Vaginitis Differential & Treatment in Primary care
Vaginal discharge, itching, burning, and irritation are common primary care complaints—but BV, yeast, trichomoniasis, cervicitis, and even normal physiologic discharge can have overlapping presentations. The challenge is knowing what questions to ask, what to look for on exam, and which testing will actually help you determine the cause.
In this episode, I walk through my approach to evaluating vaginitis in primary care, including the key history and exam, common causes of vaginal symptoms, how to use vaginal pH and microscopy, and treatment for BV, yeast, and trichomoniasis.
2026 Update: This episode was recorded in 2020 and reviewed for clinical accuracy in 2026. The overall approach in this episode remains useful, but a few recommendations have changed— see the Clinical Updates 2026 below the video.
For the current step-by-step approach to evaluating, testing, and treating common causes of vaginitis, see the updated Vaginitis Cheat Sheet in the Digital NP Binder.
Watch
What I Covered in This Episode
The key history questions to ask when a patient presents with vaginal discharge or irritation
How to distinguish BV, yeast, and trichomoniasis
Other causes to consider, including STIs/cervicitis, PID, retained foreign body, and physiologic discharge
What to look for during the pelvic exam
How vaginal pH, wet mount, KOH, and the whiff test help narrow the diagnosis
First-line treatment options for BV, yeast, and trichomoniasis
When recurrent or persistent symptoms need further evaluation
Clinical Updates as of 2026
The overall approach in this episode remains useful, but a few recommendations have changed:
Trichomoniasis treatment has changed. For assigned female at birth (AFAB) patients, the recommended metronidazole regimen is 500 mg twice daily for 7 days rather than the single 2 g dose discussed as an option in this episode.
Partner management is important with trichomoniasis. Current partners should be treated, patients should abstain from sex until they and their partners have completed treatment and symptoms have resolved, and sexually active AFAB patients should be retested in about 3 months.
Avoiding alcohol with metronidazole is no longer routinely recommended based on concern for a disulfiram-like reaction.
Keep cervicitis/STIs and other diagnoses in the differential. Vaginal symptoms can overlap with gonorrhea, chlamydia, PID, genital lesions, and noninfectious vulvovaginal conditions, so broaden the evaluation when the presentation doesn't fit uncomplicated vaginitis.
For the current step-by-step approach to evaluating, testing, and treating common causes of vaginitis, see the updated Vaginitis Cheat Sheet in the Digital NP Binder.
Key Takeaways
Not all vaginal discharge is abnormal. Start by determining whether there's actually been a change from the patient's baseline and whether other vulvovaginal symptoms are present.
BV, yeast, and trichomoniasis are common—but don't stop the differential there. Consider cervicitis/STIs, PID, a retained foreign body, and noninfectious causes based on the presentation.
Don't diagnose BV, yeast, or trichomoniasis from the discharge description alone. Use vaginal pH plus wet mount/KOH microscopy when available, or a vaginitis molecular/NAAT panel. If microscopy is negative but suspicion remains, consider more sensitive testing—especially for trichomoniasis or yeast. A routine vaginal bacterial culture does not diagnose the common causes of vaginitis.
Pay attention to findings that don't fit uncomplicated vaginitis. Pelvic pain, cervical motion tenderness, abnormal bleeding, cervical findings, or genital lesions should prompt evaluation for another or additional diagnosis.
If symptoms persist or recur, reassess the diagnosis rather than repeatedly treating presumed BV or yeast without further evaluation.
Want a Quick Reference for Vaginitis Visits?
The Vaginitis Cheat Sheet gives you a step-by-step approach to evaluating vaginal discharge and vulvovaginal symptoms—including key history questions, red flags, the exam, testing for BV, yeast, and trichomoniasis, when to consider STIs or another diagnosis, and first-line treatment options. Get the Vaginitis Cheat Sheet in the Digital NP Binder.
