Clinical Expert Series

Management of Persistent Vaginitis
Paul Nyirjesy,


With vaginitis remaining a common condition that leads women to seek care, it is not surprising
that some women develop chronic vulvovaginal problems that are difficult to diagnose and
treat. With a differential diagnosis that encompasses vulvar disorders and infectious and
noninfectious causes of vaginitis, accurate diagnosis is the cornerstone of choosing effective
therapy. Evaluation should include a symptom-specific history, careful vulvar and vaginal
examination, and office-based tests (vaginal pH, amine test, saline and 10% potassium hydroxide
microscopy). Ancillary tests, especially yeast culture with speciation, are frequently crucial to
obtaining a correct diagnosis. A heavy but normal physiologic discharge can be determined by
excluding other causes. With vulvovaginal candidiasis, differentiating between Candida albicans
and non-albicans Candida infection has important treatment ramifications. Most patients with C
albicans infections can be successfully treated with maintenance antifungal therapy, usually with
fluconazole. Although many non-albicans Candida, particularly Candida glabrata, may at times
be innocent bystanders, vaginal boric acid therapy is an effective first choice for many true nonalbicans Candida infections. Recurrent bacterial vaginosis, a difficult therapeutic challenge, can
often be controlled with maintenance therapy. Multiple options, especially high-dose tinidazole,
have been used for metronidazole-resistant trichomoniasis. With the aging of the U.S. population, atrophic vaginitis and desquamative inflammatory vaginitis, both associated with hypoestrogenism, are encountered frequently in women with persistent vaginitis.
(Obstet Gynecol 2014;0:1–12)
DOI: 10.1097/AOG.0000000000000551


aginal complaints are considered one of the most
common reasons that women seek the care of
a health care provider.1 Although the word “vaginitis”
is used as a diagnostic term by patients and health care
providers alike, it is a nonspecific term encompassing
a broad range of conditions that cause vulvovaginal
symptoms and affect women in virtually every age
group. After a standard evaluation, it is estimated that
70% of episodes of vaginitis in premenopausal women
are caused by bacterial vaginosis, vulvovaginal candi-

From the Department of Obstetrics and Gynecology, Drexel University School of
Medicine, Philadelphia, Pennsylvania.
Continuing medical education for this article is available at http://links.lww.
Corresponding author: Paul Nyirjesy, MD, 245 North 15th Street, New
College Building, 16th Floor, Philadelphia, PA 19102; e-mail: pnyirjes@
Financial Disclosure
Dr. Nyirjesy has been a consultant for Novadigm, Viamet Pharmaceuticals,
Symbiomix, Cepheid, and Hologics. He has received research grants from
Novadigm, Viamet Pharmaceuticals, Symbiomix, and Becton–Dickinson.
© 2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14

VOL. 0, NO. 0, MONTH 2014

diasis, and trichomoniasis.2 Furthermore, as the population in the United States ages, an increasing
number of women may develop symptomatic atrophic vaginitis. For most women, episodes of vaginitis
will resolve without any difficulty or long-term
On the other hand, many women with vulvovaginal symptoms remain undiagnosed or either fail to
improve or recur after treatment. Although persistent
vaginitis is seldom life-threatening, it leads to morbidities of discomfort and pain, days lost from school or
work, and impaired sexual functioning and self-image.
Because women with chronic or recurrent symptoms
are a therapeutic challenge for health care providers,
their problems may be ignored or trivialized and may
last for months or years. As a result, they often selfmedicate with various over-the-counter and alternative medicines; sometimes these treatments in turn
exacerbate symptoms and make the overall problem
worse.3 This article describes a systematic approach to
diagnosis and management, which can lead to complete cure or at least significant symptom resolution
for the vast majority of affected women.


