Eduovisual
Female Reproductive & Breast
Vulvovaginitis: differential and management
— Bacterial vaginosis (BV) — most common (~40–50%)
— Vulvovaginal candidiasis (VVC) — ~20–25%
— Trichomoniasis — ~15–20%
— Genitourinary syndrome of menopause (atrophic vaginitis)
— Contact/irritant dermatitis (soaps, douches, spermicides, scented pads)
— Lichen sclerosus, lichen planus, desquamative inflammatory vaginitis (DIV)
— Foreign body (retained tampon, condom)
— Reproductive-age woman with abnormal discharge + odor → think BV or trich
— Thick white discharge + intense pruritus → candida
— Postcoital bleeding, frothy yellow-green discharge → trichomoniasis
— Postmenopausal dyspareunia, dryness, dysuria without infection → GSM
— Prepubertal girl with discharge → consider foreign body, poor hygiene, or sexual abuse
Board pearl: The classic Step 3 trap is treating "yeast" empirically over the phone — always evaluate with exam + pH + microscopy or NAAT before treating, because misdiagnosis rates with symptom-based diagnosis alone exceed 50%. Empirical antifungal phone prescriptions are a quality-of-care red flag and a common stem distractor pointing to the wrong answer.
Step 3 management: First office visit = speculum exam, vaginal pH, wet mount/KOH, and amine (whiff) test; reserve NAAT for unclear or recurrent cases.
— Discharge character: color, consistency, amount, odor
— Symptoms: pruritus vs burning vs soreness vs odor-only
— Timing: relation to menses, intercourse, antibiotics, new products
— Sexual history: partners, condom use, new partner in past 60 days, same-sex partners (BV more common)
— Prior episodes and treatments (self-treatment with OTC azoles is huge)
— Menopausal status, last menses, contraception, pregnancy status
— Comorbidities: diabetes, HIV, immunosuppression, recent steroids/antibiotics
— BV: thin gray-white discharge, fishy odor worse after intercourse/menses, minimal itching/irritation
— Candida: thick "cottage cheese" white discharge, intense pruritus, vulvar burning, dyspareunia, no odor, often after antibiotics
— Trichomoniasis: frothy yellow-green malodorous discharge, vulvar irritation, dysuria, postcoital spotting; partner often asymptomatic
— Atrophic vaginitis: dryness, dyspareunia, scant discharge, dysuria, urinary urgency, postmenopausal
— Contact dermatitis: burning > itching, temporal link to new soap/laundry detergent/pad/lubricant
— Lichen sclerosus: chronic vulvar itching, "figure-of-8" white atrophic plaques, architectural loss
— Ulcers → HSV, syphilis, chancroid, Behçet
— Bleeding → cervical pathology, malignancy
— Pelvic/abdominal pain or fever → PID, not isolated vulvovaginitis
— Recurrent (≥4 episodes/year) candidiasis → check HbA1c, HIV
Key distinction: Pruritus dominant = candida or dermatitis; odor dominant = BV or trich; dryness/dyspareunia in postmenopausal = GSM. Itching with no discharge in an older woman → think lichen sclerosus, not infection.
Board pearl: A "fishy odor that worsens after sex" is nearly pathognomonic for BV on Step 3 — semen alkalinizes vaginal pH and volatilizes amines.
— Erythema, edema, excoriations, fissures → candida or dermatitis
— White atrophic "cigarette paper" skin, loss of labia minora, clitoral hood fusion → lichen sclerosus
— Lacy white reticulate (Wickham striae), erosions → lichen planus
— Ulcers, vesicles → HSV; painless ulcer with clean base → syphilis
— "Strawberry cervix" punctate hemorrhages → trichomoniasis (seen in only ~2% but highly specific)
— BV: thin homogeneous gray-white discharge coating walls, minimal inflammation
— Candida: erythematous walls, adherent white plaques, thick curdy discharge
— Trich: copious frothy yellow-green discharge, cervical petechiae
— Atrophic: pale, thin, friable mucosa, loss of rugae, petechiae, narrowed introitus
— DIV: purulent discharge, diffuse exudative inflammation, ecchymoses
— Vaginal pH (swab from lateral wall, not cervix or pooled discharge):
— Normal 3.8–4.5
— >4.5 → BV, trich, atrophic
— ≤4.5 → candida (does not raise pH)
— Whiff test: 10% KOH → fishy amine odor = BV or trich
— Wet mount (saline): clue cells (BV), motile flagellated trichomonads
— KOH prep: pseudohyphae/budding yeast (candida)
CCS pearl: Order "pelvic exam, vaginal pH, wet mount with KOH, whiff test" as a bundle on the initial visit. Add NAAT for gonorrhea/chlamydia/trichomonas when sexual risk factors or trich suspicion is present — Step 3 CCS rewards this efficient cluster.
