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Evaluation and Management of Vaginitis

      Abstract

      Vaginitis is a common concern for women across the lifespan. Vaginal symptoms may impact quality of life, and clinicians are challenged in the evaluation and management of bacterial vaginosis, Candida vaginitis, trichomoniasis, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause.

      Abbreviations and Acronyms:

      ACOG (American College of Obstetricians and Gynecologists), BV (bacterial vaginosis), CDC (Centers for Disease Control and Prevention), CST (community state), DIV (desquamative inflammatory vaginitis), ET (estrogen therapy), GBS (group B streptococcus), GSM (genitourinary syndrome of menopause), HIV (human immunodeficiency virus), NAAT (nucleic acid amplification test), PID (pelvic inflammatory disease), PTB (preterm birth), STI (sexually transmitted infection), UTI (urinary tract infection)
      CME Activity
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      Credit Statement: Mayo Clinic College of Medicine and Science designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      MOC Credit Statement: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 MOC point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
      Learning Objectives: On complication of this article, the reader should be able to: 1) recognize common characteristics and symptoms of vaginitis/vaginosis; 2) discuss the evaluation and diagnosis of vaginitis/vaginosis; and 3) review management of bacterial vaginitis, Candida vaginitis, trichomoniasis, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause.
      Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Medicine and Science (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation.
      In their editorial and administrative roles, Karl A. Nath, MBChB, Terry L. Jopke, Kimberly D. Sankey, and Jenna M. Pederson, have control of the content of this program but have no relevant financial relationship(s) with industry.
      The authors report no competing interests.
      Method of Participation: In order to claim credit, participants must complete the following:
      • 1.
        Read the activity.
      • 2.
        Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed. Visit www.mayoclinicproceedings.org, select CME, and then select CME articles to locate this article online to access the online process. On successful completion of the online test and evaluation, you can instantly download and print your certificate of credit.
      Estimated Time: The estimated time to complete each article is approximately 1 hour.
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      Date of Release: 2/1/2022
      Expiration Date: 1/31/2024 (Credit can no longer be offered after it has passed the expiration date.)
      Questions? Contact [email protected] .

      Vaginal Microbiome

      The vaginal microbiome is complex and unique in comparison to that of the skin, mouth, or gut.
      • van de Wijgert J.H.H.M.
      • Jespers V.
      The global health impact of vaginal dysbiosis.
      Its alterations have been linked to endometritis, infertility, preterm birth (PTB), increased risk for acquisition of human immunodeficiency virus (HIV) and other sexually transmitted diseases, and persistence of human papillomavirus.
      • van de Wijgert J.H.H.M.
      • Jespers V.
      The global health impact of vaginal dysbiosis.
      This microbiome is transiently altered by menses, sexual activity, pregnancy, antimicrobial use, hormonal therapies, perimenopause, and menopause.
      • van de Wijgert J.H.H.M.
      • Jespers V.
      The global health impact of vaginal dysbiosis.
      ,
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      It has been classified into five community states (CSTs) with four of these dominated by lactobacillus (an aerobic, gram-positive rod).
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      Lactobacilli produce lactic acid and hydrogen peroxide, and along with estrogen during the reproductive years, maintain low vaginal pH (4.5 or lower) to reduce vaginal proinflammatory cytokines and inhibit bacterial overgrowth.
      • Mitchell C.
      • Fredricks D.
      • Agnew K.
      • Hitti J.
      Hydrogen peroxide-producing lactobacilli are associated with lower levels of vaginal interleukin-1β, independent of bacterial vaginosis.
      A healthy, acidic premenopausal vagina contains 70% to 90% lactobacilli along with a heterogeneous mixture of Gardnerella vaginalis (G. vaginalis), Escherichia coli (E. coli), group B streptococcus (GBS), genital Mycoplasma species, and Candida albicans (C. albicans), among other species.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      • Mitchell C.
      • Fredricks D.
      • Agnew K.
      • Hitti J.
      Hydrogen peroxide-producing lactobacilli are associated with lower levels of vaginal interleukin-1β, independent of bacterial vaginosis.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      Community states I, II, and V are considered to be normal microbiome states whereas CST III is different in that it occurs with an abundant polymicrobial vaginal flora.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      Community state IV is composed of a low concentration or absence of lactobacilli and a high concentration of obligate anaerobes.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      Bacterial vaginosis (BV) is associated with CSTs III and IV (with obligate and facultative anaerobes), whereas desquamative inflammatory vaginitis (DIV) is seen in CST IV colonized with facultative bacteria (as E. coli, S. aureus, GBS, and Enterococcus faecalis).
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      The menopausal vagina, with its decreased concentration of lactobacilli, is also consistent with CST IV.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Gliniewicz K.
      • Schneider G.M.
      • Ridenhour B.J.
      • et al.
      Comparison of the vaginal microbiomes of premenopausal and postmenopausal women.
      Systemic and vaginal estrogen increase the concentration of lactobacilli.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.

      Vaginitis

      Vaginitis is caused by infection, inflammation, or an imbalance in the normal flora.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Typical symptoms include odor, irritation, burning, pruritus, dysuria, dyspareunia, or a change in vaginal discharge.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      The most common diagnoses are BV, which is not a true vaginitis given an absence of inflammation (22% to 50% of symptomatic women), Candida vulvovaginitis (17% to 39%), Trichomonas vaginalis (T. vaginalis) (4% to 35%), or a mix of these pathogens potentially also including Mycoplasma or Ureaplasma.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Vaginitis and cervicitis may be concomitant, with the latter most commonly associated with Neisseria gonorrhea and Chlamydia trachomatis. Both conditions should be considered during evaluation.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      An examination with appropriate testing is important to distinguish other causes of vaginal symptoms including vulvar, vaginal, and cervical cancers; pelvic inflammatory disease (PID); vulvovaginal ulcerative conditions including herpes simplex virus; vaginal fistulas; trauma; and vulvovaginal dermatoses including lichen planus or pemphigoid.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Empiric therapy for vaginitis should be avoided to prevent misdiagnosis. Chronic symptoms may require ongoing evaluation and management. We will discuss symptomatology, physical findings, diagnostic criteria, and therapies as recommended by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG).
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.

