Many healthcare providers have encountered the following scenario: A patient experiencing vaginitis reports having several “yeast" infections a year – sometimes it’s itchy, other times it smells funny.

They’ve used over-the-counter creams and pills prescribed by their provider in the past. But, the problem persists, and so they ask if you can prescribe something to help, preferably through a teleconsultation rather than an in-person visit.

Vaginitis is an inflammation of the vagina that is quite common and, sometimes, frustrating to correctly diagnose. It is responsible for 6 to 10 million office visits per year. The economic impact of over-the-counter treatment of vaginitis is $4.8 billion globally. 

The different causes of vaginitis can be difficult to identify, which can make self-diagnosis and virtual diagnosis inaccurate. It’s essential that clinicians accurately diagnose the cause of vaginitis and help patients access the appropriate treatment regimens. That’s why the Reproductive Health Hotline (ReproHH) is here to support you with information about diagnosis and treatment options!

Bacterial Vaginosis vs. Yeast Infection

To start, the two most common causes of vaginitis are bacterial vaginosis (BV) and yeast infection. 

• BV is caused by an imbalance of vaginal bacteria, and yeast infections are caused by an overgrowth of fungus, most often the fungus candida. 
• BV often creates discharge that is thin and gray, while yeast infections create thick, white, and clumpy discharge. BV often has a fishy odor, while yeast infections are typically odorless. Yeast has a neutral or slightly acidic pH of 4.0-4.5 while BV is more basic range above 4.5.
• While both can cause discomfort or itching, yeast infections often cause intense itching, burning, and redness of the vagina. BV, on the other hand, may be present without any discomfort besides an unpleasant odor. 
• In terms of treatment, antifungal medications are required to treat yeast infection, and antibiotics are needed for BV. 

Diagnosing Causes of Vaginitis

An in-person examination is important for diagnosing vaginitis. We know that self-diagnosis and phone diagnosis can be inaccurate. One study approached symptomatic people at a pharmacy who were buying antifungal creams and offered them same-day clinical examinations. The results were telling:

• 50% were found to have other infections
• 20% had a mixed vaginitis (bacterial vaginosis + candidal infection)

This means that 70% of patients would have been treated inappropriately without hands-on examination. Not being seen in person can also result in missing more consequential diagnoses like desquamative inflammatory vaginitis (DIV), sexually transmitted infections (STIs), vulvar dermatoses, dysplasia/cancer, genitourinary syndrome of menopause or lactation, vulvodynia, or azole-resistant candida.

Diagnosis can be made with point-of-care microscopy, molecular testing, and/or culture. 

• Point-of-care microscopy can provide same-day diagnosis, is helpful for diagnosing bacterial vaginosis, and is essential for a DIV diagnosis. However, point-of-care microscopy has a low sensitivity and specificity for yeast infections, and not all clinics have access to a microscope or the time to use one in a busy clinical day. 
• Molecular testing may be preferred in a busy clinical setting because it is more accurate and has lower follow-up costs. Examples of molecular tests include BD Max, Aptima, NuSwab, and Xpert Xpress. Not all clinics have access to these tests yet, but it is worth advocating for in your clinical setting given their benefits. 
• Finally, culture testing can be helpful for yeast specification and sensitivities.

Recurrent Yeast Infection Treatment

Recurrent yeast infections are defined as three or more infections in one year OR two or more infections in six months. 

The induction dose to treat recurrent yeast infections is fluconazole (every 72 hours for 3 doses followed by a maintenance dose of a topical azole twice weekly or oral fluconazole weekly, for 6 months). 

More than 50% of patients might experience recurrence at one year, and some might need a longer maintenance therapy period of >6 months. There is also a new option of treatment with Oteseconazole, but patients should be on a highly effective method of birth control to prevent pregnancy during treatment due to fetal toxicity.

Recurrent Bacterial Vaginosis (BV) Treatment

The mainstay treatment for recurrent BV is vaginal metronidazole (weekly x 3 months). Avoiding a longer course of oral metronidazole is important due to the risk of neuropathy. 

Vaginal boric acid (600mg daily x 14 days, followed by twice weekly x 3 months) is another option, which could be particularly helpful for patients with a history of mixed vaginitis. 

Additionally, patients can choose a combination of PO and PV treatment (e.g. oral metronidazole plus vaginal clindamycin or boric acid). Unfortunately, 25% of patients have recurrence by the end of treatment and 50% recurrence within 3 months of completing treatment. 

New data from the StepUp trial indicates that treating male partners with dual antibiotics (oral metronidazole + topical clindamycin cream) significantly cut BV recurrence by over half (from 63% to 35%), leading to updated guidelines like the American College of Obstetricians & Gynecologists (ACOG) recommending partner therapy for recurrent cases. 

Sometimes patients may ask you about probiotics. A study has shown that a probiotic with a particular strain of Lactobacillus crispatus might be helpful for the vaginal biome and prevention of recurrent BV. A commercially available vaginal suppository is currently being developed and studied at the time of this blog post and will hopefully be available in the future.

Do you have questions about treatment for patients with recurrent vulvovaginal candidiasis, bacterial vaginosis, or non-albicans yeast infections? Are you curious about the new update for sexual partner therapy for patients with recurrent bacterial vaginosis? Do you have questions about the new anti-fungal medications that are available? Give us a call at ReproHH! We are here to support you in your diagnosis and treatment of vaginitis.

To utilize the Reproductive Health Hotline, call 1-844-ReproHH (844-737-7644) after reading our Terms of Service.

ReproHH provides clinical information to U.S.-based health care providers only. Information provided is for educational purposes and is not intended as a substitute for professional medical care or advice, nor to replace a healthcare professional’s clinical judgement regarding their individual patient care. 

ReproHH does not provide medical or legal determinations, nor does the information provided substitute for local medical-legal consultation or employer-specific protocols. 

ReproHH provides clinical guidance that is based on evidence-informed practices, current medical guidelines, and standards of care in the state of California. The clinicians staffing this hotline are based in California, and the information they provide is intended to adhere to their licensure and the laws of the state of California governing the provision of medical care.