Vaginal Discharge

Last updated 1 Jun 2026 · Women's Health / Infectious Disease

📋 Key Information Summary

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Vaginal discharge is physiological (cervical mucus, vaginal transudate, endometrial secretions) or pathological; the character, odour, pH, microscopy, and point-of-care tests differentiate aetiology.
Bacterial vaginosis (BV) is the most common cause of pathological discharge in Australian women of reproductive age (prevalence 10–30%); it is a polymicrobial dysbiosis, not a sexually transmitted infection.
Vulvovaginal candidiasis (VVC) affects ~75% of women at least once; Candida albicans accounts for ~85% of episodes; non-albicans species require alternative therapy.
Trichomoniasis is the most common non-viral STI globally; Australian notification rates are rising, particularly in remote and ATSI communities; treat all sexual partners concurrently.
Chlamydial cervicitis is the most frequently notified STI in Australia; it often presents with increased discharge and is commonly asymptomatic; nucleic acid amplification testing (NAAT) is the gold standard.
Atrophic vaginitis is a leading cause of discharge and dyspareunia in postmenopausal women; vaginal oestrogen is first-line therapy.
First-line BV treatment: oral metronidazole 400 mg BD for 7 days or intravaginal clindamycin 2% cream nightly for 7 days; recurrence rates are high (50% within 12 months).
First-line uncomplicated VVC: fluconazole 150 mg PO stat or intravaginal clotrimazole 500 mg pessary stat; recurrent VVC (≥4 episodes/year) requires induction then maintenance fluconazole.
First-line trichomoniasis: metronidazole 2 g PO stat (or 400 mg BD for 7 days); treat partners; test for concurrent STIs. First-line chlamydia: doxycycline 100 mg BD for 7 days.
A vaginal pH >4.5 suggests BV or trichomoniasis; pH ≤4.5 suggests candidiasis or atrophic vaginitis.
All women with new or multiple sexual partners should be screened for chlamydia and gonorrhoea alongside discharge evaluation.
Aboriginal and Torres Strait Islander women have significantly higher rates of BV, trichomoniasis, and chlamydia; culturally safe, opportunistic screening is essential.

Introduction & Australian Epidemiology

Vaginal discharge is one of the most common presenting complaints in Australian general practice, accounting for approximately 4–5% of all female consultations. While physiological discharge (leucorrhoea) is a normal finding—comprising cervical mucus, vaginal transudate, desquamated epithelial cells, and endometrial secretions—pathological discharge signals infection, hormonal change, or mucosal irritation and warrants systematic evaluation.

The differential diagnosis of pathological vaginal discharge encompasses a broad range of conditions, but in clinical practice five entities account for the vast majority of cases:

Bacterial vaginosis (BV) — the most common cause of vaginal discharge overall, affecting 10–30% of Australian women of reproductive age, with higher prevalence in Aboriginal and Torres Strait Islander communities (up to 50% in some remote settings).
Vulvovaginal candidiasis (VVC) — the second most common cause; approximately 75% of women experience at least one episode in their lifetime, with 5–8% developing recurrent VVC (≥4 episodes per year).
Trichomonas vaginalis infection — an under-recognised STI with rising notification rates in Australia since 2010, particularly in the Northern Territory and Far North Queensland; notified rates in ATSI populations are 10–30 times those of non-Indigenous Australians.
Chlamydial cervicitis — the most commonly notified STI in Australia (over 100,000 notifications annually), disproportionately affecting sexually active women aged 15–29; 70–80% of infections are asymptomatic.
Atrophic vaginitis — a frequent cause of discharge, dryness, and dyspareunia in postmenopausal women, driven by oestrogen deficiency and resulting in mucosal thinning, increased pH, and altered microbiome.

Less common but important causes include gonorrhoccal cervicitis, genital herpes simplex virus (HSV), foreign body (including retained tampon), allergic or irritant vulvovaginitis, and (rarely) malignancy. These must be considered when initial workup for the five main conditions is negative.

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Red-flag features requiring urgent assessment: Fever, pelvic pain, and purulent cervical discharge raise concern for pelvic inflammatory disease (PID) — a gynaecological emergency. Postcoital or intermenstrual bleeding with abnormal discharge may indicate cervical pathology and warrants speculum examination and cervical screening review.