      Bacterial Vaginosis

      Bacterial vaginosis affects approximately 22 million US premenopausal women yearly with higher rates in Hispanic and Black women, possibly associated with a greater likelihood of vitamin D deficiency and vaginal microbiome dominated by Lactobacillus iners (observed in CST III) in these women.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Dunlop A.L.
      • Jordan S.L.
      • Ferranti E.P.
      • et al.
      Total and free 25-hydroxy-vitamin D and bacterial vaginosis in pregnant African American women.
      ,
      • Wells J.S.
      • Chandler R.
      • Dunn A.
      • Brewster G.
      The vaginal microbiome in U.S. Black women: a systemic review.
      With the shift in the vaginal microbiome to an overgrowth of G. vaginalis and Atopobium vaginae, a biofilm or scaffolding forms through the vagina and/or endometrium to which anaerobic species adhere resulting in symptomatic odor and transudative discharge.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      A symptomatic counterpart has not been described in men, making it difficult to determine whether BV is sexually transmitted.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Having new and multiple male and female sexual partners has been linked with BV.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Bacterial vaginosis is prevalent in women having sex with women but is less an issue with a single partner.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Other risk factors include douching, cigarette smoking, and increased body mass index.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Bacterial vaginosis can be associated with sexually transmitted infections (STIs) including herpes simplex 2, HIV, gonorrhea, chlamydia, T. vaginalis, and human papillomavirus.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      The CDC recommends that women positive for BV should be tested for STIs.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Because endometrial colonization can occur, BV may be associated with plasma cell endometritis, PID, post-hysterectomy vaginal cuff cellulitis/abscess, postabortion infection, chorioamnionitis, postpartum fever, and PTB.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Brown R.G.
      • Marchesi J.R.
      • Lee Y.S.
      • et al.
      Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin.
      The clinical characteristics and diagnostic criteria for BV are listed in Table 1.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Mohammadzadeh F.
      • Dolatian M.
      • Jorjani M.
      • Majd H.A.
      Diagnostic value of Amsel’s clinical criteria for diagnosis of bacterial vaginosis.
      ,
      • Cartwright C.P.
      • Lembke B.D.
      • Famachandran K.
      • et al.
      Comparison of nucleic acid amplification assays with BD affirm VP III for diagnosis of vaginitis in symptomatic women.
      More than 50% of women testing positive for BV may be asymptomatic, with many experts suggesting no treatment is necessary and others associating treatment with lower risk of infertility.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Vaginal culture for G. vaginalis is not recommended for diagnosis nor is cervical cytology given high false-positive and false-negative rates.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Table 1Common Characteristics and Diagnoses of BV, Candida, Trichomoniasis, DIV, and GSM
      BV, bacterial vaginosis; CV, candida vaginitis; d/c, discharge; DIV, desquamative inflammatory vaginitis; GSM, genitourinary syndrome of menopause; KOH, potassium hydroxide; PCR, polymerase chain reaction; NAAT, nucleic acid amplification testing; STI, sexually transmitted infection; UTI, urinary tract infection; WBC, white blood cell.
      ,
      The information in this table has been obtained from other sources. 4,6-10,14-18
      Vaginitis subtypeSymptomsSignsDiagnosis
      BVMilky, gray thin homogenous discharge (d/c) and “fishy” odor

      No dysuria, dyspareunia, pruritus, burning unless copathogen present
      White, gray thin d/c with odor. No vaginal inflammation, ± vulvar irritation from d/cAmsel criteria, ≥ 3 present: (1) homogenous, thin, white-gray discharge, (2) pH >4.5, (3) +KOH whiff test (with 10% KOH added to d/c), and (4) wet prep with ≥20% clue cells (epithelial cells coated with bacteria), absence of lactobacilli and WBCs (Sensitivity 92%, Specificity 77%);

      BV gram stain (Sensitivity 70%, Specificity 94%), uses Nugent criteria to score bacterial morphotypes;

      Rapid chromogenic point of care assay (OSOM BV Blue Test, FemExam Card) (Sensitivity 88% to 91%, Specificity 62% to 95%), detects enzymatic sialidase activity of pathogens;

      DNA probe assay/Affirm VPIII vaginitis panel (Sensitivity 90%, Specificity 86% to 97%), detects pathogenic levels of G. vaginalis along with Candida and Trichomonas;

      Single swab multiplex, real-time PCR/NAAT (NuSwab, BD Max, MDL BV, Aptima BV) (Sensitivity 91% to 99%, Specificity 86% to 94%), amplifies DNA or RNA targets, detecting ratio of lactobacilli to BV bacteria; can detect multiple infections
      CandidaPruritus, thick, curd-like d/c, (premenopause), ± odor, burning, irritation/soreness, dysuria, dyspareunia

      D/c may be thin, watery in menopause, also thin with C. glabrata, C. parapsilosis
      Vulvar erythema (satellite lesions), excoriations/fissures, edema, vaginal erythema, thick white/yellow to thin watery d/c, normal pH 4.0 to 4.5KOH wet prep budding yeast, hyphae, or pseudohyphae (Sensitivity 50% to 70%);

      Vulvar or vagina culture (can speciate Candida strain especially in recurrent or refractory disease);

      DNA probe assay/Affirm VPIII vaginitis panel (Sensitivity 76% to 91%, Specificity 94% to 99%);

