One-liner#
Abnormal vaginal discharge requires differentiation between vaginitis (BV, yeast, trich) and cervicitis (chlamydia, gonorrhea)—with treatment based on clinical findings, wet prep, or syndromic approach.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
- Smartphrase snippets
Red flags / send to ED#
- Fever + pelvic pain + discharge → PID; if severe or unable to tolerate PO, needs IV antibiotics
- Pregnant + fever + discharge → risk of chorioamnionitis, preterm labor
- Toxic-appearing with vaginal symptoms → consider toxic shock syndrome
Key history#
Characterize the discharge:
- Color: white, gray, yellow, green
- Consistency: thick/cottage cheese, thin/watery, frothy
- Odor: fishy (BV, trich), none (yeast), foul
- Amount: increased from baseline
- Duration
Associated symptoms:
- Itching: prominent with yeast, present with trich
- Dysuria: external (yeast, trich) vs internal (UTI)
- Dyspareunia: suggests cervicitis, PID, or atrophy
- Pelvic/abdominal pain: concerning for PID
- Vulvar irritation, burning
Risk factors:
- Recent antibiotics (yeast)
- New sexual partner, multiple partners (STI, BV)
- Unprotected intercourse
- Douching (BV)
- Diabetes, immunosuppression (recurrent yeast)
- IUD (actinomyces, PID risk)
- Postmenopausal (atrophic vaginitis)
Menstrual history:
- LMP, cycle regularity
- Pregnancy possibility
- Postmenopausal status
Prior episodes:
- Recurrent yeast infections
- Prior STIs
- What treatments have worked before
Focused exam#
External genitalia:
- Erythema, edema, excoriations (yeast, trich)
- Lesions, ulcers (herpes, syphilis)
- Vulvar atrophy (postmenopausal)
Speculum exam:
- Vaginal discharge: character, amount, location
- Vaginal walls: erythema, petechiae (“strawberry cervix” with trich—rare)
- Cervix: discharge from os (cervicitis), friability, lesions
Bimanual exam:
- Cervical motion tenderness (CMT) → PID
- Adnexal tenderness → PID, TOA
- Uterine tenderness
Key exam findings by diagnosis:
- BV: thin, gray, homogeneous discharge coating vaginal walls; fishy odor
- Yeast: thick, white, “cottage cheese” discharge; vulvar erythema, edema
- Trichomoniasis: frothy, yellow-green discharge; vulvar erythema; strawberry cervix (rare)
- Cervicitis: mucopurulent discharge from cervical os; cervical friability
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Bacterial vaginosis | “Fishy smell,” “grayish discharge,” “worse after sex” | Thin gray discharge, fishy odor (especially post-coital), minimal itching | Thin gray homogeneous discharge; pH >4.5; positive whiff test | Wet prep or clinical diagnosis; metronidazole |
| Vulvovaginal candidiasis | “Itchy,” “cottage cheese,” “thick white discharge” | Intense pruritus, thick white discharge, recent antibiotics, diabetes | Vulvar erythema, edema; thick white discharge; pH <4.5 | Clinical diagnosis or wet prep; fluconazole or topical azole |
| Trichomoniasis | “Frothy discharge,” “yellow-green,” “itchy and burning” | Frothy yellow-green discharge, vulvar irritation, STI risk | Frothy discharge; strawberry cervix (rare); pH >4.5 | Wet prep or NAAT; metronidazole |
| Cervicitis (chlamydia) | “Discharge,” “bleeding after sex,” “partner tested positive” | Mucopurulent cervical discharge, may be asymptomatic, young/sexually active | Mucopurulent discharge from os; cervical friability | NAAT for CT/GC; treat empirically if high suspicion |
| Cervicitis (gonorrhea) | “Yellow discharge,” “pelvic pain,” “partner has something” | Purulent discharge, more symptomatic than chlamydia | Purulent cervical discharge; friability | NAAT for CT/GC; treat empirically |
| Physiologic discharge | “More discharge than usual,” “no smell or itch” | Clear/white, no odor, no itching, varies with cycle | Normal exam; clear mucoid discharge | Reassurance; no treatment needed |