— Strip applied to lateral vaginal wall; avoid cervical mucus, blood, semen (all raise pH)
— Normal 3.8–4.5 (lactobacilli dominant)
— Elevated >4.5 narrows to BV/trich/atrophic; rules in/out candida quickly
— Thin homogeneous gray-white discharge
— Vaginal pH >4.5
— Positive whiff test (KOH amine odor)
— Clue cells ≥20% on saline wet mount (epithelial cells studded with coccobacilli, obscured borders)
— Saline wet mount: clue cells (BV), motile trichomonads (sensitivity only ~50–60%, must view within minutes), increased PMNs (trich, DIV, cervicitis)
— 10% KOH prep: dissolves epithelial cells, reveals pseudohyphae and budding yeast (sensitivity ~50–70%)
— Trichomonas NAAT (sensitivity >95%; replaces wet mount as preferred test in CDC 2021 STI guidelines)
— Combined BV/candida/trich NAAT panels available; useful for recurrent or refractory cases
— Gonorrhea/chlamydia NAAT on all sexually active women <25 or with risk factors
— Urine pregnancy test before any medication choice (metronidazole, fluconazole considerations)
— HbA1c if recurrent candidiasis
— HIV test if recurrent infections or new STI diagnosis
Board pearl: Trichomoniasis is a reportable STI in some states and an indicator for full STI screening including HIV, syphilis, gonorrhea, and chlamydia. The wet mount is insensitive — order NAAT when suspicion is high but microscopy negative.
Step 3 management: Don't culture for candida routinely; reserve fungal culture with speciation for recurrent VVC (≥4/year) or treatment failure to identify non-albicans species (glabrata, krusei).
— Indicated for recurrent VVC, symptoms refractory to fluconazole, or atypical microscopy
— Identifies C. glabrata (often azole-resistant) and C. krusei (intrinsically fluconazole-resistant)
— Guides switch to boric acid 600 mg vaginal capsules or nystatin for non-albicans
— Indicated for: suspected lichen sclerosus (high risk of vulvar SCC — ~4–5% lifetime), lichen planus, persistent white/red/pigmented lesions, ulcers >2 weeks, suspected VIN (vulvar intraepithelial neoplasia) or vulvar cancer
— Use Keyes punch (3–4 mm) at lesion edge
— Always biopsy lesions that fail empirical therapy — do not chase repeat antifungals
— HIV (4th-gen Ag/Ab), syphilis (RPR or treponemal), gonorrhea/chlamydia NAAT, hepatitis B/C
— Offer HPV co-testing/cytology per age-based screening
— HbA1c and fasting glucose
— Consider immunodeficiency workup if other infections present
— Review estrogen status and medications (chemotherapy, immunosuppressants, broad-spectrum antibiotics, SGLT2 inhibitors → genital mycotic infections)
— DIV: purulent discharge, pH >4.5, increased PMNs, parabasal cells, no clue cells, no trich; responds to topical clindamycin or hydrocortisone
— Cytolytic vaginosis: pH <4.5, lactobacilli overgrowth, cyclic premenstrual symptoms; treated with baking soda sitz baths, not antifungals
Key distinction: Recurrent "yeast" that doesn't respond to fluconazole is rarely true recurrent candidiasis — most often it's non-albicans candida, DIV, lichen sclerosus, contact dermatitis, or cytolytic vaginosis. Biopsy and culture before escalating therapy.
Board pearl: Lichen sclerosus requires lifelong surveillance with annual exams given the SCC risk; biopsy any new thickened, ulcerated, or asymmetric lesion.