This guideline provides a structured approach to the diagnosis and management of vaginal discharge in Australian primary care, covering the diagnostic model, the four principal pathological causes, and special population considerations including Aboriginal and Torres Strait Islander health.

Vaginal Discharge Diagnostic Model

A systematic, stepwise approach to vaginal discharge integrates history, examination findings, bedside tests, and laboratory investigations. The Australian diagnostic model relies on clinical features combined with vaginal pH testing, saline and KOH microscopy (where available), and point-of-care rapid tests to narrow the differential before definitive treatment.

Step 1: Focused History

Key elements of the history include:

Discharge character: colour (white, yellow-green, grey, blood-stained), consistency (thin, thick, clumpy, frothy), volume, and odour (fishy, yeasty, malodorous).
Associated symptoms: pruritus, dyspareunia, dysuria, lower abdominal pain, intermenstrual or postcoital bleeding.
Sexual history: number of recent partners, new partner, condom use, partner symptoms, history of STIs.
Menstrual & hormonal history: last menstrual period, menopausal status, use of hormonal contraception or HRT, pregnancy status.
Medications: recent antibiotics (predispose to VVC), immunosuppressants, SGLT2 inhibitors (predispose to VVC).
Other: douching practices, soap or product use, history of diabetes mellitus or immunodeficiency.

Step 2: Speculum Examination

A careful speculum examination provides direct visualisation of the vaginal walls, cervix, and discharge. Key features to note:

Feature	Bacterial Vaginosis	Vulvovaginal Candidiasis	Trichomoniasis	Chlamydia / Gonorrhoea
Discharge appearance	Thin, homogeneous, grey-white, coats vaginal walls	Thick, white, curd-like ("cottage cheese")	Yellow-green, frothy, copious	Mucopurulent, yellow, from cervical os
Odour	Fishy (amine odour, enhanced by KOH)	Usually odourless or mildly yeasty	Often malodorous	Often odourless
Vaginal pH	>4.5 (typically 5.0–6.0)	≤4.5 (normal)	>4.5 (typically 5.0–6.5)	Normal (≤4.5)
Vulval signs	Usually none	Erythema, oedema, excoriation, satellite lesions	Vulvitis, "strawberry cervix" (colpitis macularis) in ~2%	Usually normal vulva; cervical friability

Step 3: Point-of-Care & Laboratory Testing

Essential Vaginal pH testing Narrow-range pH paper (4.0–6.0); >4.5 supports BV or trichomoniasis; ≤4.5 suggests VVC or atrophic vaginitis. Available in most GP practices.

Available Wet-mount saline microscopy Detects clue cells (BV), motile trichomonads (trichomoniasis), hyphae/pseudohyphae (VVC). Sensitivity for trichomoniasis ~60–70%; requires immediate reading. Available in many sexual health clinics; limited in general practice.

Available KOH (whiff) test & microscopy 10% KOH releases amine odour from BV discharge (positive whiff test) and reveals yeast forms. Can be combined with saline mount.

Available Amsel criteria (clinical BV diagnosis) ≥3 of 4: (1) homogeneous grey-white discharge, (2) vaginal pH >4.5, (3) positive whiff test, (4) clue cells on microscopy. Specificity ~90% when all four present.

Essential Nugent scoring (Gram stain of vaginal smear) Gold standard for BV diagnosis (score 7–10). Requires laboratory processing; not routinely performed in general practice but useful for recurrent or refractory cases.

Available Point-of-care BV/yeast tests PCR-based multiplex vaginal panels (e.g., BVBlue®, OSOM BV Blue) detect sialidase activity (BV) and may detect Candida. Increasingly available in Australian pharmacies and GP clinics.

Essential NAAT for Chlamydia trachomatis & Neisseria gonorrhoeae First-line test for chlamydia and gonorrhoea (self-collected vaginal swab or clinician-collected endocervical swab). MBS item 69313. Sensitivity >95%. Test all women with new/multiple partners or STI risk factors.

Available NAAT for Trichomonas vaginalis Most sensitive test for trichomoniasis (sensitivity >95%); often bundled with CT/NG multiplex panels. Preferred over microscopy. MBS item 69313 (where multiplexed).

