All women have some vaginal discharge. Physiological discharge varies considerably and is affected by the menstrual cycle.
• Before ovulation—mucus is clearer, wetter, stretchy, and slippery
• After ovulation—mucus is thicker and stickier
Causes of ‘abnormal’ discharge 5 causes account for 95% cases:
- Excessive normal secretions
- Bacterial vaginosis (BV)
- Candida albicans
- Cervicitis (gonococcal, chlamydial, or herpetic)
- Trichomonas vaginalis (TV)
Rarer causes Cervical ectropion/polyp; IUCD/IUS; chemical vaginitis (avoid perfumed or disinfectant bath additives and vaginal douches); foreign body (e.g. retained tampon—remove and treat with metronidazole); genital tract tumour; fistula.
History Ask about:
• Symptoms Vaginal discharge (itchy, offensive, colour, duration), vulval soreness and irritation, lower abdominal pain, dyspareunia, heavy periods, intermenstrual bleeding, fever, vulval pain
• Sexual history Recent sexual contact with new partner, multiple partners, presence of symptoms in partner, worries about STIs
• Medical history Pregnancy, diabetes mellitus, recent antibiotics
• Attempts at self-medication
Examination Always offer examination if:
• High risk for STI—age <25y; new sexual partner or >1 sexual partner in the past year; diagnosis of STI in the past 12mo
• Upper reproductive tract symptoms—abnormal bleeding (heavy, post-coital ± intermenstrual); pelvic/abdominal pain; deep dyspareunia; fever
• Pregnant, postpartum, or after miscarriage/termination
• After instrumentation (e.g. insertion of IUS/IUCD, after colposcopy)
• Recurrent infection or failed treatment
• Requesting examination/STI testing
Do an abdominal, bimanual pelvic, and vaginal speculum examination. look for tenderness on lower abdominal or bimanual palpation, cervical erosion/contact bleeding, discharge, foreign bodies, warts, or ulcers.
Investigation Check pH of secretions with narrow-range pH paper. If >4.5, BV or TV is likely; pH is 4.5 with physiological discharge and candida infection. Other investigations to consider:
• High vaginal swab for M,C&S—only if symptoms/signs and/or pH consistent with specific diagnosis; the patient is pregnant, postpartum, or after miscarriage/termination; after instrumentation; or if there is recurrent infection/treatment has failed
• Endocervical swabs for gonorrhoea and chlamydia
• Viral swab if herpes is suspected (if not available, refer to GUM)
• Opportunistic cervical smear if indicated
• Self-taken vulvovaginal swab if examination is declined
Management Treat the cause. If unclear refer to GUM or gynaecology.