      Multiplex PCR (BD Max) to check for BV, Trichomonas, and 6 strains of Candida: C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis, C. glabrata, and C. krusei

      (Sensitivity 90%, Specificity 94%);

      Aptima CV/TV (detects specific Candida strains) (Sensitivity 85% to 92%, Specificity 95% to 99%)
      TrichomoniasisThin to profuse, purulent, malodorous, white/gray/yellow/green d/c; burning, pruritus, dysuria, frequency, dyspareuniaVulvar erythema, edema; d/c thin to frothy, purulent odorous white/gray/yellow/ greenWet prep motile trichomonads (flagellated, undulating), increased WBCs (Sensitivity 50% to 60%);

      Antigen point-of-care assay (AmpliVue, Solana, OSOM Trichomonas assays) (Sensitivity 88%, Specificity 99%);

      DNA probe assay/Affirm VPIII vaginitis panel (Sensitivity 93%, Specificity 99%);

      NAAT/multiplex PCR/DNA probe (Sensitivity 93% to 99%, Specificity 99%)
      DIVCopious vaginal d/c, clear/gray, purulent yellow or green without odor, severe vaginal or introital pain, burning, irritation, pruritus, dyspareuniaCopious d/c, introital or vestibule erythema, edema, marked vaginal and cervical inflammation with focal or diffuse ecchymosis, erythema, petechiae, erosions, pH>4.5Wet prep increased parabasal cells and inflammatory cells, WBC-to-epithelial cell ratio >1:1 (often a marked increase in polymorphonuclear WBCs); exclusion of other vaginitis, STIs
      GSMVulvovaginal dryness, burning, irritation, dyspareunia, dysuria, urgency, recurrent UTIs, postcoital spottingClitoral atrophy, phimosis of prepuce, labial atrophy, urethral caruncle, prolapse, or polyps, introital/vaginal dryness, introital narrowing, vagina friable, pale to erythematous, petechiae, ulcerations, fissures, pH≥5.0 to 5.5Wet prep or cytology >1 WBC per epithelial cells, immature vaginal cells with enlarged nuclei (parabasal cells), decreased or absent superficial vaginal squamous cells
      a BV, bacterial vaginosis; CV, candida vaginitis; d/c, discharge; DIV, desquamative inflammatory vaginitis; GSM, genitourinary syndrome of menopause; KOH, potassium hydroxide; PCR, polymerase chain reaction; NAAT, nucleic acid amplification testing; STI, sexually transmitted infection; UTI, urinary tract infection; WBC, white blood cell.
      b The information in this table has been obtained from other sources.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Mohammadzadeh F.
      • Dolatian M.
      • Jorjani M.
      • Majd H.A.
      Diagnostic value of Amsel’s clinical criteria for diagnosis of bacterial vaginosis.
      • Cartwright C.P.
      • Lembke B.D.
      • Famachandran K.
      • et al.
      Comparison of nucleic acid amplification assays with BD affirm VP III for diagnosis of vaginitis in symptomatic women.
      • Stemmer S.M.
      • Mordechai E.
      • Adelson M.E.
      • Gygax S.E.
      • Hilbert D.W.
      Trichomonas vaginalis is most frequently detected in women at the age of peri-/premenopause: an unusual pattern for a sexually transmitted pathogen.
      • Gaydos C.A.
      • Klausner J.D.
      • Pant Pai N.
      • Kelly H.
      • Coltart C.
      • Peeling R.W.
      Rapid and point-of-care tests for the diagnosis of Trichomonas vaginalis in women and men.
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      Women with symptomatic BV should be treated.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Symptomatic partner(s) of women having sex with women should be treated whereas treatment of male partner(s) is not recommended with the possible exception of recurrent BV.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      See Table 2 for CDC and ACOG treatment guidelines of acute BV, including standard and alternative therapy for nonpregnant women.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Therapy may decrease STI transmission risk.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Side effects of oral nitroimidazoles, the most common treatment selection, include nausea, vomiting, metallic taste, neutropenia, increased internationalnormalized ratio with warfarin, neuropathy, rash, urticaria, pruritus, and rarely anaphylaxis.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Intravaginal metronidazole or clindamycin are alternative therapies if troublesome nausea and vomiting occur with oral therapy.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Condoms, diaphragms, and cervical caps should not be used with clindamycin cream as it may breakdown latex.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Oral and intravaginal metronidazole are equally efficacious for BV.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Symptomatic and asymptomatic women with BV undergoing hysterectomy and abortion should be treated.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Table 2Vaginitis Treatment Options (Non-Pregnant and Pregnancy)
      BID, twice daily; BV, bacterial vaginitis; CDC, Centers for Disease Control and Prevention; DHEA, dehydroepiandrosterone; GSM, genitourinary syndrome of menopause; PID, pelvic inflammatory disease; QD, once daily; QID, four times daily; SERM, selective estrogen receptor modulator.
      ,
      The information in this table has been obtained from other sources.4,6-10,19-22
      VaginitisNonpregnantPregnant or breastfeeding treatment
      Bacterial vaginosis (first-line treatment)Metronidazole 500 mg BID by mouth x7 d

      OR

      Metronidazole 0.75% vaginal gel QD x5 d

      OR

      Clindamycin 2% vaginal cream QD x7 d

      OR

      Alternative therapies:

      Tinidazole 2 g QD by mouth x2 d

      OR

      Tinidazole 1 g QD by mouth x5 d

      OR

      Secnidazole 2 g by mouth single dose

      OR

      Clindamycin 300 mg BID by mouth x7 d

      OR

      Clindamycin 100 mg vaginal ovules QD x3 d, no condoms ∗∗Alcohol no longer needs to be avoided with oral nitroimidazoles (metronidazole, tinidazole, or secnidazole)
      Metronidazole: not contraindicated in pregnancy, no known teratogenic effects. Defer breastfeeding during and for 12 to 24 hours after last dose;

