eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Vaginitis: Treatment & Medication
Updated: Dec 8, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
T vaginalis infection
- Recommended regimens for T vaginalis infection
- Metronidazole 2 g orally in a single dose
OR - Tinidazole 2 g orally in a single dose
- Metronidazole 2 g orally in a single dose
- An alternative regimen - Metronidazole 500 mg orally twice a day for 7 days
- Because trichomonads often infect the urethra and the Skene and Bartholin glands, metronidazole gel is considerably less efficacious than an oral preparation; therefore, use of the gel is not recommended.
- Sex partners of patients with T vaginalis should be treated and avoid intercourse till both are treated and are asymptomatic.
- Pregnant women with trichomoniasis may be treated with 2 g of metronidazole in a single dose.
- Lactating women should withhold breastfeeding during treatment and for 12-24 hours after the last dose of metronidazole. For women taking tinidazole, breastfeeding should be interrupted during treatment and for 3 days after the last dose.
- Metronidazole (Flagyl) is the treatment of choice both for patients who are immunocompetent and for those who are immunocompromised.
- Topical treatment with nonoxynol-9 and povidone-iodine douches has been shown to be effective in treating T vaginalis infection in women unable to use metronidazole. Further studies are needed to confirm this preliminary finding.
- A vaccine of killed "aberrant lactobacilli" is available in Europe. This vaccine has not been evaluated in well-controlled, double-blind prospective trials.
Bacterial vaginosis
- Recommended regimens for bacterial vaginosis
- Metronidazole 500 mg orally twice a day for 7 days
OR - Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once a day for 5 days
OR - Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days
- Metronidazole 500 mg orally twice a day for 7 days
- Alternative regimen
- Clindamycin 300 mg orally twice a day for 7 days
OR - Clindamycin ovules 100 mg intravaginally once at bed time for 3 days.
- Clindamycin 300 mg orally twice a day for 7 days
- Patients should be advised to avoid alcohol consumption during and 24 hrs after treatment with metronidazole.
- Clindamycin cream is oil based and might weaken latex condoms and diaphragms for 5 days after use.
- Clindamycin should not be used in the second half of pregnancy.
- Routine follow-up visits are unnecessary.
- Routine treatment of sex partners is not recommended.
- Regimens for pregnant women with bacterial vaginosis
- Metronidazole 500 mg orally twice a day for 7 days
OR - Metronidazole 250 mg orally 3 times a day for 7 day
OR - Clindamycin 300 mg orally twice a day for 7 day
- Metronidazole 500 mg orally twice a day for 7 days
- Pregnant women should have a follow up visit 1 month after completion of treatment.
- Treatment regimens in patients with HIV are the same as in patients without HIV, but bacterial vaginosis appears to be more persistent in women who are HIV positive.
Vaginal candidiasis
- Classification of vulvovaginosis candidiasis (VVC)
- Uncomplicated VVC - Sporadic or infrequent VVC and mild-to-moderate VVC and likely to be Candida albicans candidiasis and nonimmunocompromised women
- Complicated VVC - Recurrent VVC or severe VVC or non - albicans or immunocompromised women
- Recommended regimens - Intravaginal agents
- Butoconazole 2% cream 5g intravaginally for 3 days
OR - Butaconazole 2% cream 5g (butaconazole 1 sustained release) single intravaginal application
OR - Clotrimazole 1% cream 5 g intravaginally for 7-14 days
OR - Clotrimazole 100 mg vaginal tablet for 7 days
OR - Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
OR - Miconazole 2% cream 5 g intravaginally for 7 days
OR - Miconazole 100 mg vaginal suppository, 1 suppository for 7 days
OR - Miconazole 200 mg vaginal suppository, 1 suppository for 3 days
OR - Miconazole 1200 mg vaginal suppository, 1 suppository for 1 day
OR - Nystatin 100,000 unit vaginal tablet, 1 tablet for 14 days
OR - Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
- Butoconazole 2% cream 5g intravaginally for 3 days
- Recommended regimens - Oral agents
- Fluconazole, 150 mg oral tablet in single dose
- The cream and suppositories are oil based and might weaken latex condoms.
- Patients are instructed to return only if symptoms persists or recur within 2 months of onset of initial symptoms.
- Routine treatment of sex partners is not indicated.
