Vaginitis

1st line – intravaginal clindamycin: intravaginal cream

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1st line –

metronidazole

Treatment is indicated in all symptomatic women with bacterial vaginosis 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).[4]

Metronidazole is the treatment of choice.[44]

Oral and vaginal formulations have been shown to be equally effective. Choice depends on the patient compliance and preference.

Primary options

metronidazole: 500 mg orally twice daily for 7 days

metronidazole vaginal: (0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days

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1st line –

intravaginal clindamycin: intravaginal cream

Vaginal clindamycin cream is recommended as an alternative first-line treatment option.[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.

Primary options

clindamycin vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days

2nd line – tinidazole or secnidazole

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2nd line –

tinidazole or secnidazole

Oral tinidazole or secnidazole may be used as an alternative second-line regimen. Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract.

Primary options

tinidazole: 2 g orally once daily for 2 days; or 1 g orally once daily for 5 days

secnidazole: 2 g orally as a single dose

2nd line – clindamycin: oral preparations or intravaginal ovules

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2nd line –

clindamycin: oral preparations or intravaginal ovules

Oral preparations and intravaginal ovules of clindamycin may be given as second-line options.

Primary options

clindamycin: 300 mg orally twice daily for 7 days

clindamycin vaginal: 100 mg ovule into the vagina once daily at night for 3 days

1st line – nitroimidazole therapy

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1st line –

nitroimidazole therapy

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

Systemic metronidazole is the treatment of choice but tinidazole is an effective alternative.[4] Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract.

Topical treatment is not as effective. It is believed that the microorganism can colonize the urethra and associated glands and, although the topical treatment might relieve symptoms, it is better to use systemic medication for clearance.

Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs.[4] 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][50] Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.

Retesting for T vaginalis is recommended for all sexually active women within 3 months following initial treatment.[4]

Primary options

metronidazole: 500 mg orally twice daily for 7 days

Secondary options

tinidazole: 2 g orally as a single dose

uncomplicated vulvovaginal candidiasis

1st line – antifungal therapy

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1st line –

antifungal therapy

Several agents are available orally or topically.

Uncomplicated candidiasis refers to: Candida albicans, sporadic episodes, mild to moderate symptoms, and healthy nonpregnant women.

This can be treated with a short-course of a topical antifungal agent.[4]

Creams and vaginal suppositories in this regimen are oil-based and might weaken latex condoms and diaphragms.

There is no preference between agents. Choice is based on patient compliance/comfort (between topical and oral). Cost and availability might also need to be taken into consideration.

If a male sexual partner presents with symptoms (e.g., irritation), these may be managed with topical agents.[4]

Primary options

butoconazole vaginal: (2% sustained-release cream) insert 5 g (one applicatorful) into the vagina once daily at night as a single dose

clotrimazole vaginal: (1% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days

miconazole vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days; 100 mg vaginal suppository into the vagina once daily at night for 7 days; 200 mg vaginal suppository into the vagina once daily at night for 3 days; 1200 mg vaginal suppository into the vagina once daily at night as a single dose

terconazole vaginal: (0.4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (0.8% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days; 80 mg vaginal suppository into the vagina once daily at night for 3 days

tioconazole vaginal: (6.5% ointment) insert 5 g (one applicatorful) into the vagina once daily at night as a single dose

nystatin vaginal: 100,000 unit vaginal tablet into the vagina once daily at night for 14 days

fluconazole: 150 mg/dose orally as a single dose

complicated vulvovaginal candidiasis

1st line – antifungal therapy

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1st line –

antifungal therapy

Several agents are available orally or topically.

Complicated candidiasis refers to: nonalbicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.

Treatment for complicated disease should be initiated with a short course of antifungal therapy, followed by maintenance therapy.[4]

There is no preference between agents; choice is based on patient compliance/comfort (between topical and oral), and additional considerations might be cost and availability.

Topical azole antifungals are recommended for 7-14 days. Many of these agents are available over the counter, and any of the options recommended for uncomplicated vulvovaginal candidiasis can be used.

Primary options

fluconazole: 150 mg orally every 3 days for a total of 3 doses

pregnant: isolated acute episode

1st line – intravaginal or oral metronidazole

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1st line –

intravaginal or oral metronidazole

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 pregnant women are relief of vaginal symptoms, reduced signs of infection, and potentially a decreased risk of acquiring HIV and other STIs (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, viral STIs).

Oral and vaginal formulations of metronidazole have been shown to be equally effective. Choice depends on patient compliance and preference.