1. Pregnant? → alters drug choice (avoid fluconazole in 1st trimester; use topical azoles)
2. Reproductive vs postmenopausal? → atrophic vaginitis dominates differential after menopause
3. Recurrent (≥3–4 episodes/year)? → requires maintenance therapy plan
4. STI risk? → trich and BV co-occur with GC/CT; screen broadly
— Uncomplicated: immunocompetent, non-pregnant, sporadic, mild-moderate, presumed albicans → single-dose fluconazole or short topical course
— Complicated: severe symptoms, recurrent (≥4/yr), pregnancy, diabetes, immunocompromised, non-albicans → longer/induction regimens
— Symptomatic → treat
— Asymptomatic → generally don't treat EXCEPT before hysterectomy, IUD insertion, or gynecologic surgery (reduces post-op infection)
— Pregnancy: treat symptomatic BV; routine screening of asymptomatic low-risk patients not recommended
— Always treat, including asymptomatic
— Treat all sexual partners (expedited partner therapy where legal)
— Abstain from sex until both partners complete therapy and are asymptomatic ≥7 days
— Retest at 3 months due to high reinfection rate
— First line: vaginal moisturizers + lubricants
— If inadequate: low-dose vaginal estrogen (cream, tablet, ring) — minimal systemic absorption
— Alternative: ospemifene (oral SERM) or DHEA (prasterone) vaginal inserts
Step 3 management: Don't treat asymptomatic BV in non-pregnant women routinely — exception is pre-procedural (hysterectomy, abortion, IUD placement). This is a frequent Step 3 distractor.
Board pearl: In pregnancy with symptomatic BV, treat with oral metronidazole 500 mg BID × 7 days or clindamycin — both safe in all trimesters per CDC.
— Metronidazole 500 mg PO BID × 7 days (first line)
— Metronidazole 0.75% gel 5 g intravaginally daily × 5 days
— Clindamycin 2% cream 5 g intravaginally QHS × 7 days (oil-based; weakens latex condoms × 5 days)
— Alternatives: tinidazole 2 g daily × 2 days; secnidazole 2 g single oral granule dose
— Avoid alcohol during and 24h after metronidazole (disulfiram-like reaction — though evidence weak, still tested)
— No partner treatment needed
— Fluconazole 150 mg PO × 1 dose (preferred for convenience)
— OR topical azoles: clotrimazole, miconazole, terconazole 1–7 day courses (OTC for many)
— Symptoms improve in 2–3 days
— Fluconazole 150 mg PO q72h × 2–3 doses
— Recurrent VVC induction: fluconazole 150 mg q72h × 3 doses, then maintenance 150 mg weekly × 6 months
— Non-albicans (glabrata): boric acid 600 mg vaginal capsule QHS × 14 days (NEVER oral — fatal); alternative nystatin vaginal tablets
— Women: metronidazole 500 mg PO BID × 7 days (NEW first line, replaced single 2 g dose due to higher cure rates, especially with HIV)
— Men: metronidazole 2 g PO × 1 dose
— Alternative: tinidazole 2 g PO × 1
— Treat partners; consider expedited partner therapy (EPT) where legal
— Vaginal estradiol cream (0.01%) 0.5–1 g 2–3×/week
— Estradiol vaginal tablet 10 mcg or ring 7.5 mcg/day
Board pearl: 2021 CDC trichomoniasis update — women now get 7-day metronidazole, not single dose. This change is heavily tested. Men still get single-dose 2 g.
Step 3 management: Counsel BV/trich patients to avoid alcohol with metronidazole/tinidazole; remind candida patients that OTC misuse delays correct diagnosis.
— Induction: metronidazole 500 mg BID × 7 days OR metronidazole gel nightly × 10 days
— Suppression: metronidazole 0.75% gel twice weekly × 4–6 months
— Adjuncts: boric acid 600 mg vaginally nightly × 21 days between courses (especially for biofilm)
— Emerging: vaginal probiotics (Lactobacillus crispatus — Lactin-V); FDA-approved 2023 secnidazole 2 g granules
— Confirm with culture and speciation before chronic suppression
— Induction fluconazole 150 mg q72h × 3 doses → maintenance 150 mg PO weekly × 6 months
— Oteseconazole (FDA-approved 2022) — long-acting oral azole for recurrent VVC in non-reproductive-potential women
— Ibrexafungerp — novel oral glucan synthase inhibitor; useful for fluconazole-resistant
— Boric acid 600 mg vaginal capsule QHS × 14 days (cure rate ~70%)
— Topical nystatin 100,000 units intravaginally QHS × 14 days
— Refractory glabrata: topical flucytosine 17% ± amphotericin B compounded; specialist referral
— Repeat metronidazole 500 mg BID × 7 days
— If fails → tinidazole 2 g daily × 7 days
— Refractory: high-dose tinidazole 2–3 g/day + intravaginal tinidazole; CDC consultation for nitroimidazole resistance testing
— Clindamycin 2% vaginal cream nightly × 4–6 weeks
— OR hydrocortisone 10% vaginal suppositories nightly
— Maintenance taper after remission
— Clobetasol 0.05% ointment nightly × 4–12 weeks, then taper to maintenance 1–3×/week indefinitely
— Annual surveillance for SCC; biopsy suspicious lesions
CCS pearl: When recurrent "yeast" doesn't respond to fluconazole, order fungal culture with speciation before escalating — empirical second-line antifungals without speciation is a classic wrong answer.