      Tinidazole: limited data in pregnancy. CDC advises avoiding in pregnancy. Defer breastfeeding during and for 72 hours after last dose;

      Secnidazole: not contraindicated in pregnancy but data limited. Defer breastfeeding for 96 hours after dose
      Bacterial vaginosis (recurrent)Change antibiotic from that initially used

      OR

      Extend course of antibiotic

      OR

      Metronidazole vaginal gel 0.75% 2 times weekly x16-24 weeks after treatment of the acute episode

      OR

      Boric acid 600 mg vaginal capsules (never oral) at bedtime x21 d; followed by metronidazole vaginal gel twice weekly x16-24 weeks

      OR

      Metronidazole 2 g by mouth + fluconazole (Diflucan) 150 mg by mouth once monthly

      OR

      Initial course of nitroimidazole x7-10 d by mouth followed by metronidazole vaginal gel twice weekly x16-24 weeks

      OR

      Initial course of nitroimidazole by mouth + boric acid 600 mg vaginal capsules (never oral) at bedtime x21 d (same time), followed by metronidazole vaginal gel twice weekly x16-24 weeks
      Metronidazole: Not contraindicated in pregnancy, no known teratogenic effects. Defer breastfeeding during & for 12-24 hours after last dose;

      Tinidazole: Limited data in pregnancy. CDC advises avoiding in pregnancy. Defer breastfeeding during & for 72 hours after last dose;

      Secnidazole: Not contraindicated in pregnancy but data limited. Defer breastfeeding for 96 hours after dose
      Vaginal candidiasisUncomplicated infection

      Clotrimazole (Gyne-Lotrimin)

      1% vaginal cream 1 applicator (5 g) daily x7 d

      OR

      2% vaginal cream 1 applicator (5 g) daily x3 d;

      Miconazole (Monistat)

      2% vaginal cream 1 applicator (5 g) daily x7 d

      OR

      4% vaginal cream 1 applicator (5 g) daily x3 d

      OR

      100 mg vaginal suppository daily x7 d

      OR

      200 mg vaginal suppository daily x3 d (kit may include 2% cream for external use)

      OR

      1200 mg vaginal suppository x1 dose (kit may include 2% cream for external use);

      Terconazole (Terazol)

      0.4% vaginal cream 1 applicator (5 g) at bedtime x7 nights

      OR 0.8% vaginal cream 1 applicator (5 g) at bedtime x3 nights

      OR

      80 mg vaginal suppository at bedtime x3 nights;

      Tioconazole (Vagistat)

      6.5% vaginal ointment 1 applicator (5 g) x1 dose bedtime

      OR

      Butoconazole (Gynazole)

      2% vaginal cream 1 applicator (5 g) x1 dose bedtime

      OR Fluconazole

      150 mg by mouth x1 dose (not recommended in pregnancy)

      OR

      Alternative Antifungal: Itraconazole 200 mg BID by mouth x1 d; in HIV-infected women 200 mg QD for 3-7 d;

      Complicated infection: Fluconazole

      150 mg by mouth every 72 h x2-3 doses

      OR

      Vaginal azole as above daily x7-14 days with low-potency topical corticosteroid such as Triamcinolone 0.1% vaginal ointment bid x48 h for vulvar irritation∗∗New alternative non-azole antifungal Ibrexafungerp (Brexafemme) 150 mg 2 by mouth BID x 1 d;

      Recurrent candidiasis:

      Fluconazole 150 mg by mouth every 72 h x3 doses, then 1 tablet by mouth weekly x6 mo

      OR

      Vaginal azole x 10-14 d (or alternative itraconazole 200 mg QD by mouth for 3-7 d) followed by topical clotrimazole 200 mg 2% vaginal cream twice weekly OR 500 mg vaginal suppository weekly x 6 mo;

      Non-albicans candida vaginitis:

      C. Glabrata: vaginal boric acid 600 mg daily x14 d (never oral) OR Nystatin 100,000 vaginal insert or suppository daily x14 d; if fails, 17% flucytosine vaginal cream (5 g) nightly x14 d alone or in combination with 3% Amphotericin B vaginal cream x14 d;

      C. Krusei: intravaginal clotrimazole, miconazole, or terconazole x7-14 d;

      All other species: conventional dose fluconazole;

      Compromised host (poorly controlled diabetes mellitus, immunosuppression, debilitation) and Candida isolate susceptible to azoles: by mouth or topical therapy x7-14 d
      Vaginal clotrimazole or miconazole x7 days, repeat if needed
      TrichomoniasisMetronidazole 500 mg BID by mouth x7 d recommended in women

      OR

      Metronidazole 2 g by mouth single dose (single dose in men)

      OR alternative

      Tinidazole 2 g by mouth single dose (either gender)

      In refractory disease:

      Tinidazole 2 g by mouth single dose or daily x7 d

      OR

      Tinidazole 2-3 g by mouth in divided dose x14 d (if failure again, consult CDC and refer to infectious disease specialist);

      Partners should ideally be treated same time
      Metronidazole 500 mg BID by mouth x 7 d recommended in pregnancy, defer during breastfeeding and for 12-24 h after last dose;

      As for BV, tinidazole should be avoided in pregnancy and breastfeeding deferred during and for 72 hours after last dose

      DIVClindamycin 2% vaginal cream daily at hs x1-3 weeks, then 1-2 times weekly x2-6 mo

      OR

      Vaginal hydrocortisone 300-500 mg daily at hs x3 weeks, then 1-2 times weekly x2-6 months

      OR

      Clobetasol 0.05% vaginal cream daily at hs x1 week, longer use not evidence based

      Additional recommendations with above:

      Fluconazole 150 mg 1 tablet by mouth weekly

      Vaginal estrogen 2 times weekly
      Not commonly seen in pregnancy

      Clindamycin 2% cream intravaginally daily at hs x1-3 weeks, then 1-2 times weekly x2-6 mo

      OR

      Hydrocortisone 300-500 mg intravaginally daily at hs x3 weeks, then 1-2 times weekly x2-6 mo

      OR

      Clobetasol intravaginally daily at hs x1 week, longer use not evidence based

      Vaginal estrogen 2 times weekly
      Mycoplasma and Ureaplasma

      Treatment recommended for symptomatic nongonococcal urethritis, cervicitis, or PID
      Nonpregnant treatment for uncomplicated genital infections:

      M. hominis:

      Doxycycline 100 mg BID by mouth x 7-14 d

      Alternatives:

      Clindamycin 300-450 mg QID by mouth x 7-14 d

      OR

      Ciprofloxacin 500 mg BID by mouth x 7-14 d

      OR

      Levofloxacin 500 mg daily by mouth x 7-14 d

      M. hominis is often resistant to macrolides as erythromycin or azithromycin

      Ureaplasma:

      Doxycycline 100 mg BID by mouth x 7-14 d

      Alternatives: Azithromycin 1 g by mouth single dose OR

      Azithromycin 500 mg by mouth day 1, then 250 mg by mouth days 2-5





      Ureaplasma often resistant to clindamycin

      M. genitalium:

      Doxycycline 100 mg BID by mouth x7 d, then azithromycin 1 g by mouth followed by 500 mg by mouth days 2-4 ∗∗Test of cure recommended for M.genitalium 21 days after completion of therapy

      If macrolide resistant:

      Doxycycline 100 mg BID by mouth x7 d, then moxifloxacin 400 mg daily by mouth x7 d
      Pregnant or breastfeeding:

      M. hominis:

      Clindamycin 300-450 mg QID by mouth for 7 to14 d

      Ureaplasma:

      Azithromycin 500 mg by mouth day 1, 250 mg by mouth days 2-5

      OR

      Azithromycin 1 g by mouth day 1, then 500 mg by mouth days 2-4

      Avoid doxycycline and fluoroquinolones in this population if possible
      GSMOrganic-based lubricants and moisturizers;

      Vaginal estrogen or DHEA:

      Premarin 0.5-1 g nightly x2 weeks, then 2 times weekly

      OR

      Estrace 0.5-1 g nightly x2 weeks, then 2 nights weekly

      OR

      Vagifem or Yuvafem 10 μg nightly x2 weeks, then 2 nights weekly

      OR

      Imvexxy 4 or 10 μg nightly x2 weeks, then 2 nights weekly

      May alternatively give the above twice weekly without an initial burst nightly x2 weeks

      Estring 2 mg vaginal ring every 3 months

      OR

      Intrarosa (DHEA, Prasterone) 6.5 mg intravaginal insert suppository nightly

      OR

      Oral SERM

      Ospemifene (Osphena) 60 mg by mouth daily
      Not generally a cause of vaginitis but can apply to women who are breastfeeding and have symptoms of vaginal dryness

      Vaginal estrogen:

      Premarin 0.5-1 g nightly x2 weeks, then 2 times weekly

      OR

      Estrace 0.5-1 g nightly x2 weeks, then 2 nights weekly

      OR

      Vagifem or Yuvafem 10 μg nightly x2 weeks, then 2 nights weekly

      OR

      Imvexxy 4 or 10 μg nightly x2 weeks, then 2 nights weekly
      a BID, twice daily; BV, bacterial vaginitis; CDC, Centers for Disease Control and Prevention; DHEA, dehydroepiandrosterone; GSM, genitourinary syndrome of menopause; PID, pelvic inflammatory disease; QD, once daily; QID, four times daily; SERM, selective estrogen receptor modulator.
      b The information in this table has been obtained from other sources.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.R.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America.
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      • Reichman O.
      • Sobel J.
      Desquamative inflammatory vaginitis.
      Sexually Transmitted Infections Treatment Guidelines.
      ACOG, the US Preventative Services Task Force, and the CDC recommend that only symptomatic pregnant women be tested for BV and treated when positive.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Brown R.G.
      • Marchesi J.R.
      • Lee Y.S.
      • et al.
      Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin.
      ,

      STI screening recommendations. Accessed March 28, 2021. www.uspstf/org.

      Currently, there is insufficient evidence that screening asymptomatic pregnant women, with or without risk for preterm labor, prevents PTB.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Brown R.G.
      • Marchesi J.R.
      • Lee Y.S.
      • et al.
      Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin.
      ,
      Sexually Transmitted Infections Treatment Guidelines.

      STI screening recommendations. Accessed March 28, 2021. www.uspstf/org.

      Currently available oral and vaginal probiotics are largely ineffective for BV, but a probiotic containing Lactobacillus Crispatus which dominates CST I is forthcoming.
      • Cohen C.R.
      • Wierzbicki M.R.
      • French A.L.
      • et al.
      Randomized trial of Lactin-V to prevent recurrence of bacterial vaginosis.

      Recurrent Bacterial Vaginosis

      Thirty percent of women with initial response to therapy have a recurrence within 3 months whereas 58% recur within 12 months.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      Table 2 outlines preventive therapy for frequent BV (three or more episodes per year).
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      Sexually Transmitted Infections Treatment Guidelines.
      ,
      • Faught B.M.
      • Reyes S.
      Characterization and treatment of recurrent bacterial vaginosis.
      Clinical response rates are 50% to 75%.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Faught B.M.
      • Reyes S.
      Characterization and treatment of recurrent bacterial vaginosis.
      Although guidelines do not recommend treatment of partners, it is reasonable to consider treating partners in the setting of recurrent BV.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      ACOG MicroRounds Series Units I-V Bacterial Vaginosis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Vaginal microbiome transplant is under investigation for women with recurrent BV.
      • Lev-Sagie A.
      • Goldman-Wohl D.
      • Cohen Y.
      • et al.
      Vaginal microbiome transplantation in women with intractable bacterial vaginosis.