Copyright ª American College of Obstetricians and Gynecologists


questions about soaps. or combinations thereof. Because selfdiagnosis and telephone diagnosis are frequently inaccurate. color. the length of therapy for each course (episodic or maintenance). erosions. Although these results may be different in other practice populations. but being aware of possible causes creates a framework for evaluation and management. Although this type of review may seem time-consuming. and the response to each type of therapy (complete. and acute exacerbations of chronic discomfort. asking about chronic dyspareunia and whether it is with intromission as opposed to thrusting is quite important. both). atrophic vaginitis (15%). or vagina can be helpful. because cervicitis can cause an abnormal irritating discharge. Finally. and physiologic discharge (9%). Patients who report an abnormal discharge are asked about quantity. atrophy. vestibule. Examination of the vestibule should also include palpation with a swab to look for tenderness. estrogen). douching. antibiotics. 18% had two or more concurrent diagnoses. Patient symptoms can be broadly grouped into those of discharge. In this population in which selftreatment is common. or alterations in the vulvar architecture such as periclitoral scarring or resorption of the labia minora. ulcers. finding erosive lichen planus in the mouth or hidradenitis suppurativa in the axillae makes it easier to recognize it on the vulva. a sexual history may lead to testing for sexually transmitted infections. because any recent medication hampers the clinician’s ability to do a thorough evaluation. Similarly. corticosteroids. masses. a sign of possible vestibulodynia. knowing the timing of the last dose of any treatment is important. the cervix itself should be examined to assess for any mucopurulent discharge or areas of contact bleeding. we review what types of treatments have been administered (antifungals. and neuropathic pain conditions. because women with localized provoked vestibulodynia have pain with penetration but few daily symptoms. they serve to underscore the broad differential diagnosis. burning. but health care providers should note that many women with persistent “vaginitis” have chronic vulvar diseases. With symptoms such as itching. viscosity. When doing so. and even synechiae before obtaining samples. recurrent vulvovaginal candidiasis (21%).6 Obtaining an appropriate history is the first step to proper diagnosis. the mode of administration (oral. Pelvic examination should begin with inspection of the vulva. Thus. feminine hygiene products. she is much more likely to have vulvovaginal candidiasis than someone who describes no improvement. including separating all the skin folds to look for abnormalities such as redness. it is helpful to review patient symptoms in detail with a structured interview.3 the differential diagnosis encompasses a broad array of vulvar and vaginal conditions. dermatologic. In one prospective survey of 200 patients evaluated at a tertiary care vaginitis center. Those reporting an abnormal odor are asked to describe it in more detail. if a woman reliably improves after each course of antifungal therapy only to recur later. we try to distinguish among acute episodes. vaginal evaluation should start with inspection to look for evidence of inflammation. For example. chronic discomfort. Asking patients whether symptoms are located mainly in 2 Nyirjesy Management of Persistent Vaginitis the vulva. irritation. even short term. Practice guidelines by both the American College of Obstetricians and Gynecologists6 and the Centers OBSTETRICS & GYNECOLOGY Copyright ª American College of Obstetricians and Gynecologists . Nyirjesy and colleagues4 found that the most common diagnoses were contact dermatitis (21%). With contact dermatitis commonly found in this population. and use of over-the-counter antifungal and numbing agents containing sensitizers such as benzocaine are important for identifying and removing possible irritants. fissures. inflammatory. Furthermore. it only takes a few minutes and provides a concise picture of what symptoms are bothering the patient. localized provoked vestibulodynia (13%). This review focuses on the etiology and treatment of those entities that cause primarily vaginal symptoms. recently discussed by the American College of Obstetricians and Gynecologists.EVALUATION OF PATIENTS WITH PERSISTENT VAGINITIS Although most women with chronic vaginitis believe that they have recurrent yeast infections. accurate diagnosis is the cornerstone of effective therapy. including infectious. For example. even women with obvious vulvar diseases such as lichen sclerosus can also have vaginal processes such as candidiasis or atrophic vaginitis. Because patients have frequently received many different forms of treatment. erosions.5 Conversely. burning or irritation. itching. Finally. which complicate management and prevent overall improvement. which we routinely administer in our tertiary care vaginitis center. It may seem daunting to evaluate a woman who has seen multiple health care providers and tried many therapies over the years without improvement. A general physical examination may yield a diagnosis before doing a pelvic examination. odor. they should be avoided wherever possible. and relationship to the menstrual cycle. partial. particularly in women with chronic symptoms. nonexistent). topical. 62% of whom had had symptoms for more than 1 year.

vaginal pH testing in particular can be used to drive the entire diagnostic process. Finally. Figure 1 describes the pH-based algorithm that we use in practice. enterococci. If Trichomonas vaginalis infection is suspected but not proven. antigen and DNA tests for candida. by assessing for increased white blood cells and abnormal cytology such as parabasal cells. fissures. A pH-based framework for diagnosing the most common causes of vaginitis. because normal vaginal flora such as Escherichia coli. Vaginal Fig. they are more costly than current modalities.7. Reprinted with kind permission from Springer Science+Business Media: Nyirjesy P. and in the case of PCR testing for yeast and bacterial vaginosis. and group B streptococci are frequently found. Polymerase chain reaction testing for Neisseria gonorrhoeae and Chlamydia trachomatis and bacterial cultures looking specifically for group A strep- tococci or Staphylococcus aureus should be considered in women with many white blood cells on saline microscopy.8 Saline microscopy can aid in diagnosing bacterial vaginosis and trichomoniasis. these easily available tests can frequently diagnose common forms of vaginitis. However. In addition. Gardnerella vaginalis. should be considered for focal abnormalities. MONTH 2014 Nyirjesy Management of Persistent Vaginitis Copyright ª American College of Obstetricians and Gynecologists 3 . VOL. vulvar biopsies. Routine bacterial cultures are otherwise unhelpful and can be misleading. PCR testing for yeast and bacterial vaginosis). which lowers the pH of the vagina to less than 4. 1. 0. and both saline and 10% potassium hydroxide microscopy. treating. Lactobacilli become the dominant flora. those with many white blood cells on microscopy. the vagina is thinned and has a high pH.4 understanding the normal vaginal environment is important. Curr Infect Dis Rep 2005. Although these latter two organisms may be commensals. Sobel JD. Advances in diagnosing vaginitis: development of a new algorithm. and ruling out vulvovaginal candidiasis. Food and Drug Administration–cleared APTIMA T vaginalis assay.9 For other tests for vaginal infections (ie. office testing has poor performance characteristics. Frequently underused. they are also occasional causes of purulent vaginitis. and ancillary tests are frequently indicated. and those in whom evaluation is consistent with recurrent bacterial vaginosis. and trichomoniasis. Under the influence of estrogen. Gardnerella. and. Before puberty. As shown in Table 1. Nyirjesy.for Disease Control and Prevention7 stress the importance of in-office testing for vaginal pH. yeast cultures with speciation of the organism play an integral part in diagnosing. amines. The findings of vesicles. particularly if the etiology is unclear. vaginal biopsies. We perform this latter test in all of our patients at risk for a sexually transmitted infection. NO. During a woman’s reproductive years. there is currently little evidence that they are superior to current gold standards. saline microscopy tests for atrophic vaginitis and desquamative inflammatory vaginitis. the vaginal epithelium thickens. less commonly. Figure 2. estrogen plays a key role in maintaining the normal vaginal environment. Obstet Gynecol 2014. including skin and fecal flora and lactobacilli. NORMAL VAGINAL PHYSIOLOGY AND DISCHARGE With physiologic discharge occurring as the final diagnosis in 9% of the patients referred to our tertiary care program. 0. or ulcers should routinely lead to PCR tests for herpes simplex virus and possibly type-specific immune globulin G antibody testing.S. point-of-care enzymatic. Management of Persistent Vaginitis. culture of the vagina demonstrates a variety of organisms. Of those. the gold standard test remains either culture or the more easily available polymerase chain reaction (PCR) with the U.7:458–62.

