Treatment for Vaginitis in Reproductive-Age Women
Treatment depends entirely on the specific type of vaginitis diagnosed, as bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis each require distinctly different therapies and cannot be treated empirically without proper diagnosis. 1, 2
Diagnostic Approach Before Treatment
Accurate diagnosis is mandatory before initiating any therapy and requires three key steps: 1, 2
- Measure vaginal pH using narrow-range pH paper—pH ≤4.5 suggests vulvovaginal candidiasis, while pH >4.5 indicates bacterial vaginosis or trichomoniasis 2
- Perform wet mount microscopy with two preparations: one in normal saline to identify motile trichomonads or clue cells, and one in 10% KOH to visualize yeast or pseudohyphae 1, 2
- Conduct the whiff test by adding KOH to vaginal discharge—a fishy odor suggests bacterial vaginosis 3, 2
For bacterial vaginosis specifically, diagnosis requires three of four Amsel criteria: homogeneous white discharge coating vaginal walls, clue cells on microscopy, pH >4.5, and positive whiff test. 3, 1
Treatment for Bacterial Vaginosis
First-line treatment is oral metronidazole 500 mg twice daily for 7 days. 3, 1
Alternative regimens include: 3, 1
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally at bedtime for 7 days
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days
- Metronidazole 2g orally as a single dose (though 7-day regimen preferred)
Critical caveat: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward. 1 Treatment of male sex partners is not recommended, as it does not prevent recurrence. 3, 1
Treatment for Vulvovaginal Candidiasis (Uncomplicated)
For uncomplicated VVC, prescribe either oral fluconazole 150 mg as a single dose OR topical azole therapy for 3-7 days—both achieve 80-90% cure rates. 1, 2, 4
Recommended topical options include: 1, 5
- Clotrimazole 1% cream 5g intravaginally for 7-14 days
- Miconazole 2% cream 5g intravaginally for 7 days
- Terconazole 0.4% cream 5g intravaginally for 7 days
- Terconazole 0.8% cream 5g intravaginally for 3 days
For complicated VVC (severe symptoms, recurrent episodes ≥4 per year, non-albicans Candida, or immunocompromised patients), use extended therapy with topical azoles for 7-14 days or fluconazole 150 mg every 72 hours for 3 doses. 1, 2 Maintenance therapy with weekly oral fluconazole for up to 6 months may be effective for recurrent cases. 1
Treatment for Trichomoniasis
First-line treatment is metronidazole 2g orally as a single dose, with cure rates up to 88%. 1, 6
Alternative regimen: 1
- Metronidazole 500 mg twice daily for 7 days
Critical requirement: Sex partners must be treated simultaneously to prevent reinfection. 1, 2 This is a sexually transmitted infection, and failure to treat partners leads to treatment failure. 3
Special Considerations for Pregnancy
- For bacterial vaginosis in pregnancy: Treatment may reduce risk of preterm birth, especially in high-risk women with prior preterm delivery 3, 1
- For VVC during pregnancy: Use ONLY 7-day topical azole therapy—never prescribe oral fluconazole due to associations with spontaneous abortion and congenital defects 1, 2
- For trichomoniasis in pregnancy: Oral metronidazole remains the treatment, as benefits outweigh risks 1
Critical Pitfalls to Avoid
- Never treat Candida identified on microscopy in asymptomatic women—10-20% of women normally harbor yeast in the vagina without infection 1, 2
- Only recommend over-the-counter antifungals for women previously diagnosed with VVC who experience identical recurrent symptoms 1, 5, 2
- Patients must complete the full treatment course even if symptoms improve early—premature discontinuation leads to treatment failure 1
- Women whose symptoms persist after OTC treatment or recur within 2 months must seek medical evaluation rather than self-treat 1, 5, 2
- Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms—counsel patients accordingly 5, 2