What is the treatment for vaginitis?

Treatment of Vaginitis

The treatment of vaginitis depends on the specific cause, with metronidazole being the first-line treatment for bacterial vaginosis and trichomoniasis, while azole medications (topical or oral fluconazole) are recommended for vulvovaginal candidiasis. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Bacterial vaginosis (BV) is diagnosed using Amsel criteria (requiring 3 of 4): homogeneous white discharge, vaginal pH >4.5, positive whiff test (fishy odor with KOH), and clue cells on microscopy 1, 2
• Vulvovaginal candidiasis (VVC) is diagnosed by symptoms (pruritus, white discharge) and microscopic examination with KOH showing yeast or pseudohyphae 1, 2
• Trichomoniasis is diagnosed by wet mount showing motile trichomonads or more accurately by nucleic acid amplification testing 1, 3, 2

Treatment by Type of Vaginitis

Bacterial Vaginosis

Recommended regimen:

• Metronidazole 500 mg orally twice daily for 7 days 1, 3

Alternative regimens:

• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once or twice daily for 5-7 days 1, 3

For recurrent BV:

• Extended treatment courses are recommended 3, 4
• Consider vaginal products containing Lactobacillus crispatus for prevention 4

Vulvovaginal Candidiasis

For uncomplicated VVC:

• Fluconazole 150 mg oral tablet, single dose 1, 5, 3
• OR topical azole medications (multiple options available):
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
  • Miconazole 2% cream 5g intravaginally for 7 days 1
  • Butoconazole 2% cream 5g intravaginally for 3 days 1
  • Several other topical options with varying durations (1-7 days) 1

For complicated/recurrent VVC:

• Initial intensive therapy followed by maintenance therapy 1, 3
• Maintenance: weekly oral fluconazole for up to 6 months 3, 4

Trichomoniasis

Recommended regimen:

• Metronidazole 500 mg orally twice daily for 7 days 6, 3, 4
• OR Metronidazole 2g orally in a single dose (slightly lower efficacy) 1, 3

Important considerations:

• Sexual partners should be treated simultaneously to prevent reinfection 6, 3
• Test of cure is not recommended after treatment 3
• For resistant cases, higher doses may be needed 3, 4

Special Populations

Pregnancy

• For BV: Symptomatic pregnant women should be treated 1
• For VVC: Only topical azoles are recommended during pregnancy 2
• For trichomoniasis: Treatment with oral metronidazole is warranted to prevent preterm birth 3

HIV-infected patients

• Same treatment regimens as HIV-negative patients 1

Treatment Pitfalls and Considerations

• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1
• Women whose symptoms persist after using OTC preparations or who experience recurrence within 2 months should seek medical care 1
• For non-responsive cases, consider alternative diagnoses such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia 4
• Common side effects of metronidazole include nausea, metallic taste, and potential disulfiram-like reaction with alcohol 6
• Common side effects of fluconazole include headache (13%), nausea (7%), and abdominal pain (6%) 5

Treatment Algorithm

1. Identify the type of vaginitis through clinical assessment and laboratory testing
2. For BV: Start with oral metronidazole for 7 days
3. For VVC: Use single-dose oral fluconazole or topical azole for uncomplicated cases
4. For trichomoniasis: Treat with oral metronidazole and ensure partner treatment
5. For persistent/recurrent cases: Consider extended treatment duration and alternative diagnoses