Vaginal discharge resident survival guide
Synonyms and keywords: Approach to Vaginal discharge, Leukorrhea

# Overview
Vaginal discharge is a common complaint in primary care which can be a subjective complaint or an objective finding. So, it is important to differentiate between normal physiological discharge and pathological discharge. Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. It is produced by the cells of the vagina and cervix. Normal vaginal discharge changes with the menstrual cycle, such as the character of the discharge is clearer with a stretchable consistency around ovulation, then may be thicker and slightly yellow during the luteal phase. Normal healthy discharge should not be associated with symptoms such as itching, redness and swelling, and does not have a strong odor. It is important to take complete history and ask about the associated symptoms like dysuria, dyspareunia, lower abdominal pain, itching, and fever. While considering the causes, it is necessary to distinguish between infectious and non-infectious. The infectious causes are infection with Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis, Chlamydia trachomatis, Neisseria gonorrhea, Herpes Simplex Virus. Diagnosis must be confirmed by laboratory tests and cultures. Non-infectious causes include puberty, menstrual cycle, foreign body, cervical cancer, vaginal cancer, diabetes etc. Treatment depends on the cause of the discharge.

# Causes
Infectious causes
Non-sexually transmitted infection:
- Bacterial vaginosis mostly happens during the reproductive age of women characterized by a shift in the vaginal flora from the dominant Lactobacillus to a polymicrobial flora.
- Vaginal yeast infection
Sexually transmitted infection:
- Chlamydia,sexually transmitted infections.
- Gonorrhea,sexually transmitted infections
- Herpes
- Trichomoniasis,a parasitic infection typically contracted and caused by having unprotected sex
Non-infectious causes
Physiological:
- Puberty
- Menstrual Cycle
- Sexual Activity
- Pregnancy
- Menopause
Non-physiological:
- Foreign body vaginitis
- Cervical cancer
- Vaginal cancer
- Diabetes
- Drug side effects of antibiotic or steroid use such as,  Amoxicillin and Clavulanic Acid  , Butoconazole Vaginal Cream  , Clotrimazole  , Combined oral contraceptive pill, Estradiol Topical  , Estradiol Transdermal  , Estrogen and Progestin (Oral Contraceptives)  ,Estrogen Injection  , Estrogen Vaginal  , Etonogestrel and Ethinyl Estradiol Vaginal Ring  , Glatiramer Injection  ,Hormone replacement therapy (trans), Letrozole, Leuprolide  , Medroxyprogesterone Injection  , Metronidazole Topical  ,Miconazole  , Nafarelin  , Natalizumab injection  , Norelgestromin and ethinyl estradiol transdermal system  , Ospemifene, Oxcarbazepine  , Pramipexole, Progesterone, Tamoxifen  , Terconazole Vaginal Cream, Vaginal Suppositories  , Toremifene, Zoledronic Acid Injection
- Gynaecological causes:
Atrophic vaginitis or senile vaginitis, as a result of estrogen deficiency that leads to vaginal dryness, itching, irritation, discharge, and dyspareunia.
Vulval dermatitis
Cervical ectopy
- Atrophic vaginitis or senile vaginitis, as a result of estrogen deficiency that leads to vaginal dryness, itching, irritation, discharge, and dyspareunia.
- Vulval dermatitis
- Cervical ectopy

# Diagnosis
Shown below is an algorithm summarizing the diagnosis of vaginal discharge.
Abbreviations: BP: Blood pressure, RR=Respiratory rate,
HR=Heart Rate, OCP= Oral Contraceptive Pill, NAAT= Nucleic Acid Amplification Test

# Treatment
Shown below is an algorithm summarizing the treatment of Vaginal discharge.
Abbreviations: QHS : Every bedtime , BID: 2 times daily, TID: Three times a day, QID: Four times a day, IM :Intramuscular
Patient should be referred to a gynecologist if following are present. 
- Retained foreign bodies.
- Recent instrumentation or surgery of the genital tract such as hysterosalpingography, dilation and curettage, hysteroscopy, termination of pregnancy/evacuation of retained products of conception, laparoscopy and major gynaecological surgical procedure.
- Suspected tumor of the genital tract.
- Cervical ectopy or polyps.
- Recurrent vulvovaginal candida infections.
- Pregnant woman with abnormal vaginal discharge
- Symptoms of upper genital tract infections as fever, lower abdominal pain
Treatment in pregnancy:
- Vulvovaginal Candidiasis: It frequently occurs during pregnancy. Only topical azole therapies for 7 days are recommended for use among pregnant women.
- Trichomoniasis: Metronidazole 2 g orally  single dose is recommended. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.
- Bacterial vaginosis: Treatment is recommended for all symptomatic pregnant women. Metronidazole  250-mg regimen is effective. But, Metronidazole 500 mg twice daily can be used.

# Dos
- The use of topical azole formulations can weaken latex condoms and diaphragms. This risk should be mentioned to the woman prior to starting these medications.
- Referral to a gynecologist should be considered if there is a history of recent instrumentation or surgery of the genital tract, retained foreign body, cervical ectopy or polyp, or suspicion of tumor on examination; or in women with symptoms of upper genital tract infection or recurrent vulvovaginal candida infections, pregnant women with abnormal vaginal discharge, or women who have failed routine treatment strategies.
- Women should be advised to avoid alcohol consumption during treatment for up to 24 hours after completion of Metronidazole or 72 hours after completion of Tinidazole to reduce the possibility of a disulfiram-like reaction.
- Women with Trichomoniasis should be advised to abstain from sexual intercourse until treatment is completed and symptoms have resolved, as it is sexually transmissible.

# Don'ts
- Patient should be advised to avoid tight-fitting synthetic clothing.
- Patient should be told to avoid local irritants such as perfumed products and soap gels and vaginal doucheing.
- There is no clear and consistent evidence across currently published studies regarding the role of probiotics for vaginal health.