- Complicated VVC
- Recurrent VVC is 4 or more episodes of symptomatic VVC in 1 year.
- Recommended regimen: 7-10 days of topical therapy or 100 or 150 mg oral dose of fluconazole every third day for a total of 3 doses (day 1, 4, and 7).
- Maintenance regimen: Oral fluconazole 100 or 150 mg weekly for 6 months is first line of treatment.
- Topical azole therapies applied for 7 days are recommended in pregnant patients.
Consultations
For resistant infections, consider an infectious disease consultation. Notification of the Centers for Disease Control and Prevention (CDC) may be warranted.
Diet
Acidophilus supplements in the diet may help prevent vaginitis, especially if patients are taking antibiotics.
Activity
Instruct patients to abstain from sexual activity and from douching until a diagnosis has been made. Patients also should abstain from unprotected sexual activity (sexual activity without proper male condom use) until the infection has been treated.
Medication
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and eradicate the infection.
Antiprotozoal agents
Metronidazole is the antimicrobial agent of choice to treat T vaginalis infections and bacterial vaginosis.
Metronidazole (Flagyl)
Causes chemical reduction reaction within anaerobic bacteria and sensitive protozoa. Readily absorbed and permeates all tissues, including cerebral spinal fluid, breast milk, and alveolar bone. Metabolized and excreted in liver and kidneys. Treatment of partners increases cure rates.
Adult
2 g PO as single dose (to treat trichomoniasis) or 500 mg PO bid for 7 d
Recurrence: 2 g PO qd for 3-5 d
Pediatric
15 mg/kg/d PO divided tid for 7 d; not to exceed adult dose
Possible increased toxicity with concurrent administration of cimetidine; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol; may cause psychosis with disulfiram; possible decreased effects with phenytoin and phenobarbital
Documented hypersensitivity; long-term blood dyscrasias
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; may cause nausea, headaches, dry mouth or metallic taste in mouth, and reddish or dark-colored urine; rarely, vomiting, diarrhea, insomnia, weakness, dizziness, stomatitis, rash, urethral burning, vertigo, and paresthesias may occur; if pregnant, delaying use is recommended until after first trimester (however, no increased risk of congenital abnormalities, stillbirths, or low birth weight infants has been reported); try to avoid in breastfeeding women; the current STD guidelines published by the CDC recommend deferring use of metronidazole past the first trimester
Antifungals
Imidazole derivatives that exert a fungicidal effect by altering permeability of the fungal cell membrane. The mechanism of action also may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to fungal cell.
Miconazole (Monistat 3, Monistat 7 suppository or cream, Monistat Dual Pak)
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death. Metabolism occurs in the liver. Products available OTC are indicated. Recurrent infections usually are treated with intravaginal regimens for 10-14 d, followed by maintenance oral treatment for 6 mo. Dual Pak is not for use in children.
Adult
200-mg vaginal supp: Insert 1 qhs for 3 d
100-mg vaginal supp: Insert 1 qhs for 7 d
2% cream: Insert 1 applicator full (5 g) intravaginally qhs for 7 d
Monistat Dual Pak: 1200 mg vaginal insert once plus 2% cream for external use
Pediatric
Administer as in adults
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; adverse effects include vaginal burning, irritation, and dyspareunia
Clotrimazole (Gyne-Lotrimin, Mycelex 7, Mycelex G)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Adult
100-mg tab: Insert 1 tab intravaginally qhs for 7 d or 2 tabs intravaginally for 3 d
500-mg tab: Insert 1 tab intravaginally once
1% cream: Insert 1 applicator full intravaginally qhs for 7-14 d
Pediatric
Children: Not established
Adolescents: Administer as in adults
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy
Terconazole (Terazol 7, Terazol 3)
Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death
Adult
0.4% cream: Insert 1 applicator full (5 g) intravaginally for 7 d
0.8% cream: Insert 1 applicator full (5 g) intravaginally qhs for 3 d
80-mg vaginal supp: Insert 1 qhs for 3 d
Pediatric
Not established
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; high doses may cause fever or flulike symptoms
Tioconazole (Vagistat 1)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Adult
6.5% ointment: Insert 1 applicator full (5 g) intravaginally once
Pediatric
Not established
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with eyes; if irritation or sensitivity develops, discontinue use
Butoconazole (Femstat 3, Mycelex 3)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Adult
2% cream: Insert 1 applicator full (5 g) intravaginally qhs for 3 d
Pediatric
Not established
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with eyes; if irritation or sensitivity develops, discontinue use
Nystatin (Mycostatin)
Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.
