Vaginitis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Overview
The cause of the infection determines the appropriate treatment. It may include oral or topical antibiotics and/or antifungal creams, antibacterial creams, or similar medications. A cream containing cortisone may also be used to relieve some of the irritation. If an allergic reaction is involved, an antihistamine may also be prescribed. For women who have irritation and inflammation caused by low levels of estrogen (postmenopausal), a topical estrogen cream might be prescribed.
Medical Therapy
- Treatment is recommended for women with symptoms.
- The established benefits of therapy in nonpregnant women are to relieve vaginal symptoms and signs of infection. Other potential benefits to treatment include reduction in the risk for acquiring C. trachomatis or N. gonorrhoeae, HIV, and other viral STDs.
- Providers should consider patient preference, possible side-effects, drug interactions, and other coinfections when selecting a regimen.
- Women should be advised to refrain from intercourse or to use condoms consistently and correctly during the treatment regimen.
- Douching might increase the risk for relapse, and no data support the use of douching for treatment or relief of symptoms.
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Follow-Up
Follow-up visits are unnecessary if symptoms resolve. Because recurrence of BV is common, women should be advised to
- return for evaluation if symptoms recur.* Detection of certain BV-associated organisms have been associated with antimicrobial resistance and might determine risk for subsequent treatment failure .
- Using a different treatment regimen might be an option in patients who have a recurrence; however, re-treatment with the same topical regimen is another acceptable approach for treating recurrent BV during the early stages of infection .
- Monthly oral metronidazole administered with fluconazole has also been evaluated as suppressive therapy.
Management of Sex Partners
The results of clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s). Therefore, routine treatment of sex partners is not recommended.
Special Considerations
Allergy or Intolerance to the Recommended Therapy
Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole. Intravaginal metronidazole gel can be considered for women who do not tolerate systemic metronidazole. Intravaginal metronidazole should not be administered to women allergic to metronidazole.
Pregnancy
- Treatment is recommended for all pregnant women with symptoms.
- Although BV is associated with adverse pregnancy outcomes, including premature rupture of membranes, preterm labor, preterm birth, intra-amniotic infection, and postpartum endometritis, the only established benefit of therapy for BV in pregnant women is the reduction of symptoms and signs of vaginal infection.
- Additional potential benefits include reducing the risk for infectious complications associated with BV during pregnancy and reducing the risk for other infections (other STDs or HIV).
Trichomoniasis
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- Topically applied antimicrobials (e.g., metronidazole gel) are unlikely to achieve therapeutic levels in the urethra or perivaginal glands; therefore, use of this gel is not recommended.
- Several other topically applied antimicrobials occasionally have been used for treatment of trichomoniasis; however, these preparations likely are no more effective than metronidazole gel.
Follow-Up
- Because of the high rate of reinfection among patients in whom trichomoniasis was diagnosed (17% were reinfected within 3 months in one study), rescreening for T. vaginalis at 3 months following initial infection can be considered for sexually active women with trichomoniasis.
- No data support rescreening in men diagnosed with T. vaginalis.
- While most recurrent T. vaginalis infections are thought to result from having sex with an untreated partner (i.e., reinfection), some recurrent cases can be attributed to diminished susceptibility to metronidazole.
Management of Sex Partners
- Sex partners of patients with T. vaginalis should be treated. Patients should be instructed to abstain from sex until they and their sex partners are cured (i.e., when therapy has been completed and patient and partner[s] are asymptomatic).
- Male partners should be evaluated and treated with either tinidazole in a single dose of 2 g orally or metronidazole twice a day at 500 mg orally for 7 days.
Special Considerations
Allergy, Intolerance, and Adverse Reactions
- Metronidazole and tinidazole are both nitroimidazoles. Patients with an immediate-type allergy to a nitroimidazole can be managed by metronidazole desensitization in consultation with a specialist .*Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%).
Pregnancy
Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and low birth weight. *However, metronidazole treatment has not been shown to reduce perinatal morbidity.
- Treatment of T. vaginalis might relieve symptoms of vaginal discharge in pregnant women and might prevent respiratory or genital infection of the newborn and further sexual transmission.
- In lactating women who are administered metronidazole, withholding breastfeeding during treatment and for 12–24 hours after the last dose will reduce the exposure of the infant to metronidazole.
- For women treated with tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose.
HIV Infection
- There is increasing evidence for epidemiologic and biologic interaction between HIV and T. vaginalis .
- T. vaginalis infection in HIV-infected women might enhance HIV transmission by increasing genital shedding of the virus, and treatment for T. vaginalis has been shown to reduce HIV shedding .
