ARTICLE IN PRESS

Current Obstetrics & Gynaecology (2006) 16, 211217

Available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/curobgyn

Vaginal discharge: common causes and management

Radhika McCathie
Department of Genitourinary Medicine, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK

KEYWORDS
Discharge;
Vagina;
Vaginal discharge;
Vaginitis;
Vulvovaginitis

Summary
Vaginal discharge is a common symptom in women of reproductive age. The causes can be
divided into those that are infective or non-infective, the most common being the
infective agents. Initial assessment of a patient with vaginal discharge requires a thorough
history, including sexual history, examination, and testing for these common infections.
The non-sexually transmitted infections (STIs)bacterial vaginosis and candidiasisare
the most frequently encountered and these can often be diagnosed immediately by the
clinical findings and simple bedside tests. Persistence or recurrence of these infections is
also seen and might require repeated or prolonged courses of treatment.
The STIschlamydia, gonorrhoea and trichomoniasiscan also cause vaginal discharge
and diagnosis requires appropriate laboratory tests to be performed. Partner notification
and treatment is an essential part of the management.
In the absence of any infections, physiological discharge should be considered as a possible
cause.
& 2006 Elsevier Ltd. All rights reserved.

Introduction

Taking a history

Vaginal discharge is a common reason for women to present

to a medical professional. They might present to a number
of different services, including primary care, family planning, genitourinary medicine and gynaecology. Many women
have a perception, rightly or wrongly, of what the cause of
the discharge might be and this can influence which
speciality they seek help from. Often, women immediately
assume that any new or different vaginal discharge is due to
a sexually transmitted infection (STI), however it is a nonspecific symptom and poorly predictive of the presence of an
STI.

The woman might be embarrassed about her symptoms and

therefore the history-taker needs to be as sensitive as
possible. Table 1 lists important questions to ask women who
complain of vaginal discharge.
The sexual history is extremely important to identify risk
factors for STIs (Box 1). Medical practitioners outside the
genitourinary clinic can then decide whether they have the
resources available to test, treat and perform partner notification for an STI or whether to refer a woman with identified risk
factors directly to the genitourinary medicine clinic.

Aetiology
Corresponding author. Tel.: +44 115 9691196;

fax: +44 115 9627684.

E-mail address: Radhika.Nirula@nuh.nhs.uk.
0957-5847/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.curobgyn.2006.05.004

The causes of vaginal discharge are listed in Table 2.

The remainder of this article concentrates on the

ARTICLE IN PRESS
212

R. McCathie

Table 1

Table 2

History taking.

Causes of vaginal discharge.

About the discharge

Duration
Onset/timing in relation to
cycle
Colour
Odour
Consistency
Any precipitating factors,
e.g. sexual intercourse,
recent antibiotics

Associated symptoms
Itching, soreness, irritation
of vulva/vagina
Dysuria
Intermenstrual/post-coital
bleeding
Dyspareunia
Lower abdominal pain

Infective

Non-infective

Common causes (arranged

in order of frequency)
Bacterial vaginosis
Candida infection
Chlamydia trachomatis
Neisseria gonorrhoeae
Trichomonas vaginalis

Common causes
Physiological
Cervical ectropian
Cervical polyp
Retained tampon/condom
Retained products of
conception
Allergy

Sexual history
Recent change of sexual
partner
Symptoms in partner
Condom use
History of previous STIs

Other
Prescribed medication, e.g.
antibiotics, hormone
preparation
Treatment used already,
prescribed or shop bought
Personal hygiene practices,
e.g. douching, bubble baths

Less common causes

Cervical herpes simplex
Cervical warts
Primary syphilis (vaginal/
cervical chancre)
Post-operative/postabortal/ puerperal pelvic
infection
Toxic shock syndrome

Less common causes

Trauma
Neoplasms
Fistulae (rectovaginal/
vesicovaginal)

 Sexually transmitted infections.

Box 1









Risk factors for the presence of STIs.