Adult
100,000-U tab: Insert 1 tab intravaginally qd for 14 d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat systemic mycoses
Fluconazole (Diflucan)
Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha demethylation.
Adult
150-mg tab PO as single dose
Pediatric
5 mg/kg PO as single dose; not to exceed 150 mg/d
Levels may increase with hydrochlorothiazides; fluconazole levels may decrease with chronic coadministration of rifampin; may increase concentrations of theophylline, phenytoin, tolbutamide, cyclosporine, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration
Documented hypersensitivity; liver failure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely if rashes develop and discontinue drug if lesions progress; possible clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions (eg, AIDS, malignancy) and while taking multiple concomitant medications; not recommended for breastfeeding women; convenience and efficacy of the single-dose regimen should be weighed against the difficulties resulting from a higher incidence of adverse reactions reported with oral fluconazole versus intravaginal agents; causes nausea, vomiting, rashes, abdominal pain, headaches, and hepatic impairment
Ketoconazole (Nizoral)
Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, which results in fungal cell death. Usually used for maintenance therapy for recurrent vulvovaginal candidiasis
Adult
100 mg (half of 200-mg tab) PO qd for up to 6 mo
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Isoniazid may decrease bioavailability of ketoconazole; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels
Documented hypersensitivity; fungal meningitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2-blockers at least 2 h after taking ketoconazole; may cause nausea, vomiting, rash, abdominal pain, headache, and elevation of serum transaminases; may lead to gynecomastia and decreased libido by inhibiting synthesis of adrenal steroids and androgens; starting maintenance ketoconazole therapy not recommended until culture confirms cause of vaginitis
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Clindamycin (Cleocin, Clinda-Derm, C/T/S)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys. For recurrent infections, administer a trial of alternative regimens. Used as an alternative treatment to metronidazole in pregnancy.
Adult
Insert 1 applicator full (5 g) intravaginally qhs for 7d
Alternatively, administer 300-mg tab PO bid for 7d
Pediatric
10-20 mg/kg/d PO divided tid for 7d; not to exceed adult dose
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis (Clostridium difficile is causal organism and usually will resolve with vancomycin treatment); may cause nausea or rashes; occasionally, impaired liver function and neutropenia
Hormones
Indicated for atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.
Estrogen (Premarin, Estrace)
Reserved for women experiencing vaginal changes secondary to a deficiency of estrogen.
Adult
Premarin: 0.625 mg topically or PO qd
Estrace 0.01% vaginal cream: 2-4 g intravaginally qd for 1-2 wk, then half the dose for 1-2 wk, then 1 g up to 3 times/wk as maintenance
Premarin vaginal cream: 2-4 g qd for 3 wk (with 1 wk off in between) for 3-6 mo
Dienestrol 0.01% cream: Insert 1-2 applicators full for 1-2 wk, then decrease dosage
Pediatric
Not established
May reduce hypoprothrombinemic effects of anticoagulants; levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and pregnancy; increase in fluid retention caused by estrogen intake may reduce seizure control
Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Anti-infectives, topical
Boric acid can be used in the treatment of refractory, recurrent vaginal candidiasis.
Boric acid (Boroformol, Borofax)
Soothing to chafed skin, abrasions, burns, and other skin irritations. For recurrent infection, maintain treatment at qod initially, then decrease to 2 times per wk.
Adult
600 mg in a gelatin size 0 capsule intravaginally qd until culture results are negative (10-14 d)
Pediatric
Not recommended
Increases riboflavin excretion
Documented hypersensitivity; inflamed skin; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Excessive amount can lead to severe chemical vaginitis
More on Vaginitis |
| Overview: Vaginitis |
| Differential Diagnoses & Workup: Vaginitis |
 Treatment & Medication: Vaginitis |
| Follow-up: Vaginitis |
| References |
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References
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Further Reading
Keywords
vaginitis, vaginal infection, Trichomonas vaginalis, vaginal candidiasis, Candida infection, bacterial vaginosis, BV, pelvic inflammatory disease, PID, yeast infection, vaginal pH