| Atrophic vaginitis | “Dry,” “discharge,” “painful sex,” postmenopausal | Postmenopausal, vaginal dryness, dyspareunia, may have thin discharge | Pale, dry vaginal mucosa; loss of rugae; petechiae | Vaginal estrogen |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| PID | “Pelvic pain,” “fever,” “hurts during sex” | Lower abdominal pain, fever, cervical discharge, sexually active | CMT, adnexal tenderness, fever | Treat empirically; if severe, ED for IV antibiotics |
| Tubo-ovarian abscess | “Severe pelvic pain,” “high fever,” “very sick” | Severe pain, high fever, may have palpable mass | Adnexal mass/fullness, severe tenderness, fever | ED for imaging and IV antibiotics |
| Desquamative inflammatory vaginitis | “Discharge won’t go away,” “painful,” “tried everything” | Chronic purulent discharge, dyspareunia, not responding to standard treatment | Purulent discharge, vaginal erythema, epithelial erosions | Gynecology referral |
| Foreign body | “Forgot tampon,” “bad smell,” “bloody discharge” | Foul-smelling discharge, may have forgotten tampon or other object | Foreign body visible on speculum exam | Remove foreign body; antibiotics if infection |
Workup#
Office-based testing (if available):
- Vaginal pH: <4.5 (yeast, physiologic) vs >4.5 (BV, trich, atrophic)
- Wet prep (saline): clue cells (BV), trichomonads (motile), WBCs
- KOH prep: pseudohyphae/budding yeast (candida); whiff test (fishy odor = BV)
- Whiff test: add KOH to discharge; fishy odor positive in BV
Amsel criteria for BV (3 of 4):
- Thin, homogeneous gray discharge
- Vaginal pH >4.5
- Positive whiff test
- Clue cells on wet prep (>20%)
If no microscopy available:
- Syndromic treatment based on clinical presentation
- Send vaginal swab for BV/yeast/trich panel (PCR-based)
- NAAT for chlamydia/gonorrhea
STI testing:
- NAAT for chlamydia and gonorrhea (vaginal swab preferred; urine acceptable)
- Trichomonas NAAT (more sensitive than wet prep)
- Consider HIV, syphilis, hepatitis B if new STI diagnosis
When to test for STIs:
- All sexually active women <25 annually
- New or multiple partners
- Partner with STI
- Mucopurulent cervical discharge
- Cervical friability
When NOT to order:
- Do NOT treat asymptomatic BV (except in pregnancy)
- Do NOT routinely culture for yeast—clinical diagnosis usually sufficient
- Do NOT order “vaginitis panel” for every discharge complaint—targeted testing is more appropriate
Initial management#
BV:
- Metronidazole (oral or vaginal)
- No need to treat male partners
Yeast:
- Fluconazole (oral) or topical azole
- OTC options appropriate for uncomplicated cases
Trichomoniasis:
- Metronidazole (oral)
- MUST treat partners
- Test for other STIs
Cervicitis/suspected STI:
- Treat empirically if high suspicion
- Treat partners
- Test for HIV, syphilis
PID:
- Outpatient treatment if mild-moderate and can tolerate PO
- ED if: severe, pregnant, TOA suspected, unable to tolerate PO
Management by diagnosis#
Bacterial Vaginosis#
Education:
- Imbalance of normal vaginal bacteria; not an STI
- Associated with sexual activity but not transmitted sexually
- Recurrence is common (30% within 3 months)
- Avoid douching
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Metronidazole | 500 mg PO BID x 7 days | Avoid alcohol (disulfiram reaction) | None | $ | First-line; warn about alcohol |
| Metronidazole gel 0.75% | 5 g intravaginally daily x 5 days | None | None | $$ | Alternative; less GI side effects |
| Clindamycin cream 2% | 5 g intravaginally at bedtime x 7 days | None | None | $$ | Alternative; may weaken latex condoms |
| Clindamycin | 300 mg PO BID x 7 days | None | None | $ | Oral alternative |
| Secnidazole (Solosec) | 2 g PO single dose | Avoid alcohol | None | $$$$ | Single-dose option; expensive |
Recurrent BV (3+ episodes/year):
- Metronidazole gel 0.75% twice weekly x 4-6 months (suppressive)
- Consider boric acid 600 mg intravaginally daily x 21 days, then twice weekly
Pregnancy:
- Treat symptomatic BV
- Metronidazole 500 mg PO BID x 7 days (safe in pregnancy)
- Metronidazole gel less effective in pregnancy
Follow-up: None needed if symptoms resolve. No test of cure required.