— Atrophic vaginitis (GSM) dominates differential — affects up to 50% of postmenopausal women
— Symptoms: dryness, dyspareunia, burning, recurrent UTIs, urinary urgency
— Exam: pale, thin, friable mucosa; loss of rugae; pH >4.5 (loss of lactobacilli with low estrogen)
— Treatment ladder:
— Non-hormonal moisturizers (Replens, hyaluronic acid) 2–3×/week
— Lubricants for intercourse
— Low-dose vaginal estrogen (cream, tablet, ring) — minimal systemic absorption, safe even in many breast cancer survivors (discuss with oncology)
— Ospemifene oral SERM — alternative in patients avoiding estrogen
— Vaginal DHEA (prasterone) — alternative
— Vaginal estrogen does NOT require progestin for endometrial protection in standard doses
— Metronidazole: no dose adjustment in mild-moderate CKD; consider reducing in ESRD/dialysis
— Fluconazole: reduce dose by 50% if CrCl <50 mL/min for multi-dose regimens; single 150 mg dose generally safe
— Boric acid topical — minimal systemic absorption; safe
— Fluconazole: hepatotoxicity risk; avoid in active liver disease, monitor LFTs with prolonged courses
— Metronidazole: reduce dose by 50% in severe hepatic impairment (Child-Pugh C)
— Ketoconazole oral — avoid entirely (black box hepatotoxicity, adrenal suppression)
— Fluconazole ↑ warfarin INR (potent CYP2C9 inhibitor) — check INR within 3–5 days
— Fluconazole + statins → ↑ myopathy risk
— Metronidazole + warfarin → ↑ INR
— Metronidazole + lithium → ↑ lithium levels
Board pearl: In a postmenopausal woman with recurrent UTIs and dyspareunia, vaginal estrogen reduces UTI recurrence by ~50% — highly tested intervention with low harm profile.
Step 3 management: Recheck warfarin INR within 3–5 days of starting fluconazole or metronidazole in any anticoagulated patient.
— BV in pregnancy: associated with preterm birth, PROM, postpartum endometritis; treat all symptomatic patients
— Metronidazole 500 mg PO BID × 7 days (preferred; safe all trimesters per CDC)
— Clindamycin 300 mg PO BID × 7 days alternative
— Routine screening of asymptomatic low-risk women NOT recommended
— Candidiasis in pregnancy:
— Topical azoles × 7 days (clotrimazole, miconazole) — first line
— Avoid oral fluconazole, especially 1st trimester (teratogenic at high doses; modest miscarriage signal even at 150 mg)
— Trichomoniasis in pregnancy:
— Associated with preterm birth, low birth weight, PROM
— Treat symptomatic with metronidazole 500 mg BID × 7 days
— Treatment of asymptomatic is debated; CDC supports treatment
— Most common cause: nonspecific vulvovaginitis from poor hygiene, irritants, low estrogen
— Treatment: sitz baths, loose cotton underwear, gentle cleansing, avoid bubble baths/soaps
— Specific infectious causes: group A strep (perianal/vulvar), Shigella, pinworms (nocturnal itching — tape test)
— Foreign body (toilet paper wad) → bloody/foul discharge → exam under anesthesia
— Persistent or STI organism (GC, CT, trich) in prepubertal child → MANDATORY evaluation for sexual abuse and report to CPS
— Confidentiality protections under most state minor consent laws for STI care
— Counsel on contraception, condoms, HPV vaccination
— More severe, recurrent, and non-albicans candida
— Trichomoniasis cure rates lower with single-dose metronidazole → use 7-day regimen
— Lower threshold for culture and longer treatment courses
Board pearl: Gonorrhea, chlamydia, or trichomonas in a prepubertal child = sexual abuse until proven otherwise — mandatory report. This is a high-yield ethics/safety question.
Key distinction: Avoid fluconazole in pregnancy; use topical azoles × 7 days instead.
