Definitions of the grades of recommendation based on levels of evidence (A-C, Good Practice Point) are provided at the end of the "Major Recommendations" field.
What are the commonest causes of vaginal discharge in women of reproductive age?
- In women of reproductive age complaining of vaginal discharge the commonest cause is physiological, but infective and other causes (e.g., foreign body, cervical ectopy) should be excluded (Good Practice Point).
Refer to Table 1, "Causes of vaginal discharge in women of reproductive age" in the original guideline document for additional information.
Why is it important to take a clinical history from a woman complaining of vaginal discharge?
- A clinical history (to ascertain associated symptoms) and a sexual history (to assess sexually transmitted infection [STI] risk) can guide a clinician in the further management of a woman with vaginal discharge (Grade B).
- A clinician should ask a woman: how her discharge has changed; what she is concerned about; whether there is any odour or itch; whether there are any symptoms suggestive of upper reproductive tract infection (i.e., pain, dyspareunia, bleeding) and should assess risk of STIs (Good Practice Point).
- Risk factors for STIs to be sought are: age <25 years; change in sexual partner in the last year; more than one partner in the last year (Grade B).
When should a woman complaining of vaginal discharge be investigated?
- A woman of reproductive age complaining of vaginal discharge should be investigated if: she requests investigation; she is deemed to be at higher risk of STIs; there are symptoms indicative of upper reproductive tract infection; previous treatment has failed; she is postnatal, postmiscarriage or post-abortion; or she is within 3 weeks of intrauterine contraceptive insertion (Grade C).
- A woman of reproductive age presenting with vaginal discharge who is low risk for STIs and without symptoms indicative of upper reproductive tract infection may be given empirical treatment, based on symptoms, without taking swabs at first presentation (Grade C).
Refer to Figure 1, "Flow chart for the assessment of women attending non-genitourinary medicine settings complaining of vaginal discharge" in the original guideline document for additional information.
What point-of-care investigations can be performed in non-genitourinary medicine settings?
- Together with symptoms and signs, assessment of vaginal pH aids the clinician in the management of a woman complaining of vaginal discharge (Grade C).
- Vaginal pH can be measured on secretions obtained from the lateral vaginal walls using narrow range pH paper (Good Practice Point).
Refer to Table 2, "Summary of symptoms and signs (including point-of-care test for vaginal pH) associated with common infective causes of vaginal discharge in women of reproductive age" in the original guideline document for additional information.
What laboratory investigations can be performed on women complaining of vaginal discharge?
- Clinicians should liaise with their local laboratory to find out how specimens are processed and what information they will be able to provide (Good Practice Point).
- Clinicians should provide laboratory staff with appropriate clinical information when submitting specimens from women with vaginal discharge including: risk of STIs, suspicion of STIs and associated symptoms (Good Practice Point).
Refer to Table 3, "Summary of laboratory processing of specimens from women complaining of vaginal discharge" in the original guideline document for additional information.
Which treatments are appropriate for women complaining of vaginal discharge?
Treatment of non-sexually transmitted infections
Treatment of bacterial vaginosis (BV)
- The recommended treatment for BV is oral metronidazole (400 to 500 mg twice daily for 5 to 7 days, or a single 2 g dose) (Grade A).
- Testing and treatment of the male sexual partner(s) is not indicated (Grade C).
- Women using combined hormonal contraception should be advised to use additional contraceptive protection (e.g., condoms) during the antibiotic course and for 7 days afterwards (Grade C).
Treatment of vulvovaginal candidiasis (VVC)
- Vaginal and oral antifungals (azoles) are equally effective in the treatment of VVC (Grade A).
- Vulval antifungals (in addition to oral or vaginal regimens) can be used if women have vulval symptoms (Good Practice Point).
- There is no need for routine screening or treatment of male partner(s) (Grade C).
- Women should be advised that latex condoms, diaphragms and cervical caps may be damaged by some vaginal/vulval antifungal treatments (Grade C).
Use of lactobacillus
- Women may use probiotics (live yoghurts) in the management of VVC or BV but evidence of effectiveness is poor (Good Practice Point).
Treatment of sexually transmitted infections
Treatment of Trichomonas vaginalis (TV)
- The recommended treatment for TV is oral metronidazole (a single 2 g oral dose or 400 mg twice daily for 5 to 7 days) (Grade A).
- Women should be informed that TV is an STI and partner notification and treatment is recommended for all partners in the last 6 months (Grade C).
Treatment of Chlamydia trachomatis and Neisseria gonorrhoeae
- Women identified as having an STI should be treated according to national guidance. Local integrated care pathways should be in place for testing for other STIs and for partner notification (Good Practice Point).
Partner notification
- Patient treatment and partner notification can take place in genitourinary medicine (GUM) clinics, general practice or family planning services if staff have the appropriate skills (Good Practice Point).
How should clinicians manage women with vaginal discharge in special circumstances?
Vaginal discharge in pregnancy
Bacterial vaginosis (BV)
- Pregnant women with BV should be treated as for non-pregnant women (Grade A).
Vulvovaginal candidiasis (VVC)
- Women with VVC in pregnancy should be given vaginal azole regimens but may require up to 7 days' treatment (Grade A).
- Women with VVC in pregnancy should avoid oral antifungals because of potential teratogenicity (Grade C).
Trichomonas vaginalis (TV)
- There is no indication for routine screening for TV in pregnancy. However, treatment is indicated if TV is diagnosed (oral metronidazole 400 mg twice daily for 7 days) (Grade A).
Vaginal discharge following miscarriage, abortion or delivery
- Women with vaginal discharge after miscarriage, abortion or delivery should be investigated at first presentation. Treatment for likely causal organisms may be appropriate while awaiting swab results (Good Practice Point).
Recurrent vaginal discharge
- Consideration should be given to underlying causes in women presenting with recurrent vaginal discharge due to BV or candida (Grade C).
- Clinicians should be aware of psychosexual problems and depression, which can occur in women with recurrent vaginal infections (Good Practice Point).
Recurrent bacterial vaginosis (BV)
- For women with recurrent BV, suppressive regimens (outside the product licence) may be considered, but evidence to support their effectiveness is limited (Grade C).
- Women can be advised to avoid use of douches, shower gels, antiseptic agents and shampoo in the bath (Grade C).
Recurrent vulvovaginal candidiasis (VVC)
- For women with recurrent VVC (four or more episodes in 12 months) an 'induction and maintenance' regimen may be used for 6 months (Grade B).
- Women can be advised to avoid douching, local irritants, perfumed products and tight-fitting synthetic clothing (Grade C).
Recurrent Trichomonas vaginalis (TV)
- Recurrent TV is usually due to re-infection, but consideration should be given to the possibility of drug resistance (Grade C).
Refer to Table 4, "Medical treatments for common infective causes of vaginal discharge in women of reproductive age" in the original guideline document for additional information.
Definitions:
Grades of Recommendations
A Evidence based on randomised controlled trials (RCTs)
B Evidence based on other robust experimental or observational studies
C Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the expert group
