Approach

Treatment is initiated following diagnosis, which is based on clinical symptoms and microscopy of vaginal secretions. Therapy depends on the aetiological organism and whether it is a first presentation or recurrence. Women who have bacterial vaginosis or trichomoniasis, and who are also HIV-positive, should receive the same treatment regimen as those who are HIV-negative.[4]

Bacterial vaginosis

Treatment is indicated in all symptomatic women with bacterial vaginosis.[4] Although bacterial vaginosis is known to increase the risk of certain pregnancy and neonatal complications, the only established benefits of treatment in both pregnant and non-pregnant women are to relieve vaginal symptoms, reduce signs of infection, and potentially to decrease the risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).

In non-pregnant women, oral or topical metronidazole or topical clindamycin are the treatments of choice.[4] Topical and oral preparations of metronidazole seem equally effective, but intravaginal application may be associated with fewer adverse events.[40][41] Metronidazole single-dose oral therapy has the lowest efficacy for bacterial vaginosis and is no longer recommended.[42]

Vaginal clindamycin cream is a useful first-line alternative to metronidazole therapy.[4][41]​ Second-line treatment options include oral tinidazole or secnidazole, oral clindamycin, and vaginal clindamycin ovules.[41]

For persistent or recurrent infection, metronidazole intravaginal gel is administered for a longer period of 4-6 months after completion of a recommended regimen.[43] Suppressive therapy has been shown to reduce the risk of recurrences but this benefit might not persist after discontinuation.[43]

Pregnant women can be safely treated with metronidazole. Clindamycin is an effective alternative.[4]

Women of childbearing age need to be aware that due to its oil-based formula, clindamycin cream might weaken latex condoms and diaphragms for 5 days after use.

Although non-antibiotic treatments are available (e.g., benzydamine), their safety and efficacy are not well supported by long-term scientific data.[44] There is also no significant scientific evidence to support the use of antiseptics or disinfectants in bacterial vaginosis.[45][46]

Treatment of sexual partners is not recommended. [ Cochrane Clinical Answers logo ] [Evidence A]

Trichomoniasis

Treatment of trichomoniasis results in the relief of symptoms and might reduce transmission.[4] Isolation of the microorganism is not necessary in all cases: for example, in a symptomatic patient with a prior history of trichomoniasis or a known disease in sexual partner. 

Non-pregnant women can be treated with multi-dose therapy with oral metronidazole or a single dose of tinidazole. Pregnant women should be treated with multi-dose therapy with oral metronidazole, but tinidazole should be avoided. Treating sexual partners will help in preventing recurrence; however, different partner management interventions (e.g., patient referral, provider referral, contract referral, or expedited partner therapy) have similar efficacies.[4][47]​​

For resistant organisms and persistent infection, a different treatment approach is required. This involves higher doses of metronidazole or treatment with tinidazole. Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract. Several T vaginalis isolates have lower minimum inhibitory concentrations to tinidazole than metronidazole.[4] Secnidazole is also approved by the US Food and Drug Administration for the treatment of trichomoniasis, although the Centers for Disease Control and Prevention do not yet recommend it for this patient group.​

If treatment is unsuccessful after the woman has been re-exposed to an untreated partner, multi-dose therapy with metronidazole should be repeated.

Condom use, although not 100% effective, should be discussed with the patient as part of sexually transmitted disease prevention.

Vulvovaginal candidiasis

Several therapeutic options are available, both intravaginally and orally. It is important to distinguish between uncomplicated and complicated Candida vaginitis (recurrence, severity, infection with Candida species other than Candida albicans, pregnancy, and immunocompromise, including women with diabetes).

Uncomplicated candidiasis refers to:Candida albicans, sporadic episodes, mild to moderate symptoms, and healthy non-pregnant women. About 10% to 20% of women have complicated candidiasis: non-albicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.[4]

For uncomplicated infection, treatment with oral or topical azole antifungal agents should be started.[4] Uncomplicated vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sexual partners is not recommended, but should be considered in women who have recurrent infection. If a male sexual partner presents with symptoms (e.g., irritation), these may be managed with topical agents.[4]

For complicated infections, short-course antifungal therapy (oral or topical) for infection is initiated, followed by maintenance therapy (oral or topical) for approximately 6 months.[4]

Pregnant women are treated only with topical azoles, for no longer than 7 days.[4]

If the patient has concomitant diabetes, improvement in glycaemic control will also prevent recurrence.

Atrophic vaginitis

Dyspareunia may be treated with lubricant gels before intercourse and these may be initiated immediately, to be used until successful treatment is established with topical oestrogen or longer term in women wishing to avoid hormonal treatment.[28] For women on hormone replacement therapy (HRT), concomitant use of a lubricant may be adequate in controlling symptoms. As with initiation of HRT, a detailed discussion with the patient should take place to explain the intended local therapy. Benefits and risks of oestrogen therapy should be carefully weighed for each individual patient, aiming to minimise both the amount of oestrogen and length of treatment.[48][49] The potential adverse effects versus associated benefits of the different formulations should be considered. While oestrogen rings provide the freedom of every 3-month replacement, the vaginal creams may offer a significant and immediate soothing effect to the atrophic area. The easiest applicable method, at the lowest dose, for each individual patient also needs to be considered (e.g., a patient with joint deformities from arthritis may find it difficult to apply an oestrogen cream every night, and an oestrogen ring may be the most appropriate approach for this patient).

Non-infective or allergic contact vaginitis

Preventive measures are the mainstay of treatment. Avoiding causative agents, such as feminine hygiene products, latex condoms/diaphragms, douching, and irritants such as strong soaps or bubble baths, can help prevent vaginitis. Hormone-free vaginal creams and gels, often called emollients, are available without prescription and are commonly used to restore vaginal pH and to relieve vaginal irritation and pruritus, and to increase vaginal moisture.[29]

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