Vaginitis and Vaginosis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Vulvovaginal candidiasis (VVC): Inflammation of the vagina and vulva caused by infection with Candida sp.
- Bacterial vaginosis (BV): A syndrome in which the hydrogen peroxide–producing lactobacilli normally found in the vagina are replaced by other bacteria, usually anaerobes
- VVC and BV are not generally considered sexually transmitted infections.
- Other causes of vaginitis include allergic and contact dermatitis (from feminine hygiene products: Fragrances, creams, douches, lubricants, and their preservatives).
- Atrophic vaginitis is covered separately in Menopause.
- See separate article entitled Trichomoniasis.
- A number of dermatoses such as lichen planus, lichen sclerosus, and psoriasis may mimic vaginitis symptoms.
- System(s) affected: Reproductive; Skin/Exocrine
- Synonym(s): VVC: Monilial vulvovaginitis; Vaginal yeast infection; BV: Gardnerella vaginosis; Nonspecific vaginitis; Haemophilus vaginitis; Corynebacterium vaginitis
- Both VVC and BV are common among reproductive-age females.
- Most cases of VVC are related to C. albicans but may be caused by other Candida sp. (e.g., C. glabrata).
- VVC related to C. glabrata may be more common among diabetic women.
- VVC: 2nd most common cause of vaginitis after BV:
- 75% of women diagnosed at least once with VVC; up to 45% diagnosed more than once
- <5% of females are diagnosed with recurrent VVC (defined as 4 or more episodes of VVC in 1 year).
- Studies have shown that up to 50% of females may be colonized with yeast but do not exhibit the symptoms of vaginitis. This may be as high as 72%.
- BV: Prevalence varies based on age, race/ethnicity, and socioeconomic status:
- Most common vaginal infection among reproductive-aged women
- NHANES data reported an overall prevalence of 29%, with the highest rates (50%) among black women.
VVC and BV are less common before the onset of puberty and after menopause.
- Diabetes mellitus (DM) with poor glycemic control
- Antibiotic therapy
- Immunosuppression (e.g., corticosteroid therapy, HIV infection)
- High-estrogen states (e.g., pregnancy, oral contraceptive use, hormone-replacement therapy); C. albicans accounts for 85–90% of cases in pregnancy.
- Black race
- Lower socioeconomic status
- New or multiple sex partner(s)
- Female sex partners
- Spermicide use
- Vulvar hygiene (see General Measures); avoid implicated feminine hygiene products.
- Maintenance therapy for recurrent cases
- Treatment of sexual partners generally is not recommended but may be considered in recurrent cases.
- VVC: Overgrowth of yeast in the vagina
- BV: Shift from a healthy lactobacilli-based endogenous flora to an anaerobically based endogenous flora, including G. vaginalis, Mobiluncus sp., Mycoplasma hominis, Peptostreptococcus, Prevotella, Bacteroides, and Fusobacterium sp.; the rectum may be a reservoir of organisms leading to autoinfection.
Commonly Associated Conditions
- Sexually transmitted infections
- Balanitis in male partners may occur rarely.
- In same-sex partners, research is limited. Symptomatic partners should be evaluated.
Neither symptoms alone nor findings on physical examination have good sensitivity or discriminatory power for vaginal infections. Light microscopy is most helpful when classic findings are present (1,2)[A].
- Vaginal and vulvar pruritus
- Vulvar pain, external dysuria, and dyspareunia
- Thick, curdlike vaginal discharge
- Many women asymptomatic
- Unpleasant musty or fishy vaginal odor, exacerbated immediately after intercourse
- 10–30% may have vaginal/vulvar irritation
- Thin gray–white or frothy vaginal discharge
- Thick, curdlike vaginal discharge
- Vulvar erythema and edema
- Vulvar fissures and excoriations
- Normal vaginal pH (<4.5)
- 10–30% may have vaginal/vulvar irritation.
- Thin gray–white vaginal discharge is mildly adherent to vaginal walls.
- 10% have frothy discharge.