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Self-collected vaginal swabs are recommended by the Australian STI Guidelines for chlamydia and gonorrhoea screening and are preferred by many women. They are equivalent in sensitivity to clinician-collected swabs for NAAT and should be offered as an option.

Step 4: Differential Diagnosis Algorithm

pH >4.5 + Fishy odour + Thin grey discharge

Likely bacterial vaginosis. Confirm with Amsel criteria or Nugent score. If frothy/yellow-green, also test for Trichomonas.

pH ≤4.5 + White clumpy discharge + Pruritus

Likely vulvovaginal candidiasis. KOH microscopy to confirm. Consider culture if recurrent or treatment failure.

pH >4.5 + Yellow-green frothy discharge + Multiple partners

Likely trichomoniasis. NAAT preferred; wet-mount if NAAT unavailable. Screen for concurrent STIs.

Mucopurulent cervical discharge + Young sexually active

Likely chlamydia or gonorrhoea. NAAT on self-collected vaginal swab. Screen for both; consider empiric treatment if high suspicion.

Watery discharge + Postmenopausal + Dyspareunia

Likely atrophic vaginitis. Examine for pale, thin vaginal mucosa with petechiae. Exclude infection first. Trial vaginal oestrogen.

Bacterial Vaginosis & Atrophic Vaginitis

Bacterial Vaginosis (BV)

Bacterial vaginosis is a polymicrobial syndrome characterised by a shift from the normal Lactobacillus-dominant vaginal microbiome to a diverse anaerobic community including Gardnerella vaginalis, Atopobium vaginae, Mobiluncus spp., Bacteroides spp., and Mycoplasma hominis. It is not classified as a sexually transmitted infection, although sexual activity is a risk factor.

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BV and adverse reproductive outcomes: Untreated BV in pregnancy is associated with preterm birth, prelabour rupture of membranes (PROM), low birthweight, and postpartum endometritis. Symptomatic BV in pregnancy should be treated; screening and treatment of asymptomatic BV in high-risk pregnant women is recommended by some guidelines.

Risk factors for BV:

New or multiple sexual partners
Douching or vaginal irrigation
Smoking (independent risk factor)
Intrauterine device (IUD) insertion — particularly in the preceding 30 days
Recent antibiotic use
Absence of condom use
Aboriginal and Torres Strait Islander ethnicity (higher baseline prevalence)

Treatment of BV

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Metronidazole (oral)

Flagyl® · Generic · Nitroimidazole antibiotic

Adult dose 400 mg PO BD for 7 days

Paediatric dose Not routinely indicated in prepubertal children; adolescent: adult dose

Renal adjustment No adjustment required (caution if eGFR <10 mL/min; reduce dose)

Hepatic adjustment Reduce dose in severe hepatic impairment; avoid in hepatic encephalopathy

Key counselling Avoid alcohol during treatment and for 24 hours after last dose (disulfiram-like reaction). Metallic taste common.

PBS status ✔ PBS General Benefit

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Clindamycin (intravaginal)

Dalacin V® · Lincosamide antibiotic

Adult dose 2% cream (5 g applicator) intravaginally at night for 7 days

Key counselling Oil-based vehicle may weaken latex condoms and diaphragms for up to 5 days after use. Warn patient regarding this interaction.

PBS status ⚠️ PBS Restricted Benefit

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Clindamycin vaginal ovules

Dalacin V Ovules® · Lincosamide antibiotic

Adult dose 100 mg intravaginally at night for 3 days (alternative to 7-day cream)

PBS status ⚠️ PBS Restricted Benefit

Alternative regimen: Oral clindamycin 300 mg BD for 7 days may be used in women who cannot tolerate metronidazole. Single-dose metronidazole 2 g PO stat is less effective and not recommended as first-line.

Recurrent BV (≥3 episodes in 12 months): Confirm diagnosis (Nugent score), exclude trichomoniasis, consider extended or suppressive metronidazole (vaginal gel 0.75% for 10 days, then twice weekly for 4–6 months). Partner treatment has not been shown to reduce recurrence in randomised trials.

Atrophic Vaginitis

Atrophic vaginitis results from oestrogen deficiency following menopause (natural, surgical, or chemotherapy-induced), lactation, or use of aromatase inhibitors. Thinning of the vaginal epithelium, loss of glycogen, decreased Lactobacillus colonisation, and increased vaginal pH (>5.0) lead to symptoms including vaginal dryness, dyspareunia, watery or blood-stained discharge, urinary urgency, and recurrent urinary tract infections.