Vulvovaginal Candidiasis#
Education:
- Yeast infection; not an STI
- Common after antibiotics, in diabetes, with immunosuppression
- OTC treatments work well for uncomplicated cases
- Partners do not need treatment unless symptomatic (rare)
Uncomplicated (sporadic, mild-moderate, likely C. albicans, immunocompetent):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Fluconazole | 150 mg PO x 1 | Pregnancy (1st trimester); drug interactions | None | $ | Most convenient; avoid in pregnancy |
| Miconazole 2% cream | 5 g intravaginally daily x 7 days | None | None | $ | OTC; safe in pregnancy |
| Miconazole 200 mg suppository | 1 suppository daily x 3 days | None | None | $ | OTC; safe in pregnancy |
| Clotrimazole 1% cream | 5 g intravaginally daily x 7 days | None | None | $ | OTC; safe in pregnancy |
| Terconazole 0.4% cream | 5 g intravaginally daily x 7 days | None | None | $$ | Prescription; for resistant cases |
Complicated candidiasis:
- Severe symptoms: fluconazole 150 mg, repeat in 72 hours
- Non-albicans species: longer course (7-14 days); boric acid 600 mg intravaginally daily x 14 days
- Immunocompromised: longer course; may need maintenance
Recurrent candidiasis (4+ episodes/year):
- Induction: fluconazole 150 mg every 72 hours x 3 doses
- Maintenance: fluconazole 150 mg weekly x 6 months
- Check HbA1c (rule out diabetes)
- Consider HIV testing
Pregnancy:
- Topical azoles only (7-day course preferred)
- Avoid oral fluconazole (teratogenic in 1st trimester)
Follow-up: None needed if symptoms resolve. Return if recurrent.
Trichomoniasis#
Education:
- STI caused by parasite
- Partners MUST be treated
- Can be asymptomatic, especially in men
- Increases HIV transmission risk
- Abstain until both partners treated and asymptomatic
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Metronidazole | 500 mg PO BID x 7 days | Avoid alcohol x 24 hours after | None | $ | Preferred in women; better cure rate |
| Metronidazole | 2 g PO single dose | Avoid alcohol x 24 hours after | None | $ | Alternative; slightly lower cure rate |
| Tinidazole | 2 g PO single dose | Avoid alcohol x 72 hours after | None | $$ | Alternative if metronidazole fails |
Partner treatment:
- Treat all partners from past 60 days
- Expedited partner therapy where legal
Pregnancy:
- Metronidazole 2 g single dose (safe in all trimesters)
- Treat to prevent preterm birth and transmission
Follow-up: Retest in 3 months (high reinfection rate). Test of cure only if symptoms persist.
Cervicitis (Chlamydia/Gonorrhea)#
Education:
- Bacterial infection; curable with antibiotics
- Partners must be treated
- Can lead to PID and infertility if untreated
- Abstain until treatment complete and partners treated
Treatment:
For chlamydia:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Doxycycline | 100 mg PO BID x 7 days | Pregnancy | None | $ | Preferred; more effective than azithromycin |
| Azithromycin | 1 g PO x 1 | None | None | $ | Alternative if adherence concern |
For gonorrhea (always co-treat for chlamydia):
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Ceftriaxone | 500 mg IM x 1 | Severe cephalosporin allergy | None | $ | Required for gonorrhea |
| PLUS Doxycycline | 100 mg PO BID x 7 days | Pregnancy | None | $ | Covers chlamydia |
Pregnancy:
- Chlamydia: azithromycin 1 g x 1 (doxycycline contraindicated)
- Gonorrhea: ceftriaxone 500 mg IM + azithromycin 1 g
Follow-up: Rescreen in 3 months. Test of cure only if pregnant or symptoms persist.
