The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
What Are the Commonest Causes of Altered Vaginal Discharge in Women of Reproductive Age?
Health professionals should be aware that the most common causes of altered vaginal discharge are physiological, bacterial vaginosis (BV) and candida, but sexually transmitted infections (STIs) and non-infective causes must be considered. (Good Practice Point)
Refer to Table 1 in the original guideline document for additional information.
Management of Women Presenting with Vaginal Discharge
Examination, Point-of-Care Investigations and STI Testing
A detailed history, including sexual history, is essential to identify the necessary investigations and treatment options. (Good Practice Point)
Women experiencing vaginal discharge who are at low risk of STI can be treated by syndromic or empirical management (see Figure 1 In the original guideline document). (Grade C)
All women with persistent vaginal discharge should be examined to exclude serious pathology. (Good Practice Point)
Women assessed as being at risk of STI, or who request testing, should be offered appropriate tests for chlamydia, gonorrhoea, syphilis and human immunodeficiency virus (HIV). (Good Practice Point)
A high vaginal swab (HVS) is of limited diagnostic value in the management of vaginal discharge except in cases of inconclusive assessment, recurrent symptoms, treatment failure, or in pregnancy, postpartum, post-abortion or post-instrumentation. (Good Practice Point)
Which Treatments Are Appropriate for Women Complaining of Vaginal Discharge?
Treatment of Non-sexually Transmitted Infections
Metronidazole and clindamycin administered either orally or vaginally are effective in the treatment of BV. (Grade A)
In the management of BV, testing and treatment of male sexual partners is not indicated but testing and treatment of female sexual partners can be considered. (Grade C)
Vulvovaginal Candidiasis (VVC)
Vaginal and oral azole antifungals are equally effective in the treatment of VVC. (Grade A)
Women with vulval symptoms of VVC may use topical antifungals (in addition to oral or vaginal treatment) until symptoms resolve. (Good Practice Point)
There is no need for routine screening or treatment of sexual partners in the management of candidiasis. (Grade C)
Treatment of Sexually Transmitted Infections
Trichomonas Vaginalis (TV)
Oral nitroimidazole drugs (e.g., metronidazole) are effective in treating trichomoniasis. (Grade A)
Current sexual partners of women diagnosed with TV should be offered a full sexual health screen and should be treated for TV irrespective of the results of their tests. (Grade B)
Management of Vaginal Discharge in Special Circumstances
Vaginal Discharge in Pregnancy
Women with BV who are pregnant or breastfeeding may use metronidazole 400 mg twice daily for 5–7 days or intravaginal therapies. A 2 g stat dose of metronidazole is not recommended in pregnancy or breastfeeding women. (Grade C)
Women with VVC in pregnancy should avoid oral antifungals. (Grade C)
Women with VVC in pregnancy can be treated with topical imidazoles. Single-dose treatment is less effective than longer regimens of up to 7 days. (Grade A)
Vaginal Discharge in Women with Human Immunodeficiency Virus (HIV)
For HIV-positive women with TV, longer treatment regimens with oral metronidazole may be more effective than a single dose. (Grade B)
Recurrent Vaginal Discharge
For women with recurrent BV, suppressive treatment with metronidazole vaginal gel may be considered. Evidence to support other regimens is limited. (Grade A)
Women using acidifying gels for recurrent BV can be advised to use them alternate evenings for 1 month or longer if required. (Good Practice Point)
For women with recurrent VVC, an induction and maintenance regimen may be used for 6 months. (Grade B)
Recurrent TV is usually due to re-infection, but consideration should be given to the possibility of drug resistance. (Grade C)
Contraception and Vaginal Discharge
Is the Efficacy of Contraception Affected by Vaginal Discharge Treatments?
Additional contraceptive precautions are not required when using antibiotics that do not induce liver enzymes. (Grade D)
Women and male partners should be advised that latex contraceptives may be damaged by some vaginal/vulval antifungal treatments. (Grade C)
Does Contraception Affect Vaginal Discharge?
Women using combined hormonal contraception (CHC) who experience recurrent VVC may wish to consider switching to an alternative method of contraception. (Grade C)
Women with a copper-bearing intrauterine device (Cu-IUD) who experience recurrent BV may wish to consider switching to an alternative method of contraception. (Grade C)
Personal Hygiene and Vaginal Discharge
Women experiencing vaginal discharge can be advised to avoid douching and local irritants as part of general management. (Grade C)
Grading 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