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0:00
well hey there it's Liz Rohr from real
0:01
world MP and you're watching MP practice
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made simple the weekly videos to help
0:05
save you time frustration and help you
0:07
learn faster so you can take the best
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care of your patients so in this video
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I'm gonna be talking about the top
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differential diagnoses and when it comes
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to vaginitis how to know the differences
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between them and then the main
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treatments going forward a lot of
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clinical pearls as well as pitfalls to
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important notes so Before we jump in
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number one is that there's a cheat sheet
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that goes along with this video so you
0:26
can pause download it now if you haven't
0:28
already printed out keep it at your desk
0:29
easy reference goes along with all the
0:31
topics that we're talking about here a
0:32
little bit a little bit more information
0:34
there as well and then the second note
0:36
is that the lab interpretation crash
0:38
course for new nurse practitioners opens
0:39
next week and I'm super excited so if
0:42
you're struggling with labs either as a
0:43
brand new grad or if you've been in
0:44
practice for a while it goes over the
0:46
main labs in primary care so CBC CMP TSH
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lip is urinalysis and then a brand new
0:51
endocrine module that's the main topics
0:53
in primary care including low
0:54
testosterone and PCOS things like that
0:56
so if you're interested in joining us
0:58
head over to real world NP comm slash
1:00
labs you can hop on the waitlist and
1:02
then you'll get an email when enrollment
1:04
opens it's only open a couple times a
1:06
year so definitely head over there if
1:07
you're interested so a lot of your
History
1:09
information is gonna come from the
1:10
history I don't know where this quote
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came from that 80% of your diagnosis
1:13
comes from history but I find that it's
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totally true and so specific to
1:17
vaginitis I'm looking down here me know
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so I don't forget anything one of the
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things about it is that it's a very
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sensitive topic and a lot of people are
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really embarrassed not only to be there
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for that problem but to disclose a lot
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of information about it and so
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especially patients will wait a really
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long time before they actually get care
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for it because they're typically
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prioritizing other people and that's a
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gross generalization but it happens so
1:40
often or they're just too embarrassed to
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come in they know those kinds of things
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so I'll always offer that as an option
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so hung has it been going on for days
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weeks months you know longer than that
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just so I don't make them feel
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embarrassed and they also feel safe
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enough to disclose that another thing is
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that I offer the typical symptoms that
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I'm looking for because sometimes people
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don't want to talk about that either so
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is their owner is they're eating is it
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just discharged if they have abdominal
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pain - burning when they pee like things
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like that and a couple of other touchy
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history questions but it's really
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important that you ask all of these
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because it's very
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informative one of them is Heather's
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happened before how often has it
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happened is it recently because then
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you're kind of getting into the area of
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like recurrent infections and recurrent
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infections are treated a little bit
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differently than other ones sexual
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health history getting a comprehensive
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sexual health history as possible so I
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definitely plan on making another video
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specifically about that because there's
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I don't feel like nationally or maybe
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even internationally we're doing a very
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good job talking well this is a topic
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and especially as a brand-new grad can
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be very uncomfortable and I typically
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always blush but I'm talking anyway with
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patients and that's fine because you
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know what it's better to ask them to not
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ask and they're more comfortable you can
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be with asking those particular
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questions the more comfortable they're
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going to be and the less like sheepish
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you're gonna be about it but anyway to
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be continued I plan on making another
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video about that privately so definitely
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hang out on the email list if you're
3:05
interested in watching that one you
3:07
always want to ask what the use of
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contraceptives you know are they taking
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oral contraceptives but they have an IUD
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because that can definitely have some
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impact on vaginitis or the current
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vaginitis using use of panty liners and
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so maybe this is just the populations
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that I've been working with but I think
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a lot of people use panty liners every
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single day which can reduce the airflow
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in the area would predispose people to
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things like BV I always asked about
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soaps that they're using any scented
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things that they're dishing at all like
