Vulvovaginitis: diagnosing thrush, BV, and other vaginal conditions

What vulvovaginitis is

Vulvovaginitis refers to inflammation of the vulva (external genitalia) and vagina. It is one of the most common presentations in women’s health general practice across all age groups. The pattern of symptoms, the underlying cause, and the appropriate treatment differ substantially between the major categories — which is why assessment and often simple testing before treatment is more effective than empirical management.

The major causes fall into four groups:

• Infectious — bacterial vaginosis (BV), vulvovaginal candidiasis (thrush), trichomoniasis, and occasional others
• Hormonal — atrophic vaginitis after menopause or during breastfeeding
• Dermatological — lichen sclerosus, lichen planus, contact or irritant dermatitis
• Neoplastic — vulvar intraepithelial neoplasia (VIN), vulvar squamous cell carcinoma — uncommon but must not be missed

A. Core clinical — the AU general practice framework

History and examination

A focused history identifies the most likely cause in many cases before any test:

• Discharge character — thin and watery suggests BV; thick, white, cottage-cheese-like suggests thrush; frothy yellow-green suggests trichomoniasis
• Odour — fishy smell strongly suggests BV; thrush has little or no odour
• Itch — predominantly thrush and contact dermatitis; BV causes little itch
• Soreness, dyspareunia — thrush, atrophic vaginitis, lichen sclerosus, lichen planus
• Dysuria — UTI (common differential), trichomoniasis, severe vulvar inflammation
• Sexual history — STI risk assessment determines whether NAAT swabs are indicated
• Contraception, menopausal status, HRT — contextualise hormonal causes
• Antibiotic use — common precipitant of thrush
• Hygiene practices — douching and scented products disrupt vaginal flora and increase BV risk

Examination includes inspection of the external vulva for erythema, excoriation, white skin changes, ulcers, or lumps; speculum examination of the vaginal walls, discharge, and cervix; and vaginal pH testing (pH paper against the lateral vaginal wall — not touching cervical mucus).

Key diagnostic tests

eTG recommends targeted investigation based on the likely diagnosis:

High vaginal swab (HVS) for MCS — identifies BV (clue cells, reduced lactobacilli), Candida species (confirms thrush and identifies non-albicans species in recurrent disease), and aerobic organisms.

pH and whiff test — pH above 4.5 plus a fishy odour on adding potassium hydroxide (KOH whiff test) points to BV. Normal pH (below 4.5) in a woman with itch and discharge strongly suggests thrush.

NAAT (nucleic acid amplification test) for STIs — for chlamydia, gonorrhoea, and trichomoniasis, NAAT swabs from the vagina or first-pass urine are far more sensitive than culture. ASHM guidelines recommend a comprehensive STI screen when trichomoniasis or any co-STI is possible.

Urine dipstick and MSU — when dysuria is a feature, exclude UTI.

HbA1c or fasting glucose — for women with four or more episodes of thrush per year, diabetes is a commonly missed driver.

Vulvar biopsy — essential for any non-healing ulcer, a firm or atypical lump, persistent lesion despite treatment, or white skin changes where lichen sclerosus or VIN is possible. Biopsy is also the standard for confirming lichen sclerosus at baseline. This can be performed by a trained GP or referred to a gynaecologist or dermatologist.

Cause-specific management

Bacterial vaginosis

First-line per eTG: metronidazole 400 mg twice daily for 7 days orally. Alternatives include topical metronidazole vaginal gel or intravaginal clindamycin cream for women who prefer to avoid oral medication. A metronidazole 2 g single oral dose is an option when adherence to a 7-day course is a concern, though the 7-day course has better cure rates.

In pregnancy, symptomatic BV should be treated — metronidazole at standard doses is considered safe from the second trimester.

For recurrent BV (3 or more episodes per year), a longer initial course followed by suppressive metronidazole gel twice weekly for 4–6 months can reduce recurrence. Women who have sex with women may benefit from partner treatment. Vaginal probiotics containing Lactobacillus rhamnosus and L. reuteri have modest supporting evidence as adjuncts to reduce recurrence. Stopping douching, avoiding scented products, and quitting smoking all reduce recurrence risk.

