What are the treatment options for a woman with vaginitis or vulvovaginitis, considering potential causes such as bacterial vaginosis, vulvovaginal candidiasis, or atrophic vaginitis?

Treatment of Vaginitis and Vulvovaginitis

The treatment of vaginitis depends entirely on identifying the specific causative organism through pH testing and microscopic examination, with bacterial vaginosis treated with metronidazole or clindamycin, vulvovaginal candidiasis treated with topical azoles or oral fluconazole, and trichomoniasis treated with metronidazole—all symptomatic women require treatment regardless of pregnancy status. 1

Diagnostic Algorithm Before Treatment

The diagnosis must be established before initiating therapy, as treatment varies dramatically by etiology 1:

• Measure vaginal pH using narrow-range pH paper: pH >4.5 suggests bacterial vaginosis or trichomoniasis, while pH ≤4.5 suggests vulvovaginal candidiasis 1
• Perform saline wet mount microscopy to identify motile Trichomonas vaginalis or clue cells characteristic of bacterial vaginosis 1
• Perform 10% KOH preparation to visualize yeast or pseudohyphae (Candida), and note any fishy amine odor immediately upon KOH application (positive "whiff test" indicates bacterial vaginosis) 1
• Culture for Trichomonas is more sensitive than microscopy when clinical suspicion is high 1

Bacterial Vaginosis Treatment

Standard Regimens

Metronidazole 500 mg orally twice daily for 7 days is the primary recommended treatment 1, 2

Alternative regimens include 1:

• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally once daily for 5 days
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
• Clindamycin 300 mg orally twice daily for 7 days

Critical Clinical Considerations

• Up to 50% of women with bacterial vaginosis are completely asymptomatic, but all symptomatic women require treatment 1, 3
• Bacterial vaginosis during pregnancy is associated with adverse outcomes including preterm delivery, and treatment is recommended for all symptomatic pregnant women 1
• High-risk pregnant women (those with prior preterm delivery) may benefit from screening and treatment even when asymptomatic 1
• Treatment before invasive gynecologic procedures (surgical abortion, hysterectomy, IUD placement) is recommended even in asymptomatic women to prevent serious ascending infections including endometritis, pelvic inflammatory disease, and vaginal cuff cellulitis 3, 2
• Treating male sexual partners does not prevent recurrence and is not recommended 1, 4
• Recurrence rates are high (50-80% within one year), and extended maintenance therapy may be needed for recurrent cases 4, 5

Vulvovaginal Candidiasis Treatment

Uncomplicated VVC (Mild-to-Moderate, Sporadic, Non-Recurrent)

Short-course topical azole therapy (1-3 days) or single-dose oral fluconazole 150 mg effectively treats 80-90% of uncomplicated cases 1

Recommended intravaginal regimens 1:

• Fluconazole 150 mg oral tablet, single dose (most convenient option) 1, 6
• Miconazole 2% cream 5 g intravaginally for 7 days (available OTC)
• Clotrimazole 1% cream 5 g intravaginally for 7-14 days (available OTC)
• Terconazole 0.8% cream 5 g intravaginally for 3 days
• Butoconazole 2% cream 5 g intravaginally for 3 days (available OTC)
• Tioconazole 6.5% ointment 5 g intravaginally, single application (available OTC)

Complicated VVC (Severe, Recurrent, Abnormal Host, or Non-Albicans Species)

Complicated cases require longer treatment duration (7-14 days) and may need maintenance therapy 1:

• Severe local disease: Use 7-14 day topical azole regimen
• Recurrent VVC (≥4 episodes/year): Initial treatment followed by maintenance fluconazole 150 mg weekly for 6 months 5, 7
• Non-albicans Candida (especially C. glabrata): Vaginal boric acid 600 mg in gelatin capsule intravaginally daily for 14 days is first-line 5, 7

Special Populations and Caveats

• During pregnancy, only topical azoles are recommended; oral fluconazole should be avoided 1, 2
• Self-treatment with OTC preparations should only be advised for women previously diagnosed with VVC who experience identical recurrent symptoms 1
• Women whose symptoms persist after OTC treatment or recur within 2 months must seek medical evaluation 1
• Identifying Candida by culture in asymptomatic women (10-20% of women) is not an indication for treatment 1
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 1

Trichomoniasis Treatment

Metronidazole 2 g orally in a single dose is the recommended treatment, and simultaneous treatment of all sexual partners is mandatory to prevent reinfection 1, 2

Alternative regimen 1:

• Metronidazole 500 mg orally twice daily for 7 days (preferred for recurrent or treatment-failure cases) 5, 8

Critical Management Points

• Trichomoniasis is sexually transmitted, and treatment of partners is essential—this is the only sexually transmitted infection where treatment recommendations vary by sex 2, 5
• During pregnancy, metronidazole 2 g single dose can be used 2
• Patients should abstain from alcohol during and for 24 hours after metronidazole treatment to avoid disulfiram-like reaction 8
• Nucleic acid amplification testing (NAAT) is superior to wet mount microscopy for diagnosis, as microscopy has low sensitivity 2, 8

Atrophic Vaginitis Treatment

Vaginal estrogen therapy is the most effective treatment for genitourinary syndrome of menopause causing atrophic vaginitis 5, 9:

• Vaginal estrogen cream, tablets, or rings
• Nonhormonal vaginal moisturizers and lubricants for women who cannot use estrogen
• Avoid chemical irritants including soaps, douches, and vaginal products 3

Treatment Failure and Reconsideration

When patients do not respond to initial treatment 5, 9:

• Reconsider the diagnosis—laboratory testing fails to identify the cause in a substantial minority of women 1
• Consider alternative diagnoses: desquamative inflammatory vaginitis (treated with topical clindamycin and steroids), vulvodynia, or erosive vulvovaginal disease 5, 9
• Yeast culture with speciation is crucial for persistent candidiasis to identify non-albicans species requiring alternative therapy 7
• Rule out cervicitis from Chlamydia trachomatis or Neisseria gonorrhoeae, which can present with vaginal discharge 1, 2