and time missed from work.14 Thus.7 Unremarkable. a common event for almost every woman. polymerase chain reaction.2 complaints of a thick white discharge often lead to repeated use of unnecessary antifungal therapy and raise fears of recurrent infection. examination may reveal vulvar redness. burning. In our experience. a heavy discharge coming from the upper genital tract may be the result of an endometrial polyp or fallopian tube malignancy. swelling. and despite evidence that the symptom of discharge is nonspecific. soreness. including local transport from the perineum and perianal areas. the prerequisite is colonization with Candida species. the current definition of recurrent disease.8 billion. depending on the health care provider. may have high false-positive rates. almost doubling the rate of diagnosis. or dyspareunia. 4 Nyirjesy Management of Persistent Vaginitis 50% of women will experience sporadic recurrences. or excoriations.4. four weekly self-obtained cultures for yeast increased the number of positives from 59 at baseline to 111 in 441 women with suspected recurrent candidiasis. irritation. digital introduction. Furthermore.7 $4. Even more uncommonly. with women noting a clear mucus midcycle to a thick white discharge at other times. and these medications number in the top 10 of all over-the-counter medications sold in the United States. fissures. only has a sensitivity of approximately 50%13 and.12 Although findings may be minimal. 6white blood cells.4. were estimated to be $1.10 The associated annual costs of vulvovaginal candidiasis in the United States in 1995. bacillary flora Hyphae.7 Parabasal cells. up to 30% at any single time and 70% if followed longitudinally for 1 year. external dysuria. when a discharge is physiologic. pelvic ultrasonography or sonohysterography should be considered. Testing for Causes of Vaginitis Vaginal pH Saline or 10% Potassium Hydroxide Microscopy Normal . including medical and treatment expenses.12 Office microscopy (Table 1). Because many women and health care providers are taught that a thick white discharge is most frequently caused by vulvovaginal candidiasis. OBSTETRICS & GYNECOLOGY Copyright ª American College of Obstetricians and Gynecologists .Table 1. which typically causes itching. increased white blood cells. discharge usually becomes heavier. coccobacillary flora Positive Trichomoniasis Varies Trichomonads Variable Atrophic vaginitis Desquamative inflammatory vaginitis $4. when suspected. which will be discussed later. the first line in diagnosis. decreased mixed flora Parabasal cells. an abnormal discharge may sometimes be the result of occult urinary incontinence.15 To develop a symptomatic infection. and perhaps 8–10% will suffer from four or more episodes every year. usually with Candida albicans. some patients require multiple visits with normal evaluations to be fully reassured. a woman’s perception of her discharge correlates quite poorly with vulvovaginal candidiasis. yeast cultures with speciation should be obtained to confirm the diagnosis. Vaginal colonization occurs through multiple routes. travel costs. blastospores Negative Bacterial vaginosis $4. Diagnosing a discharge as physiologic can only be done by excluding potential causes.11 Although most people believe that a thick white discharge is the hallmark symptom of yeast infections. vaginal signs are usually limited to erythema or occasionally thrush. Repeated sampling through patient vaginal self-culture for yeast may further aid in diagnosis. the annual market has been estimated at $275 million.11 Approximately 75% of women will develop symptomatic vulvovaginal candidiasis at least once in their lives.7 Negative Clinical diagnosis Vulvovaginal candidiasis . in a study at a Dutch dermatology clinic. or sexual transmission. Hormonal influences will change a discharge. which can be diagnosed by having a patient take phenazopyridine for 1–2 days and looking for a change in the color of the discharge. mixed flora Negative Negative Yeast culture with speciation Gram stain (Nugent score) Trichomonas vaginalis PCR Maturation index Clinical diagnosis Condition Amines Current Gold Standard PCR.7 Clue cells. certainly in women with recurrent infection and possibly in those in whom candidiasis is suspected but not proven. is present in normal healthy women. VULVOVAGINAL CANDIDIASIS With the proliferation of over-the-counter antifungal drugs.4. Candida colonization.

