What are the treatment options for vaginitis?

Treatment Options for Vaginitis

The treatment of vaginitis depends on the specific cause, with bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis being the most common infectious causes requiring different therapeutic approaches. 1, 2

Diagnostic Approach

• Accurate diagnosis is essential before initiating treatment and should include assessment of vaginal pH, microscopic examination of vaginal discharge, and specific tests for suspected pathogens 3
• Bacterial vaginosis (BV) is diagnosed using Amsel criteria (at least 3 of: homogeneous discharge, pH >4.5, positive whiff test, clue cells) or Gram stain 3
• Vulvovaginal candidiasis (VVC) is diagnosed by visualization of yeast/pseudohyphae in KOH preparation or positive culture 3
• Trichomoniasis is diagnosed by identifying motile trichomonads in saline wet mount or through more sensitive nucleic acid amplification testing 3, 4

Treatment for Bacterial Vaginosis

• First-line treatment: Oral metronidazole 500 mg twice daily for 7 days 3
• Alternative regimens:
  • Metronidazole 2 g orally in a single dose 3
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 3
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, twice daily for 5 days 3
  • Tinidazole is FDA-approved for bacterial vaginosis in adult women 5
• Patients should avoid alcohol during treatment with metronidazole and for 24 hours afterward 3
• Treatment of male sex partners is not recommended as it has not been shown to prevent recurrence 3

Treatment for Vulvovaginal Candidiasis

• For uncomplicated VVC, both topical azoles and oral fluconazole 150 mg as a single dose are equally effective with 80-90% cure rates 3
• Recommended topical treatments include:
  • Clotrimazole 1% cream 5 g intravaginally for 7-14 days 3
  • Miconazole 2% cream 5 g intravaginally for 7 days 3
  • Butoconazole 2% cream 5 g intravaginally for 3 days 3
  • Terconazole 0.4% cream 5 g intravaginally for 7 days 3
• For complicated VVC (severe symptoms, recurrent infections, non-albicans species):
  • Longer duration of therapy (7-14 days) is recommended 3, 6
  • For recurrent VVC (≥4 episodes/year), maintenance therapy with weekly oral fluconazole for up to 6 months after initial treatment 3, 6
• Note that oil-based creams and suppositories may weaken latex condoms and diaphragms 3

Treatment for Trichomoniasis

• First-line treatment: Metronidazole 2 g orally in a single dose OR metronidazole 500 mg twice daily for 7 days (both equally effective with cure rates up to 88%) 3, 6
• Tinidazole is FDA-approved for trichomoniasis caused by Trichomonas vaginalis 5
• Sex partners should be treated simultaneously to prevent reinfection 3, 6
• For treatment-resistant cases, higher-dose therapy may be needed 6
• Test of cure is not routinely recommended following treatment 6

Special Considerations

Pregnancy

• For BV in pregnancy, treatment may be considered to reduce risk of preterm birth, especially in high-risk women 3
• For VVC during pregnancy, only topical azoles are recommended 3
• For trichomoniasis in pregnancy, treatment with oral metronidazole is warranted to prevent preterm birth 6

Recurrent Infections

• For recurrent BV, longer courses of therapy are recommended 6
• For recurrent VVC, maintenance therapy with weekly oral fluconazole for up to 6 months is effective 6

Common Pitfalls and Caveats

• Self-medication with over-the-counter preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 3
• Premature discontinuation of therapy can lead to treatment failure; patients should complete the full course even if symptoms improve 7
• Unnecessary or inappropriate use of OTC preparations can delay proper diagnosis and treatment of other causes of vaginitis 3
• Women whose symptoms persist after using an OTC preparation or who have recurrence within 2 months should seek medical care 3
• Identifying Candida in the absence of symptoms should not lead to treatment, as 10-20% of women normally harbor yeast in the vagina 3