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Patient history in insufficient.

Symptoms alone do not allow clinicians to distinguish confidently between the causes of vaginitis.

Lack of itching makes candidiasis less likely (range of LRs, 0.18 [95% confidence interval [CI], 0.05-0.70] to 0.79 [95% CI, 0.72-0.87])

Lack of perceived odor makes bacterial vaginosis unlikely (LR, 0.07 [95% CI, 0.01-0.51]).

Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291(11):1368-1379.

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Providers are bad at diagnosis.

303 symptomatic women evaluated per standard office practice.

290 women with additional swabs collected for vaginosis NAAT, gram stain for BV, yeast culture and second NAAT for TV

170 with lab diagnosed vaginitis

81 (47%) received inappropriate prescriptions

120 without BV, TV or VVC

41 (34%) were prescribed abx or antifungals

Conclusions: 42% of women with vaginitis symptoms received inappropriate treatment. Women without infections who received empiric treatment were more likely to have recurrent visits within 90 days.

Hillier SL, Austin M, Macio I, Meyn LA, Badway D, Beigi R. Diagnosis and Treatment of Vaginal Discharge Syndromes in Community Practice Settings. Clin Infect Dis. 2021 May 4;72(9):1538-1543. doi: 10.1093/cid/ciaa260. PMID: 32350529;

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History

sexual history (including number and gender identification of sex partners and specific sexual practices)

self-treatment with over-the-counter medications or prescription medications

vulvovaginal hygiene practices (eg, shaving, douching)

underlying medical conditions (eg, diabetes, HIV status, inflammatory bowel disease)

relation of symptoms to the menstrual cycle

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Yeast infection

KOH is only ~50% sensitive for detecting yeast.

False positives are only ~5%

Yeast culture should be done:

In someone with typical symptoms and negative wet mount
In recurrent or severe VVC
In high risk conditions (DM, immunocompromise)

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Yeast culture collection

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Recurrent VVC = 3 or more episodes in <1 year

Consider suppressive therapy

Treat with fluconazole 150mg every 3 days x 3, then weekly for 6mo

If non-albicans yeast confirmed on culture, consider boric acid 600mg PV x 28 days

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All that itches is not yeast...

Atrophic vaginitis, lichen simplex chronicus, lichen sclerosis, psoriasis, allergic/irritant dermatitis

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Case example 1

Betty is a postmenopausal female with a history of DM2 on metformin, glargine and empagliflozin with good control, last A1c 7.1.
She reports recurrent vaginal itching that she has been treating with OTC yeast creams. Last treated >1 mo ago, currently with mild vaginal itching recurring.
Exam:

GU: external genitalia with bilateral areas of hypopigmentation skin changes where labia majora meet groin, vaginal mucosa atrophic, scant thin white discharge

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Wet mount

Yeast culture

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Case 1 Conclusion

Betty is treated for atrophic vaginitis with vaginal estrogen cream and lichen simplex chronicus of vulva with topical steroids. Her symptoms improve dramatically and she is able to continue SGLT2 for diabetes control.

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Case example 2

Rita is a 47yo postmenopausal female presenting with severe vaginal itching and burning. Persistent over months. History of lichen sclerosus but running out of clobetasol. Uncontrolled DM2 with last A1c >13, on metformin and dapagliflozin.

Exam:

GU: extensive erythematous plaques of the labia with linear erosions of lateral labia minora.

Vaginal: scant discharge, atrophic changes

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Wet mount

Yeast culture

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Case 2 Conclusion

Rita is treated for severe candidiasis with fluconazole 150mg every 3 days x 3 doses. A plan is made to stop dapaglifozin and start long-acting insulin to expedite and maximize diabetes control.

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Bacterial�Vaginosis

Diagnosis requires

Gram stain (run on wet mount swab)

Amsels criteria = 3 of 4 criteria met

Typical homogenous thin, milky discharge smoothly coating vaginal walls on exam
PH > 4.5
Positive whiff (fishy odor with or without KOH)
>20% Clue cells on microscopy

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In a patient without typical discharge on exam and/or without a positive "whiff" test (fishy odor with or without KOH),

you cannot diagnose BV with this wet prep alone.

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Gram stain for BV collection

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Other BV tips

Routine screening for BV among asymptomatic pregnant women at high or low risk for preterm delivery for preventing preterm birth is not recommended.
Metronidazole is generally safe in pregnancy and breastfeeding at 500mg BID dosing
Alcohol and metronidazole is okay to mix, this does not cause a disulfiram-like reaction as previously thought.

Antibiotics (like doxy and metro) can often cause nausea on an empty stomach, recommend taking with food.

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Trichomoniasis

Wet mount has low sensitivity
Trichomonas NAAT (vaginal preferred for females, urine for males)

Additional tips:

Test those with vaginal discharge.

Consider screening for those with STI risk factors

(multiple sex partners, transactional sex, drug misuse, or a history of STIs or incarceration)

Screen people with vaginas and HIV yearly.

Pap is not diagnostic for Trich, rescreen with NAAT.

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Mycoplasma genitalium

Testing recommended in recurrent cervicitis (with negative GC/CT/TV) and in PID

Consider in women with intermenstrual and post-coital bleeding (signs of persistent cervicitis) if initial STI screen negative

Vaginal swab preferred (same swab as GC/CT/TV), first void urine
Treatment is doxy 100mg BID x 7 days followed by moxifloxacin 400mg daily x 7 days

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