Age under 25 years

No condom use
Change in sexual partner in past 3 months
Frequent change of sexual partner
Symptoms in partner, e.g. dysuria
Previous STI
Associated symptoms suggestive of upper genital
tract complications, e.g. IMB/PCB, pelvic pain

Table 3
BV.

Risk factors and complications associated with

Risk factors

Complications

Younger age
Black ethnicity

Postpartum endometritis
Post-TOP (surgical)
endometritis and pelvic
inflammatory disease
Vaginal cuff cellulitis
following transvaginal
hysterectomy
Increased risk of preterm
birth, premature rupture
of membranes and late
miscarriage
Increased risk of acquiring
human immunodeficiency
virus

Vaginal douching

symptoms, diagnosis and management of the most common

of these.
Use of intrauterine device

Bacterial vaginosis (BV)

This is the most common cause of vaginal discharge in
women of reproductive age. Its prevalence varies widely
between different populations within the UK with rates of
9% in general practice and 30% in genitourinary medicine
clinics.
BV occurs as a result of overgrowth of a number of species
of bacteria, with reduced or absent lactobacilli. The variety
of overgrowing bacteria is wide including anaerobes,
Gardnerella vaginalis and genital mycoplasmas. Although
BV is associated with an increase in sexual partners,
recurrences do not decrease if the male partner is treated.
It is not considered to be an STI and partner notification and
treatment is not recommended.
Several risk factors and complications associated with BV
are shown in Table 3.
Up to 50% of women with a clinical diagnosis of BV are
asymptomatic. When present, however, the symptoms
include a profuse, malodorous vaginal discharge. The

offensive smell is due to the production of amines by

anaerobic bacteria and is often worse after sex and during
menses, when the higher pH causes further release of the
amines. The discharge itself is usually white, thin and
homogenous and not associated with any inflammation of
the vulva or vagina.
The diagnosis of BV can be made in one of two ways;

1. Using Amsels criteria. For a positive diagnosis three of

the following should be present:

ARTICLE IN PRESS
Vaginal discharge: common causes and management

213

(a) a thin, homogenous discharge on examination

(b) vaginal pH44.5 using narrow range pH paper
(c) amine odour (fishy) on adding 10% potassium hydroxide to vaginal fluid on a glass slide
(d) at least 20% of epithelial cells covered with bacteria
(clue cells) on microscopy of vaginal discharge mixed
with saline.
2. Using a vaginal Gram-stained smear. The smear can be
interpreted microscopically on-site or transported to the
laboratory for interpretation. The slides are interpreted
by reference to one of three criteria: Spiegel, Nugent or
Hay and Ison.

terms of recurrence. In women with an intrauterine device

(IUD) in situ, changing to another form of contraception
might help to reduce recurrences. As semen raises the
vaginal pH, regular use of condoms might also help.
Suppressive antibiotic therapy has been used with some
success. One option is metronidazole 0.75% vaginal gel
pessaries daily for 10 days and then twice weekly for 46
months. Another choice may be oral metronidazole 400 mg
twice daily for 3 days at the start and end of menstruation.
Currently there is no definitive treatment for recurrent BV
and the management is largely based on expert opinion.

It is important to note that isolation of G. vaginalis on a

high vaginal swab is a poor test for BV as up to 55% of women
can be asymptomatic carriers of this.
Treatment of BV is recommended for all women who are
symptomatic of vaginal discharge. If asymptomatic, treatment is not required except for women undergoing
gynaecological surgery (including termination of pregnancy)
or pregnant women with a previous preterm birth.
All women should be given general advice to avoid vaginal
douching and other potential irritants, e.g. antiseptic
agents or shampoo in the bath.

Candida infection

Practice points
Recommended treatment regimens for BV:

 Metronidazole 400 mg orally twice daily for 57 days

or

 Metronidazole 2 g orally as a single dose.

Alternative treatment regimens:

 Metronidazole 0.75% vaginal gel pessaries, 5 g daily

for 7 days.

 Clindamycin 2% vaginal cream, 5 g daily for 7 days

(can weaken condoms).

