What are the treatment options for vaginitis?

Treatment Options for Vaginitis

The treatment of vaginitis should be targeted to the specific cause, with metronidazole as the first-line treatment for bacterial vaginosis, topical or oral azoles for vulvovaginal candidiasis, and metronidazole for trichomoniasis. 1

Diagnosis and Classification

Proper diagnosis is essential for effective treatment. The three most common types of vaginitis are:

1. Bacterial Vaginosis (BV) - 40-50% of cases
2. Vulvovaginal Candidiasis (VVC) - 20-25% of cases
3. Trichomoniasis - 15-20% of cases
4. Non-infectious causes - 5-10% of cases (atrophic, irritant, allergic, inflammatory)

Diagnostic Features

Feature	Bacterial Vaginosis	Vulvovaginal Candidiasis	Trichomoniasis
Discharge	Homogeneous, white, thin	White, thick, "cottage cheese-like"	Frothy, yellow-green
Odor	Fishy (positive whiff test)	Minimal or none	Foul-smelling
pH	>4.5	≤4.5	>5.4
Key symptom	Discharge and odor	Intense itching	Discharge, irritation
Microscopy	Clue cells	Pseudohyphae/yeast	Motile trichomonads

Treatment Regimens

1. Bacterial Vaginosis

First-line treatment:

• Metronidazole 500mg orally twice daily for 7 days (95% cure rate) 1

Alternative regimens:

• Metronidazole gel 0.75% intravaginally once daily for 5 days
• Clindamycin cream 2% intravaginally at bedtime for 7 days
• Tinidazole is also FDA-approved for bacterial vaginosis in adult women 2

For recurrent BV:

• Extended treatment with metronidazole 500mg twice daily for 10-14 days
• Followed by maintenance therapy with metronidazole gel twice weekly for 3-6 months 1

2. Vulvovaginal Candidiasis

Uncomplicated VVC options:

Topical treatments:

• Clotrimazole 1% cream 5g intravaginally for 7-14 days
• Clotrimazole 100mg vaginal tablet for 7 days
• Clotrimazole 500mg vaginal tablet, single application
• Miconazole 2% cream 5g intravaginally for 7 days
• Terconazole 0.4% cream 5g intravaginally for 7 days
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

Oral treatment:

• Fluconazole 150mg oral tablet, single dose 3

For recurrent VVC (≥4 episodes in 12 months):

• Initial intensive therapy: Fluconazole 150mg every 72 hours for three doses
• Followed by maintenance: Weekly fluconazole 150mg for 6 months 1
• Alternative maintenance regimens include clotrimazole (500mg vaginal suppositories once weekly) 3

3. Trichomoniasis

Standard treatment:

• Metronidazole 2g orally in a single dose 1
• Alternative: Metronidazole 500mg twice daily for 7 days (up to 88% cure rate) 4

Important note:

• Sex partners should be treated simultaneously to prevent reinfection 4

Special Populations

Pregnant Women

• For VVC: Only topical azoles should be used; oral fluconazole is contraindicated 1
• For BV:
  • First trimester: Clindamycin cream is recommended
  • Second and third trimesters: Metronidazole oral or gel, or clindamycin cream 1
• For trichomoniasis: Oral metronidazole is warranted for prevention of preterm birth 4

Recurrent Infections

• Recurrent BV: Extended treatment duration followed by maintenance therapy 1
• Recurrent VVC: Longer initial therapy followed by maintenance antifungal regimen for 6 months 3, 1
• Non-albicans VVC: Longer duration therapy (7-14 days) with non-fluconazole azole; if recurrence, consider boric acid 600mg vaginally daily for 2 weeks 3

Patient Education and Prevention

• Self-medication with OTC preparations only for women previously diagnosed with VVC experiencing recurrence of same symptoms 3
• Follow-up visits generally not needed unless symptoms persist or recur within 2 months 3
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 3
• Consistent condom use during sexual intercourse may help prevent recurrence of bacterial vaginosis 1

Common Pitfalls

1. Misdiagnosis: Failure to properly identify the specific cause of vaginitis leads to ineffective treatment
2. Inadequate treatment duration: Especially for recurrent infections
3. Not treating partners: Particularly important for trichomoniasis
4. Overlooking non-infectious causes: Atrophic, irritant, allergic, or inflammatory vaginitis require different approaches
5. Ignoring recurrence: Persistent symptoms require reevaluation and possibly different treatment strategies

By following these evidence-based treatment guidelines and tailoring therapy to the specific cause of vaginitis, most patients can achieve symptom resolution and prevent recurrence.