- pH >4.5
Diagnostic Tests & Interpretation
- Wet mount: Prepare 2 slides, both with fresh vaginal discharge: NaCl and 10% KOH:
- The presence of budding yeasts and hyphae consistent with VVC (KOH)
- Clue cells >10–20% of total epithelial cells considered clinically significant for diagnosis of BV (saline)
- White blood cells (WBCs) are not numerous in BV but may be present in large numbers in VVC.
- Amsel criteria for BV (need 3 out of 4): Clue cells, characteristic vaginal discharge, vaginal pH >4.5, and positive “whiff test” (transient but potent amine or fishy odor with the addition of 10% KOH); vaginal pH also may suggest need for testing for Trichomonas (3)[B].
- Consider vaginal culture for VVC when characteristic symptoms are present, vaginal pH is normal, and no yeast are present on wet mount or to identify species if no improvement with treatment or relapse occurs within 2 months.
- Positive culture for Candida sp. or other yeasts sometimes may only indicate colonization; clinical correlation is required.
- VVC or BV: May be noted on cytology but must be correlated with clinical symptoms; asymptomatic women generally do not need treatment.
- DNA probe–based tests are available (Affirm VP III, Becton Dickinson, Sparks, MD), but it is unclear that identification of the presence of yeast (or low numbers of G. vaginalis) indicates that the organism is the cause of symptoms. Use may not be cost-effective.
- Physiologic discharge and cervical ectropion
- Contact dermatitis
- Mechanical/chemical irritation
- Cervicitis (chlamydial or gonococcal)
- Urinary tract infection (UTI)
- Atrophic vaginitis
- Dermatoses: Lichen sclerosus, lichen planus, seborrheic dermatitis, psoriasis
- Short-course therapy with topical azoles is effective in 80–90% of patients.
- Many topical therapies are available over the counter.
- Miconazole: 2% cream 5 gm intravaginally × 7 days, or 200-mg vaginal suppository × 3 days, or 1,200-mg vaginal suppository × 1 day
- Butoconazole: 2% cream 5 gm intravaginally × 3 days, or sustained-release single intravaginal application
- Terconazole: 0.4% cream 5 g intravaginally × 7 days, or 0.8% cream × 3 days, or 80-mg vaginal suppository × 3 days
- Clotrimazole: 1% cream 5 g intravaginally × 7–14 days, or 100-mg vaginal tablets, 1 tablet × 7 days or 2 tablets × 3 days
- Tioconazole: 6.5% ointment 5 g intravaginally, single application; complete relief may take up to 7 days.
- Nystatin: 100,000-unit vaginal tablet × 14 days
- Oral therapy: Fluconazole, 150 mg p.o. once; use with caution in patients with liver disease and with coadministration of other drugs.
- Metronidazole (Flagyl): 500 mg p.o. b.i.d. × 7 days or
- Metronidazole vaginal gel: 0.75% 5 g intravaginally daily × 7 days or
- Clindamycin: 2% vaginal cream 5 g intravaginally daily × 7 days
Oil-based preparations may weaken latex condoms.
- Recurrent VVC: Obtain cultures. Infections associated with C. glabrata (5–15%) are less responsive to 1st-line therapies (4,5).
- Consider longer-duration therapy (7–14 days of topical or oral fluconazole every 3rd day for a total of 3 doses).
- Suppressive maintenance therapy (oral fluconazole weekly × 6 months or topical treatments weekly) (6)
- Women with recurrent candidiasis may benefit from fluconazole 150 mg per week plus cetirizine 10 mg/d (7)[B] for allergy or itching.
- Boric acid: 600-mg gelatin capsule inserted vaginally daily × 2 weeks (indicated for non-Albicansdisease; 70% clinical and mycologic cure rate) (5)
- Metronidazole: 2 g p.o. single dose (less effective than 7-day regimen)
- Clindamycin: 300 mg p.o. daily × 7 days
- Clindamycin ovules: 100 g intravaginally at bedtime × 3 days (clindamycin creams are less effective than metronidazole)
- Tinidazole: 1 g p.o. × 5 days has been shown to be effective and may produce fewer side effects than metronidazole.
Metronidazole produces a disulfiramlike effect when alcohol is ingested. Avoid any alcohol-containing product while taking metronidazole.