 Clindamycin 300 mg orally twice daily for 7 days.

 Tinidazole 2 g orally as a single dose.
All of the treatments have been shown to achieve cure
rates of 7080% after 4 weeks. Metronidazole can be used
during pregnancy. Although it is not recommended in the
first trimester, current evidence does suggest it is safe at any
time in pregnancy.
Recurrent BV is defined as three or more proven episodes
in 12 months. It is important to remember that women who
return complaining of recurrent symptoms could have
another diagnosis and should be fully reassessed. The reason
for recurrences is not absolutely clear but is probably due to
the inter-relation of several factors, the most important of
which seems to be a rise in vaginal pH causing proliferation
of anaerobic and other bacteria.
Management of patients with recurrent BV must include
thorough counselling to ensure the avoidance of all possible
irritants and to reassure the patient that this is not a STI.
Treatment of the male partner demonstrates no benefit in

Vaginal candidiasis occurs at least once in 75% of women

during their lifetime. The causative organism in 90% of cases
is the yeast infection Candida albicans; other Candida
species involved include C. glabrata. Candida is not
considered to be an STI and treatment of the male partner
is neither necessary nor beneficial in terms of a reduction of
recurrences in women.
Candida is an infection that affects many healthy and
immunocompetent women from all strata of society. There
are some predisposing factors, however, which increase its
incidence (Box 2).
The symptoms of vaginal candida are familiar to most
physicians and do not help to distinguish C. albicans from
the non-albicans species. They include vulval itching or
soreness, curdy white vaginal discharge without a smell,
dysuria or superficial dyspareunia. Vulval itching is the most
common symptom and the discharge might be absent in 50%
of cases. The clinical signs include erythema of the vulva or
vagina, vulval fissuring and oedema, and satellite lesions.
The diagnosis of a candida infection can be made entirely
clinically, based on the symptoms and signs above. It is
helpful to test the pH of the discharge, as this is usually
normal with candidiasis (4.04.5) and a raised pH might
suggest another cause for the discharge, such as trichomoniasis. Microscopy is a helpful diagnostic tool, using either
direct microscopy of a Gram-stained vaginal slide or dark
ground microscopy of a wet slide (sample of discharge in
normal saline). This allows the visualisation of spores and/or
pseudohyphae and has a sensitivity of 4065% in symptomatic cases. The most sensitive method of diagnosis is
culture on Sabourauds media. This is particularly useful in
women with persistent or recurrent symptoms, especially if
microscopy is negative. Culture allows identification of nonalbicans species and in some centres enables antimicrobial
sensitivities to be performed. Women who are asymptomatic
might also have diagnostic evidence of candida, as 1020% of

Box 2 Predisposing factors for vaginal candida

infection.






Pregnancy
Diabetes mellitus
Immunosuppression
Antibiotic therapy

ARTICLE IN PRESS
214

R. McCathie

women in their reproductive years can be carriers. These

women do not require treatment.
A number of effective drug preparations are available for
vaginal candida infections, both intravaginal and oral. A full
list of these can be found in the National Guidelines referred
to at the end of this article. The majority of drugs consist of
imidazole antifungals (e.g. clotrimazole) or triazole antifungals (e.g. fluconazole). These drugs will give a cure rate
of 8095% in non-pregnant women with an acute episode.
The polyene anti-fungal, nystatin, can be used in a cream or
pessary form and has a cure rate of 7090%. Nystatin is
especially useful for treatment of non-albicans species.
Many of the pessary and intravaginal cream formulations
can damage latex condoms and diaphragms and patients
must be advised of this. Also, the oral triazole preparations
are not safe for use in women who are pregnant or
breastfeeding.
Treatment should also include general advice to avoid
local irritants, e.g. perfumed soaps, bubble baths and avoid
tight-fitting, synthetic clothing.

Practice points
Intravaginal treatment regimes for candida infection:

 Clotrimzole pessary 500 mg as a single dose

or

 Miconazole pessary 100 mg once daily for 14 days.