      Candida Vulvovaginitis

      At least 20% of reproductive women and 7% of menopausal women have asymptomatic vaginal candidiasis.
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Overgrowth of Candida is associated with pruritus, discharge, vulvovaginal burning, irritation, soreness, dysuria, and dyspareunia.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      Self-treatment availability limits estimate of true prevalence.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Progression from asymptomatic colonization to extensive vulvovaginal involvement appears complex, involving host inflammatory responses and yeast virulence factors.
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      ,
      • Swidsinski A.
      • Guschin A.
      • Tang Q.
      • et al.
      Vulvovaginal candidiasis: histologic lesions are primarily polymicrobial and invasive and do not contain biofilms.
      Although it is often a copathogen with Gardnerella or Lactobacillus species, vaginal Candida does not form a biofilm as seen in BV.
      • Swidsinski A.
      • Guschin A.
      • Tang Q.
      • et al.
      Vulvovaginal candidiasis: histologic lesions are primarily polymicrobial and invasive and do not contain biofilms.
      Candida albicans constitutes 80% to 92% of vulvovaginal candidiasis in the United States whereas Candida glabrata, Candida parapsilosis, and other strains make up the rest.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Incidence of a single or sporadic infection increases with age, and Black women are most frequently affected.
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Risk factors associated with Candida include diabetes mellitus, HIV, other immunosuppressive conditions, immunosuppressive or antibiotic use, higher estrogen levels associated with pregnancy, estrogen-containing contraceptives, systemic hormone therapy or vaginal estrogen in menopause, and the use of intrauterine contraception, vaginal sponges, diaphragms, and cervical caps.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Although vulvovaginal Candida is not considered sexually transmitted, male partners are more likely to be colonized with the same Candida strain.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Orogenital, rather than anogenital, sex appears linked with vulvovaginal candidiasis.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Characteristics and diagnostic criteria of Candida are listed in Table 1.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Cervical cytology is positive in 25% of women with culture-positive, symptomatic candidiasis, but screening with this modality is insensitive and not recommended.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      Vulvovaginal Candida infections are regarded as uncomplicated when C. albicans symptoms are mild to moderate, occur three or fewer times yearly, and C. albicans occurs in healthy immunocompetent and nonpregnant women.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Complicated infections are associated with severe symptoms, non-albicans species occurring three or more times yearly in women with uncontrolled diabetes, immune compromise or HIV, immunosuppressive therapy, debilitation, or pregnancy.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Goncalves B.
      • Ferreira C.
      • Alves C.T.
      • Henriques M.
      • Azeredo J.
      • Silva S.
      Vulvovaginal candidiasis: epidemiology, microbiology, and risk factors.
      Table 2 lists treatment regimens using oral and vulvovaginal azoles for uncomplicated versus complicated candida vulvovaginal infections.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.R.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America.
      C. glabrata and C. krusei infections are often fluconazole resistant.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.R.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America.
      Pregnant women should avoid fluconazole given case reports regarding craniofacial and cardiac abnormalities with dosages of 400 to 800 mg daily and conflicting data regarding miscarriage.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.R.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America.
      Fluconazole allergy incidence is unknown, but if angioedema or severe rash occur, topical azoles are preferred.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Pappas P.G.
      • Kauffman C.A.
      • Andes D.R.
      • et al.
      Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America.

      Trichomoniasis

      Trichomoniasis is the most common global nonviral STI and is caused by the mobile anaerobic protozoan Trichomonas vaginalis.
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      It is often present with other STIs and is especially prevalent in women with HIV.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Trichomoniasis affects approximately 3.7 million people yearly in the United States.
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Coinfection rate in partners is 30% to 80%, and prevention includes having fewer partners, using condoms and spermicide, and avoiding douching.
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      T. vaginalis occurs mainly in premenopausal and perimenopausal women.
      • Stemmer S.M.
      • Mordechai E.
      • Adelson M.E.
      • Gygax S.E.
      • Hilbert D.W.
      Trichomonas vaginalis is most frequently detected in women at the age of peri-/premenopause: an unusual pattern for a sexually transmitted pathogen.
      Non-Hispanic Black women are affected more frequently than White women.
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Trichomoniasis is associated with cervical dysplasia, post-hysterectomy cuff cellulitis/abscess, PID, infertility, and potential acquisition and transmission of HIV.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Wiringa A.E.
      • Ness R.B.
      • Darville T.
      • Beigi R.H.
      • Haggerty C.L.
      Trichomonas vaginalis, endometritis and sequela among women with clinically suspected pelvic inflammatory disease.
      In pregnant women with T. vaginalis, there is an increased risk of premature rupture of membranes, PTB, fetal growth restriction, and potential for neonatal infection.
      • Brown R.G.
      • Marchesi J.R.
      • Lee Y.S.
      • et al.
      Vaginal dysbiosis increases risk of preterm fetal membrane rupture, neonatal sepsis and is exacerbated by erythromycin.
      Women range from being asymptomatic to symptomatic with characteristics and diagnostic criteria as per Table 1.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Gardella C.
      • Eckert L.O.
      • Lentz G.M.
      Genital tract infections: vulva, vagina, cervix, toxic shock syndrome, endometritis, and salpingitis.
      ,
      • Gaydos C.A.
      • Klausner J.D.
      • Pant Pai N.
      • Kelly H.
      • Coltart C.
      • Peeling R.W.
      Rapid and point-of-care tests for the diagnosis of Trichomonas vaginalis in women and men.
      ,
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Per the CDC, screening should be performed yearly in HIV-positive women, including during their initial prenatal visits.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Women without HIV who have new or multiple sexual partners or those with other STIs need screening.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      Centers for Disease Control and Prevention
      Trichomoniasis — CDC Fact Sheet. January 31,2017.
      Treatment of T. vaginalis should be prescribed in symptomatic and asymptomatic women and their partners as in Table 2.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      Sexually Transmitted Infections Treatment Guidelines.
      It is important to evaluate for other STIs.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Kissinger P.
      Epidemiology and treatment of trichomoniasis.
      Sexual partners should be evaluated for other STIs even if expediated partner therapy is provided.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      It is recommended that women avoid intercourse for approximately 1 week after they and their partner(s) have been treated.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Treating trichomoniasis found on cervical cytology is not recommended.
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      For recurrent trichomoniasis, consider noncompliance and treat partner(s).
      Vaginitis in nonpregnant patients. Number 215. American College of Obstetricians and Gynecologists.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Sexually Transmitted Infections Treatment Guidelines.
      In recurrent disease or suspected failure of single-dose therapy, follow guidelines in Table 2 for refractory disease.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Sexually Transmitted Infections Treatment Guidelines.
      If these guidelines fail, in vitro culture and susceptibility are recommended and available through the CDC with referral to an infectious disease expert recommended.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Pregnant or nursing women with symptoms must be tested and treated as per Table 2.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Sexually Transmitted Infections Treatment Guidelines.
      Pregnant women should avoid intercourse until asymptomatic for 1 week and all partners have completed therapy.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      Test of cure should be obtained in pregnant and nonpregnant women within 3 months, although nucleic acid amplification testing (NAAT) can be performed as early as 2 weeks after completing therapy.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      • Cartwright C.P.
      • Lembke B.D.
      • Famachandran K.
      • et al.
      Comparison of nucleic acid amplification assays with BD affirm VP III for diagnosis of vaginitis in symptomatic women.

