Primary care management

of women with persistent

vaginal discharge
Abstract: Vaginal discharge is a common complaint managed by NPs in ambulatory
settings. This article reviews noninfectious etiologies of vaginal discharge with diagnostic
criteria and recommended treatment to aid the NP in correctly managing these patients.

By Hilary S. Morgan, PhD, CNM

Ps see a variety of common primary care com- a withdrawal from intimate relationships.6-8 The NP must

N plaints. In women’s health, vaginal symptoms—

specifically vaginal discharge with or without
accompanying pruritus and odor—account for 10% of office
visits.1 Most often, the patient is diagnosed with a vaginal
infection, such as vulvovaginal candidiasis, bacterial vagino-
sis, or trichomoniasis. These infections account for over 75%
of vaginitis complaints, with vulvovaginal candidiasis and
bacterial vaginosis causing up to 90% of vaginal infections.2,3
Appropriate diagnosis and treatment result in symptom
relief for patients; however, up to 30% of women remain
without a diagnosis after workup and may receive an inap-
propriate treatment just to placate them.4 Not surprisingly,
these women continue to seek a diagnosis from different
providers or chose to self-medicate with over-the-counter
(OTC) medications in an attempt to find a cure, increasing
the cost to themselves and the healthcare system. The failure
to appropriately treat may also aggravate symptoms rather
than alleviate them.5
Additionally, the chronic nature of persistent vaginal
discharge may impact a woman’s psychosocial health.
Women may view vaginal complaints as a threat to their
reproductive health, which may lead to poor self-image and
Keywords: atrophic vaginitis, bacterial vaginosis, desquamative inflammatory vaginitis, genitourinary syndrome of menopause, lichen planus,
lichen sclerosus, persistent vaginal discharge, trichomoniasis, vaginal discharge, vulvovaginal candidiasis
recognize other, noninfectious causes of vaginal discharge
and diagnose and treat the patient appropriately. If the NP
cannot relieve the patient of her symptoms, a referral to a
gynecologic specialist is warranted.
■ Normal vaginal flora
Women of reproductive age have vaginal flora that consists
predominately of lactobacillus, a Gram-positive rod that
produces lactic acid from glucose and contributes to a nor-
mal vaginal pH between 4.0 and 4.7.5,9 The acidity of the
vagina protects it from pathogens.10 After menarche, estro-
gen aids in the deposit of glycogen in the vaginal epithelial
cells, which in turn converts the glycogen to glucose. The
lactobacillus then converts the glucose to lactic acid.9
A thickening of the vaginal mucosa also occurs with
puberty due to the influence of estrogen.11 As women age,
estrogen levels decline, resulting in a higher vaginal pH (over
4.7). There is less glycogen in the epithelial cells and fewer
lactobacilli present to convert the glucose to lactic acid,
resulting in less lactic acid production and a higher vaginal
pH.5,11 Additionally, the loss of estrogen leads to vaginal
atrophy and thinning.8

1 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Primary care management of women with persistent vaginal discharge

It is normal for women to have a physiologic vaginal is more likely indicative of reinfection, whereas a woman
discharge. The endocervix produces mucus, which combines with chronic symptoms not relieved with previous treatment
with epithelial sloughing, normal vaginal flora, and transudate should lead the NP to suspect inflammation unrelated to
to produce a vaginal discharge.2 This discharge is considered infectious process (see Evaluation of vaginal discharge by pH
part of a self-cleansing mechanism in a woman’s vagina and measurement).14 The timing of the symptoms in relation to
varies throughout the menstrual cycle due to effects of estro- the menstrual cycle may also yield clues, as a heavier dis-
gen and progesterone. The consistency of vaginal discharge charge is noted at ovulation.
is clear and stretchy during ovulation and thick, white, and Other symptoms, such as vulvovaginal burning and
tacky during the remainder of the cycle.5,12 The amount of pruritus, bleeding, dysuria, or dyspareunia may provide
vaginal discharge produced varies among women but averages information.5,15 The NP should ask if there are other associ-
approximately 1 mL to 4 mL fluid per 24 hours.2 ated symptoms, such as fever, nausea, vomiting, and pelvic
pain, which may indicate a more systemic issue. The sever-
■ Patient history ity of the complaints should be elicited as well as any aggra-
A detailed history is paramount if the NP is to succeed in vating or alleviating factors. Any history of sexually
correctly diagnosing women complaining of persistent transmitted infections and use of any type of contraceptives
vaginal discharge. Although the NP may consider a patient should also be obtained.