Diagnosis is primarily clinical: pale, smooth vaginal mucosa with loss of rugae, petechiae, and friability on speculum examination. Infection should be excluded with swabs before attributing symptoms solely to atrophic changes.

Treatment of Atrophic Vaginitis

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Oestriol (intravaginal cream)

Ovestin® · Oestrogen (oestriol)

Adult dose 1 mg/g cream: 1 applicator (0.5 mg oestriol) intravaginally nightly for 2–4 weeks, then reduce to maintenance (twice weekly)

Key counselling Low systemic absorption with vaginal oestriol; minimal endometrial stimulation. Safe for long-term use. Can be used in women with breast cancer on aromatase inhibitors (discuss with oncologist).

PBS status ✔ PBS General Benefit

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Estradiol (intravaginal pessary)

Vagifem® · Oestrogen (17β-oestradiol)

Adult dose 10 mcg pessary intravaginally nightly for 2 weeks, then twice weekly for maintenance

Key counselling Convenient tablet formulation. Progestogen cover is NOT required for vaginal estradiol at this dose (minimal systemic absorption). Improvement may take 2–4 weeks.

PBS status 🔒 PBS Authority Required

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Estradiol (vaginal ring)

Estring® · Oestrogen (17β-oestradiol)

Adult dose 7.5 mcg/24 hours ring inserted intravaginally; replace every 90 days

Key counselling Suitable for women who prefer infrequent dosing. Self-insertable. Avoid use with pessaries that may dislodge the ring.

PBS status 🔒 PBS Authority Required

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Non-hormonal adjuncts: Vaginal moisturisers (e.g., RepHresh®, Hyalofemme®) used 2–3 times per week provide symptom relief and can be combined with vaginal oestrogen. Water-based lubricants should be recommended for intercourse. These are available OTC in Australian pharmacies.

Vulvovaginal Candidiasis (VVC)

Vulvovaginal candidiasis is the second most common cause of vaginal discharge. It is caused by Candida species colonising the vagina and vulva, most commonly C. albicans (85–90% of episodes). Non-albicans species, particularly C. glabrata (5–10%), are increasingly recognised, especially in recurrent and treatment-refractory cases.

Risk factors for VVC:

Recent broad-spectrum antibiotic use (most common precipitant)
Pregnancy (prevalence 20–40% in third trimester)
Diabetes mellitus (poorly controlled HbA1c)
Immunosuppression (HIV, corticosteroids, chemotherapy)
Combined oral contraceptives (high-oestrogen formulations)
SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin — glycosuria promotes candidal growth)
Tight, non-breathable clothing

Classification of VVC

Uncomplicated

Sporadic VVC

≤3 episodes/year; mild-to-moderate symptoms; C. albicans; non-pregnant; non-immunocompromised

Setting: GP / self-treatment with OTC antifungals

Complicated

Recurrent or Severe VVC

≥4 episodes/year; severe symptoms (extensive erythema, oedema, fissuring); non-albicans species; pregnancy; immunosuppression; diabetes

Setting: GP with specialist referral if recurrent

Refractory

Non-albicans Candidiasis

C. glabrata or other non-albicans species; typically resistant to standard azole therapy; often in immunocompromised or postmenopausal women

Setting: Infectious diseases / gynaecology referral

Treatment — Uncomplicated VVC

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Fluconazole (oral)

Diflucan® · Generic · Triazole antifungal

Adult dose 150 mg PO stat (single dose)

Paediatric dose Not recommended for uncomplicated VVC in children; if required: 6 mg/kg stat (max 150 mg)

Renal adjustment Reduce dose by 50% if eGFR <50 mL/min for repeated doses (single dose generally no adjustment)

Key counselling Avoid in pregnancy (Category D). Minimal drug interactions at single-dose regimen. Effective and convenient — preferred first-line for many patients.

PBS status ✔ PBS General Benefit

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Clotrimazole (intravaginal pessary)

Canesten® · Imidazole antifungal

Adult dose 500 mg pessary intravaginally as a single dose (stat), plus clotrimazole 1% cream BD to vulva for symptom relief

Key counselling Safe in all trimesters of pregnancy. Available OTC. Oil-based pessary vehicle may weaken latex condoms.