Primary options

metronidazole vaginal: (0.75% gel) insert 5 g (one applicatorful) into the vagina once daily at night for 5 days

metronidazole: 500 mg orally twice daily for 7 days

1st line – intravaginal or oral clindamycin

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1st line –

intravaginal or oral clindamycin

Symptomatic pregnant women can be treated with either of the oral or vaginal regimens recommended for nonpregnant women.[4]

Primary options

clindamycin vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days

Secondary options

clindamycin vaginal: 100 mg ovule into the vagina once daily at night for 3 days

clindamycin: 300 mg orally twice daily for 7 days

vulvovaginal candidiasis

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1st line –

metronidazole

Systemic metronidazole is the treatment of choice.[4][53]

In pregnancy, delaying use is recommended until after the first trimester.

Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.

Primary options

metronidazole: 500 mg orally twice daily for 7 days

1st line – topical antifungal therapy

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1st line –

topical antifungal therapy

Topical azole antifungal therapies are recommended for use in pregnant women.[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]

Primary options

miconazole vaginal: (2% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 7 days; (4% cream) insert 5 g (one applicatorful) into the vagina once daily at night for 3 days

atrophic vaginitis

1st line – estrogen therapy

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1st line –

estrogen therapy

Benefits and risks of estrogen therapy should be carefully weighed for each individual patient, aiming to minimize both the amount of estrogen and length of treatment.[51][52]

There is no clinical preference between different options.[54] Many women will prefer the silicone ring for easier use than tablets or cream; the efficacy and safety have been proven to be the same.[55][56]

Administration may be symptomatic, continuous, or cyclic (3 weeks on and 1 week off).

The ring should be removed after 3 months and, if appropriate, replaced by a new ring. The need to continue treatment should be assessed at 3- to 6-month intervals.

Primary options

estradiol vaginal: (50-100 micrograms/24 hours) insert ring into vagina and change every 3 months as required; place the ring into the posterior vaginal fornix; it is to remain in place continuously for 3 months

estrogens, conjugated vaginal: (0.625 mg/g) insert 0.5 to 2 g into the vagina once daily at night for 1-2 weeks

irritant or allergic vaginitis

1st line – irritant avoidance ± emollients

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1st line –

irritant avoidance ± emollients

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.

ONGOING

nonpregnant: persistent or recurrent symptoms

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1st line –

metronidazole

If multiple recurrences do occur, it is recommended that metronidazole gel 0.75% twice per week is given for 4-6 months after completion of a recommended regimen.[4] Suppressive therapy has been shown to reduce the risk of recurrences but this benefit might not persist after discontinuation.[46]

Primary options

metronidazole vaginal: (0.75% gel) apply to the vagina twice a week for 4-6 months

1st line – nitroimidazole therapy

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1st line –

nitroimidazole therapy

If multidose therapy with metronidazole or treatment with a single dose of tinidazole for 7 days is unsuccessful (and reinfection is excluded), it is recommended to treat the patient and her partner(s) with metronidazole or tinidazole 2 g once daily for 7 days.[4] Tinidazole has a longer serum half-life than metronidazole and also reaches higher levels in the genitourinary tract. If treatment is unsuccessful after the woman has been reexposed to an untreated partner, multidose therapy with metronidazole should be repeated.

Sexual partners of individuals with Trichomonas vaginalis should be treated and offered screening for other STIs. 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][50] Individuals should avoid sex until they and their sexual partners are cured, or should at least use condoms.

Primary options

metronidazole: 500 mg orally twice daily for 7 days

Secondary options

metronidazole: 2 g orally once daily for 7 days

tinidazole: 2 g orally once daily for 7 days

complicated vulvovaginal candidiasis

1st line – antifungal therapy

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1st line –

antifungal therapy

Several agents are available orally or topically.

Complicated candidiasis refers to: nonalbicans candidiasis; more than 4 episodes a year; and women with uncontrolled diabetes, debilitation, or immunosuppression.

Treatment for complicated disease may involve longer duration of initial oral or topical treatment, followed by maintenance therapy for 6 months.[57]

There is no preference between agents; choice is based on patient compliance/comfort (between topical and oral), and additional considerations might be cost and availability.

Primary options

fluconazole: 150 mg orally once weekly for 6 months

pregnant: persistent or recurrent symptoms

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1st line –

metronidazole

If, after a short course of metronidazole, treatment is unsuccessful, high-dose metronidazole for 7 days is recommended.

Primary options

metronidazole: 500 mg orally twice daily for 7 days