Vaginal Discharge In Women

All women with a vaginal discharge must have a vaginal examination. Some vaginal discharges are normal. However, any woman concerned about a vaginal discharge should be examined and the patient managed appropriately.

All women presenting with abnormal vaginal discharge that looks like a yeast infection (curd-like discharge, redness of the vulva and vulva itching) should receive treatment for candida. All women with an abnormal vaginal discharge that is not consistent with candida should receive treatment for bacterial vaginosis and trichomoniasis and gonorrhoea and chlamydia.

Treatment for cervical infection both gonococcal and chlamydia infection should be given in situations where infection seems likely or the risk of developing complications is high. Treatment for cervical infection should be added to the treatment for vaginal infections if suspected (for example a patient's partner has urethral discharge), or if the signs of cervical infection (mucopurulent cervical discharge or easy bleeding) are seen on speculum examination.

First line treatment vaginal discharge

Therapy for bacterial vaginosis

	Medicine	Adult Dose	Frequency	Duration
	metronidazole po	400mg or 500mg	3 times/day or twice daily	7 days
or	metronidazole po	2g	once only
or	clindamycin po	300mg	twice day	7 days
Therapy for Trichomoniasis if clindamycin given for BV
	metronidazole po	400mg or 500mg	3 times/day or twice daily	7 days
or	metronidazole po	2g	once only*
or	tinidazole po#	500mg	twice daily	5 days
or	tinidazole po#	2g	once only

*Likely to be less effective than longer course if HIV infected

# Tinidazole not recommended in pregnancy.

#Defer breastfeeding by 72 hours following a single 2g dose of tinidazole

Avoid alcohol consumption during treatment with either Metronidazole or Tinidazole

PLUS

Therapy for yeast infection if curd-like white discharge, vulvo-vaginal redness and itching are present

	Medicine	Adult dose	Frequency	Duration
	miconazole pv	200mg	every night	3 days
or	clotrimazole pv	100mg	every night	7 days
or	nystatin pessary	200,000iu	at night	7 days

PLUS

Therapy for cervical infection if partner has urethral discharge or mucopurulent cervicitis / easy bleeding.

	Medicine	Adult Dose	Frequency	Duration
	ceftriaxone im	250mg	one dose only
or	kanamycin im	2g [1g into each buttock]	one dose only
and	doxycycline po	100mg	twice a day	7 days
or	azithromycin po	1g	one dose only

Second line treatment for vaginal discharge

If the patient still has a vaginal discharge, or evidence of cervicitis 7 days after start of treatment, suspect re-infection, poor treatment compliance or antimicrobial resistance in Neisseria gonorrhoeae. If reinfection is suspected re-start first line treatment.

Otherwise treat the patient with second line therapy or refer for investigations and laboratory guided treatment.

Second Line:

	Medicine	Adult dose	Frequency	Duration
	ceftriaxone im	500mg	one dose only
Or	cefixime po	400mg	one dose only
and	metronidazole po	400mg	three times a day	7 days
and	doxycycline po (Dependent on 1st line Rx* if 1st line Azithromycin)	100mg	twice a day	7 days
Or	azithromycin po (if 1st line doxycycline)	1g	one dose only

If these medicines are not available locally, refer to the next level.

CAUTION IN PREGNANCY: See chapter Obstetric and Gynaecological Conditions. Doxycycline should not be used during pregnancy, or in lactating women. In pregnant women chlamydia/ infection is best treated with azithromycin or erythromycin (which-ever is available) while kanamycin or ceftriaxone should be used for gonococcal infection.