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all of that stuff can throw off the pH
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vaginally and then haven't used any
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over-the-counter treatments so far so
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have they used like a like a yeast
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treatment suppository because that's
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gonna impact your testing and your
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treatment going forward and then one
Diagnosis
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other thing to think about if it's very
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classic or they're very forthcoming with
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their symptoms this might not be as
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something you have to ask about but
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sometimes if it's really unclear you
4:00
want to ask like you know are your
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symptoms more on the outside are they on
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the inside is it the whole thing like
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you can kind of like figure out exactly
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what's going on so because when it comes
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to the differential diagnosis there's
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like a top three that are most common
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but the actual list laundry list is
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really long of possible options so top
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diagnoses you probably learned a lot of
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this in school but this is going to be
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hopefully a refresher and very practical
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hands-on way to
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incorporate this in your practice and so
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the top ones that are seen in primary
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care are vector of vaginosis yeast Turku
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bonus those are the top three infectious
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ones the ones that I see additionally
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are foreign bodies so things like
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retained tampons and then cervicitis you
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always want to think about improv I keep
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wanting to say peripheral arterial
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disease but pelvic inflammatory disease
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whenever you're thinking about sexually
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transmitted infections you always want
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to think about PID as well and
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cervicitis doesn't necessarily cause of
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vaginitis but it can cause a nonspecific
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vaginal discharge that you would only
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kind of figure out based on their
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history of symptoms and then their
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physical exam so diagnosis so how do you
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approach diagnosis so it's really
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important to get that comprehensive
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sexual health history to assess their
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risk for sexually transmitted infections
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and consider doing that as part of your
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workup if they are at risk however the
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steps kind of going forward there's some
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really simple tools that you can use to
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really help you especially if you don't
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have access to testing and so when it
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comes to the top three BV trichomonas
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and yeast so a couple things can really
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help you first one is pH and so if you
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have pH paper what you can do is just
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test the pH of the vaginal secretions
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and is it high normal or low so if it's
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on the higher side that's more
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consistent with bv & trichomonas they
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basically look exactly the same
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fortunately or unfortunately there are
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similar treatments as well whereas he
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used is slightly on the lower side
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versus if it's normal one other thing
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that I didn't mention in the
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differentials is that it's likely it
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could be normal because I am very
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passionate about women's health for a
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number of reasons but I get really fired
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up talking about lack of understanding
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and knowledge and shame when it comes to
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these type of issues and so people don't
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necessarily know what physiologic
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discharges so that's something to kind
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of consider in your differential
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diagnosis you might need to kind of do
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some education there but the pH paper is
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your is a great first step and they can
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kind of point you in the one direction
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or the other the next one is using
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potassium hydroxide the Koh that little
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tiny bottle and when you have a sample
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you can put the pewte the Koh bottle on
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there breaks open the cells and releases
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an Emmy and odor am i an e or a fishy
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odor and that will point you in the
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direction of a BV or a trichomonas
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whereas if it doesn't have
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in order it's less likely to be that one
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so stepping back a little bit there's
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something called AM Souls criteria I
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wish to sound real fancy if you talk
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about it like that but that's basically
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on the criteria that you can use to
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diagnose BV clinically meaning just
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looking at a patient physically doing a