      Desquamative Inflammatory Vaginitis

      Desquamative inflammatory vaginitis is a poorly understood, chronic inflammatory vaginitis without a specific pathogen identified.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      It may be frustrating for both patients and clinicians in that women have intermittent symptoms despite multiple therapies before diagnosis. Women with DIV have a CST IV vaginal microbiome with colonization by facultative anaerobes (such as E. coli, S. aureus, GBS, or E. faecalis) consistent with “aerobic vaginitis.”
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      The DIV microbiome is notable for vaginal inflammation, increased white blood cells (WBCs), and nearly absent lactobacilli.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      Proposed etiologies include estrogen deficiency, a toxic reaction to bacteria such as S. aureus, E. coli, E. faecalis, GBS, or an immunologic abnormality.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      Desquamative inflammatory vaginitis presents in pre- and perimenopause, with copious vaginal discharge and irritative vulvovaginal symptoms.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      Desquamative inflammatory vaginitis has been linked with increased risk of STIs, premature rupture of membrane, PTB, chorioamnionitis, and miscarriage.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      It might also increase the risk of E. coli urinary tract infection (UTI) and neonatal GBS infection.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      Table 1 lists characteristics and diagnoses of DIV.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      The differential diagnosis includes genitourinary syndrome of menopause (GSM), erosive lichen planus, pemphigus vulgaris, and cicatricial pemphigoid.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      All of the following criteria must be present: (1) at least 1 present—vaginal discharge, dyspareunia, pruritus, burning, and irritation; (2) vaginal inflammation (spotted ecchymosis or petechiae, erythema, focal or linear erosions); (3) vaginal pH greater than 4.5; and (4) saline microscopy showing increased parabasal and inflammatory cells, leukocyte-to-epithelial cell ratio greater than 1:1, and exclusion of BV, trichomoniasis, gonorrhea, and chlamydia.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      ,
      • Reichman O.
      • Sobel J.
      Desquamative inflammatory vaginitis.
      Treatments are summarized in Table 2, although they have not been studied in randomized controlled trials.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Reichman O.
      • Sobel J.
      Desquamative inflammatory vaginitis.
      Clindamycin treats the facultative bacteria linked to DIV and acts as an anti-inflammatory agent as does intravaginal hydrocortisone for several weeks followed by maintenance therapy to reduce flare-ups.
      • Paavonen J.
      • Brunham R.C.
      Bacterial vaginosis and desquamative inflammatory vaginitis.
      ,
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      ,
      • Reichman O.
      • Sobel J.
      Desquamative inflammatory vaginitis.
      Topical estrogen for a heavy parabasal-cell component may be helpful to reduce symptom duration.
      • Donders G.G.G.
      • Bellen G.
      • Grinceviciene S.
      • Ruban K.
      • Vieira-Baptista P.
      Aerobic vaginitis: no longer a stranger.
      ,
      • Reichman O.
      • Sobel J.
      Desquamative inflammatory vaginitis.