with C glabrata and Candida parapsilosis being the most common. when a woman with persistent vaginitis has a positive yeast culture.27 Most treatment guidelines distinguish between uncomplicated and complicated vulvovaginal candidiasis. determined by a negative follow-up culture.7 However. diabetes.7 In at least half of women with recurrent vulvovaginal candidiasis. but some women develop a symptomatic infection that goes away easily with standard antifungal therapy.20 In menopausal women. 0. An effective approach to resolve the question is to treat her and see if successful treatment. prescription to over-the-counter.29 Most experts agree that management begins by obtaining a positive yeast culture with speciation of the organism to confirm the diagnosis and identify the pathogen and then using that information to aggressively treat the infection. Women with recurrent infections have increased vaginal Candida species colonization rates. 0. with many women asymptomatically colonized with yeast. candida may be a commensal organism. and treatment of the male partner to prevent vulvovaginal candidiasis is not recommended. women with uncomplicated infections are otherwise healthy women with mild-to-moderate symptoms resulting from sporadic episodes of infections caused by C albicans.24 As reviewed by Fidel.23 As reviewed by Sobel. Of these.23 Whatever the cause. and behavioral factors are familiar to most health care providers. C albicans remains by far the most common cause of infection.6.28 For uncomplicated disease. phospholipases.23 Although up to 20% of male partners of women with recurrent infections may harbor candida strains on their penises. immunosuppression. there are no clear risk factors.11 The transition from asymptomatic colonization to symptomatic infection may be the result of intrinsic host. environmental. or a diaphragm with spermicide have all been associated with increased infection. there is a more complicated course with either failure to respond to treatment and the development of chronic infection17 or relatively rapid relapse after successful antifungal therapy and eventual recurrent disease. NO.16 After colonization. or organism-related factors. Diabetics may be more prone to developing infections caused by Candida glabrata18. they all have similar efficacy for C albicans infections with an expected cure rate of 80– 90% in uncomplicated patients. including genetic factors. exogenous estrogen use increases the risk of both candidal colonization and infection.for most. ranging from oral to topical. perhaps 54% of women have no improvement of symptoms after successful eradication. In the past. systemic immunosuppression is rare in women with vulvovaginal candidiasis. and subsequent germination promotes subsequent vaginitis.26 adherence of yeast cells to vaginal epithelium causes colonization. this is a transient asymptomatic event. more recently. actual transmission is thought to be uncommon. symptomatic episodes seem to occur mainly in women with preexisting colonization. it has been suggested that symptomatic candidiasis is the result of an increased sensitivity to yeast. although topical and systemic corticosteroid use may be more common. other host factors. approximately 30% of women will be infected by other species of yeast. antibiotic and estrogen use. most women with recurrent disease develop a pattern in which the infection clears with antifungal therapy only to recur within a few weeks to months. which result in increased susceptibility to infection. it was felt that these women had a decreased immune response. Virulence factors produced by Candida species. 40% have a similar result. is associated with a relief of symptoms.22 and using contraception with oral contraceptives.19 With antibiotic use. an intrauterine device. and mycotoxins. there are many available treatments. which in turn causes symptoms. Furthermore. Although each has its own advantages and disadvantages. For infections resulting from C albicans.21 In our experience. it can be difficult to distinguish between one who truly has vulvovaginal candidiasis as opposed to one who is asymptomatically colonized with yeast and has a separate cause for the symptoms. Sexual activity. usually with the same strain of yeast. as many 5%. but. In an even smaller group.27 However. particularly orogenital sex. glycosuria may be one mechanism contributing to both colonization and symptomatic infection. including secreted aspartate proteinases. the approach that is commonly used is maintenance Nyirjesy Management of Persistent Vaginitis Copyright ª American College of Obstetricians and Gynecologists 5 .25 most affected women seem to exhibit altered local immunoregulatory mechanisms. leading to an inflammatory response to yeast colonization. and with C parapsilosis. these regimens are clearly inadequate in women with complicated disease with failure rates of 35% within just 1 month of treatment. should be considered complicated and are more likely to fail standard antifungal therapy. may inhibit phagocytic activity and suppress the local immune system. proteases.26 In tertiary care vaginitis programs. its eradication results in a relief of symptoms in up to 90% of cases. behavioral.25 Finally. with C glabrata. VOL. other women. and 1-day to 7-day regimens. With C albicans infections. MONTH 2014 In most women with vulvovaginal candidiasis.7 In general. perhaps with sporadic recurrence. including those with recurrent vulvovaginal candidiasis and those with nonalbicans Candida infections. may be at play.

