What are the diagnosis and treatment options for a female of reproductive age experiencing white discharge from the cervix?

White Discharge from the Cervix: Diagnosis and Treatment

White discharge from the cervix requires systematic evaluation to distinguish between physiologic cervical ectropion, infectious cervicitis, and vaginal infections, with treatment directed at identified pathogens rather than empiric prolonged antibiotics when testing is negative.

Initial Diagnostic Approach

Speculum Examination Findings

The cervix should be completely visualized to assess specific characteristics that guide diagnosis:

• Cervical ectropion (transition zone visible on exocervix) is a normal developmental finding that can cause significant white or mucoid vaginal discharge without infection, particularly common in adolescents and postpartum women 1, 2
• White plaques on the cervix that cannot be removed with a swab suggest condyloma acuminata (HPV infection) 1
• Friability and hyperemia of the cervix indicate infectious cervicitis, most commonly from sexually transmitted infections 1
• Mucopurulent discharge (yellow-green) suggests cervicitis from Chlamydia trachomatis or Neisseria gonorrhoeae, though many cases have no identifiable organism 2, 3

Essential Laboratory Testing

Obtain the following tests before initiating treatment:

• Nucleic acid amplification tests (NAATs) for both C. trachomatis and N. gonorrhoeae are the most sensitive and specific tests available 4
• Vaginal wet mount preparation to identify yeast (hyphae/budding), trichomonads (moving flagellated organisms), clue cells (bacterial vaginosis), and white blood cells 1
• Potassium hydroxide (KOH) preparation to enhance visualization of yeast not seen on saline prep 1
• Vaginal pH testing: normal pH <4.5; elevated pH suggests bacterial vaginosis or trichomoniasis 1, 5
• Whiff test: fishy odor when KOH is added to vaginal secretions indicates bacterial vaginosis 1, 5

Differential Diagnosis and Treatment

Physiologic Cervical Ectropion (Non-Infectious)

When cervical ectropion is prominent and all infectious testing is negative:

• No antimicrobial therapy is indicated as this represents normal columnar epithelium on the ectocervix 2
• Discontinue potential chemical irritants including douches, feminine hygiene products, and spermicides 2, 3
• Avoid prolonged empiric antibiotics, which provide no proven benefit and risk adverse effects 2, 3

Vulvovaginal Candidiasis

When wet mount or KOH prep reveals yeast:

• Topical azole antifungals are first-line treatment with 80-90% cure rates 1
• Recommended regimens include clotrimazole 1% cream 5g intravaginally for 7-14 days, miconazole 2% cream 5g intravaginally for 7 days, or terconazole 0.4% cream 5g intravaginally for 7 days 1
• Oral fluconazole 150mg single dose is an alternative for uncomplicated cases 6
• Partner treatment is not required 7

Bacterial Vaginosis

When clue cells are present, pH >4.5, and positive whiff test:

• Metronidazole 500mg orally twice daily for 7 days or metronidazole gel 0.75% one applicator intravaginally daily for 5 days 8
• Alternative: clindamycin cream 2% one applicator intravaginally at bedtime for 7 days 1
• Partner treatment is not indicated 7

Trichomoniasis

When motile trichomonads are identified on wet mount:

• Metronidazole 2g orally as a single dose is the standard treatment 1, 8
• Sexual partners must be treated simultaneously with the same regimen to prevent reinfection 1, 8
• Abstain from sexual intercourse for 7 days after single-dose therapy 4

Cervicitis (Chlamydia/Gonorrhea)

When NAATs are positive or high clinical suspicion exists:

• For pregnant women: Azithromycin 1g orally as a single dose is the preferred treatment, providing directly observed therapy 4, 9
• For non-pregnant women: Azithromycin 1g orally single dose or doxycycline 100mg orally twice daily for 7 days 9
• Add gonorrhea coverage if local prevalence >5% or if gonorrhea is confirmed 4
• Treat presumptively without awaiting results if patient is age <25 years, has new or multiple partners, or if follow-up cannot be ensured 4
• All sexual partners within preceding 60 days must be notified and treated 4

Critical Pitfalls to Avoid

• Do not continue indefinite courses of antibiotics for culture-negative persistent cervicitis, as this has no proven benefit and risks adverse effects 2, 3
• Do not assume all white discharge is infectious; physiologic cervical ectropion is common and requires no antimicrobial treatment 2
• Do not use doxycycline in pregnant women—it is absolutely contraindicated 4
• Do not forget partner treatment for sexually transmitted infections, as reinfection rates are higher when partners are untreated 4, 8
• Wet mount can miss trichomoniasis 30-50% of the time; consider NAAT testing if clinical suspicion is high 1

When Symptoms Persist Despite Treatment

For persistent symptoms after appropriate treatment and negative repeat testing:

• Consider non-infectious inflammation in the zone of ectropy, which may not respond to antimicrobial therapy 2, 3
• Evaluate for retained products of conception in postpartum women with ultrasound (endometrial thickness >10-12mm suggests retained tissue requiring mechanical removal) 2
• Reassess for chemical irritants and ensure discontinuation of douching and feminine hygiene products 2, 3
• Additional antimicrobial therapy may be of minimal benefit when relapse and reinfection have been excluded 2