PBS status ✔ PBS General Benefit (pessary) · OTC also available

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Miconazole (intravaginal)

Monistat® / Fungilin® · Imidazole antifungal

Adult dose 2% cream (5 g applicator) intravaginally at night for 7 days, or 400 mg pessary at night for 3 days

Key counselling Available OTC. Safe in pregnancy. Cream may be preferred for external vulval symptoms.

PBS status ✔ PBS General Benefit (pessary) · OTC cream

Treatment — Recurrent VVC (≥4 episodes/year)

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Recurrent VVC requires confirmation of diagnosis by vaginal culture before initiating suppressive therapy. Non-albicans species (especially C. glabrata) are more likely in recurrent cases and may not respond to standard fluconazole.

Induction phase: Fluconazole 150 mg PO every 72 hours for 3 doses (days 1, 4, and 7).

Maintenance phase: Fluconazole 150 mg PO weekly for 6 months. Reassess at 6 months; step-down to fortnightly or discontinue with monitoring.

Non-albicans candidiasis (e.g., C. glabrata):

Intravaginal boric acid 600 mg capsule nightly for 14 days (compounded by pharmacist — not PBS-listed)
Intravaginal amphotericin B 50 mg cream nightly for 14 days (compounded)
Refer to infectious diseases or gynaecology for resistant cases

VVC in Pregnancy

VVC is common in pregnancy (20–40% prevalence). Oral fluconazole is contraindicated (Category D in high/repeated doses; teratogenicity concern with first-trimester exposure). Use intravaginal clotrimazole or miconazole — both are safe in all trimesters. Longer courses (7 days) may be needed. Advise the patient that symptoms may recur and to return for reassessment.

Trichomoniasis & Chlamydial Infection

Trichomoniasis

Trichomoniasis, caused by the flagellated protozoan Trichomonas vaginalis, is the most common non-viral sexually transmitted infection worldwide. In Australia, notifications have risen significantly since 2010, with the highest rates in the Northern Territory, Western Australia, and Far North Queensland. It is a notifiable STI in most Australian jurisdictions.

Up to 50% of infections in women are asymptomatic. Symptomatic infection presents with copious yellow-green frothy malodorous vaginal discharge, vulvovaginal irritation, dysuria, and dyspareunia. "Strawberry cervix" (colpitis macularis) — punctate haemorrhages on the cervix — is pathognomonic but seen in only ~2% on naked-eye examination and ~45% on colposcopy.

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All sexual partners must be treated concurrently for trichomoniasis. Reinfection is common if partners are not treated. Advise abstinence from sexual intercourse for 7 days after both partners have completed treatment. Screen for concurrent STIs (chlamydia, gonorrhoea, HIV, syphilis).

Treatment of Trichomoniasis

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Metronidazole (oral — single dose)

Flagyl® · Generic · Nitroimidazole

Adult dose 2 g PO stat (single dose) — preferred first-line per eTG and CDC

Alternative 400 mg PO BD for 7 days (equally effective; preferred if GI side effects anticipated with single dose)

Key counselling Avoid alcohol during and for 24 hours after treatment. Advise partner treatment and STI screening. Treat even if asymptomatic.

PBS status ✔ PBS General Benefit

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Tinidazole (oral)

Fasigyn® · Nitroimidazole

Adult dose 2 g PO stat (single dose) — alternative if metronidazole intolerance

Key counselling Better GI tolerance than metronidazole. Same alcohol avoidance advice. More expensive.

PBS status ✔ PBS General Benefit

Metronidazole-resistant trichomoniasis: Uncommon (~2–5%). Options include higher-dose metronidazole (500 mg PO TDS for 7 days or intravaginal metronidazole 500 mg BD for 7 days in combination with oral), or referral for intravaginal paromomycin. Infectious diseases specialist advice is recommended.

Chlamydial Infection

Chlamydia trachomatis is the most commonly notified STI in Australia, with over 100,000 notifications annually. Rates have been increasing year-on-year and are highest among sexually active women aged 15–29. Most infections (70–80%) are asymptomatic; untreated infection can lead to pelvic inflammatory disease (PID), tubal factor infertility, and ectopic pregnancy.

