What is the treatment for vaginitis?

Treatment of Vaginitis

The first-line treatment for vaginitis depends on the specific type: bacterial vaginosis requires metronidazole 500mg orally twice daily for 7 days, vulvovaginal candidiasis requires fluconazole 150mg oral single dose or topical azoles, and trichomoniasis requires metronidazole 2g oral single dose. 1

Diagnosis and Classification

Before treatment, proper diagnosis is essential as different types of vaginitis require different treatments:

Bacterial Vaginosis (BV)

• Accounts for 40-50% of vaginitis cases 2
• Diagnostic criteria (Amsel criteria):
  • Thin, homogeneous white discharge
  • Vaginal pH >4.5
  • Positive whiff test (fishy odor with KOH)
  • Presence of clue cells on microscopy 1

Vulvovaginal Candidiasis (VVC)

• Accounts for 20-25% of vaginitis cases 2
• Diagnostic features:
  • Thick, white "cottage cheese-like" discharge
  • Intense itching
  • Normal vaginal pH (≤4.5)
  • Visualization of yeast or pseudohyphae on microscopy 1

Trichomoniasis

• Accounts for 15-20% of vaginitis cases 2
• Features:
  • Frothy discharge
  • Vaginal pH >5.4
  • Positive whiff test
  • Trichomonads seen on microscopy 3

Treatment Regimens

Bacterial Vaginosis Treatment

1. First-line treatment:

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

2. Alternative treatments:

   • Metronidazole gel 0.75% intravaginally once daily for 5 days (95% cure rate)
   • Clindamycin cream 2% intravaginally at bedtime for 7 days 1

3. For pregnant women:

   • First trimester: clindamycin cream
   • Second and third trimesters: metronidazole (oral or gel) or clindamycin cream 1

4. For recurrent BV (occurs in up to 50% of women within one year):

   • Extended metronidazole treatment (10-14 days) 1
   • Consider probiotics containing Lactobacillus crispatus as adjunctive therapy 4

Vulvovaginal Candidiasis Treatment

1. Uncomplicated VVC:

   • Fluconazole 150mg oral tablet, single dose OR
   • Topical azoles (clotrimazole, miconazole, etc.) 1, 5

2. For pregnant women:

   • Only topical azoles are recommended 2

3. For recurrent VVC (defined as ≥4 episodes per year):

   • Initial therapy followed by maintenance with weekly oral fluconazole for up to 6 months 6
   • Symptomatic VVC may require longer courses of therapy 6

Trichomoniasis Treatment

1. Standard treatment:

   • Metronidazole 2g orally as a single dose OR
   • Metronidazole 500mg twice daily for 7 days (both with up to 88% cure rate) 1, 6

2. Important considerations:

   • Treat sexual partners simultaneously to enhance cure rates 6
   • Test of cure is not recommended after treatment 6
   • For treatment-resistant cases, higher-dose therapy may be needed 6
   • In pregnancy, treatment is warranted to prevent preterm birth 6

Special Considerations

Side Effects of Treatments

• Fluconazole: Headache (13%), nausea (7%), and abdominal pain (6%) are common side effects 5
• Metronidazole: Nausea, headache, and metallic taste are common side effects 7

Treatment Failures

• For recurrent bacterial vaginosis not responding to extended treatment:

  • Consider vaginal boric acid as an alternative option 4
  • Evaluate for other potential causes 4

• For non-responsive cases, consider:

  • Desquamative inflammatory vaginitis
  • Genitourinary syndrome of menopause
  • Vulvodynia 4

Follow-up Recommendations

• Follow-up visits are generally not necessary if symptoms resolve 1
• All pregnant women should have a follow-up evaluation one month after treatment completion 1
• Patients should return for additional treatment if symptoms recur 1

Prevention Strategies

• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Daily lukewarm baths (30 minutes) can help remove discharge and debris 1
• For recurrent infections, mild antiseptic baths 2-3 times weekly with chlorhexidine, octenidine, or polyhexanide may be beneficial 1