From the Guidelines
The workup for abnormal vaginal discharge should begin with a thorough history and physical examination, including speculum examination to visualize the discharge characteristics, and collect samples for microscopy, vaginal pH testing, and cultures or nucleic acid amplification tests (NAATs) as recommended by the Infectious Diseases Society of America in 2016 1. The most common causes of abnormal vaginal discharge include bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis.
- Bacterial vaginosis is characterized by thin, gray discharge with fishy odor, positive whiff test, and clue cells on microscopy.
- Vulvovaginal candidiasis is characterized by thick, white, cottage cheese-like discharge with normal pH, and can be diagnosed with a wet-mount preparation and 10% potassium hydroxide to demonstrate the presence of yeast or hyphae 1.
- Trichomoniasis is characterized by frothy, yellow-green discharge with elevated pH. Testing should include gonorrhea and chlamydia screening, particularly in sexually active patients, as these infections can sometimes cause vaginal discharge 1. For bacterial vaginosis, treatment options include metronidazole 500mg orally twice daily for 7 days, or clindamycin cream 2% intravaginally at bedtime for 7 days. For candidiasis, treatment options include fluconazole 150mg orally as a single dose, or topical azoles like clotrimazole or miconazole for 3-7 days, with uncomplicated infection achieving >90% response with single-dose fluconazole or short-course fluconazole for 3 days 1. Trichomoniasis requires metronidazole 2g orally as a single dose or 500mg twice daily for 7 days. If discharge persists despite treatment, consider less common causes like atrophic vaginitis, retained foreign body, or cervicitis, and refer to gynecology if needed, as proper diagnosis is essential to prevent inappropriate antibiotic use that can disrupt vaginal flora and worsen symptoms 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Abnormal Vaginal Discharge Workup
The workup for abnormal vaginal discharge involves a combination of symptoms, physical examination findings, and office-based or laboratory testing 2. The most common causes of vaginitis, which is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning, are:
- Bacterial vaginosis
- Vulvovaginal candidiasis
- Trichomoniasis
Diagnostic Criteria
The diagnosis of these conditions can be made using the following criteria:
- Bacterial vaginosis: Amsel criteria, Gram stain, or newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity 2
- Vulvovaginal candidiasis: combination of clinical signs and symptoms with potassium hydroxide microscopy or DNA probe testing 2, 3
- Trichomoniasis: nucleic acid amplification testing 2, 4
Laboratory Tests
Laboratory tests that can be used to diagnose abnormal vaginal discharge include:
- pH testing
- Saline and KOH preps 5
- Gram stain
- Potassium hydroxide microscopy
- DNA probe testing
- Nucleic acid amplification testing
Treatment
Treatment for abnormal vaginal discharge depends on the underlying cause and can include:
- Oral metronidazole or intravaginal metronidazole for bacterial vaginosis 2, 4
- Oral fluconazole or topical azoles for vulvovaginal candidiasis 2, 3, 4
- Oral metronidazole or tinidazole for trichomoniasis 2, 3, 4
- Hormonal and nonhormonal therapies for atrophic vaginitis 2
- Topical clindamycin and steroid application for inflammatory vaginitis 2