5% vaginal cream.34 For other non-albicans Candida infections. Although resistance to fluconazole seems to be fortunately rare.001). administered daily in a gelatin capsule for 14 days. respectively.75% vaginal gel 5 g/d310 d..33 Finally. it is inexpensive and well-tolerated. Centers for Disease Control and Prevention. or cost. has been shown to be effective32 but has become prohibitively expensive. and 12 months in the fluconazole group were 91. in which patients are treated with a prolonged (usually 6-month) regimen. The initial regimen used was 100 mg ketoconazole daily for 6 months.9% compared with 36. flucytosine compounded into a 15. then twice a week for 6 months. NAMS. 73. which prevent the use of fluconazole. raises new concerns and underscores the need to bring the patients on maintenance therapy back to make sure that they have a negative culture and are responding to treatment appropriately. Although alternate topical maintenance regimens with clotrimazole have been described and shown to be effective. Initial Treatment Options for Women With Chronic Vaginitis Condition Treatments Normal Vulvovaginal candidiasis Candida albicans Non-albicans Candida Bacterial vaginosis Trichomoniasis Atrophic vaginitis (vaginal treatments) Desquamative inflammatory vaginitis Source None indicated Fluconazole 150 mg orally every 3 d33. and 22%.32 Apart from occasionally causing local irritation and an abnormal discharge. 6 Nyirjesy Management of Persistent Vaginitis OBSTETRICS & GYNECOLOGY Copyright ª American College of Obstetricians and Gynecologists .6. maintenance fluconazole therapy is a well-tolerated and effective approach to treating recurrent C albicans infections (Table 2). This approach gives almost all women a prolonged period of symptom relief. Regimens of miconazole 2% cream or clotrimazole 1% cream. 3 g/d34 wk Sobel30 Sobel32 Sobel43 CDC7 NAMS51 Sobel58 CDC. Of the 343 patients who were studied for efficacy. many health care providers restart maintenance if the pathogen remains C albicans. to induce a negative culture. and 42. and only one had a mild elevation in aminotransferase levels. a recent report by Marchaim31 of clinically fluconazole-resistant C albicans vulvovaginal candidiasis. 9.7. then twice/wk Estradiol (2 mg) ring every 3 mo Clindamycin 2% vaginal cream. have been used successfully in our practice (unpublished observation). They were then randomized to weekly 150 mg fluconazole or placebo for 6 months (treatment phase). given 5 g daily for 14 days. and then followed for an additional 6 months (observation phase). Only one patient discontinued treatment because of an adverse event (headache) attributable to fluconazole.6 The advent of fluconazole in the early 1990s led to the replacement of ketoconazole by fluconazole as maintenance. In a study of maintenance fluconazole for recurrent vulvovaginal candidiasis. the same cannot be said for non-albicans Candida species. allergy. with C parapsilosis. but the approaches used for C glabrata or Table 2. Although unstudied. Current guidelines7 suggest using topical regimens intermittently. 28.32 Vaginal boric acid at 600 mg.625 mg/g) cream 0.7 because they may be more easily accepted by prescription plans. one case series described successful mycologic cure in 17 of 19 patients receiving 200 mg fluconazole twice a week for a month and six of six patients receiving 600-mg daily boric acid vaginal capsules twice daily for 2 weeks. For women who recur after maintenance therapy (approximately 50%). The second line of therapy.01% vaginal cream 2–4 g/d daily for 1–2 wk. then 1 g 1–3 times/wk Conjugated estrogen (0. possibly induced by long-term use of fluconazole. gastrointestinal discomfort.5 g twice/wk Estradiol (0. used daily for 14 days. There are some situations such as pregnancy. alternate doses of fluconazole (100 or 200 mg) are also recommended. Although clinical and in vitro resistance to C albicans is rare. Limited experience with topical amphotericin B as a 50-mg suppository offers another option for C glabrata infections. headaches. in the placebo group (P.30 women were initially given three doses of 150 mg fluconazole. evidence is limited to case reports or small case series. the proportions of women who remained disease-free at 6. is recommended as initial therapy and cures up to 70% of C glabrata infections (Table 2). North American Menopause Society. then twice/wk34 mo Tinidazole 2 g/d daily for 5 d Estradiol 0. Thus. 3 days apart. 5 g/d34 wk Hydrocortisone 10% vaginal cream. those specific formulations are no longer commercially available.antifungal therapy.010 mg) tablet/d32 wk. then once/wk36 mo Boric acid 600-mg capsules vaginally per d32 wk Metronidazole 0. but it is no longer recommended because of the risk of liver toxicity.

7 After treatment. living at or near the federal poverty level. Megasphaera type 1. including urinary tract infections. With standard antibiotic regimens. preterm birth. and postpartum endometritis in pregnant women. later research suggested that it was instead caused by complex changes in vaginal flora and G vaginalis was ignored until recently. These data suggest that it is not the mere presence of G vaginalis that causes bacterial vaginosis. the bacterial load may be decreased but the biofilm may not be eliminated.6. the biofilm consists primarily of G vaginalis and sometimes with A vaginae. After the early report by Gardner and Dukes40 describing G vaginalis as a possible cause of bacterial vaginosis. including Atopobium vaginae. Amsel’s criteria have a sensitivity of 92%. A vaginal Gram stain. cervicitis. Diagnosis relies on finding three of four Amsel’s criteria (abnormal gray discharge.2 Associated sociodemographic factors include a younger age. they also found that women with both A vaginae and G vaginalis present initially had a much higher rate of recurrence at 1 year than those in whom G vaginalis alone was present (83% compared with 38%. bacterial vaginosis-associated bacteria-3. 0. Metronidazole (oral or topical). and greater than 20% clue cells on saline microscopy). pelvic inflammatory disease. Nyirjesy Management of Persistent Vaginitis Copyright ª American College of Obstetricians and Gynecologists 7 . In women with disease.38 In a cohort of 130 Australian women treated with a 7-day course of oral metronidazole. which can be demonstrated on electron microscopy of vaginal biopsies. particularly those resulting from C glabrata.6. and an increased susceptibility to human immunodeficiency virus. because the yeast may be an innocent bystander in at least 50% of cases. increased risk of infection after gynecologic surgery. 0.. Usually.001). trichomonal.7 They offer equivalent efficacy and can be distinguished from each other on the basis of cost.C parapsilosis are likely to be effective. Biofilms are a type of slime produced by bacteria. In a molecular analysis of uncultivated organisms.28 BACTERIAL VAGINOSIS Affecting approximately 30% of women. thus setting the stage for recurrence after treatment.36 This disturbed vaginal flora is a risk factor for many infectious morbidities. Leptotrichia species and many others.37 Culture for G vaginalis is not recommended because of a lack of specificity. being non-Hispanic black or Mexican American. As reviewed by Verstraelen and Swidsinski. P. having less than a high school education. and douching. tinidazole (oral). having a regular sex partner throughout the study. the most common complaints are of an abnormal vaginal discharge and a fishy odor. Eggerthella species. chlamydial. positive amine test. high vaginal pH.39 Recent controversies about the role of the sexual partner and the possible development of vaginal biofilms as a result of G vaginalis infection have fueled new discussion of why women get bacterial vaginosis and why some women recur. Bacteroides species. and that hormonal contraception had a protective effect. Peptostreptococcus species. Mobiluncus species. As noted earlier. Fusobacterium species. Prevotella species. mode of administration. are found in vaginal samples of infected women. or having a female sex partner. where the presence or absence of different bacterial morphotypes is scored. and genital herpes infections in nonpregnant women as well as spontaneous abortion. MONTH 2014 PCR-based modalities to diagnose bacterial vaginosis using various criteria. known as the Nugent score.6 Compared with the Nugent score and much easier to perform in an office setting. but rather biofilm-associated G vaginalis. and adverse events.6 Although at least 50% of infected women have no symptoms.41 recent studies have found that 90% of women with and 10% without bacterial vaginosis have a complex polymicrobial biofilm. Bradshaw and colleagues found that the risk factors for recurrence were a history of bacterial vaginosis.7 Although commercial laboratories now offer VOL. they can often be cured with a second course of the same therapy. and clindamycin (oral or topical) are all recommended as initial treatments. which coats certain surfaces and within which bacteria hide from and are protected from the effects of antibiotics. the vulvovaginal examination will be normal apart from a discharge described as watery and gray.35 Bacterial vaginosis is marked by a disturbance in the vaginal microflora with a lack of the normal hydrogen peroxide-producing lactobacilli and an overgrowth of primarily anaerobic organisms. the best known example is the biofilm that occurs on infected foreign bodies such as central venous catheters. Megasphaera species. bacterial vaginosis-associated bacteria-2. If patients fail an initial course of treatment. there is no evidence of clear clinical superiority of these expensive tests over Amsel’s and Nugent criteria nor have they been shown to help in guiding therapy. NO. is considered the gold standard. bacterial vaginosis is considered the most common form of vaginitis. there may be less of a need to treat non-albicans Candida infections. a single recurrence or more may occur in up to 58% of women within 12 months. Initially thought to be caused by G vaginalis. bacterial vaginosisassociated bacteria. gonococcal. more recent studies using standard culture and DNA-based technologies have shown that a broad range of bacteria.

