What is the treatment for vaginitis?

Treatment of Vaginitis

Vaginitis treatment depends on the specific causative organism: bacterial vaginosis is treated with oral metronidazole 500 mg twice daily for 7 days, vulvovaginal candidiasis with topical azoles or oral fluconazole 150 mg single dose, and trichomoniasis with metronidazole 2 g orally as a single dose or 500 mg twice daily for 7 days. 1

Diagnostic Framework Before Treatment

Accurate diagnosis is essential before initiating any therapy and requires three key assessments: 1

• Vaginal pH measurement using narrow-range pH paper (pH >4.5 suggests bacterial vaginosis or trichomoniasis; pH ≤4.5 suggests vulvovaginal candidiasis) 2
• Saline wet mount microscopy to identify motile trichomonads or clue cells 2, 1
• 10% KOH preparation to visualize yeast/pseudohyphae (KOH also disrupts cellular material and produces a "whiff test" for bacterial vaginosis) 2, 1

Bacterial Vaginosis Treatment

First-Line Therapy

• Oral metronidazole 500 mg twice daily for 7 days achieves 95% cure rates and is the CDC-recommended first-line treatment 1, 3
• Patients must avoid alcohol during treatment and for 24 hours afterward to prevent disulfiram-like reactions 1, 3, 4

Alternative Regimens

• Metronidazole 2 g orally as a single dose (84% cure rate, but less effective than 7-day regimen) 3
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally twice daily for 5 days 1, 3
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days 1, 3
• Clindamycin 300 mg orally twice daily for 7 days 3

Key Management Points

• Treatment of male sex partners is not recommended as it does not prevent recurrence or improve cure rates 2, 1, 3
• Follow-up visits are unnecessary if symptoms resolve 3
• For recurrent bacterial vaginosis, use longer courses of the same first-line agents 5

Vulvovaginal Candidiasis Treatment

Uncomplicated VVC (80-90% cure rate)

• Oral fluconazole 150 mg as a single dose is equally effective as topical azoles 1, 6
• Topical azole options (all equally effective): 2, 1
  • Clotrimazole 1% cream 5 g intravaginally for 7-14 days
  • Miconazole 2% cream 5 g intravaginally for 7 days
  • Butoconazole 2% cream 5 g intravaginally for 3 days
  • Terconazole 0.4% cream 5 g intravaginally for 7 days

Complicated or Severe VVC

• Use 7-14 day regimens rather than single-dose or 3-day treatments for severe infections 2, 1
• For recurrent VVC (≥4 episodes per year), maintenance therapy with oral fluconazole weekly for up to 6 months is effective 1, 5

Critical Caveats

• Do not treat asymptomatic Candida colonization, as 10-20% of women normally harbor yeast in the vagina 2, 1
• Self-medication with over-the-counter preparations should only occur in women previously diagnosed with VVC who experience identical recurrent symptoms 2, 1
• Women whose symptoms persist after OTC treatment or recur within 2 months must seek medical evaluation 2, 1
• During pregnancy, only topical azoles are recommended—oral fluconazole is contraindicated 1

Trichomoniasis Treatment

First-Line Therapy (up to 88% cure rate)

• Metronidazole 2 g orally as a single dose 1, 4, 5
• Alternative: Metronidazole 500 mg twice daily for 7 days (equal efficacy) 1, 5

Essential Management Steps

• Sex partners must be treated simultaneously to prevent reinfection, even without testing 1, 4
• Test of cure is not recommended after standard treatment 5
• For treatment-resistant cases, higher-dose therapy may be needed 5
• In pregnancy, treatment with oral metronidazole is warranted to prevent preterm birth 5

Special Populations

Pregnancy Considerations

• Bacterial vaginosis in pregnancy: Treatment may reduce preterm birth risk, especially in high-risk women 1
• VVC in pregnancy: Only topical azoles are recommended (no oral fluconazole) 1
• Trichomoniasis in pregnancy: Oral metronidazole is indicated for symptomatic infection to prevent preterm birth 5
• First trimester bacterial vaginosis: Use clindamycin vaginal cream (metronidazole contraindicated in first trimester) 3

HIV-Infected Patients

• Patients with HIV and trichomoniasis receive the same treatment as HIV-negative patients 2

Common Pitfalls to Avoid

• Premature discontinuation of therapy leads to treatment failure—patients must complete the full course even if symptoms improve early 1, 7
• Unnecessary use of OTC antifungals delays proper diagnosis of other vaginitis causes 1
• Failure to advise alcohol avoidance during metronidazole treatment can cause severe disulfiram-like reactions 3
• Treating asymptomatic yeast colonization is inappropriate and wastes resources 2, 1
• Not treating sex partners in trichomoniasis leads to reinfection cycles 1, 4
• Oil-based vaginal creams and suppositories may weaken latex condoms and diaphragms 7