What is the treatment for a 45-year-old woman with chronic leukorrhea (white vaginal discharge) and pruritus (itching) for 5 months?

Treatment for Chronic White Itchy Vaginal Discharge

For a 45-year-old woman with white itchy vaginal discharge for 5 months, oral fluconazole 150 mg as a single dose is the recommended first-line treatment for vulvovaginal candidiasis, which is the most likely diagnosis based on the symptoms. 1

Diagnostic Considerations

The chronic white vaginal discharge with itching for 5 months strongly suggests vulvovaginal candidiasis (VVC), which is characterized by:

• Pruritus (itching) - the primary symptom
• White vaginal discharge that may resemble cottage cheese
• Erythema and inflammation in the vulvovaginal area
• Possible vaginal soreness, vulvar burning, dyspareunia, and external dysuria

A proper diagnosis should include:

• Vaginal pH measurement (VVC typically has normal pH ≤4.5)
• Microscopic examination with 10% KOH preparation to visualize yeast or pseudohyphae
• Culture may be considered if symptoms persist despite treatment

Treatment Algorithm

1. First-Line Treatment Options

Oral Option:

• Fluconazole 150 mg oral tablet, single dose 2, 1

Topical Options:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 2, 3
• Clotrimazole 100 mg vaginal tablet for 7 days 2
• Clotrimazole 100 mg vaginal tablet, two tablets for 3 days 2
• Clotrimazole 500 mg vaginal tablet, single application 2
• Miconazole 2% cream 5g intravaginally for 7 days 2
• Miconazole 200 mg vaginal suppository, one suppository for 3 days 2
• Miconazole 100 mg vaginal suppository, one suppository for 7 days 2

2. For Complicated VVC (Severe or Recurrent)

If this is a severe case or recurrent infection (given the 5-month duration), consider:

• Longer duration of therapy (10-14 days) with either topical or oral azoles 2
• For recurrent VVC: After initial treatment, maintenance therapy with fluconazole 150 mg weekly for 6 months may be considered

Important Considerations

1. Duration of symptoms: The 5-month duration suggests either recurrent episodes or inadequate previous treatment, which may require a longer treatment course.

2. Rule out other causes: While symptoms strongly suggest VVC, other conditions to consider include:

   • Bacterial vaginosis (would have fishy odor and thin discharge)
   • Trichomoniasis (typically has yellow-green discharge)
   • Atrophic vaginitis (common in perimenopausal women)

3. Follow-up: Patient should return if symptoms persist after treatment or recur within 2 months 2

4. Precautions:

   • Oil-based creams and suppositories may weaken latex condoms and diaphragms 2
   • Fluconazole can cause liver problems in rare cases and has drug interactions 1

Treatment Efficacy

Treatment with azoles results in relief of symptoms and negative cultures in 80-90% of patients who complete therapy 2. The ease of administering oral agents like fluconazole is an advantage over topical therapies, making it a practical first-line option for many patients 2, 4.

Management of Partners

VVC is not typically considered sexually transmitted, so treatment of sex partners is not routinely recommended unless the partner has symptomatic balanitis (erythematous areas on the glans with pruritus or irritation) 2.

Given the chronic nature of the symptoms (5 months), proper diagnosis and appropriate treatment are essential to improve the patient's quality of life and prevent complications from chronic inflammation.