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physical exam so one is like a thin
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whitish grey ash discharge to is a high
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pH 3 is the amine odor when using that
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Koh whiff test and then 4 is clue cells
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on microscopy and so you might not
7:08
necessarily feel comfortable with gotta
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cross compete or have access to that so
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if you have those first three then that
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is suggestive of BB when it comes to
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used technically a low pH is consistent
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with that it may also have like a
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whitish clumpy appearance in terms of
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discharge on physical exam however it's
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technically to diagnose it you're
7:26
supposed to be able to see it on culture
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you'll definitely see a lot of
7:30
real-world practice people diagnosing it
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just by looking at it and based on their
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symptoms there's itching and stuff like
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that and it doesn't have the other signs
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and symptoms of BV then people will
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treat it kind of clinically without that
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test I think to possum to pitfalls I
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want to want you to be aware of one is
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that BV can present as a whitish clumpy
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discharge and have that positive amine
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odor and not have any yeast in there
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fun fact I've seen that a number of
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times and then to is that when people
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talk about testing they don't
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necessarily know what to test so what
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tests can you do if you're not doing
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that clinical diagnosis one it depends
8:05
on the lab that you work with
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but there's specific a vaginitis panel
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that it requires its own type of swab
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and I can't really talk to that because
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there are so many different laboratories
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but that's something you want to think
8:15
about going forward people will I've
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definitely seen this pitfall a lot of
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people sending out a regular like a
8:20
aerobic culture to it's like a red top
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or a blue top and thinking if they send
8:25
that out for a culture when it comes
8:27
back as something like gardnerella
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that's gonna be consistent with
8:30
bacterial vaginosis but that is not the
8:32
case BV is just a dysbiosis and
8:35
imbalance of the normal flora and so you
8:37
cannot diagnose it with an anaerobic
8:38
culture it could be suggestive that
8:40
gardnerella predominance
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could be consistent with BV however
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please don't use it baby not type of -
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so but the good news is if you use the
8:49
koh and you use the
8:50
each paper you're you're well on your
8:52
way to making a diagnosis when it comes
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to trichomonas it's very similar to BV
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all this information is in the handout
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down below if you feel like this is like
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way too much information but trichomonas
9:00
the main differentiator is that you can
9:03
see those those little guys on
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microscopy if you do microscopy but you
9:07
can also do one of those nucleic
9:09
amplification tests or those rapid
9:11
antigen tests there are rapid tests that
9:13
you can do in the clinic they're about
9:14
they're mostly they're mostly since that
9:16
have been specific so yeah when it comes
Treatment
9:18
to the main treatment I mean the
9:19
differential list is actually quite a
9:21
lot longer than that but again it's on
9:22
that sheet sheet down below and if it's
9:24
not if it's not matching up those
9:26
classic ways of your first past okay
9:28
yeast or BV or trichomonas or a service
9:31
situs of some kind or a foreign body
9:32
then you can kind of take those next
9:34
paths forward and then always catching
9:36
yourself and being like is this normal
9:38
is this physiologist right do I need to
9:41
educate them on normal odor normal
9:42
appearance etc etc especially I mean it
9:46
actually doesn't matter how old the
9:47
person is I find a lot of younger adults
9:49
need that kind of education and
9:50
knowledge but it doesn't matter how old
9:51
they are quite honestly so the main
9:53
treatment is really just dependent on
9:54
what we're talking about so when it
9:55
comes to bacterial vaginosis vaginosis
9:57
there's a couple different treatments
9:59
there's topical metronidazole and then
10:01
there's oral metronidazole and those are
10:03
both first-line and I just give patients
10:06
the option because it's their bodies and
10:08
you control them so do would you prefer
10:11
a cream or would you prefer it though
10:12
keeping in mind that with oral
10:14
metronidazole you're technically
10:15
supposed to avoid alcohol 24 hours
10:18
before and 48 hours after the entire
10:20
course to prevent this kind of like
10:22
antabuse type of vomiting effect doesn't
10:24
happen with everybody but I always warn
10:26
people of that the the main benefit of
10:29
doing oral metronidazole is that if
10:31
you're not testing for trichomonas you
10:32
could potentially cover them for
10:34
trichomonas trichomonas is typically
10:36
like a one-time 2 gram dose if
10:38
metronidazole or a week long of twice a
10:40
day however keeping in mind if you're
10:42
not treating the partner of somebody
10:43
then they can get it right back again if
10:45
you feel like it is too unless you
10:46
really should test for it the other
10:48
thing to think about when it comes to
10:49
used there are a couple of first-line
10:51
options there all the azole antifungals
10:53
basically and you can either do the oral
10:55
kind or you can do the topical kind and
10:58
the
10:59
isn't necessarily one that's better than
11:00
the other I typically go based on
11:02
insurance keeping in mind that my con is
11:04
ole which is the one that's typically
11:06
over-the-counter can burn for some
11:08
people some people have no problem with
11:09
it but some people it burns and then
11:11
fluconazole is the oral main first-line
11:14
oral regimen that you can even do like a
11:16
one time pill or want one pill over the
11:19
course of a couple of days it's all on
11:21
the cheat sheet down below but um the
11:23
main thing to think about with that is I
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can interact with a number of
11:26
medications so just can't keeping that
11:28
one in mind so hopefully hopefully that
11:31
was helpful let me know if you have any
11:32
questions or if there's any particular
11:33
topics you want to hear about again I'll
11:35
be definitely be working on that central
11:36
health history at some point but yeah if
11:38
you're interested in the lam
11:40
interpretation crash course don't forget
11:41
to sign up at real world and be calm
11:43
slash labs it's coming up super soon and
11:45
I'm super excited for it I'd love to
11:47
have you thank you so much for watching
11:49
hang in there and I'll see you soon
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