and 28 weeks from the initial visit was 87. culture or PCR is recommended. Thus.6. not all patients with trichomoniasis are straightforward.43 In this study of 127 evaluable women. oral or parenteral desensitization to metronidazole followed by treatment has been shown to be highly effective in a study of 15 patients treated and cured with such an approach.2 trichomoniasis is a surprisingly uncommon diagnosis at our tertiary care vaginitis 8 Nyirjesy Management of Persistent Vaginitis center and is found in fewer than 1% of the women referred to us (unpublished observation). despite serious limitations. a variety of potential treatment interventions make sense. but routine screening or treatment of the female partner is not. more recently. the data implicating the male partner from the Bradshaw study and the finding of similar flora in the male partners of women with bacterial vaginosis. as summarized by Muzny and Schwebke. health care providers should check to make sure that the treatment was taken and that reinfection did not occur. a 51% recurrence rate within 3 months and 59% rate of vulvovaginal candidiasis because of prolonged antibiotic therapy demonstrate the need for more effective therapy. an alternate regimen of 500 mg metronidazole or tinidazole twice a day for 7 days followed by 21 days of 600 mg boric acid daily followed by an additional twice weekly metronidazole gel regimen for 16 weeks was studied in 77 episodes of recurrent bacterial vaginosis. dyspareunia. Although up to 50% of infected women may be asymptomatic. Most uncomplicated cases will be cured with treatment with either oral metronidazole or tinidazole along with treatment of the sexual partner. With a sensitivity of 60–70%. Other tests. and metronidazole resistance.7 However. Physical findings include vulvovaginal erythema. treatment of partner studies.S. we routinely recommend consistent condom use for 3–6 months. Treatment failure can be related to noncompliance. With a resistant infection. Food and Drug Administration–cleared OSOM Trichomonas Rapid Antigen Test may provide a rapid (less than 10 minutes) result in the office.7 However. or persistence of a vaginal biofilm. With resistance. although data supporting this recommendation are lacking.001). a patient with this uncommon clinical scenario should be managed in conjunction with an allergist.48 Thus. respectively. and occasionally punctate hemorrhages of the vaginal mucosa and cervix.47 Thus. it remains difficult to truly cure women with recurrent bacterial vaginosis. reinfection. The finding of polymicrobial G vaginalis–dominant biofilm in men has added further fuel to the debate. with a failure rate of 50% by 36 weeks of follow-up. Because in vitro resistance correlates poorly with clinical outcome. the latter estimated at anywhere between 1.42 data in favor of sexual transmission include evidence that bacterial vaginosis can be transmitted between female sexual partners. To date. However. tinidazole. patients who are allergic to nitroimidazoles represent a therapeutic challenge. the only controlled study consisted of metronidazole gel twice weekly for 4 months after an initial 10-day course of therapy (Table 2). metronidazole-resistant trichomoniasis is primarily a clinical diagnosis. TRICHOMONIASIS Considered the third most common cause of infectious vaginitis. To date.7 In an attempt to prevent reinfection. but this theory was later discounted. the best approach seems to be maintenance therapy. the in vitro mechanisms are the result of both aerobic and anaerobic pathways.44 Cumulative cure at 12. have shown no benefit and are not recommended. discharge.7 and 10. Although these results represent the most promising ones to date. infection recurred in 26% of metronidazole gel and 59% of placebo patients (P5. However. Fortunately. Based on these various theories. 78. As noted in a review of 45 cases seen in a specialty vaginitis clinic. saline microscopy alone is simply not a good enough test to reliably diagnose trichomoniasis. such as the U. Although hypersensitivity reactions have been rare.42 and recolonization with lactobacillus supplements.1%.45 symptomatic women will complain of an abnormal discharge (clear to yellow–green and frothy). health care providers may also encounter women with allergic reactions to nitroimidazoles. vulvovaginal soreness and itching. In women who have sex with women. if T vaginalis infection is suspected but not proven. other cases were incident cases occurring in women being treated for other conditions.6. failure to reestablish normal lactobacillus-dominant flora. 16.46 Occasionally. if a patient returns with ongoing trichomoniasis after treatment. Centers for Disease Control and Prevention guidelines recommend obtaining cultures OBSTETRICS & GYNECOLOGY Copyright ª American College of Obstetricians and Gynecologists . the most common issues pertaining to trichomoniasis in women with persistent vaginitis are missed diagnosis (31%) and metronidazoleresistant infection (33%).41 Thus. bacterial vaginosis and its recurrence could be the result of one or several mechanisms: reinfection through sexual activity.7 For now. and pain on urination. and 65%. The mainstay of therapy has been metronidazole and.Gardner and Dukes40 had also hypothesized that bacterial vaginosis was sexually transmitted. the cleaning of shared sex toys between uses is encouraged.