Oral treatment regimes for candida infection:

 Fluconazole capsule 150 mg as a single dose

or

 Itraconazole capsule 200 mg twice daily for 1 day.

Recurrent candida is defined as four mycologically

proven, symptomatic episodes in 12 months. Again, it is
important to reassess any woman with recurrent or
persistent discharge to confirm the diagnosis. Some cases
of recurrence might be due to non-albicans strains or due to
drug-resistant strains of candida. In these cases, treating
with nystatin can help; however, culture and sensitivity
testing of the candida species is particularly useful and
should be requested. The majority of recurrent episodes are
caused by incomplete eradication of a fully sensitive C.
albicans and might respond to longer courses of antifungals.
The regimes that are used generally involve giving a
treatment course of therapy followed by a maintenance
regime, for instance fluconazole 100 mg weekly or clotrimazole pessary 500 mg weekly for 6 months. For women who
seem to have recurrences on a cyclical basis, using
prophylactic therapy around the time of their menses may
help to reduce recurrences, for instance clotrimazole
pessary 500 mg used on day 7 and 21 of the cycle for 6
months. As with recurrent BV, these women need counselling to ensure they avoid irritants and to give reassurance
that this is not an STI. Treatment of male partners makes no
beneficial difference to recurrence rates.

Chlamydia trachomatis
The prevalence of C. trachomatis in the UK was reported to
be 35% of sexually active women attending their GP. More
recently, a chlamydia screening pilot study showed higher
rates of 1014% in the under-25 age group.
The causative organism, C. trachomatis, has a unique
lifecycle rather similar to a virus due to its obligate
intracellular growth. Within the genital tract, the primary
site of infection in women is the cervix with the urethra also
infected in about 50% of cases. Other sites that can be
infected are the rectum, pharynx and the conjunctiva.
Chlamydia is an STI and therefore management requires
partner notification and treatment. The cumulative risk of
transmission between sexual partners is about 6070%. It
might also be associated with other STIs and therefore
testing for gonorrhoea, Trichomonas vaginalis and bloodborne STIs like syphilis and HIV should be considered.
Vaginal discharge, usually purulent in nature, can be a
presenting symptom of chlamydia in women; however, 80%
of those infected are asymptomatic. Other signs and
symptoms include post-coital bleeding, intermenstrual
bleeding, mucopurulent cervicitis and lower abdominal
pain. Box 3 lists the possible complications of chlamydia
and gonorrhoea infections. The risk of ascending infection is
increased with instrumentation such as TOP or IUD insertion,
therefore prior to any such event women should be tested
and treated if necessary.
Due to its unusual life cycle, diagnosis of chlamydia via
cell culture is extremely expensive and requires a high level
of expertise. It is performed in a few laboratories for
research and forensic purposes and is still currently used as a
gold standard; however, it has no role in routine
diagnostics. Until recently, the most common method used
for diagnosis was enzyme immunoassay (EIA). This test is
inexpensive and has a high specificity; however, the
sensitivity varies from 60% to 80% depending on the swab
and assay used. For the greatest sensitivity it is essential to
send a good cervical swab together with a urethral swab.
Over the past few years, most laboratories have switched
from using EIA to nucleic acid amplification tests (NAAT) for
chlamydia. The major advantages of NAAT tests are the
increased sensitivity and the possibility of using less-invasive
samples. Although it is more expensive than EIA, increased
government funding should mean that all laboratories in
England and Wales are able to provide this service in the
near future. A number of different sample sites have been
used for NAAT testing. Current evidence suggests vulvova-

Box 3
rhoea.

Complications of chlamydia and gonor-

 Ascending infection causing endometritis/salpingitis/pelvic inflammatory disease

 Tubal damage resulting in tubal factor infertility/

ectopic pregnancy

 Chronic pelvic pain

 Bartholins/Skenes gland abscesses,
 Perihepatitis (FitzHughCurtis syndrome).

