29-year-old with itching and thin gray-white discharge
A 29-year-old woman comes to clinic for 3 months of increased vaginal discharge and intermittent vulvar itching. She is sexually active with one new partner and uses condoms inconsistently. She has no fever, pelvic pain, or dysuria. Examination shows normal vital signs, thin gray-white discharge coating the vaginal walls, and no cervical motion tenderness. Vaginal pH is 5.5, and a saline wet mount shows epithelial cells studded with adherent bacteria. Which of the following is the most appropriate treatment?
See the answer and explanation below:
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B
Explanation
Clinical Pearl:
Thin gray discharge, elevated vaginal pH, and clue cells indicate bacterial vaginosis. First-line therapy is metronidazole or an equivalent recommended regimen, and routine partner treatment is not needed.
Explanation:
This patient has bacterial vaginosis, suggested by thin gray-white discharge, pH above 4.5, and clue cells on wet mount. Recommended treatment is oral metronidazole for 7 days, which is a standard first-line regimen. Fluconazole and topical clotrimazole are used for vulvovaginal candidiasis, which typically causes thick curdy discharge and usually has a normal vaginal pH. Ceftriaxone plus doxycycline would be appropriate for cervicitis or pelvic inflammatory disease, neither of which is supported by this examination. Single-dose azithromycin alone is not the preferred treatment for this presentation and would target chlamydial cervicitis rather than the vaginal flora imbalance seen here. The absence of pelvic pain, fever, and cervical motion tenderness helps narrow this to uncomplicated vaginitis due to bacterial vaginosis.
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