— Increased acquisition/transmission of HIV, HSV-2, gonorrhea, chlamydia, trichomonas
— Pelvic inflammatory disease (PID) risk increased
— Postoperative infections after hysterectomy, abortion, IUD insertion
— Pregnancy: preterm labor, PROM, chorioamnionitis, postpartum endometritis
— Post-IVF: reduced implantation rates
— HIV acquisition risk ~1.5–2× higher
— Preterm birth, low birth weight, PROM in pregnancy
— PID, infertility, post-hysterectomy cuff cellulitis
— In men: nongonococcal urethritis, prostatitis, epididymitis, possible link to prostate cancer
— Rarely systemic in immunocompetent; severe local inflammation, fissures, superinfection
— In poorly controlled diabetes: extensive vulvar dermatitis, intertrigo
— Recurrent VVC → significant QoL impact, dyspareunia, anxiety
— Recurrent UTIs
— Sexual dysfunction, relationship strain
— Pelvic organ prolapse symptoms worsen
— Vulvar fissures, bleeding
— Vulvar squamous cell carcinoma in ~4–5% lifetime risk
— Architectural distortion: labial fusion, clitoral phimosis, introital stenosis → dyspareunia
— Requires lifelong surveillance
— Metronidazole: metallic taste, nausea, peripheral neuropathy with prolonged use, disulfiram-like reaction with alcohol, rare CNS toxicity (encephalopathy, cerebellar syndrome)
— Fluconazole: hepatotoxicity, QT prolongation, drug interactions (warfarin, statins, sulfonylureas)
— Boric acid: vaginal burning; fatal if ingested orally — must counsel patient
— Topical clindamycin: weakens latex condoms × 5 days post-treatment
Board pearl: Boric acid vaginal capsules look like oral capsules — always counsel "for vaginal use only, fatal if swallowed" and store away from children. This is a Step 3 patient-safety pearl.
Key distinction: BV and trich both increase HIV acquisition; this is why treating asymptomatic trichomoniasis is recommended.
— Recurrent VVC unresponsive to maintenance fluconazole
— Non-albicans candida requiring complex regimens
— Recurrent or refractory BV despite suppressive therapy
— Refractory trichomoniasis after second nitroimidazole course → CDC consultation for resistance testing
— Suspected lichen sclerosus, lichen planus, DIV → biopsy and ongoing topical steroid management
— Vulvar ulcers, masses, or pigmented lesions requiring biopsy
— Suspected VIN or vulvar carcinoma
— Severe atrophic vaginitis refractory to vaginal estrogen
— Refractory trichomoniasis with documented resistance
— Recurrent infections in immunocompromised hosts
— Disseminated or invasive fungal disease
— PID with severe illness: high fever, intractable vomiting, pregnancy, tubo-ovarian abscess, inability to tolerate oral medications → IV antibiotics, admission
— Toxic shock syndrome from retained foreign body: fever, hypotension, rash → resuscitation, removal, IV antibiotics, ICU
— Severe vulvar cellulitis or necrotizing infection (rare; diabetic/immunocompromised) → surgical evaluation
— Severe systemic reaction to medication (Stevens-Johnson, anaphylaxis)
— Chronic vulvar symptoms with significant QoL impact, depression, sexual dysfunction → consider counselor or sex therapist alongside medical treatment
CCS pearl: On Step 3 CCS, a patient with vulvovaginitis-like symptoms plus fever, CMT, adnexal tenderness changes the case from outpatient vulvovaginitis to PID — order CBC, hCG, GC/CT NAAT, pelvic US if TOA suspected, and start ceftriaxone + doxycycline ± metronidazole per CDC.
Board pearl: Suspect tubo-ovarian abscess in a patient with PID symptoms who fails 72h of appropriate antibiotics — image and consider drainage.