- VVC: Oral azoles relatively contraindicated in pregnancy (pregnancy Category C); choose topical therapy if possible.
- BV: Associated with preterm delivery; however, it is unclear whether the treatment of BV prevents preterm delivery. All symptomatic women should be treated, screening reserved for women at high risk for preterm delivery. Avoid creams; metronidazole 500 mg p.o. b.i.d. × 7 days or clindamycin 300 mg p.o. 2 b.i.d. × 7 days. Package labeling of metronidazole indicates that it is contraindicated in the 1st trimester of pregnancy, but this is not supported by recent meta-analyses of available data.
- Avoid use of panty liners, pantyhose, and occlusive pants and undergarments.
- Avoid douching.
- Regular use of condoms may help to prevent BV.
Issues for Referral
Treating the male sexual partner does not reduce symptoms or prevent recurrence, but this may be considered in patients who have recurrent infection. Relapses of both conditions are fairly common, and several regimens have been suggested for prophylaxis/maintenance.
Complementary and Alternative Medicine
- Lactobacillus supplementation is not effective in prevention.
- Use of garlic and tea tree oil has no known efficacy.
Delay sexual relations until symptoms clear/discomfort resolves.
Generally, no specific follow-up needed; if symptoms persist or recur within 2 months, repeat pelvic exam and culture.
Reduction of sugar intake has been recommended but is not supported by evidence.
American College of Obstetricians and Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; (800) 762-ACOG; http://www.acog.org
VVC: 80–90% of uncomplicated cases cured with appropriate treatment; 30–50% of recurrent infections return after discontinuation of maintenance therapy; there is a relatively high spontaneous remission rate of untreated symptoms as well.
- VVC may occur following treatment of BV.
- BV has been associated with an increased risk of acquisition and transmission of sexually transmitted diseases (STIs), including HIV.
- BV has been associated with increased risk of pregnancy complications, including preterm birth, postpartum and postabortal endometritis, and pelvic inflammatory disease (PID).
1. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291:1368–79.
2. Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstet Gynecol. 2009;113:89–95.
3. Carr PL, Rothberg MB, Friedman RH, et al. “Shotgun” versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis. J Gen Intern Med. 2005;20:793–9.
4. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004;70:2125–32.
5. Ray D, Goswami R, Banerjee U, et al. Prevalence of Candida glabrata and Its Response to Boric Acid Vaginal Suppositories in Comparison With Oral Fluconazole in Patients With Diabetes and Vulvovaginal Candidiasis. Diabetes Care. 2007;30:312–7.
6. Pappas, et al. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Disease Society of America. Clinical Infectious Diseases 2009;48(5):503–535.
7. Neves NA, Carvalho LP, Lopes AC, et al. Successful treatment of refractory recurrent vaginal candidiasis with cetirizine plus fluconazole. J Low Genit Tract Dis. 2005;9:167–70.
Allsworth JE, Peipert JF. Prevalence of bacterial vaginosis: 2001–2004 National Health and Nutrition Examination Survey data. Obstet Gynecol. 2007;109:114–20.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines. MMWR.2006;55(No. RR-11):54–6.
Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 2005;353:1899–911.
See Also (Topic, Algorithm, Electronic Media Element)
Algorithm: Discharge, Vaginal
- 041.9 Bacterial infection, unspecified, in conditions classified elsewhere and of unspecified site
- 112.1 Candidiasis of vulva and vagina
- 616.10 Vaginitis and vulvovaginitis, unspecified
- 72605008 candidal vulvovaginitis (disorder)
- 198212006 vaginitis and vulvovaginitis (disorder)
- 419760006 bacterial vaginosis (disorder)
- Clinical symptoms, signs, and microscopy have relatively poor performance compared with so-called gold standards such as culture and DNA probe assays, but these more sensitive assays may detect organisms that may not be causing symptoms.
- Most women experience relief of symptoms with therapy chosen without such gold standard tests, and even when the treatment does not correspond with the underlying infection.
- Vaginal pH is underused as a diagnostic tool for evaluation of vaginitis.
- Treatment of sexual partners is not currently the standard of care for either BV or VVC.