What is the recommended treatment for a female with 1 month of vaginal discharge and dyspareunia?

Treatment of Vaginal Discharge and Dyspareunia

The recommended first-line treatment is a single 150 mg oral dose of fluconazole for presumed vaginal candidiasis, which is the most common cause of these symptoms. 1

Clinical Approach

The combination of 1 month of vaginal discharge with painful intercourse (dyspareunia) most commonly suggests vulvovaginal candidiasis, though bacterial vaginosis and trichomoniasis must also be considered in the differential diagnosis.

Primary Treatment Recommendation

For vaginal candidiasis, administer fluconazole 150 mg orally as a single dose. 1

• This regimen achieves 69% clinical cure rates and 55% therapeutic cure rates (complete resolution of symptoms plus negative cultures) at one month post-treatment 1
• The single-dose regimen ensures compliance and is comparable in efficacy to 7-day intravaginal azole therapy 1
• Approximately 80% of patients with acute vaginitis (<4 episodes per year) achieve clinical cure with this regimen 1

Alternative Consideration: Trichomoniasis

If clinical suspicion for trichomoniasis exists (frothy discharge, strawberry cervix, or confirmed by wet mount/testing), treatment differs:

For trichomoniasis, use metronidazole 2 grams orally as a single dose OR 250 mg three times daily for 7 days. 2

• The single-dose regimen ensures compliance, particularly important when patient adherence is uncertain 2
• The 7-day regimen may provide higher cure rates and minimize reinfection by allowing time for partner treatment 2
• Partner treatment is essential to prevent reinfection 2

Important Clinical Caveats

Pregnancy Considerations

• If the patient is pregnant, do NOT use fluconazole or metronidazole in the first trimester 2
• For pregnant patients beyond the first trimester requiring trichomoniasis treatment, avoid the single-dose metronidazole regimen as it produces higher serum levels that reach fetal circulation; use the 7-day regimen instead 2

Expected Adverse Effects

• Fluconazole causes more gastrointestinal events (16% vs 4% with vaginal products), primarily mild-to-moderate nausea (7%), abdominal pain (6%), and headache (13%) 1
• These events rarely require discontinuation given the single-dose administration 1

Recurrent Vaginitis

• If the patient has recurrent vaginitis (≥4 episodes per year), expect lower cure rates with single-dose fluconazole (57% clinical cure, 40% therapeutic cure) 1
• These patients may require longer suppressive therapy regimens beyond the scope of single-dose treatment 1

Follow-up Strategy

• Clinical relapse occurs in approximately 14-22% of patients within 2-4 weeks after fluconazole treatment 1
• If repeat treatment courses are needed, allow 4-6 weeks between courses and reconfirm the diagnosis with appropriate laboratory testing 2