Vulvovaginal candidiasis (thrush)

For uncomplicated thrush in non-pregnant women, fluconazole 150 mg orally as a single dose is first-line and is available without prescription in Australia. A clotrimazole 500 mg vaginal pessary (single dose) or a 6–7-day topical clotrimazole cream plus pessary combination are equally effective alternatives.

Recurrent thrush (four or more episodes per year) requires induction and maintenance therapy: eTG recommends fluconazole 150 mg every 72 hours for three doses (induction) followed by fluconazole 150 mg weekly for 6 months (maintenance). Before starting maintenance, confirm with a swab that Candida albicans is the causative organism — non-albicans species such as Candida glabrata are intrinsically resistant to fluconazole and require specialist management with compounded boric acid 600 mg vaginal pessaries for 14 nights.

In pregnancy: avoid oral fluconazole, particularly in the first trimester. Topical clotrimazole for 7 days is recommended.

Trichomoniasis

Trichomoniasis is a sexually transmitted infection caused by the protozoan Trichomonas vaginalis. It produces a frothy, yellow-green discharge with vulvar soreness and the characteristic “strawberry cervix” appearance. Diagnosis requires a NAAT swab (far more sensitive than wet microscopy). Per ASHM guidelines: metronidazole 2 g as a single oral dose, with partner notification and treatment essential — untreated partners will re-infect. A comprehensive STI screen is indicated for any confirmed trichomoniasis diagnosis.

Atrophic vaginitis (genitourinary syndrome of menopause)

After menopause, falling oestrogen causes the vaginal epithelium to thin, reducing lubrication and raising vaginal pH. This leads to dryness, burning, dyspareunia, and sometimes urgency and recurrent UTIs. Topical vaginal oestrogen is the most effective treatment.

Available Australian formulations include:

• Vagifem 10 mcg pessary — inserted nightly for 2 weeks then twice weekly long-term
• Estring vaginal ring — replaced every 3 months
• Ovestin cream — applied externally or intravaginally

Systemic absorption from these low-dose formulations is very low. Jean Hailes for Women’s Health advises that topical vaginal oestrogen is safe for the majority of women, including most women with a history of oestrogen-receptor-positive breast cancer — oncology review is recommended for individual guidance.

Non-hormonal options — vaginal moisturisers used regularly (every 2–3 days) and water-based lubricants used during sex — are effective adjuncts or alternatives for women who prefer to avoid oestrogen.

Lichen sclerosus

Lichen sclerosus is a chronic autoimmune dermatosis producing white, thin, wrinkled skin on the vulva, perianal skin, and sometimes the inner labia. Long-standing disease causes progressive scarring that can narrow the vaginal opening. The 5% lifetime risk of vulvar squamous cell carcinoma at affected sites makes consistent treatment and regular surveillance essential.

AMH and the Australasian College of Dermatologists recommend:

• Clobetasol propionate 0.05% cream as first-line treatment — applied daily for 4–12 weeks (induction), then reduced to a maintenance frequency of 1–2 times weekly long-term
• Emollients for daily skin care and symptom relief
• Biopsy at baseline for histological confirmation
• Lifelong dermatology or gynaecology follow-up, typically 6–12 monthly, for SCC surveillance
• Clobetasol is Authority Required on the PBS for severe inflammatory dermatosis

Any persistent ulcer, firm nodule, or non-healing area in a patient with lichen sclerosus warrants urgent biopsy and specialist review.

B. Evidence summary — getting the diagnosis right

The most common error in managing vulvovaginitis is empirical treatment for thrush when BV or another cause is present. Studies consistently show that about one-third of women who self-diagnose and self-treat for thrush actually have BV or another condition — leading to delayed diagnosis, unnecessary antifungal use, and potential fluconazole resistance.

Key evidence points:

• eTG recommends swab confirmation when thrush is recurrent, atypical, or fails first-line treatment
• Non-albicans Candida species (glabrata, krusei) account for up to 20% of recurrent VVC and do not respond to fluconazole — species identification changes management
• Trichomoniasis NAAT has approximately 95–99% sensitivity versus under 60% for wet microscopy — wet microscopy alone is insufficient when trichomoniasis is possible
• Vaginal probiotics have reasonable evidence for reducing BV recurrence as an adjunct, but insufficient evidence to replace antibiotic treatment
• Topical vaginal oestrogen for atrophic vaginitis has strong evidence for symptom relief, reduced UTI recurrence, and improved quality of life

C. Avoiding the things that make it worse

Several common practices worsen or precipitate vulvovaginitis:

Douching — the vagina is self-cleaning. Douching with water or commercial products disrupts the Lactobacillus-dominant flora and strongly increases BV risk.