Symptomatic cervicitis presents with increased vaginal discharge (often mucopurulent), postcoital bleeding, intermenstrual bleeding, and dysuria. Examination may reveal mucopurulent cervical discharge and cervical friability (easily induced bleeding on swabbing).

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Screen all sexually active women under 30 years for chlamydia annually. RACGP Red Book recommends opportunistic chlamydia screening for all sexually active people aged 15–29. Self-collected vaginal swabs are equally sensitive as clinician-collected swabs for NAAT testing.

Treatment of Chlamydial Infection

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Doxycycline

Doxy® · Generic · Tetracycline antibiotic

Adult dose 100 mg PO BD for 7 days — first-line per eTG and Australian STI guidelines

Paediatric dose Adolescent ≥12 years: adult dose. Weight <45 kg: 2.2 mg/kg BD for 7 days

Renal adjustment No adjustment required

Key counselling Take with food and water; remain upright for 30 min after dose. Avoid dairy products within 2 hours. Photosensitivity — use SPF 50+. Avoid in pregnancy (Category D).

PBS status ✔ PBS General Benefit

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Azithromycin

Zithromax® · Generic · Macrolide antibiotic

Adult dose 1 g PO stat (single dose) — reserved for situations where doxycycline is contraindicated or adherence is a concern

Paediatric dose 20 mg/kg stat (max 1 g)

Key counselling Take on empty stomach for optimal absorption. GI side effects common (nausea, diarrhoea). Safe in pregnancy (Category B1). Note: doxycycline is preferred first-line due to increasing azithromycin resistance concerns for urogenital chlamydia.

PBS status ⚠️ PBS Restricted Benefit

Chlamydia in pregnancy: Azithromycin 1 g PO stat is first-line (doxycycline is contraindicated). Amoxicillin 500 mg PO TDS for 7 days is an alternative if azithromycin is not tolerated.

Partner notification: All sexual partners from the preceding 6 months (or the most recent partner if >6 months) should be notified, tested, and treated. Patient-delivered partner therapy (PDPT) is available in some Australian jurisdictions for chlamydia — check local regulations. For trichomoniasis, direct partner treatment is essential to prevent reinfection.

Test of cure: Not routinely recommended for chlamydia if treated with doxycycline for 7 days. Recommended at 4 weeks post-treatment if treated with azithromycin (single dose), in pregnancy, or if adherence is uncertain. For trichomoniasis, test of cure by NAAT at 2 weeks is recommended in all cases given rising resistance.

Quick Reference — First-Line Regimens

Bacterial Vaginosis

Metronidazole 400 mg PO BD

7 days

Or clindamycin 2% cream PV nocte × 7 nights

Uncomplicated VVC

Fluconazole 150 mg PO stat

Single dose

Or clotrimazole 500 mg pessary PV stat

Recurrent VVC

Fluconazole 150 mg PO

Induction: every 72 h × 3; then weekly × 6 months

Confirm with culture first; exclude non-albicans species

Trichomoniasis

Metronidazole 2 g PO stat

Single dose

Treat partners; test of cure at 2 weeks

Chlamydia

Doxycycline 100 mg PO BD

7 days

Azithromycin 1 g stat if adherence concern / pregnancy

Atrophic Vaginitis

Oestriol 0.1% cream PV nocte

2–4 weeks induction, then twice weekly

Or Vagifem® 10 mcg PV (Authority Required)

Monitoring & Follow-Up

Follow-up requirements vary by diagnosis:

Condition	Follow-Up	Test of Cure	Re-screening
BV	If symptoms recur; no routine follow-up if asymptomatic	Not routinely required	N/A
VVC	Review at 4–6 weeks if recurrent VVC; otherwise return PRN	Not required for uncomplicated VVC	N/A
Trichomoniasis	Review 2 weeks post-treatment	NAAT at 2 weeks — recommended for all patients	Re-test at 3 months (reinfection risk)
Chlamydia	Review 1–2 weeks post-treatment for counselling	At 4 weeks if azithromycin used, pregnancy, or adherence uncertain	Re-test at 3 months (reinfection risk; recommended for all)
Atrophic vaginitis	Review at 6–8 weeks for treatment response	N/A	Ongoing maintenance with vaginal oestrogen

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Reinfection vs. treatment failure: For both trichomoniasis and chlamydia, reinfection is more common than true treatment failure. A positive test of cure should prompt assessment of partner treatment and sexual exposure history before considering resistance or alternative therapy.

