuria, relationship of symptoms to menses, medications (especially antibiotics, OCPs), soaps, douches, scented party-liners, spermicides, or lubricant. Remember, symptoms alone cannot differentiate between the causes of vaginitis. A pelvic exam is indicated for all women in which vaginitis is suspected to determine etiology and rule out cervicitis/PID.
• Physical – pelvic exam to assess for discharge, erythema or atrophy as well as cervical discharge or abdominal tenderness (the latter two raising concern for cervicitis/PID – see Cervicitis & PID for details)
• Labs/tests – 
  • Vaginal pH (most important test!)
  • Wet mount microscopy with saline and KOH, “whiff test.”  See “Vaginal Wet Mount” under Procedures section for details. 
  • If concern for cervicitis or risk factors, test for gonorrhea/chlamydia
  • If risk factors, order urine pregnancy test.

Non-Infectious Etiologies of Vaginitis

• ​Atrophic Vaginitis
  • Clinical features – vaginal soreness and dryness, dyspareunia, pruritis, burning, and occasional spotting. Most tend to have minimal discharge, but some may have clear, yellow, or even malodorous discharge. The vaginal epithelium may appear thin and erythematous, with loss of rugae and elasticity, erosions, pH 5-7. 
  • Pathogenesis – decreased estrogen in postmenopausal women may cause thinning vaginal epithelium & eventual decrease in lactic acid production with flora alteration & increased pH. 
  • Treatment:
    • Mild sx: Use vaginal moisturizers for regular maintenance of hydration (e.g Replens) or lubricants to be applied directly before sexual activity (e.g. Astroglide).  Note: these treatments are for symptom management only and do not improve atrophic vaginal changes.  Remember to counsel that oil-based lubricants should not be used in combination with condoms.
    • Moderate to severe sx: Rx topical estrogen creams and other vaginal estrogen preparations; these preparations are systemically absorbed (though minimally) so long-term use should be monitored or avoided.  Leads to changes in vaginal physiology. Note that recent data suggests that low-dose vaginal estrogen is not more effective than non-hormonal vaginal moisturizers in relieving symptoms.   Co-administration of a progestin is not necessary for low-dose vaginal estrogen, but may be appropriate for full-dose vaginal estrogen, despite lack of clear evidence of increased risk of endometrial cancer. (Low dose is defined as < 50 mcg estradiol or <0.3mg conjugated estrogens.)
      • Vaginal cream: Estrogen (Premarin) cream 0.5 vaginally daily x 1-2 weeks, then twice weekly x 1-2 more weeks.  
      • Vaginal insert: Vagifem insert one tablet intravaginally QD x 2 weeks, followed by twice weekly. 10 mcg estradiol per tablet
      • Estrogen vaginal ring: Estring: Low-dose ring, considered topical vaginal estrogen therapy 
    • Avoid estrogen if history of breast cancer, caution in endometrial or ovarian cancer.
  • Encourage continued sexual activity; abstinence may lead to further stricture and dyspareunia
• Vaginitis caused by Irritants
  • Clinical features -- Burning, vaginal soreness, erythema
  • Pathogenesis -- Often caused by chemical irritation from soaps, toilet paper, douches, and other topical preparations. Ask about sex toys, pessaries, clothing. Contact dermatitis and allergic hypersensitivity to latex, spermicides, and preservatives can occur.  Lichen simplex chronicus is the result of the itch-scratch cycle, and can be treated with potent topical steroids for 4-6 weeks.
  • Treatment – Remove potential offending agents

Infectious Etiologies of Vaginitis

Pelvic exam is necessary to distinguish between causes, given the poor predictive value of patient-reported history/symptoms alone, even in those with prior diagnosis of candidiasis, etc.

*Counsel on potential disulfram-like reaction with alcohol

References

Anderson MR et al. Evaluation of vaginal complaints. JAMA 2004 Mar 17;291(11): 1368-79.

Barrons R, Tassone D. Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther. 2008 30(3):453-68.

Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev. 2013;(1): CD000262.

Paladine HL. Vaginitis: Diagnosis and Treatment. Am Fam Physician 2018 Mar 1; 97(5)321-329)

Mitchell, CM, Reed SD, Diem S. Efficacy of Vaginal Estradiol or Vaginal Mositurizer vs. Placebo for Treating Postmenopausal Vulvovaginal Symptoms: A Randomized Clinical Trial. JAMA Intern Med. Published online March 19, 2018. doi:10.1001/jamainternmed.2018.0116

Workowski KA and Bolan GA.Sexually transmitted diseases treatment guidelines, 2015. MMWR Morb Mortal Wkly Rep 2015 Jun 5; 64:1.