Scented products — perfumed soaps, panty liners, deodorants, and wipes are frequent triggers for contact dermatitis and can precipitate or worsen vulvar inflammation. Use plain water or a non-perfumed soap on the external vulva only.

Antibiotics — any antibiotic course can precipitate a thrush episode by reducing bacterial competitors of Candida. Women prone to thrush can use a single prophylactic fluconazole dose at the start and end of an antibiotic course.

Tight synthetic clothing — traps heat and moisture; cotton underwear and loose-fitting clothing reduce vulvar maceration.

D. Australian operations — MBS, PBS, and referrals

Standard GP consultation items (23, 36, 44) apply. HVS and NAAT swabs are covered under MBS pathology items (69300 and 69405 range). The GP Chronic Disease Management Plan (GPMP, item 721) and Team Care Arrangements (item 723) apply in chronic conditions including lichen sclerosus and recurrent vulvovaginal disease.

The GPCCMP (items 965/967) — for complex care in general practice — is available for chronic recurrent vulvovaginal conditions including lichen sclerosus, atrophic vaginitis, and recurrent thrush.

PBS access: metronidazole (general schedule); fluconazole 150 mg (over the counter); clotrimazole, miconazole pessaries and cream (over the counter); topical vaginal oestrogen (general schedule); clobetasol 0.05% (Authority Required for severe inflammatory dermatosis — lichen sclerosus qualifies).

When to refer:

• Urgent — suspected vulvar SCC, severe Bartholin abscess, atypical or rapidly changing vulvar lesion
• Same week — possible lichen sclerosus needing biopsy, recurrent or refractory infection, complex STI
• Routine — dermatology or gynaecology for chronic dermatoses, complex atrophic vaginitis management

E. Special populations

Postmenopausal women: vaginal atrophy and lichen sclerosus are both more common after menopause; topical oestrogen and appropriate surveillance address the major management needs.

Pregnancy: avoid oral fluconazole, especially in the first trimester. Metronidazole for BV is used with caution and generally from the second trimester. Cryotherapy and TCA are safe for external warts; topical clotrimazole is safe for thrush.

Women with diabetes: recurrent thrush is common and often the presenting symptom of undiagnosed or poorly controlled type 2 diabetes. Glycaemic optimisation reduces thrush recurrence.

Paediatric vulvovaginitis: usually non-specific in young girls, related to hygiene, and managed with practical advice (avoid bubble bath, use gentle wash, change wet swimmers promptly). Investigations and child protection assessment are indicated if the cause is unclear, symptoms are recurrent, or features suggest possible abuse.

Aboriginal and Torres Strait Islander women: trichomoniasis rates are higher in some remote communities. STI screening as part of comprehensive care at ACCHS services is important, and culturally safe approaches support engagement.

Women who have sex with women: BV risk is higher; partner treatment for BV in this group has evidence and should be discussed.

When to escalate

See your GP urgently if you notice:

• A vulvar lump, ulcer, or non-healing skin lesion — needs biopsy
• Rapidly worsening pain, fever, and vulvar swelling — possible Bartholin abscess or Fournier’s necrotising fasciitis
• Symptoms that recur despite two courses of appropriate treatment
• Visible white skin changes on the vulva that persist — possible lichen sclerosus

What this article is and is not

This is general health information drawn from eTG, ASHM Australian STI Management Guidelines, AMH, Jean Hailes for Women’s Health, and the Australasian College of Dermatologists. It does not constitute personal medical advice. Decisions about treatment, investigation, and referral are made with your own GP.

Australian consumer resources: HealthDirect — Vulvovaginitis, Jean Hailes for Women’s Health, Better Health Channel.

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Sources cited

1. eTG complete — Antibiotic: Vaginal infections
2. ASHM Australian STI Management Guidelines
3. Jean Hailes for Women’s Health
4. Australian Medicines Handbook (AMH)
5. Australasian College of Dermatologists — Lichen sclerosus
6. PBS — antifungals, vaginal oestrogen, clobetasol
7. MBS Online
8. HealthDirect — Vulvovaginitis
9. Better Health Channel
10. RACGP — Women’s health