presenting with a complaint of vaginal discharge a problem- The woman’s sexual history must also be gathered,
focused visit, a thorough history (including medical and including if she is having sex with men, women, or both,
surgical history, reproductive and menstrual history, and and if they are stable or new partners. Women who have sex
nutritional history) may provide important information with women are at an increased risk of bacterial vagino-
aiding in diagnosis. The NP should keep in mind that sis.16,17 Although rare, allergy to semen has been noted, but
although some patients may be of reproductive age, there the symptoms are usually irritative rather than vaginal dis-
are medical conditions and treatments that inhibit normal charge.18 The NP should also inquire if the woman’s symp-
ovarian function, including surgical removal of the ovaries toms are noted by her partner as well.
and medications used to treat endometriosis, such as leup- It is also important to ask about any medications, both
rolide acetate.13 The NP needs to carefully avoid assumptions prescription and OTC. Recent intake of antibiotics may
based on a woman’s age. make a woman susceptible to vulvovaginal candidiasis, and
It is important to know if the woman’s symptoms are contraceptives containing estrogen may contribute to a
recent or chronic or if she has been treated successfully in heavier vaginal discharge.19 Antihistamines may cause vag-
the past and now the symptoms have recurred. Recurrence inal dryness.20 Women who use an intrauterine device for
contraception may also note a heavier discharge.21
Lastly, the woman’s hygienic practices must be evaluated.
Evaluation of vaginal discharge by Vaginal tissue is very sensitive to chemicals and allergens,
pH measurement14 and the use of products such as perfumed soaps and douches,
scented panty liners, spermicides, latex condoms, and topi-
Process Vaginal pH <4.7 Vaginal pH ≥4.7
cal lotions may cause inflammation that contributes to
Infectious • Vulvovaginal • Bacterial
vaginal discharge.22 Shared use of sex toys between partners
candidiasis vaginosis
• Trichomoniasis • Trichomoniasis without adequate cleaning between use may also be a con-
(varies) (usually elevates tributing factor.17
pH but varies)*
Noninfectious • Normal flora • Genitourinary ■ Physical exam and diagnostic testing
• Physiologic syndrome of Although it is common to diagnose a patient with a vaginal
leukorrhea menopause
• Vulvar • Desquamative
infection based on history, a speculum exam should be done
dermatitis inflammatory in women with persistent vaginal discharge. A diagnosis
• Cytolytic vaginitis based solely on history is strongly discouraged. Normal
vaginosis • Lichen planus or vaginal discharge in women with functioning ovaries or who
lichen sclerosus
are receiving estrogen supplementation is white or clear and
*Trichomoniasis generally causes elevation of vaginal pH but due to limited odorless.2 The speculum exam allows the NP to see the color,
specificity of pH paper, this result may vary.
consistency, and amount of the vaginal discharge. A thorough

2 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Primary care management of women with persistent vaginal discharge
exam of the mons, vulva, perineum, vaginal canal, cervix,
and cervical os should be performed along with palpation
of the urethra and the Bartholin and Skene glands.
Inspection for retained foreign bodies, the presence of
lesions, skin disorders, atrophy, and other signs of irritation
should be done and managed by the NP. The NP should
note any unusual or foul odors. A bimanual exam assessing
for cervical motion tenderness, uterine size, consistency and
tenderness, adnexal tenderness, and the presence of any
masses should be performed.
■ pH testing and microscopy
The value of measuring the vaginal pH to help achieve diag-
nosis cannot be overemphasized. Several commercial options
are available to the NP to obtain vaginal pH results. These
products utilize nitrazine dye either on a swab or as paper
that changes color in contact with an elevated vaginal pH.
