What is the recommended treatment for vaginitis?

Treatment of Vaginitis

The recommended treatment for vaginitis depends on the specific etiology: bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days, vulvovaginal candidiasis with topical azoles or oral fluconazole 150 mg as a 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 must include:

• Vaginal pH measurement (normal ≤4.5 for candidiasis; >4.5 for bacterial vaginosis; >5.4 for trichomoniasis) 1, 2
• Microscopic examination of vaginal discharge using both saline wet mount and 10% KOH preparation 1
• Specific pathogen testing when indicated, with nucleic acid amplification testing being superior to microscopy for most clinicians 2, 3

Critical pitfall: Identifying Candida in the absence of symptoms should NOT lead to treatment, as 10-20% of women normally harbor yeast in the vagina 1, 4

Bacterial Vaginosis Treatment Algorithm

First-Line Therapy

• Oral metronidazole 500 mg twice daily for 7 days (preferred regimen with Level I evidence) 1
• Alternative regimens include:
  • Metronidazole gel 0.75% intravaginally 1
  • Clindamycin cream 2% intravaginally 1
  • Metronidazole 2 g orally as single dose (though 7-day regimen preferred for maximal effectiveness) 1, 5

Key Management Points

• Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward 1
• Treatment of male sex partners is NOT recommended, as it has not been shown to prevent recurrence 1
• Diagnosis is made using Amsel criteria: milky discharge, pH >4.5, positive whiff test, and clue cells on wet mount 1, 2

Vulvovaginal Candidiasis Treatment Algorithm

For Uncomplicated Mild-to-Moderate VVC

Single-dose oral fluconazole 150 mg achieves 80-90% cure rates and is equally effective as topical azoles 1, 6

Alternative topical regimens (all equally effective):

• Clotrimazole 1% cream 5 g intravaginally for 7-14 days 4, 1
• Miconazole 2% cream 5 g intravaginally for 7 days 4, 1
• Butoconazole 2% cream 5 g intravaginally for 3 days 4
• Terconazole 0.4% cream 5 g intravaginally for 7 days 4, 1

For Severe or Complicated VVC

• Multi-day regimens (7-14 days) are preferred over single-dose treatments 4, 1
• For recurrent VVC (≥4 episodes/12 months), maintenance therapy with weekly oral fluconazole for up to 6 months may be effective 1

Special Considerations

• During pregnancy, ONLY topical azoles are recommended; oral fluconazole is contraindicated 1
• Over-the-counter preparations (miconazole and clotrimazole) should only be used by women previously diagnosed with VVC who experience recurrence of identical symptoms 1, 4
• Women whose symptoms persist after OTC treatment or recur within 2 months must seek medical care 1, 4

Common pitfall: In the FDA vaginal candidiasis trials, only 55% achieved therapeutic cure (complete symptom resolution plus negative culture), with substantially more gastrointestinal events (16% vs 4%) in the fluconazole group compared to vaginal products 6

Trichomoniasis Treatment Algorithm

First-Line Therapy

• Metronidazole 2 g orally as a single dose (achieves up to 88% cure rate) 1
• Alternative: Metronidazole 500 mg twice daily for 7 days (this 1-week course is now recommended as superior to single-dose therapy) 1, 3

Critical Management Points

• Sex partners MUST be treated simultaneously to prevent reinfection 1
• This is the only sexually transmitted infection for which treatment recommendations vary by sex 3
• Diagnosis should use nucleic acid amplification testing rather than wet mount microscopy, which has high false-negative rates 2, 7

Pregnancy-Specific Modifications

• For bacterial vaginosis: Treatment may reduce risk of preterm birth, especially in high-risk women; metronidazole can be used after the first trimester 1, 4
• For vulvovaginal candidiasis: Only topical azoles are safe; oral fluconazole is contraindicated 1
• For trichomoniasis: Metronidazole 2 g single dose can be used after the first trimester 4

HIV-Infected Patients

Persons with HIV infection and trichomoniasis should receive the same treatment as persons without HIV 4

Treatment Failure and Recurrence

When initial treatment fails:

• Reconsider the diagnosis and evaluate for alternative causes including desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia 3
• For recurrent bacterial vaginosis, vaginal products containing Lactobacillus crispatus may have promise 3
• For recurrent vulvovaginal candidiasis, vaginal boric acid is likely the cheapest and easiest alternative option after extended first-line therapy fails 3
• Premature discontinuation of therapy leads to treatment failure; patients must complete the full course even if symptoms improve 1

Follow-Up Recommendations

Patients should return for follow-up visits only if symptoms persist or recur after completing treatment 4, 1