Vaginitis Treatment & Management

Treatment of vaginitis may include sitz baths and instruction regarding proper toilet and hygiene techniques. Many women assume vaginal symptoms are the result of a sexually transmitted disease (STD), which is often not the case. A patient’s idea of vaginal normality may be inaccurate and result in increased or unnecessary treatment seeking. Also educate patients regarding the following:

• Avoiding irritants in the vaginal area, such as perfumes, soaps, and panty liners, among others.
• After swimming or exercise, which keeps the vaginal area moist, air-drying the area or changing the underwear.
• Always cleaning the area from front to back.

Management considerations

Intravaginal imidazoles (see Pharmacologic Therapy) can be purchased over the counter and have proven efficacy for vaginal candidiasis. Patients may purchase and utilize these medications without a doctor’s advice or prescription and the choice of treatment can be based on personal preference since they appear to be equally effective. Vaginal anti-itch creams provide only symptomatic relief. Homeopathic treatments for vaginitis (boric acid, tea tree oil, live acidophilus, garlic) have not been well studied but may have some efficacy. ^{[11, 12, 13]}

If the patient shows no improvement, despite symptomatic or over-the-counter treatment, refer her for further workup of possible STDs and other infectious causes of vulvovaginitis.

When a patient is seen for suspected vaginitis in the emergency department (ED), there is usually no need for active treatment. However, prepubertal girls with vulvovaginitis caused by a foreign body in the vagina may require sedation for removal of the foreign body.

Treatment of vaginitis varies by cause and is directed at the relevant pathogen. Inpatient care usually is not indicated, unless serious pelvic infections arise or evidence of systemic infection in an immunocompromised host is present. Parenteral treatment of infectious causes of vaginitis is rarely indicated. Complicated cases of certain infections (eg, gonorrhea, chlamydial infection) may require parenteral treatment.

A German study has suggested that a 6-day vaginal application of dequalinium chloride (10 mg) is a safe and effective treatment option for mixed vaginal infections or those with an uncertain diagnosis. ^[14] The investigators noted this antimicrobial antiseptic agent has broad bactericidal and fungicidal activity with a low risk for antimicrobial resistance and posttreatment vaginal infections. ^[14]

Atrophic vaginitis can be treated with lubricants, estrogen vaginal cream, tablets, and rings, among others. A study by Shen et al indicated that low-dose estrogen therapy in atrophic vaginitis causes a rise in the proportion of Lactobacillus species in the vaginal microbiome while reducing the proportion of Gardnerella. In addition, serum estradiol levels rose four-fold in the study, vaginal pH was reduced, and the vaginal maturation index almost doubled. ^[15]

Vaginal suppositories containing human Lactobacillus strains are under investigation, as are changes in formulation strategies to improve pharmacologic delivery and treatment modalities. ^[16]

Consultations

Refer patients with resistant infections or persistent symptoms of vulvovaginitis to a gynecologist. An infectious disease consultation may also be considered for resistant infections. Notification of the Centers for Disease Control and Prevention (CDC) may be warranted.

Other issues to consider

Patients who are immunocompromised, such as those with HIV infection, should be treated with the same regimens as other patients. Before initiating treatment with any drugs that should not be used during pregnancy, determine the possibility of pregnancy, test for pregnancy as appropriate, and maintain proper documentation. However, pregnancy should not delay treatment.

In cases of suspected sexual assault or child sexual abuse, proper documentation may assist with possible subsequent legal action.

Bacterial vaginosis

Recommended regimens for bacterial vaginosis include the following:

• Metronidazole 500 mg orally twice a day for 7 days

• Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once a day for 5 days 

• Secnidazole 2 g orally as a single dose 

• Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days

Alternative regimens include the following:

• Clindamycin 300 mg orally twice a day for 7 days

• Clindamycin ovules 100 mg intravaginally once at bed time for 3 days

Patients should be advised to avoid alcohol consumption during and 24 hours 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. The recurrence rate is 20-40% after 1 month. Twice weekly metronidazole gel for 6 months may reduce recurrences.

Regimens for pregnant women with bacterial vaginosis include the following:

• Metronidazole 500 mg orally twice a day for 7 days

• Metronidazole 250 mg orally 3 times a day for 7 day

• Clindamycin 300 mg orally twice a day for 7 day

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.

Therapy is not recommended for male partners, but female partners of women with BV should be examined and treated.

Vaginal candidiasis

For the purposes of treatment, vaginal candidiasis, also referred to as vulvovaginosis candidiasis (VVC), may be broadly classified as either complicated or uncomplicated, as follows:

• Uncomplicated - Sporadic or infrequent VVC; mild-to-moderate VVC likely to be caused by C albicans and occurring in nonimmunocompromised women

• Complicated - Recurrent VVC; severe VVC; VVC caused by a species other than C albicans or occurring in immunocompromised women

Intravaginal creams/suppositories

Note that oil-based creams and suppositories might weaken latex condoms. 