No change in color occurs if the vaginal pH is normal. If a
color change occurs, compare the pH paper to the color chart
supplied with the pH paper. These tests are easily performed
and done at the point of care with the patient. The sensitiv-
ity and specificity of the swab in diagnosing bacterial vagi-
nosis and trichomoniasis based on elevated pH results is
82.3% and 94.2%, respectively; the sensitivity and specificity
of the pH paper is 91.1% and 94.2%.23 An elevated vaginal
pH in a reproductive-age woman (pH over 4.7) is associated
with bacterial vaginosis or trichomoniasis. Candida vulvo-
vaginitis will typically have a vaginal pH between 4 and 4.5.5,24
The use of microscopy in diagnosing vaginal discharge
consists primarily of saline and potassium hydroxide (KOH)
wet mounts, and identification of causative organism.
Trichomonads and clue cells may be seen under the micro-
scope using the saline mount, whereas hyphae and buds
indicative of candidiasis are noted with KOH. The amine
test (whiff test) is also helpful in diagnosing bacterial vagi-
nosis and involves mixing vaginal discharge with KOH and
evaluating for the presence of a fishy odor.2
Amsel criteria for the diagnosis of bacterial vaginosis
include a vaginal pH over 4.5, a positive whiff test, milky
discharge, and the presence of clue cells on microscopy.25
Many NPs prefer submitting specimens for vaginal or cervi-
cal cultures to a lab to aid in identifying pathology.2 Infection
with Neisseria gonorrhoeae or Chlamydia trachomatis should
be ruled out.
■ Noninfectious conditions
Careful assessment and diagnostic testing will likely provide
a diagnosis if the vaginal discharge is due to an infectious
cause. If testing does not provide a diagnosis, the NP should
3 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
consider noninfectious causes of persistent vaginal dis-
charge. Again, pH findings may be helpful. An elevated pH
may indicate genitourinary syndrome of menopause (the
more recent terminology for atrophic vaginitis and vulvo-
vaginal atrophy), lichen planus, lichen sclerosus, or desqua-
mative inflammatory vaginitis. A normal vaginal pH with
negative diagnostic testing suggests physiologic leukorrhea
or vulvar dermatitis. A low vaginal pH may point toward
cytolytic vaginosis.2,5
Physiologic leukorrhea. Many women, particularly those
of younger reproductive age, may not realize the cyclic
variation in vaginal discharge. It is important to educate
them that all women will have some vaginal discharge.
Physiologic leukorrhea refers to the normal increased pro-
duction of discharge that occurs during ovulation and preg-
nancy. Physiologic leukorrhea may also be influenced by
diet, sexual activity, medications, hormonal contraception,
and stress. A vaginal discharge that is mostly clear, odorless,
without accompanied erythema and significant irritative
symptoms, and has a pH under 4.7 is generally considered
benign.2 Physiologic leukorrhea was diagnosed in 9% of
women in a prospective analysis of affected women.26
Cytolytic vaginosis. Also known as Döderlein’s cytolysis,
cytolytic vaginosis is characterized by an overgrowth of
lactobacillus.7 The overabundance of lactobacillus leads to
vaginal hyperacidity, which damages the vaginal epithelial
cells and increases vaginal discharge. According to Cibley
and Cibley, diagnostic criteria include the absence of tricho-
monas, monilia and bacteria on microscopy, an increase of
lactobacilli, rare white blood cells, evidence of cytolysis, and
the presence of vaginal discharge with pH between 3.5 and
4.5.27 Cytolytic vaginosis occurs more commonly during the
luteal phase of a women’s menstrual cycle.27
Cerikcioglu and Beksac tested 210 women with com-
plaints of vaginal discharge and other symptoms suggestive
of vulvovaginal candidiasis and diagnosed 7.1% with cyto-
lytic vaginosis based on lab findings. Patients diagnosed
with cytolytic vaginosis were found to have abundant lac-
tobacilli, fragmented epithelial cells, and free nuclei due to
cytolysis. Additionally, no fungal growth was identified
microscopically in these women.28 These findings were con-
firmed in another study by Hu and colleagues, which com-
pared the morphologic characteristics of vaginal discharge
of patients diagnosed with cytolytic vaginosis and vulvo-
vaginal candidiasis.29
The treatment for cytolytic vaginosis involves restoring
the vaginal pH to normal levels through the use of sodium
bicarbonate suppositories. Patients may prepare the appro-
priate treatment by filling empty gelatin capsules with
