Vaginal symptoms are common in the general population and are one of the most frequent reasons for patient visits to obstetrician–gynecologists (1). Vaginitis may have important consequences in terms of discomfort and pain, days lost from school or work, and sexual functioning and self-image. Vaginitis is associated with sexually transmitted diseases and other infections of the female genital tract, including human immunodeficiency virus (HIV) (2, 3), as well as adverse reproductive outcomes in pregnant and nonpregnant women. Treatment usually is directed to the specific causes of vaginal symptoms, which most commonly include bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. The purpose of this document is to provide information about the diagnosis and treatment of vaginitis.
Vaginitis is defined as the spectrum of conditions that cause vulvovaginal symptoms such as itching, burning, irritation, and abnormal discharge. The most common causes of vaginitis are bacterial vaginosis (22–50% of symptomatic women), vulvovaginal candidiasis (17–39%), and trichomoniasis (4–35%); 7–72% of women with vaginitis may remain undiagnosed (4). In the undiagnosed group of women, symptoms may be caused by a broad array of conditions, including atrophic vaginitis, various vulvar dermatologic conditions, and vulvodynia. Vaginitis has a broad differential diagnosis, and successful treatment frequently rests on an accurate diagnosis.
Estrogen status plays a crucial role in determining the normal state of the vagina. In the prepubertal and postmenopausal states, the vaginal epithelium is thinned, and the pH of the vagina usually is elevated (4.7 or greater). A routine bacterial culture will demonstrate a broad variety of organisms, including skin and fecal flora. During the reproductive years, the presence of estrogen increases glycogen content in vaginal epithelial cells, which in turn encourages colonization of the vagina by lactobacilli. This increased level of colonization leads 2 ACOG Practice Bulletin No. 72 to lactic acid production and a resulting decrease in the vaginal pH to less than 4.7. However, even in women of reproductive age, the normal vaginal flora remain heterogeneous, and other components of the vaginal flora, such as Gardnerella vaginalis, Escherichia coli, group B streptococci (GBS), genital mycoplasmatales, and Candida albicans, are commonly found.
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