suggests that it may be one option in problematic women. For most women. In a minority of women. the medical literature is peppered with other medications used in resistant trichomonas cases. but vestibular and vulvar ulceration is a side effect that limits its use.4 Initially thought of as a possible bacterial overgrowth of an atrophic vagina55 or even a variant of lichen planus. 0. ie. low-dose vaginal estrogen. affected women may sometimes note a heavier discharge. Unlike vulvovaginal atrophy. Findings include atrophy of the labia majora or minora. used commonly in our Thus. The nuances and controversies surrounding treatment of vulvovaginal atrophy have recently been reviewed. usually described as yellow or brown. a lack of response to topical estrogen may also serve to distinguish between the two conditions. The typical patient with desquamative inflammatory vaginitis is hypoestrogenic (on continuous lowdose birth control pills. NO. vestibular and vaginal pallor. if necessary. paromomycin had a 58% cure rate. yellow or watery. experience with paromomycin. very few controlled studies have been done to assess their effect. the most extensive experience is with high-dose tinidazole.51 Finally. 500 mg orally twice daily for 7 days. various treatment regimens have been proposed. mostly to no avail. The presence of white blood cells on saline microscopy can distinguish it from atrophy. 2 g metronidazole or tinidazole orally daily for 5 days is recommended as initial therapy (Table 2). Intravaginal dihydroepiandrosterone or hyaluronic acid may be considered as possible alternatives to estrogen. and PCR for T vaginalis. 1 g two or three times a day orally along with 500 mg a day vaginally for 14 days. the combination of high-dose (1 g three times a day) tinidazole and paromomycin cream nightly for 14 days was used successfully in two women with clinical resistance to high-dose tinidazole. A longer course of metronidazole.cdc. Importantly.53 For those women preferring systemic therapy.56 the cause remains unknown. systemic estrogen (with or without progesterone) or ospemifene may be considered. web site: http:// www. most women with vulvovaginal atrophy may not relate their symptoms to menopausal changes.50 To minimize the risk of ulceration. examination reveals severe introital and vaginal erythema and a copious vaginal discharge. When we suspect desquamative inflammatory vaginitis. 92% were cured with highdose tinidazole. and a yellow watery discharge. a loss of rugal folds.for resistance testing and can offer management recommendations (telephone: 404-718-4141. However. then. burning.49 Apart from nitroimidazoles. postpartum and breastfeeding.51 As summarized by the North American Menopause Society. In a series of 33 patients who failed courses of high-dose metronidazole. an aminoglycoside agent active against protozoa including T vaginalis. along with burning and severe dyspareunia. it should be noted that more than 50% of women older than 50 years with chronic vaginitis may have causes that are separate from atrophic vaginitis with desquamative inflammatory vaginitis (15%) and lichen sclerosus (14%) being the most common. Furthermore. 0. Laboratory findings are summarized in Table 1. contact bleeding.54 desquamative inflammatory vaginitis is a condition that is unfamiliar to most health care providers yet is found in up to 8% of women with persistent vaginitis. 5 g vaginally nightly. Despite the sensation of dryness. we routinely perform vaginal bacterial cultures. However. The main complaints are those of dryness.52 DESQUAMATIVE INFLAMMATORY VAGINITIS First described by Gray and Barnes in 1965. symptomatic vulvovaginal atrophy. patients are instructed to apply a barrier such as petrolatum to the vestibule. although published experience is very limited. where they studied 98 women Nyirjesy Management of Persistent Vaginitis Copyright ª American College of Obstetricians and Gynecologists 9 . vaginal erythema or even petechiae. Because the cause remains unknown. recognition and treatment of atrophy are part of any discussion of chronic vaginitis. MONTH 2014 continued sexual activity as initial therapy for women with vulvovaginal atrophy. VULVOVAGINAL ATROPHY As one might expect. Because some patients with severe atrophic vaginitis may have white blood cells on microscopy. and external dysuria. and even blood-tinged. The most extensive published experience was from Wayne State University. Used as a 5% cream. can provide adequate symptom relief (Table 2).49 Recently. dyspareunia.7 Beyond that. itching. looking for group A streptococci or S aureus.51 Expert consensus opinion51 recommends nonhormonal vaginal lubricants and moisturizers as well as VOL. or perimenopausal or postmenopausal) and notices the onset of an abnormal discharge. atrophic vaginitis. it may be the result of a local toxin-induced inflammatory reaction to S aureus infection57 or even group A streptococcal infection. is believed to be the most common cause of vulvovaginal symptoms in menopausal women. the degree of atrophic changes as measured by findings and maturation index does not correlate with symptoms. it was diagnosed not only in women older than 50 years (48%) but also in younger women (5%).51. in 469 women with chronic vaginitis.