ARTICLE IN PRESS
Vaginal discharge: common causes and management
ginal swabs, either self-taken or clinician collected, or
cervical swabs have sensitivities of 490%. First-void urine
samples can also be used, although the sensitivity is not as
good (about 80%). The advent of NAAT tests has allowed
more widespread testing for chlamydia from non-genitourinary medicine settings and this should certainly be
encouraged, particularly in the under-25 age group.
Treatment for chlamydia should be offered to all women
with a positive chlamydia test. It is also appropriate to treat
women with clinical evidence of pelvic inflammatory disease
(PID) or mucopurulent cervicitis, and those who have been a
definite sexual contact of a male partner with chlamydia,
once tests for chlamydia and gonorrhoea have been sent.

Practice points
Recommended treatment regimens for C. trachomatis:

 Doxycycline 100 mg orally twice daily for 7 days

or

 Azithromycin 1 g orally in a single dose.

Pregnancy and breast feeding:

 Erythromycin 500 mg orally four times daily for 7



days
or
Erythromycin 500 mg orally twice daily for 14 days
(may be better tolerated).

Azithromycin has not been fully assessed in pregnant and

lactating women but available data suggest that it is safe
and efficient.
Providing the patient is compliant, a repeat test following
treatment is not necessary unless erythromycin has been
prescribed (due to a lower cure rate). If a repeat test is
performed, this should be done at least 5 weeks after
treatment is complete as both EIA and NAAT tests will detect
dead organisms and might yield false positives if done too
early.

215
Of those women who are symptomatic, increased or
altered vaginal discharge is the most common symptom.
However, 50% of women with cervical infection can be
asymptomatic. Other symptoms and signs include dysuria,
mucopurulent cervicitis and lower abdominal pain. Postcoital and intermenstrual bleeding can also occur but are
quite unusual. The complications of gonorrhoea are as listed
above in Box 3. In comparison to Chlamydia, the consequences of untreated gonorrhoea during pregnancy are
more severe as there is a three- to six-fold increased risk of
preterm birth and a low-birth-weight baby. An extremely
rare complication of gonorrhoea (o1%) is haematogenous
dissemination, whereby the bacteria can seed into several
sites causing skin lesions, arthritis and tenosynovitis.
Diagnosis of gonorrhoea is established by culture of the
organism from a swab taken from the infected site. In
women, a cervical swab is required and pick up is increased
if a urethral swab is also sent. Within most genitourinary
clinics the swab can be immediately plated onto a selective
culture media before being sent to the laboratory but in
other settings a standard Amies swab or Stuarts swab should
be used and sent to the referring laboratory as soon as
possible. Culture is sensitive (490%), specific and inexpensive and allows antibiotic sensitivity to be performed. It is
currently the first choice for gonorrhoea diagnosis. More
recently, NAAT tests have become available to test for N.
gonorrhoeae. A number of different assays are being used
and validated at the current time but data suggests
sensitivities of 490% when compared to culture. The main
advantage of NAAT tests is that they allow less invasive
samples to be used and tests for both gonorrhoea and
chlamydia can thus be performed on a single sample.
Currently, NAAT testing for gonorrhoea is not being widely
used and culture remains the gold standard, although this
will undoubtedly be changing in the near future.
Treatment should be offered to all women with a positive
gonorrhoea test. It is also appropriate to treat women with
clinical evidence of PID or mucopurulent cervicitis, or who
have been a definite sexual contact of a male partner with
gonorrhoea, once the tests for gonorrhoea and chlamydia
have been sent.

Practice points
Neisseria gonorrhoeae

Recommended treatment regimens for gonorrhoea:

Like chlamydia and other STIs, gonorrhoea has been

increasing in frequency over the last 10 years. However, it
is less common than Chlamydia, with the highest rates in the
16- to 19-year-old age group being about 200 per 100,000.
N. gonorrhoeae is a Gram-negative intracellular diplococcus. The primary sites of infection in women are the
cervix (8595% of cases) and the urethra (6575% of cases).
Other sites that might be involved include the rectum
(2550%), the oropharynx (515%) and the conjunctiva.
Gonorrhoea is an STI and about 3040% of women with
gonorrhoea will also be infected with chlamydia. Testing for
all other STIs must therefore be considered. Again, partner
notification and treatment is an essential part of management as the cumulative risk to a male sexual partner is
about 50%.