- For sexually active women who are HIV-positive, screening for trichomoniasis at entry into care with subsequent screening performed at least annually is recommended based on the reported prevalence of T. vaginalis, the effect of treatment at reducing vaginal HIV shedding, and the potential complications of upper-genital-tract infections among women who are left untreated.
- Rescreening 3 months after completion of therapy should be considered among HIV-positive women with trichomoniasis, a recommendation based on the high proportion of recurrent or persistent infection and the association between HIV and T. vaginalis infection.
- A multi-dose treatment regimen for T. vaginalis, like 500 mg twice daily for 7 days can be considered in HIV-infected women.
Vulvovaginal Candidiasis
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Follow-Up
Patients should be instructed to return for follow-up visits only if symptoms persist or recur within 2 months of onset of the initial symptoms.
Management of Sex Partners
VVC is not usually acquired through sexual intercourse; no data support the treatment of sex partners. A minority of male sex partners might have balanitis, which is characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms.
Special Considerations
Allergy, Intolerance, and Adverse Reactions
- Topical agents usually cause no systemic side effects, although local burning or irritation might occur. Oral agents occasionally cause nausea, abdominal pain, and headache. Link title
- Therapy with the oral azoles has been associated rarely with abnormal elevations of liver enzymes.
- Clinically important interactions can occur when these oral agents are administered with other drugs, including astemizole, calcium channel antagonists,cisapride, cyclosporin A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, trimetrexate, rifampin, and warfarin.
Complicated VVC
Recurrent Vulvovaginal Candidiasis (RVVC)
RVVC, usually defined as four or more episodes of symptomatic VVC in 1 year, affects a small percentage of women (<5%). The pathogenesis of RVVC is poorly understood, and most women with RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species (including nonalbicans species), particularly Candida glabrata. Although C. glabrata and other nonalbicans Candidia species are observed in 10%–20% of patients with RVVC, C. glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy. Conventional antimycotic therapies are not as effective against these species as they are against C. albicans.
Treatment
Each individual episode of RVVC caused by C. albicans responds well to short-duration oral or topical azole therapy. However, to maintain clinical and mycologic control, some specialists recommend a longer duration of initial therapy (e.g., 7–14 days of topical therapy or a 100-mg, 150-mg, or 200-mg oral dose of fluconazole every third day for a total of 3 doses [day 1, 4, and 7]) to attempt mycologic remission before initiating a maintenance antifungal regimen.
Maintenance Regimens
Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line of treatment. If this regimen is not feasible, topical treatments used intermittently as a maintenance regimen can be considered. Suppressive maintenance antifungal therapies are effective in reducing RVVC. However, 30%–50% of women will have recurrent disease after maintenance therapy is discontinued. Routine treatment of sex partners is controversial. C. albicans azole resistance is rare in vaginal isolates, and susceptibility testing is usually not warranted for individual treatment guidance.
Severe VVC
Severe vulvovaginitis (i.e., extensive vulvar erythema, edema, excoriation, and fissure formation) is associated with lower clinical response rates in patients treated with short courses of topical or oral therapy. Either 7–14 days of topical azole or 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) is recommended.
Nonalbicans VVC
The optimal treatment of nonalbicans VVC remains unknown. Options include longer duration of therapy (7–14 days) with a nonfluconazole azole drug (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks. This regimen has clinical and mycologic eradication rates of approximately 70% (380). If symptoms recur, referral to a specialist is advised.
Special Considerations
Compromised Host
Women with underlying debilitating medical conditions (e.g., those with uncontrolled diabetes or those receiving corticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional antimycotic treatment is necessary.
Pregnancy
VVC frequently occurs during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women.
HIV Infection
The incidence of VVC in HIV-infected women is unknown. Vaginal Candida colonization rates among HIV-infected women are higher than among those for seronegative women with similar demographic characteristics and high-risk behaviors, and the colonization rates correlate with increasing severity of immunosuppression. Symptomatic VVC is more frequent in seropositive women and similarly correlates with severity of immunodeficiency. In addition, among HIV-infected women, systemic azole exposure is associated with the isolation of nonalbicans Candidaspecies from the vagina.
On the basis of available data, therapy for VVC in HIV-infected women should not differ from that for seronegative women. Although long-term prophylactic therapy with fluconazole at a dose of 200 mg weekly has been effective in reducing C. albicans colonization and symptomatic VVC (381), this regimen is not recommended for routine primary prophylaxis in HIV-infected women in the absence of recurrent VVC (129). Given the frequency at which RVVC occurs in the immmunocompetent healthy population, the occurrence of RVVC should not be considered an indication for HIV testing among women previously testing HIV negative. Although VVC is associated with increased HIV seroconversion in HIV-negative women and increased HIV cervicovaginal levels in HIV-positive women, the effect of treatment for VVC on HIV acquisition and transmission remains unknown.