PID (Pelvic Inflammatory Disease)#
Education:
- Infection of uterus, tubes, and/or ovaries
- Usually from untreated STI ascending from cervix
- Can cause infertility, chronic pain, ectopic pregnancy
- Partners must be treated
Outpatient criteria (all must be met):
- Mild-moderate symptoms
- Tolerating oral intake
- Can return for follow-up in 48-72 hours
- Not pregnant
Outpatient treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Ceftriaxone | 500 mg IM x 1 | Severe cephalosporin allergy | None | $ | Covers gonorrhea |
| PLUS Doxycycline | 100 mg PO BID x 14 days | Pregnancy | None | $ | Covers chlamydia, other organisms |
| PLUS Metronidazole | 500 mg PO BID x 14 days | Avoid alcohol | None | $ | Covers anaerobes; add if severe or TOA concern |
ED referral indications:
- Severe illness, high fever, unable to tolerate PO
- Pregnant
- Tubo-ovarian abscess suspected
- No improvement after 48-72 hours of outpatient treatment
- Surgical emergency cannot be excluded
Follow-up: 48-72 hours to assess response. If not improving, imaging and possible hospitalization.
Atrophic Vaginitis#
Education:
- Due to low estrogen after menopause
- Causes dryness, irritation, and sometimes discharge
- Vaginal estrogen is safe and effective
- Takes 4-6 weeks for full benefit
Treatment: See dysuria page for vaginal estrogen options.
Follow-up: 4-6 weeks to assess response.
Follow-up#
BV, yeast, trichomoniasis:
- No routine follow-up if symptoms resolve
- Return if symptoms persist or recur
STIs (chlamydia, gonorrhea):
- Rescreen in 3 months (high reinfection rate)
- Ensure partners treated
PID:
- 48-72 hours to assess response
- If not improving, imaging and possible hospitalization
Return precautions:
- Fever or pelvic pain (suggests PID)
- Symptoms not improving after treatment
- Symptoms recurring shortly after treatment
- New symptoms (rash, joint pain)
Patient instructions#
For bacterial vaginosis:
- Take your medication as prescribed
- Avoid alcohol while taking metronidazole and for 24 hours after
- This is not a sexually transmitted infection, but it’s associated with sexual activity
- Avoid douching—it disrupts normal vaginal bacteria
- Your partner does not need treatment
For yeast infection:
- You can use over-the-counter treatments if you’ve had yeast infections before and recognize the symptoms
- If using fluconazole, one pill is usually enough
- Your partner does not need treatment unless they have symptoms
- Call if symptoms don’t improve in a few days or keep coming back
For STIs:
- Take all your medication as prescribed
- Your partner(s) MUST be treated, or you will get reinfected
- Do not have sex until you and your partner have finished treatment (at least 7 days)
- Get tested again in 3 months
- Call if you develop fever, pelvic pain, or symptoms get worse
Smartphrase snippets#
BV: “Vaginal discharge consistent with bacterial vaginosis—thin gray discharge, positive whiff test, pH >4.5. Treated with metronidazole 500 mg BID x 7 days. Counseled to avoid alcohol during treatment. Partner treatment not indicated. Return if symptoms persist or recur.”
Yeast infection: “Symptoms and exam consistent with vulvovaginal candidiasis—pruritus, thick white discharge, vulvar erythema, pH <4.5. Treated with fluconazole 150 mg x 1. If recurrent, will evaluate for diabetes and consider suppressive therapy.”
Cervicitis/STI: “Mucopurulent cervical discharge consistent with cervicitis. NAAT sent for CT/GC. Treated empirically with [ceftriaxone 500 mg IM + doxycycline 100 mg BID x 7 days]. Partner treatment discussed; EPT provided. Advised abstinence x 7 days. Will rescreen in 3 months.”