Recommended regimens for intravaginal agents are as follows:

• Butoconazole 2% cream 5 g intravaginally for 3 days

• Butoconazole 2% cream 5 g (butoconazole 1 sustained release), single intravaginal application

• Clotrimazole 1% cream 5 g intravaginally for 7-14 days

• Clotrimazole 100 mg vaginal tablet for 7 days

• Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days

• Miconazole 2% cream 5 g intravaginally for 7 days

• Miconazole 100 mg vaginal suppository, 1 suppository for 7 days

• Miconazole 200 mg vaginal suppository, 1 suppository for 3 days

• Miconazole 1200 mg vaginal suppository, 1 suppository for 1 day

• Nystatin 100,000 unit vaginal tablet, 1 tablet for 14 days

• Terconazole 80 mg vaginal suppository, 1 suppository for 3 days

Oral antifungals

Recommended regimens for oral agents are as follows:

• Fluconazole 150 mg orally in a single dose 
• Ibrexafungerp 300 mg orally; repeat once after 12 hours for a total dosage of 600 mg  

Patients are instructed to return only if symptoms persist or recur within 2 months of the onset of initial symptoms. Routine treatment of sex partners is not indicated.

Recommendations for complicated VVC are as follows:

• Recurrent VVC (≥4 episodes of symptomatic VVC in 1 y) - 7-10 days of topical therapy or a 100 mg or 150 mg oral dose of fluconazole every third day for a total of 3 doses (days 1, 4, and 7); for maintenance, oral fluconazole 100 mg or 150 mg weekly for 6 months

• Severe VVC - 7-14 days of topical azole therapy or 150 mg of oral fluconazole repeated in 72 hours; adjunctive use of nystatin cream or low-potency steroid cream may be beneficial

• Non-albicans VVC - 7-14 days of nonfluconazole therapy; 600 mg of boric acid in a gelatin capsule vaginally twice daily for 14 days

• VVC in compromised hosts - 7-14 days of topical therapy

• VVC in pregnant patients - 7 days of topical agents; fluconazole is contraindicated

Trichomoniasis

Recommended regimens for T vaginalis infection include the following:

• Metronidazole 2 g orally in a single dose (or 500 mg orally twice a day for 7 days)

• Tinidazole 2 g orally in a single dose

• Secnidazole 2 g orally in a single dose

Metronidazole is the treatment of choice both for patients who are immunocompetent and for those who are immunocompromised.

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 infection should be treated, and intercourse should be avoided until both partners have been 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.

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 containing killed “aberrant lactobacilli” is available in Europe. This vaccine has not been evaluated in well-controlled, double-blind prospective trials.

Acidophilus supplements in the diet may help prevent vaginitis, especially if patients are taking antibiotics. In addition, an increase in the intake of garlic seems to help vaginitis symptoms and prevention.

Patients should be instructed to abstain from sexual activity and from douching until a diagnosis has been made. ^[17] Patients also should abstain from unprotected sexual activity (sexual activity without proper male condom use) until the infection has been treated.

Reducing simple carbohydrates, refined foods, and alcohol helps to reduce frequent/persistent yeast infection.

Although safe sexual practices have not extensively evaluated as means of preventing vaginitis, they may play a role in reducing the incidence of bacterial vaginosis and T vaginalis infections. Good hygiene, avoiding tight undergarments, wearing 100% cotton underwear, and keeping the area dry also may play a role in preventing candidal infections.

No studies show any benefit to douching as a treatment or prevention for vaginitis; douching may actually exacerbate symptoms. Tampon use does not seem to be associated with vaginitis.

In asymptomatic women, follow-up care is not indicated. However, in women who are pregnant or have recurrent infections, a follow-up evaluation should be performed 1 month after completion of treatment. Techniques of proper genital hygiene should be recommended.

Refer for sexual abuse evaluation all children in whom vaginitis was caused by an STD (see Pediatrics, Child Sexual Abuse). Treat sexual partners of patients with identified STDs.

Consider treatment of partners in cases of trichomoniasis. In addition, consider treatment of partners in cases of bacterial vaginosis if chronic or recurrent infections develop.

In cases of recurrent or resistant vaginal candidiasis, yeast culture, glucose intolerance test, and HIV testing should be offered. In women with recurrent candidal vaginitis that requires longer fluconazole therapy, fluconazole resistance may be related to overexpression of PIr1 protein (Pir1p). ^{[18, 19]}