Vaginal discharges are annoying and uncomfortable, but rarely if ever dangerous. Some itch, others don’t. Clinicians often simply diagnose “Yeast” if there’s itching, which is quick and avoids the need for a pelvic exam, but risks missing some important conditions. The following approach recommends collecting appropriate specimens, described in more detail in our Full Text.
1. Perform a Pelvic Exam, collect specimens. Diagnoses are mainly:
a. Bacterial Vaginosis if no itching or burning, and 3 of the following 4 criteria:
- Significant vaginal discharge that’s somewhat darkish (not clear or pure white)
- pH ≥5
- Positive Whiff Test — fishy odor noted when drop of KOH is added to discharge
- Clue Cells seen by microscope
- Typical parasites seen moving under microscope (visible in 50% of cases). If not:
- Usually itching or burning. pH of discharge ≥5.
- Can perform rapid test if available (may miss 10-15% of cases). Send-out test takes 1-2 days.
- Yeast visible under microscope (seen 50% of time). If not:
- Itching. Irritation & thick white cottage-cheese-like discharge on pelvic exam, pH 4-4.5.
- Especially think yeast if patient took antibiotics in the past week, or if diabetes with high sugar
- Often treated empirically (by clinician judgment). Various types of tests are available, recommended by professional organizations, not often used
- Inflammation of the cervix, visible on pelvic exam (see Diagram: Female Genital System)
- Usually caused by STDs (see below)
2. Test for STDs
Test for Gonorrhea & Chlamydia, esp. if unprotected sex with new partner
- If Cervicitis noted on pelvic exam, also send these tests, and give single dose azithromycin (treats Chlamydia & usually Mycoplasma genitalium).
- If chlamydia or gonorrhea are positive, other treatment will be necessary
- If tests negative for both Chlamydia and Gonorrhea, obtain test (if available), or just treat, for Mycoplasma if symptoms persist
- If had already treated Chlamydia, will now need a different antibiotic for M. genitalium
3. Other conditions can be diagnosed by history or by pelvic exam
a. Allergy / Irritation from perfumes, deodorants, douches, lubricants, pads, etc.
- Discontinue use. If improves, if patient desires she can try same product again to see if symptoms recur
b. Forgotten Tampon, other foreign body — visible on pelvic exam
c. Herpes — cluster of small blisters, sores, or crusts
- Often a history of previous episodes that got better on their own
- Obtain swab for Herpes, should be done on 1st or 2nd day (otherwise false-negatives common)
- Blood test for Herpes Type-2 antibody can prove if patient has the virus or not, but can’t prove if this specific episode is from it. Is not recommended (see link above)!
- We never give patient a definite diagnosis without a test result
d. Post-Menopausal Atrophy (Atrophic Vaginitis) — occurs around or after menopause
- Typical appearance of the vaginal and genital area during pelvic exam
- If no other diseases found, diagnosis made by history of menopause
- Vaginal pH >5.5, certain post-menopausal vaginal cells by microscope maybe helpful
e. Vaginal Fistulas — May rarely be visible on pelvic exam, but usually suspected by history
- Suspect fistulas in women from poor countries, or history of gynecologic surgery / radiation, or difficult childbirth deliveries
- Urinary tract fistulas may leak urine into vagina; anal / rectal fistulas cause very foul-smelling vaginal discharge
- Fistulas may be hard to see; if suspect, refer to gynecologist with special equipment, may need special tests that use dyes
f. Other Rare Conditions — skin and vaginal lesions, including cancer. Often need biopsy.
See Vaginal Discharge — Full Text for more in-depth explanations and discussions..