 Ceftrioxone 250 mg intramuscularly as a single dose

or

 Cefixime 400 mg orally as a single dose.

Both are safe for use in pregnancy and breastfeeding.
Alternative regimens (beta-lactam allergy):

 Ciprofloxacin 500 mg orally as a single dose

or

 Ofloxacin 400 mg orally as a single dose.

There has been an increase of quinolone-resistant
gonorrhoea in the UK and it is therefore important to check

ARTICLE IN PRESS
216
on the antibiotic sensitivity from the culture. The complete
antibiotic guideline can be found in the National Guidelines
referred to at the end of the article.
Providing the patient is compliant and the organism is
shown to be sensitive to the antibiotic used, a repeat test
following treatment is not necessary. If a repeat test is
performed this should be done by culture 472 h after
completion of antibiotic therapy.

Trichomonas vaginalis
Infection with T. vaginalis is fairly uncommon in the UK,
although worldwide the rates are high and in Africa and Asia
it is a major cause of vaginal discharge. Prevalence rates of
up to 35% have been found in parts of Africa, where it is
usually the most common STI.
T. vaginalis is a flagellated protozoa, measuring 1020 mm
wide. Unlike chlamydia and gonorrhoea, it does not affect
any extragenital sites, but it is associated with vaginitis,
cervicitis, urethritis and PID. It is an STI and cure rates in
women are significantly improved if male partners receive
treatment. Testing for all other STIs should always be
considered, as 30% of women will also have chlamydia or
gonorrhoea.
Women infected with T. vaginalis might be asymptomatic
at the time of diagnosis; however, if left untreated they
often develop symptoms. The most common complaint is
vaginal discharge, classically described as green and frothy,
althoughpractically speakingit can be any colour. About
50% of women find the discharge to be malodorous and it
often has a pH of 44.5. Other signs and symptoms of
infection with T. vaginalis include vulval or vaginal itching,
evidence of a vaginitis or a cervicitis on speculum examination and, described in all textbooks but rarely seen,
punctuate haemorrhages of the cervix (so-called strawberry cervix). Symptoms might be worse during or just after
the menses.
Making a clinical diagnosis of T. vaginalis infection
is not easy as the symptoms and signs are not always
classical and the colour, smell and pH of the discharge
makes it difficult to differentiate from bacterial vaginosis.
Other diagnostic tools are therefore required. Within
genitourinary clinics the main method is direct visualisation
using microscopy of a sample of vaginal discharge on a
wet-slide (using saline). T. vaginalis can be seen to be
about the same size as a white blood cell and has a
characteristic motility; this has a sensitivity of about 80%. It
is a cheap test that provides an instant result, although it
requires immediate access to a microscope. The gold
standard for T. vaginalis diagnosis is culture. This requires
inoculation of a highly specific T. vaginalis culture medium
(usually liquid) and incubation at 3337 1C. This has a better
sensitivity than microscopy but a specific T. vaginalis culture
medium is not always available, it is more costly and
takes up to 7 days to get a diagnosis. A standard high vaginal
swab can be sent for culture, although the sensitivity of
this is lower.
A diagnosis of T. vaginalis can be reported on a
Papanicolaou (Pap) smear. However, this is neither a
sensitive nor specific test for T. vaginalis and the diagnosis
needs to be confirmed via another method before suggesting

R. McCathie
to patient that they have an STI. More recently, a NAAT test
for T. vaginalis has been developed. Initial data suggests
good sensitivity, although lower specificity than with
culture. This technique is not widely available.
First-line treatment of infection with T. vaginalis
requires systemic rather than topical treatment because,
as outlined above, the infection is not always confined
to the vagina but may involve other parts of the urogenital
tract.