 Primary care management of women with persistent vaginal discharge
baking soda and inserting the capsules in their vagina twice
a week for 2 weeks.9 Gelatin capsules may be purchased
inexpensively at local pharmacies. Patients should experi-
ence symptom relief within 2 to 3 weeks.9
Retained foreign body. Women of all ages, particularly
younger women of reproductive age, may inadvertently leave
a tampon in their vagina for a prolonged period of time,
and this irritation may lead to a heavy discharge (usually
with odor). Surgical gauze has also been removed from
women returning for their postpartum or postgynecologic
surgery exam. In both situations, removing the foreign body
removes the irritant, and the resulting discharge resolves
fairly quickly. Some NPs prefer to treat the patient with
vaginal antibiotic cream, although the evidence is not clear
that this is necessary.30
Vulvar contact dermatitis. A study by Nyirjesy and col-
leagues identified contact dermatitis as a leading cause
(21%) of vaginal vulvar complaints.26 Contact dermatitis
may be either due to irritants or allergens. Severe outbreaks
may be painful and associated with erosion and lesions,
whereas milder cases may present with erythema and irrita-
tion. Chronic dermatitis may present as eczema with dry,
scaly patches and lichenification of tissue. The primary
symptoms in both types of contact dermatitis include itch-
ing, erythema, edema, and weeping from vulvar lesions may
be present. The vaginal pH is typically under 4.7.22,31
Soaps, laundry detergent, sanitary products, toilet tissue,
and powders are all potential sources of irritation. Treatment
involves avoidance of known irritants, changing personal
hygiene practices, and avoiding tight-fitting clothing. Med-
ication such as antihistamines and corticosteroids may be
necessary to relieve inflammation.31 NP management may
include identifying causative exposure and inflammation
treatment. Additionally, patient education on avoidance of
identified irritating exposures is imperative to avoid reoc-
currence. Referral to a gynecologic specialist for biopsy and/
or cultures may be necessary.
Estrogen deficiency. As women age, estrogen levels
decrease, and the vagina becomes atrophic. Estrogen is no
longer present at high enough levels to keep the vagina well
epithelialized and elastic. Over time, the vaginal tissue thins,
dries, and may become inflamed. With a decline in glycogen
levels, lactic acid production is diminished and the vaginal
pH rises, usually over 5.32
The vaginal tissue is more easily traumatized and sus-
ceptible to infection and inflammation. Even without a
source of infection, this inflammatory process results in an
increased discharge that often both the patient and NP believe
may be the result of a pathogen. However, if diagnostic test-
4 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ing comes up negative, the NP should consider treating the
woman with estrogen vaginal products. The results may take
a few months to demonstrate but most women will find
their vaginal discharge lessens after use of vaginal estrogen
products.31 Low-dose vaginal estrogen can be highly effective
in treating genitourinary conditions related to estrogen
deficiency (provided there are no contraindications to its
use). Contraindications include history of breast, ovarian,
or uterine cancer; undiagnosed vaginal bleeding; pregnancy
or lactation; thromboembolic disorders; or impaired liver
function.33
Estrogen deficiency may also occur in premenopausal
women, particularly during the postpartum period and while
lactating. Additionally, contraceptives containing low or no
estrogen amounts such as depot medroxyprogesterone acetate
may contribute to a lower vaginal estrogen level, production
of less lactic acid, and a higher vaginal pH.24,31,34,35 In this case,
the NP may need to consider an alternative contraceptive
option. Postpartum and lactating women should be educated
that their condition is self-limiting and once lactation is
discontinued, estrogen levels will return to normal.
Lichen planus and lichen sclerosus. These dermatologic
conditions are caused by chronic inflammation. Lichen
planus is a cell-mediated immune response disease that usu-
ally affects cutaneous areas, such as the vulva and vagina,
and the oral and esophagus regions.36,37 It is considered an
autoimmune disorder, although no defining antigen has been
identified. Lichen planus is characterized by either erosive
or papular lesions on the vulva; a friable vaginal epithelium
may be noted as well as loss of vaginal architecture.