| • Bacterial vaginosis vs trichomoniasis vs candidiasis — direct comparison: | |||
| Feature | BV | Trich | Candida |
| Discharge | Thin gray-white | Frothy yellow-green | Thick white "cottage cheese" |
| Odor | Fishy, worse post-coitus | Malodorous | None |
| Pruritus | Mild/none | Moderate | Severe |
| pH | >4.5 | >4.5 | ≤4.5 |
| Whiff | Positive | Often positive | Negative |
| Microscopy | Clue cells | Motile trichomonads | Pseudohyphae on KOH |
| STI? | No (sexually associated) | Yes | No |
| Partner Rx | No | Yes | No |
| • Desquamative inflammatory vaginitis (DIV): | |||
| — Purulent discharge, vaginal erythema, pH >4.5 | |||
| — Increased PMNs and parabasal cells on wet mount | |||
| — No clue cells, no trichomonads, no yeast | |||
| — Treat with topical clindamycin or hydrocortisone | |||
| • Cytolytic vaginosis: | |||
| — pH <4.5, lactobacilli overgrowth, cyclic premenstrual symptoms | |||
| — Falsely treated as recurrent candida | |||
| — Treat with baking soda sitz baths (alkalinize) | |||
| • Aerobic vaginitis: | |||
| — Mixed picture with E. coli, group B strep, staphylococci | |||
| — Overlap with DIV; treat with topical antibiotics ± steroids | |||
| • Cervicitis (gonorrhea, chlamydia, Mycoplasma genitalium): | |||
| — Mucopurulent cervical discharge, friable cervix, intermenstrual/postcoital bleeding | |||
| — Diagnose by NAAT; treat per CDC (ceftriaxone 500 mg IM + doxycycline for GC; doxycycline for CT) | |||
| • Genital herpes: | |||
| — Painful vesicles/ulcers, often with prodromal tingling, fever, inguinal adenopathy in primary outbreak | |||
| — Diagnose by PCR of lesion swab; treat with acyclovir/valacyclovir | |||
| Key distinction: pH ≤4.5 with thick white discharge = candida; pH >4.5 = BV, trich, or atrophic. This single measurement front-loads the differential. | |||
| Board pearl: Frothy discharge + strawberry cervix + pH 5–6 = trichomoniasis until NAAT proves otherwise. |
— Postmenopausal, dryness, dyspareunia, dysuria, pH >4.5
— Pale thin friable mucosa; treat with vaginal estrogen
— Burning > itching; temporal association with new product (soap, detergent, scented pad, lubricant, latex, spermicide)
— Erythema, edema, possible vesiculation
— Treatment: remove offending agent, low-potency topical steroid (hydrocortisone 1–2.5%), barrier cream (zinc oxide)
— Chronic vulvar pruritus, white atrophic plaques, "figure-of-8" distribution around vulva and anus
— Architectural loss, agglutination
— Biopsy to confirm; 4–5% lifetime SCC risk
— Treat with clobetasol 0.05% ointment, lifelong surveillance
— Erosive form: painful red erosions, Wickham striae (lacy white), can involve oral mucosa
— Treat with potent topical steroids; refer to derm/gyn
— Chronic scratching → thickened lichenified skin
— Treat with topical steroid + behavioral interruption of itch-scratch cycle
— Persistent lesion, ulceration, asymmetry, pigmentation, bleeding
— Biopsy any suspicious lesion; HPV-associated (usual VIN) vs differentiated VIN (lichen sclerosus-associated)
— Foul discharge, often unilateral; remove for cure
— Chronic vulvar pain/burning without identifiable lesion or infection
— Diagnosis of exclusion; treat with topical lidocaine, pelvic floor PT, TCAs, gabapentin
Board pearl: Any persistent vulvar lesion that doesn't resolve with empirical treatment must be biopsied — the most commonly missed Step 3 diagnosis in this domain is vulvar SCC mistaken for recurrent yeast.
Key distinction: Itch without discharge in older woman → lichen sclerosus; burning > itch with new product → contact dermatitis; chronic pain without lesion → vulvodynia.
— Avoid douching (disrupts flora, increases BV/PID risk)
— Avoid scented soaps, bubble baths, feminine deodorants, vaginal wipes
— Wear loose cotton underwear; avoid tight synthetics
— Wipe front to back
— Change wet swimwear/exercise clothing promptly
— Use water-based unscented lubricants for intercourse
— Counsel on douching avoidance
— Condom use during BV treatment
— Consider twice-weekly metronidazole 0.75% gel × 4–6 months for recurrent disease
— Emerging: Lactin-V (Lactobacillus crispatus) reduces recurrence by ~30%
— Treat female partners if BV recurs (newer evidence supports this in same-sex couples)
— Optimize glycemic control (HbA1c <7%) in diabetics
— Discontinue unnecessary antibiotics; use narrow-spectrum when possible
— Review SGLT2 inhibitor use (genital mycotic infections) — usually continue with hygiene measures
— Maintenance fluconazole 150 mg weekly × 6 months for recurrent VVC
— Probiotic data mixed; not first-line
— Treat all sexual partners
— Abstain from sex until both partners complete therapy and asymptomatic ≥7 days
— Retest at 3 months (CDC recommends rescreen) — reinfection rates 5–17%
— Full STI screening including HIV
— Counsel on consistent condom use
— Long-term vaginal moisturizers + lubricants
— Continue vaginal estrogen indefinitely as needed (very low systemic absorption)
— Annual reassessment
— Maintenance clobetasol 1–3×/week indefinitely
— Annual surveillance exams; biopsy new lesions
— Patient self-exams monthly
Step 3 management: Retest trichomoniasis at 3 months — high reinfection rate makes this a quality-of-care metric heavily tested.