Practice points
Recommended treatment regimens for T. vaginalis:

 Metronidazole 2 g orally in a single dose

or

 Metronidazole 400 mg orally twice daily for 5 days.

Both treatment regimens result in cure rates of 95% in
combination with partner notification and treatment.
Providing the patient is compliant and the symptoms
settle (if symptomatic) a repeat test following treatment is
not necessary.
Persistent or recurrent symptoms need to be reassessed
fully to determine whether T. vaginalis is the cause. If
T. vaginalis is found it is usually due to re-infection from
an untreated partner, in which case repeat treatment
with increased emphasis on partner notification is essential.
Very occasionally, treatment failure is due to a
metronidazole-resistant strain of organism. In these
cases, a higher dose of oral metronidazole can be useful
(e.g. metronidazole orally 2 g daily for 5 days). This
can be combined with an intravaginal metronidazole
preparation for increased effect, although a number of
patients will still not respond to this. In this situation
consultation with a genitourinary specialist is recommended
and further sensitivity testing of the organism is useful if
available.

Practice points
In addition to medication, treatment for gonorrhoea,
chlamydia and T. vaginalis requires:

 Partner notification and treatment.

 Advice to abstain from sex until they and their
partner(s) have completed their treatment.

 Advice regarding interaction between antibiotics

and oral contraceptive pill.

 General advice regarding safer sex.

Physiological discharge
The question that many patients and physicians ask with
regard to vaginal discharge is what is normal? On
questioning, the majority of women accept that some
discharge is normal, although a substantial minority feel

ARTICLE IN PRESS
Vaginal discharge: common causes and management
that a healthy vagina should be dry. The quantity of the
discharge is certainly variable between populations and in
an individual varies with the menstrual cycle, usually
increasing midcycle. The consistency of the discharge also
varies during the cycle, having maximum viscosity in the
luteal phase and decreasing to a minimum at midcycle.
The colour of normal discharge is generally considered
to be white or clear but there are certainly many
women without any genitourinary pathology who would
describe their discharge as creamy or yellowy coloured.
Finally, it is generally assumed that discharge with an
offensive smell or that causes irritation must be pathological
in nature, although evidence shows this is not always
the case.
What does this mean to physicians trying to make a
diagnosis? First, it means that we often cannot make a
diagnosis based on the description of the discharge
alone. We must take a thorough history including sexual
history and assess the risks of a sexually transmitted
versus a non-sexually transmitted cause. Second, examination of the genital area, including speculum examination
and visualisation of the cervix, is almost always required.
Third, exclusion of the common causes of discharge by
diagnostic testing as outlined in this article is often
necessary. In the absence of any positive findings following
this process the likelihood is that the discharge is physiological in nature.

217

Conclusion
Vaginal discharge can be a distressing and embarrassing
symptom for many women. The causes are numerous,
although there are clearly several particularly common
aetiologies, discussed within this article. These should be
considered and tested for at the outset, and treated
appropriately if required.

Further reading
1. British Association of Sexual Health and HIV (BASHH) Clinical
Effectiveness Group National Guidelines. Online. Available at:
http://www.bashh.org
2. Fenton KA, Ison CA, Johnson AP, Rudd E, Soltani M, Martin I, et al.
Ciprofloxacin resistance in Neisseria gonorrhoeae in England and
Wales in 2002. Lancet 2003;361:18679.
3. McMillan A, Ballard RC. Non-specific genital tract infection and
chlamydial infection, including lymphogranuloma venereum. In:
McMillan A, Young H, Ogilvie MM, Scott GR, editors. Clinical
practice in sexually transmissible infections. Elsevier Science
Limited; 2002. p. 281312.
4. Sobel JD, Wiesenfeld HC, Martens M, Danna P, et al. Maintenance
fluconazole therapy for recurrent vulvovaginal candidiasis. N
Engl J Med 2004;351:87683.
5. Wilson J. Managing recurrent bacterial vaginosis. Sex Transm
Infect 2004;80(1):811.