Pain is the most common complaint, but an irritating
vaginal discharge may also be noted. Microscopy will reveal
a marked increase in white blood cells, immature epithelial
cells (arising from erosive areas), an elevated vaginal pH,
and an absence of lactobacilli.36 Lichen planus is most com-
monly seen in women ages 50 to 60, and diagnosis is
achieved through biopsy. Treatment is difficult and usually
involves topical corticosteroids.37
Like lichen planus, lichen sclerosus is considered an
autoimmune disorder without a specifically identified caus-
ative antigen. Lichen sclerosus primarily affects the ano-
genital area, and although it shares characteristics with
lichen planus, the two are different diseases. Genetic and
environmental factors are hypothesized to contribute to the
development of lichen sclerosus; additionally, periods of low
estrogen are also thought to play a role.38,39 Recent studies
have suggested the use of oral contraceptives having anti-
androgenic properties that might trigger an early onset of
lichen sclerosus in young women.38
 Primary care management of women with persistent vaginal discharge
Lichen sclerosus primarily affects women ages 50 to 70,
but children may be affected as well. Lichen sclerosus is
characterized by intractable pruritus and burning that wors-
ens at night. The vulvar skin becomes thin (although some-
times thickened) and is often accompanied by white plaques.
Progressive scratching and development of tissue adhesions
may lead to occlusion of the introitus. The vaginal tissue
may lose its elasticity, resulting in tears and erosion and
contributes to a vaginal discharge. Diagnosis is via exam,
and biopsy and treatment, like lichen planus, also entail
topical corticosteroids.38,39
Early identification and diagnosis of lichen planus and
lichen sclerosus are crucial to preserving vaginal structure
and integrity. Lichen planus and lichen sclerosus may be
missed if a pelvic exam is not performed on a patient com-
plaining of vaginal discharge. NPs who identify signs of
lichen planus and lichen sclerosus should not hesitate to
refer the patient to a gynecologic specialist for evaluation.
Granulation tissue. The presence of persistent granula-
tion tissue following gynecologic surgery has also been
identified as a cause of vaginal discharge. A recent review
found persistent granulation tissue occurred in 19% of
postoperative cases for vaginal prolapse repair.40 Although
more likely to cause vaginal spotting, discharge may also
occur. The presence of blood in the vaginal vault may con-
tribute to a vaginal pH of 4.7 or higher. If the patient has
had gynecologic surgery within the past year, a careful
inspection of the vulva, perineum, vagina, cervix, and/or
vaginal cuff is warranted. If the bleeding or discharge is
found to originate from granulation tissue, treatment with
application of silver nitrate may be beneficial, although in
some cases, repeat surgery intervention is required.41
Desquamative inflammatory vaginitis. Although a rare
diagnosis, desquamative inflammatory vaginitis should be
considered as a possible cause of vaginal discharge, particu-
larly in perimenopausal women. It is characterized by pro-
fuse vaginal discharge accompanied by vaginal pain and
inflammation. Vaginal exam reveals ecchymotic rash, ery-
thema, and erosion. Microscopy does not identify a causative
agent; however, the vaginal pH is increased (over 4.7), and
vaginal flora is marked by an absence of lactobacilli. Unlike
with vaginal atrophy, the vaginal structure with desquama-
tive inflammatory vaginitis is maintained.41
However, vaginal atrophy and desquamative inflamma-
tory vaginitis are often confused. Treatment with estrogen
products does not alleviate symptoms with desquamative
inflammatory vaginitis.40 Instead, the treatment of desqua-
mative inflammatory vaginitis involves use of a vaginal
antibiotic cream, such as clindamycin and/or hydrocortisone
5 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
cream, intravaginally for a period of 4 to 6 weeks until the
signs and symptoms are in remission.42 If the NP suspects
desquamative inflammatory vaginitis, it maybe treated in
the primary care setting, but if there is no relief of symptoms
after 2 months, referral to a gynecologic specialist is advised.