      Mycoplasma and Ureaplasma

      Mycoplasma hominis and Ureaplasma species are found in the normal genital flora of up to 50% and 80%, respectively, of sexually active, healthy asymptomatic women, whereas Mycoplasma genitalium is found in 1% to 6%.
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      They are unlikely pathogens on their own but may be symbiotic with other pathogens in various genitourinary tract infections, such as M. hominis in PID and Ureaplasma in nongonococcal urethritis, and complications of pregnancy.
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      ,
      • Murtha A.P.
      • Edwards J.M.
      The role of Mycoplasma and Ureaplasma urealyticum in adverse pregnancy outcomes.
      M. genitalium, although often asymptomatic, may cause cervicitis and PID.
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      Colonization with Ureaplasma (35% to 90%) and M. hominis (5% to 80%) is high in the normal pregnant population.
      • Murtha A.P.
      • Edwards J.M.
      The role of Mycoplasma and Ureaplasma urealyticum in adverse pregnancy outcomes.
      Routine testing for M. hominis and Ureaplasma in nonpregnant and pregnant women who are asymptomatic or have uncomplicated genital infections is not recommended.
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      ,
      • Murtha A.P.
      • Edwards J.M.
      The role of Mycoplasma and Ureaplasma urealyticum in adverse pregnancy outcomes.
      Testing for M. genitalium is recommended for symptomatic women with cervicitis and PID.
      Sexually Transmitted Infections Treatment Guidelines.
      ,
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      Testing is by vaginal NAAT, polymerase chain reaction (PCR), or culture and treatment initiated for symptomatic nongonococcal urethritis, cervicitis, or PID.
      Sexually Transmitted Infections Treatment Guidelines.
      ,
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.
      ,
      • Murtha A.P.
      • Edwards J.M.
      The role of Mycoplasma and Ureaplasma urealyticum in adverse pregnancy outcomes.
      Treatment is summarized in Table 2.
      • Workowski K.A.
      • Bolan G.A.
      Centers for Disease Control and Prevention
      Sexually transmitted disease treatment guidelines, 2015.
      ,
      Sexually Transmitted Infections Treatment Guidelines.
      ,
      • Taylor-Robinson D.
      Mollicutes in vaginal microbiology: Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Mycoplasma genitalium.

      Genitourinary Syndrome of Menopause

      Genitourinary syndrome of menopause is vulvovaginal atrophy affecting 27% to 84% of postmenopausal women.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Kingsberg S.A.
      • Krychman M.
      • Graham S.
      • Bernick B.
      • Mirkin S.
      The women’s empower survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment.
      Symptoms include vaginal dryness, burning, irritation, dyspareunia, urgency, dysuria, and recurrent UTIs.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Kingsberg S.A.
      • Krychman M.
      • Graham S.
      • Bernick B.
      • Mirkin S.
      The women’s empower survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment.
      Unfortunately, 50% of women never seek therapy even though GSM significantly impacts sexual health and quality of life.
      • Kingsberg S.A.
      • Krychman M.
      • Graham S.
      • Bernick B.
      • Mirkin S.
      The women’s empower survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment.
      The microbiome of the menopausal vagina is consistent with CST IV and generally decreased lactobacilli and increased pH (5.0 to 5.5 or greater) without increased pathogens.
      • Smith S.B.
      • Ravel J.
      The vaginal microbiota, host defense and reproductive physiology.
      ,
      • Gliniewicz K.
      • Schneider G.M.
      • Ridenhour B.J.
      • et al.
      Comparison of the vaginal microbiomes of premenopausal and postmenopausal women.
      Wet prep microscopy shows greater than 1 WBC per epithelial cell, immature vaginal epithelial cells with relatively large nuclei termed parabasal cells, and decreased or absent superficial vaginal cells.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Diagnostic criteria is detailed in Table 1.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Genitourinary syndrome of menopause increases the likelihood of trauma, pain, recurrent UTIs, postcoital bleeding, and decline in sexual activity.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Kingsberg S.A.
      • Krychman M.
      • Graham S.
      • Bernick B.
      • Mirkin S.
      The women’s empower survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment.
      Therapies include regular use of vaginal moisturizers and lubricants for intercourse.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Table 2 lists therapies for moderate to severe GSM.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      For women with a history of breast or endometrial cancer, vaginal estrogen therapy (ET) and dehydroepiandrosterone (DHEA) may be appropriate with minimal risk.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Crandall C.J.
      • Hovey K.M.
      • Andrews C.A.
      • et al.
      Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observation Study.
      However, shared decision making with a woman and her oncologist is recommended.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Crandall C.J.
      • Hovey K.M.
      • Andrews C.A.
      • et al.
      Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observation Study.
      Product labeling for vaginal ET contains risks associated with systemic ET (coronary heart disease, stroke, venous thromboembolism, breast, and endometrial cancer), although these risks are highly unlikely given minimal systemic absorption and reassuring findings from clinical studies.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Crandall C.J.
      • Hovey K.M.
      • Andrews C.A.
      • et al.
      Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observation Study.
      Based on observational studies, a progestogen is unnecessary with low-dose vaginal ET.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Crandall C.J.
      • Hovey K.M.
      • Andrews C.A.
      • et al.
      Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observation Study.
      Although routine endometrial assessment is not recommended, transvaginal ultrasound or intermittent progestogen therapy may be considered for women at risk of endometrial cancer.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Crandall C.J.
      • Hovey K.M.
      • Andrews C.A.
      • et al.
      Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observation Study.
      Vaginal bleeding in postmenopausal women requires evaluation that may include transvaginal ultrasound, endometrial biopsy, and/or office hysteroscopy.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      Energy-based therapies such as vaginal laser and radiofrequency devices require long-term, sham-controlled safety and efficacy studies before use may be recommended.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.
      ,
      • Preti M.
      • Vieira-Baptista P.
      • Digesu G.A.
      • et al.
      The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: an ICS/ISSVD best practice consensus document.
      Platelet-rich plasma has been suggested, but prospective randomized controlled trials have not been completed.
      Treatment of Genitourinary Syndrome of Menopause after Breast Cancer with PRP.
      Genitourinary syndrome of menopause therapy can be continued long-term with appropriate follow-up to avoid bothersome symptoms.
      The 2020 genitourinary syndrome of menopause position statement of the North American Menopause Society.

      Summary

      Vaginitis remains challenging for both women and clinicians. Although vaginal microbiome research and innovative treatments are evolving, there are clinically proven, effective therapies available for symptom management after careful evaluation. Importantly, women with recurrent or complicated vaginitis should be referred to clinicians with vaginitis expertise rather than treated empirically.

      Acknowledgment

      Each of the authors equally contributed to the development of this manuscript.

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