Management of vaginal discharge

This guideline doesn’t really change management at all, but is a useful overview. I will summarise useful reminders, or things I forget to do.

Causes:

Though the commonest causes are physiological discharge, Bacterial Vaginosis (BV) and candida, remember that other pathology such as ectropion, polyps or malignancy can cause discharge too.

Commensal Organisms:

Candida will be commensal in about 20% of women, and gardnerella (causing BV) in about 40%, so (unless pregnant), you wouldn’t treat without symptoms.

History:

  • PID. Beware abnormal bleeding, abdominal pain, fever or deep dyspareunia as these could signify PID – so always ask.
  • Self-treatment. Lots of women will have self-treated on this occasion or in the past. Check what they’ve used. They may well have misdiagnosed themselves, or have used things that could be irritants.

Who needs examining?

Everyone should be offered examination, but most women don’t really need it. The following groups should definitely be examined:

  • Pregnancy / post-partum / post-instrumentation / post abortion.
  • If they are at risk of STDs (includes most under 25s).
  • Anyone with recurrent or persistent symptoms.
  • PID – if they have symptoms suggestive of PID.

What examination should be done?

  • Everyone – if they decline examination, offer for them to do self-swab for chlamydia.
  • PID – if you suspect PID, do full STD screen, speculum and bimanual exam.
  • Others – speculum exam. Don’t do HVS if symptoms are typical of candida or BV as the swab is unlikely to change management. You are really examining so as not to miss other pathology. If at STD risk, the minimum screen is chlamydia, gonorrhoea, syphilis and HIV.
  • Trichomonas Vaginalis (TV). If you suspect this (frothy green discharge), write it on the form as the lab won’t routinely test for it. The best thing is to send them to GU.

General Management:

  • Recurrent or persistent symptoms. Consider if you have the diagnosis correct. Consider referral to GUM or specialist clinic.
  • Vulval skin care. Avoid douching and irritants. See the RCOG Green Top PLOG about vulval skin disorders for excellent patient information on this.
  • Condoms. If you are using topical clotrimazole or clindamycin, then latex condoms may not work, so advise abstinence or non-latex condoms.

Bacterial Vaginosis treatment:

  • Partners – consider treating female, but not male, partners.
  • Pregnancy – can cause adverse pregnancy outcomes, so treat, even if asymptomatic.
  • Recurrent BV – lots of options for treatment are listed, but the main advised one is twice weekly metronidazole vaginal gel. There isn’t much evidence to support other treatments.

Candida treatment:

  • Vaginal and oral treatment is equally effective. There is little evidence that topical vulval treatment alone is more effective than emollients.
  • Pregnancy – no evidence of adverse outcomes on pregnancy, so only treat if they have symptoms.
  • Recurrent symptoms – there are several treatment options listed as effective. Some women may find stopping the COC beneficial (though only the depot has shown to be protective). Some women may also find having an IUCD removed helpful.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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