■ Patient education
Patients must be instructed that often, a medical diagnosis
is achieved through an elimination process, and if the symp-
toms do not improve within a specified period of time, the
patient needs to return to the same provider. Too often,
patients who are not cured on initial visit feel they have not
been cared for appropriately and present to a different pro-
vider seeking answers, and the investigative process and
treatment begins again. Patients must be educated that
follow-up care with the same provider is imperative to arrive
at a correct diagnosis.
Vaginal discharge in women may be due to a variety of
both infectious and noninfectious causes. Do not assume
that the patient has the common infectious causes of
vaginal discharge, such as vulvovaginal candidiasis, bacterial
vaginosis, or trichomoniasis. Treating a patient for a condi-
tion she does not have may exacerbate the symptoms and
lead to frustration. The NP must take a careful history,
perform a thorough physical exam, and necessary diagnos-
tic testing before deciding on a course of action. Once
vaginal infections have been ruled out, consider noninfec-
tious causes of vaginal discharge.
REFERENCES
1. Quan M. Vaginitis: diagnosis and management. Postgrad Med. 2010;122(6):
117-127.
2. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA.
2004;291(11):1368-1379.
3. Sobel JD, Hay P. Diagnostic techniques for bacterial vaginosis and vulvovagi-
nal candidiasis – requirement for a simple differential test. Expert Opin Med
Diagn. 2010;4(4):333-341.
4. Nyirjesy P, Leigh RD, Mathew L, Lev-Sagie A, Culhane JF. Chronic vulvovagini-
tis in women older than 50 years: analysis of a prospective database. J Low
Genit Tract Dis. 2012;16(1):24-29.
5. Nyirjesy P. Management of persistent vaginitis. Obstet Gynecol. 2014;124(6):
1135-1144.
6. Karasz A, Anderson M. The vaginitis monologues: women’s experiences of
vaginal complaints in a primary care setting. Soc Sci Med. 2003;56(5):1013-
1021.
7. Patel V, Pednekar S, Weiss H, et al. Why do women complain of vaginal
discharge? A population survey of infectious and psychosocial risk factors in
a South Asian community. Int J Epidemiol. 2005;34(4):853-862.
8. Bilardi JE, Walker S, Temple-Smith M, et al. The burden of bacterial vaginosis:
women’s experience of the physical, emotional, sexual and social impact of
living with recurrent bacterial vaginosis. PLOS One. 2013;8(9):e74378.
9. Suresh A, Rajesh A, Bhat RM, Rai Y. Cytolytic vaginosis: a review. Indian J Sex
Transm Dis. 2009;30(1):48-50.
10. Bowen-Simpkins P. Which patients with vaginal discharge should be
referred? Practitioner. 2008;252(1704):18,21-22,24.
 Primary care management of women with persistent vaginal discharge
11. Parma M, Stella Vanni V, Bertini M, Candiani M. Probiotics in the
prevention of recurrences of bacterial vaginosis. Altern Ther Health Med.
2014;20(suppl 1):52-57.
12. Larsen B, Monif GR. Understanding the bacterial flora of the female genital
tract. Clin Infect Dis. 2001;32(4):e69-e77.
13. Rebar RW. Premature ovarian failure. Obstet Gynecol. 2009;113(6):1355-1363.
14. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Disease
Treatment Guidelines. www.cdc.gov/std/tg2015/vaginal-discharge.htm.
15. Fischer G, Bradford J. Persistent vaginitis. Br Med J. 2011;343:1169-1173.
16. Evans AL, Scally AJ, Wellard SJ, Wilson JD. Prevalence of bacterial vaginosis
in lesbians and heterosexual women in a community setting. Sex Transm
Infect. 2007;83(6):470-475.
17. Marrazzo JM, Coffey P, Bingham A. Sexual practices, risk perception and
knowledge of sexually transmitted disease risk among lesbian and bisexual
women. Perspect Sex Reprod Health. 2005;37(1):6-12.
18. Carroll M, Horne G, Antrobus R, Fitzgerald C, Brison D, Helbert M. Testing
for hypersensitivity to seminal fluid-free spermatozoa. Hum Fertil (Camb).
2013;16(2):128-131.
19. Berry M. Vaginal infections: an overview. Pharm Pract. 2005;21(9):S1-S8.
20. Bond S, Horton LS. Management of postmenopausal vaginal symptoms in
women. J Gerontol Nurs. 2010;36(7):3-7.