Board pearl: Vaginal estrogen for GSM is indefinite therapy — stopping leads to symptom recurrence within weeks.
— Uncomplicated BV/candida/trich: no test of cure if symptoms resolve
— Trichomoniasis: rescreen at 3 months regardless of partner treatment (CDC)
— Pregnant patients treated for trich or BV: consider test of cure at 1 month
— Persistent symptoms beyond 1 week: return for reevaluation, microscopy, NAAT, consider biopsy
— Recurrent VVC: monthly visits during induction, then every 3 months during maintenance; recheck HbA1c, consider HIV test
— Recurrent BV: assess adherence, partner factors, douching, consider biofilm-targeted boric acid courses
— Lichen sclerosus: every 6–12 months indefinitely; biopsy new lesions
— Prolonged fluconazole maintenance: baseline and periodic LFTs; watch for QT prolongation with other QT drugs
— Warfarin patients started on fluconazole or metronidazole: INR within 3–5 days
— Topical clobetasol long-term: monitor for skin atrophy, telangiectasias — taper to lowest effective frequency
— Adherence: complete full course even if symptoms improve early
— Alcohol avoidance with metronidazole/tinidazole and 24–72h after
— Condom integrity: clindamycin cream and miconazole/terconazole creams (oil-based) weaken latex × 5 days
— OTC misuse: many women self-treat presumed yeast inappropriately — encourage office evaluation if symptoms recur
— Sexual transmission: BV not classically STI but partner factors matter; trich is STI
— Pregnancy planning: discuss safe regimens before conception in patients with recurrent disease
— HPV vaccination through age 26 (shared decision 27–45)
— Cervical cancer screening per age-based guidelines
— STI screening per CDC (annual GC/CT for sexually active women <25)
CCS pearl: When you place "metronidazole 500 mg PO BID × 7 days," also place "counsel: avoid alcohol, complete full course, return if symptoms persist" and "follow-up 3 months for retesting" (if trich) — these orders earn points on management quality.
— Gonorrhea, chlamydia, trichomoniasis, syphilis, or HIV in a prepubertal child = presumed sexual abuse until proven otherwise
— Mandatory report to Child Protective Services; involve child abuse pediatrician, forensic nurse, social work
— Document carefully; use NAAT (more specific than culture for legal evidentiary value, though culture historically preferred for chain of custody — current CDC accepts NAAT)
— All states require physician reporting of suspected child abuse; failure to report is criminal
— Gonorrhea, chlamydia, syphilis, HIV reportable in all US states
— Trichomoniasis reportable in some states (varies)
— Submit confidential reports to local health department
— Legal in most US states for gonorrhea, chlamydia, and increasingly trichomoniasis
— Allows prescribing for sexual partner without examining them
— Reduces reinfection; check state-specific legality
— Most states allow minors to consent to STI testing and treatment without parental notification
— Be aware of insurance billing disclosures (explanation of benefits sent to parent can breach confidentiality) — offer cash pay or 340B/Title X clinics
— Boric acid vaginal capsules: counsel "fatal if ingested orally", label clearly, store away from children — patient-safety pearl
— Off-label use (e.g., ibrexafungerp pre-2021, oteseconazole in non-reproductive-potential women): document discussion
— Patients started on prolonged maintenance fluconazole need LFT monitoring — ensure handoff if changing providers
— Patients with lichen sclerosus need lifelong dermatologic surveillance — communicate clearly at transitions
— Discussions of sexual history, partner notification, and vaginal exams require trauma-informed approach; offer chaperone; respect language preferences
Board pearl: STI in a prepubertal child → mandatory CPS report, even if the child or family offers alternative explanations. This is a non-negotiable Step 3 ethics answer.
Step 3 management: When prescribing fluconazole maintenance, document LFT baseline, drug interaction review (warfarin, statins, sulfonylureas), pregnancy counseling, and follow-up plan.