Witkin SS. Box 1. 93. p. Nyirjesy P. Neisseria gonorrhoeae and Candida trachomatis PCR. Normal genital flora. Obstet Gynecol 2011. No conclusions could be made in terms of the relative efficacy of either drug. Culhane JF. Bergman JJ. it is easy to fall into many traps. most experts will use exogenous estrogen after initial treatment to decrease the chance of recurrence. Peyton C. Jeremias J. 8. when appropriate. 5.117:856–61. 2. In: Holmes KK. Eschenbach DA. J Fam Pract 1984. amine test. Barlow R. Causes of chronic vaginitis: analysis of a prospective database of affected women.58 After initial treatment.59:1–110. and 16% were only partially controlled with ongoing treatment. Vaginitis. Polaneczky MM. herpes simplex virus PCR and type-specific immune globulin G antibodies.326:993–4.13:178–82.291:1368–79. JAMA 2004. Lemon SM. 10. BMJ 2003. Centers for Disease Control and Prevention (CDC). Obstet Gynecol 1998. J Am Board Fam Pract 2000. 3. Clinical comparison of microscopic and culture techniques in the diagnosis of Candida vaginitis. Vulvovaginal candidiasis. MMWR Recomm Rep 2010. Marrazzo JM. management algorithm. Weitz MV. Possible Pitfalls in the Treatment of Women With Chronic Vaginitis Evaluation Accepting patient self-diagnosis or telephone diagnosis Failure to:  get appropriate problem-focused history  inspect vulva. 6. Sexually transmitted disease treatment guidelines.92:757–65. because of the potential role of hypoestrogenism in triggering desquamative inflammatory vaginitis. most health care providers should be able to help the vast majority of women with chronic vaginitis achieve significant control of their symptoms. summarized in Box 1. bacterial culture. Obstet Gynecol 2006. American College of Obstetricians and Gynecologists. 1999. Holmes KK. 7. ACOG Practice Bulletin No. Sexually transmitted diseases. Some of these pitfalls such as selfdiagnosis and telephone diagnosis are at times unavoidable. 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Available at http://publicaccess.IBRARYOF-EDICINE.71:832–6. Desquamative inflammatory vaginitis: a new subgroup of purulent vaginitis responsive to topical 2% 57. Schlievert PM. Obstet Gynecol 1988. Savan K. Uhri M. Gray LA. Temur M.. Pereira N. Yoo W. Nyirjesy P. 2014. 54. Within medical research.analysis of a prospective database. Obstet Gynecol 2011. Am J Obstet Gynecol 1965. Sobel JD. Friedrich EG Jr. Obstetrics & Gynecology and Public Access A number of research-funding agencies now require or request authors to submit the postprint (the article after peer review and acceptance but not the final published article) to a repository that is accessible online by all without charge.92:125–36. Edwards L. diagnosis and treatment. 2014. Barnes ML. three funding agencies in particular have announced such policies: s4HE.ovid. 58.ATIONAL. Vaginitis in women. Vaginal toxic shock reaction triggering desquamative inflammatory vaginitis.17:88–91. Ekin M. Desquamative vaginitis: lichen planus in disguise.nih.77 WILLIDENTIFYTOTHE. Retrieved October 7. 56. Misra D. Reichman O. Edlind TD. 53. Gencer I.ATIONAL)NSTITUTESOF(EALTHPUBLIC access. Sobel JD. Am J Obstet Gynecol 1994. Retrieved October 7. the journal’s publisher (Lippincott Williams &–43. 16:24–9.- ARTICLES THATREQUIREDEPOSIT4HEJOURNALSAUTHORAGREEMENTFORMAVAILABLEAT (OWARD(UGHES-EDICAL)NSTITUTE0UBLICACCESS!VAILABLEATHTTPWWWHHMIORG about/research/journals/main?action=search. 7ELLCOME4RUST/PENACCESSPOLICY!VAILABLEATHTTPWWWWELLCOMEACUK!BOUT US 0OLICY0OLICY AND POSITION STATEMENTS74$HTM2ETRIEVED/CTOBER.117:850–5. The comparison of hyaluronic acid vaginal tablets with estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. J Low Genit Tract Dis 2012. Arch Gynecol Obstet 2011. 55. et al. Yas¸ar L.ATIONAL)NSTITUTESOF(EALTH. Prognosis and treatment of desquamative inflammatory vaginitis.)( 1 s4HE(OWARD(UGHES-EDICAL)NSTITUTE((-) 2 s4HE7ELLCOME4RUST3 As a service to our authors.pdf) provides the mechanism for identifying such articles. LWW will transmit the postprint of an article based on research funded in whole or in part by one or more of these THREEAGENCIESTO0UB-ED#ENTRAL References 53$EPARTMENTOF(EALTHAND(UMAN3ERVICES. clindamycin therapy. J Low Genit Tract Dis 2013.171: 1215–20.

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