21. Neale R, Knight I, Keane F. Do users of the intrauterine system (Mirena)
have different genital symptoms and vaginal flora than users of the
intrauterine contraceptive device? Int J STD AIDS. 2009;20(6):423-424.
22. Connor CJ, Eppsteiner EE. Vulvar contact dermatitis. Proc Obstet Gynecol.
2014;4(2):1-14.
23. Sobel JD, Nyirjesy P, Kessary H, Ferris DG. Use of the VS-sense swab in diag-
nosing vulvovaginitis. J Womens Health (Larchmt). 2009;18(9):1467-1470.
24. Mania-Pramanik J, Kerkar SC, Mehta PB, Potdar S, Salvi VS. Use of vaginal
pH in diagnosis of infections and its association with reproductive
manifestations. J Clin Lab Anal. 2008;22(5):375-379.
25. Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83(7):807-815.
26. Nyirjesy P, Peyton C, Weitz MV, Mathew L, Culhane JF. Causes of chronic
vaginitis: analysis of a prospective database of affected women. Obstet
Gynecol. 2006;108(5):1185-1191.
27. Cibley LJ, Cibley LJ. Cytolytic vaginosis. Am J Obstet Gynecol. 1991;165(4 Pt
2):1245.
28. Cerikcioglu N, Beksac MS. Cytolytic vaginosis: misdiagnosed as candidal
vaginitis. Infect Dis Obstet Gynecol. 2004;12(1):13.
6 The Nurse Practitioner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
29. Hu Z, Zhou W, Mu L, Kuang L, Su M, Jiang Y. Identification of cytolytic
vaginosis versus vulvovaginal candidiasis. J Low Genit Tract Dis.
2015;19(2):152-155.
30. Cernat G, Leung L. Odorous vaginal discharge: a case study for thorough
investigation. Aust Fam Physician. 2011;40(8):611-613.
31. Schlosser BJ. Contact dermatitis of the vulva. Dermatol Clin. 2010;28(4):
697-706.
32. Richardson MK. What can I do about chronic leukorrhea? Harv Womens
Health Watch. 2010. www.health.harvard.edu.
33. Reimer A, Johnson L. Atrophic vaginitis: signs, symptoms, and better
outcomes. Nurse Pract. 2011;36(1):22-28.
34. Domoney C. Treatment of vaginal atrophy. Womens Health (Lond). 2014;
10(2):191-200.
35. Spevack E. The long-term health implication of Depo-Provera. Integr Med.
2013;12(1):27-34.
36. Mirowski GW, Goddard A. Treatment of vulvovaginal lichen planus.
Dermatol Clin. 2010;28(4):717-725.
37. Santegoets LA, Helmerhorst TJ, van der Meijden WI. A retrospective study
of 95 women with a clinical diagnosis of genital lichen planus. J Low Genit
Tract Dis. 2010;14(4):323-328.
38. Murphy R. Lichen sclerosus. Dermatol Clin. 2010;28(4):707-715.
39. Wehbe-Alamah H, Kornblau BL, Haderer J, Erickson J. Silent no more! The
lived experiences of women with lichen sclerosus. J Am Acad Nurse Pract.
2012;24(8):499-505.
40. Mahal A, Zhang T, Zimmerman MB, Luck A, Bradley CS. Persistent
postoperative granulation tissue following vaginal prolapse repair. Proc
Obstet Gynecol. 2013;3(3):12-13.
41. Steinberg BJ, Mapp T, Mama S, Echols KT. Surgical treatment of persistent
vaginal granulation tissue using CO(2) laser vaporization under
colposcopic and laparoscopic guidance. JSLS. 2012;16(3):488-491.
42. Sobel JD, Reichman O, Misra D, Yoo W. Prognosis and treatment of
desquamative inflammatory vaginitis. Obstet Gynecol. 2011;117(4):350.
Hilary S. Morgan is an assistant professor at Jacksonville University,
Jacksonville, Fla.
The author has disclosed that she has no financial relationships related to this
article.
DOI-10.1097/01.NPR.0000508174.26163.7f