— ≤4.5 → normal or candida
— >4.5 → BV, trich, atrophic vaginitis, DIV
— Clue cells = BV
— Motile flagellates = trichomoniasis
— Pseudohyphae/budding yeast on KOH = candida
— Parabasal cells + PMNs = DIV or atrophic
— Thin gray-white + fishy → BV
— Frothy yellow-green → trich
— Thick white "cottage cheese" → candida
— Scant, dry, blood-tinged → atrophic
— Metronidazole + alcohol → disulfiram-like reaction
— Fluconazole + warfarin → ↑ INR
— Topical clindamycin/oil-based creams weaken latex condoms × 5 days
— Boric acid: vaginal only, fatal orally
— Trich diagnosis → screen for HIV, syphilis, GC, CT
— BV ↑ HIV acquisition risk
— Recurrent VVC → check HbA1c and HIV
— "Strawberry cervix" = trichomoniasis
— "Figure-of-8" white plaques = lichen sclerosus
— Wickham striae = lichen planus
— Cottage cheese discharge = candida
— Fishy odor after sex = BV
— BV: metronidazole 500 mg BID × 7 days
— Candida (uncomplicated): fluconazole 150 mg × 1
— Trich: metronidazole 500 mg BID × 7 days (NEW CDC 2021 for women)
— Glabrata: boric acid 600 mg vaginally × 14 days
— Atrophic: vaginal estrogen
— BV/trich: oral metronidazole OK all trimesters
— Candida: topical azoles × 7 days; avoid oral fluconazole
Board pearl: Memorize the 2021 CDC change — women with trich get 7-day metronidazole, not single dose. Single 2 g dose remains for men only.
Key distinction: Most vulvovaginitis answers on Step 3 hinge on pH and microscopy — always anchor your differential there.
— 28-year-old woman with thin gray discharge and fishy odor worse after intercourse, minimal itching, pH 5.0, KOH whiff positive, clue cells on wet mount.
— Answer: Metronidazole 500 mg PO BID × 7 days
— Distractor: fluconazole, topical clindamycin (acceptable alternative), treating asymptomatic partner
— 32-year-old woman with frothy yellow-green discharge, dysuria, strawberry cervix, motile organisms on wet mount.
— Answer: Metronidazole 500 mg PO BID × 7 days (NOT single 2 g dose for women)
— Next steps: HIV/syphilis/GC/CT screening, treat partner, rescreen at 3 months
— 35-year-old with 5 episodes in past year, fluconazole gives temporary relief, recent HbA1c 9.8%.
— Answer: Fungal culture with speciation, induction + maintenance fluconazole, optimize diabetes control
— Recurrent VVC with culture showing C. glabrata, fluconazole-refractory.
— Answer: Boric acid 600 mg vaginal capsule QHS × 14 days
— 62-year-old woman with dyspareunia, dryness, recurrent UTIs, pale thin vaginal mucosa, pH 6.0.
— Answer: Vaginal estrogen (cream, tablet, or ring); non-hormonal moisturizers if mild
— Postmenopausal woman with chronic vulvar itching, white "figure-of-8" atrophic plaques, labial fusion.
— Best next step: Vulvar biopsy; treatment: clobetasol 0.05% ointment; lifelong surveillance for SCC
— 6-year-old girl with vaginal discharge, NAAT positive for gonorrhea.
— Answer: Mandatory report to CPS, treat with ceftriaxone, full forensic eval
— 28-week pregnant woman with thick white discharge and pseudohyphae.
— Answer: Topical clotrimazole × 7 days; AVOID oral fluconazole
— Patient on warfarin started on fluconazole — next step? Check INR within 3–5 days
Board pearl: Step 3 favors management answers over diagnostic answers — once you've named the organism, the question is usually "what regimen, what counseling, what follow-up?"
Key distinction: When the stem mentions partner treatment, the diagnosis is trichomoniasis (always treat partners); BV does not require partner treatment routinely in heterosexual couples.
Vulvovaginitis is diagnosed by anchoring on vaginal pH and microscopy — pH ≤4.5 with pseudohyphae means candida (fluconazole 150 mg × 1), pH >4.5 with clue cells and fishy odor means BV (metronidazole 500 mg BID × 7 days), pH >4.5 with motile trichomonads or strawberry cervix means trichomoniasis (metronidazole 500 mg BID × 7 days per CDC 2021, plus partner treatment and rescreen at 3 months), and pH >4.5 in a postmenopausal woman with dryness and dyspareunia means atrophic vaginitis (vaginal estrogen) — with biopsy mandated for any persistent or atypical vulvar lesion to exclude lichen sclerosus or vulvar carcinoma.
Board pearl: When in doubt, do the speculum exam, check pH, and look at the slide — symptom-based diagnosis alone is wrong >50% of the time, and the right Step 3 answer almost always begins with proper bedside evaluation rather than empirical phone-in therapy.