Special Populations

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Pregnancy

BV in pregnancy

Oral metronidazole 400 mg BD × 7 days is safe in all trimesters. Treat symptomatic BV to reduce risk of preterm birth. Screening/treatment of asymptomatic BV in high-risk pregnancies (history of preterm birth) may be considered — discuss with obstetrician.

VVC in pregnancy

Intravaginal clotrimazole or miconazole is first-line. Avoid oral fluconazole (Category D). Use 7-day courses for adequate response. VVC is more common in pregnancy and may recur.

Trichomoniasis in pregnancy

Metronidazole is not contraindicated in pregnancy (Category B2/A in Australian classification). Treat with 400 mg BD × 7 days. Benefits of treatment outweigh theoretical risks.

Chlamydia in pregnancy

Azithromycin 1 g PO stat is first-line (doxycycline is contraindicated — Category D). Amoxicillin 500 mg PO TDS × 7 days is an alternative. Test of cure is mandatory at 4 weeks in pregnancy.

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Paediatrics & Adolescents

Prepubertal girls

Vaginal discharge is common and usually physiological or due to vulvovaginitis (poor hygiene, irritants, group A strep). STIs in prepubertal children raise safeguarding concerns — consider sexual abuse and follow jurisdiction-specific mandatory reporting requirements. BV and VVC are uncommon before menarche.

Adolescents (15–19 years)

Highest chlamydia notification rates in Australia. Annual chlamydia screening recommended for all sexually active adolescents. Treat as per adult guidelines with age-appropriate doses. Consider PDPT for chlamydia. Discuss confidentiality and youth-friendly service access.

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Elderly / Postmenopausal

Atrophic vaginitis

The most common cause of vaginal discharge in postmenopausal women. Vaginal oestrogen is first-line. Non-albicans candidiasis (especially C. glabrata) is more prevalent in this age group. Always exclude malignancy if discharge is blood-stained or persistent.

Drug interactions

Metronidazole interacts with warfarin (increased INR) and lithium. Fluconazole interacts with statins, warfarin, and many other medications via CYP2C9/3A4 inhibition. Review medications before prescribing.

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Renal Impairment

Metronidazole

Active metabolites accumulate in severe renal impairment (eGFR <10). Consider dose reduction or alternative (intravaginal clindamycin for BV). Monitor for neurotoxicity.

Fluconazole

Reduce dose by 50% if eGFR <50 mL/min for repeated doses. Single 150 mg dose generally requires no adjustment. Doxycycline requires no renal adjustment.

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Hepatic Impairment

Metronidazole

Reduce dose in severe hepatic impairment. Avoid in hepatic encephalopathy (risk of accumulation of neurotoxic metabolites).

Fluconazole

Use with caution; hepatotoxicity risk. Monitor LFTs if prolonged courses. Doxycycline is safe in hepatic impairment.

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Immunocompromised

HIV-positive women

Higher prevalence and recurrence rates for VVC, BV, and trichomoniasis. Fluconazole 150 mg PO weekly may be needed for recurrent VVC. Trichomoniasis may require prolonged treatment. STI screening should be comprehensive.

Immunosuppressive therapy

Corticosteroids, biologics, and chemotherapy increase VVC risk. Non-albicans species are more common. Consider vaginal cultures for resistant cases. SGLT2 inhibitors (empagliflozin, dapagliflozin) increase VVC risk via glycosuria.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander women experience significantly higher rates of vaginal discharge-related infections compared with non-Indigenous Australians. This is driven by a complex interplay of biological, social, and structural determinants of health. Clinicians providing care to Aboriginal and Torres Strait Islander women must apply a culturally safe, strengths-based approach that acknowledges these disparities without stereotyping individual patients.

Key epidemiological disparities:

BV prevalence in remote Aboriginal communities ranges from 30–50%, approximately double the rate in non-Indigenous urban populations.
Trichomoniasis notification rates in Aboriginal and Torres Strait Islander peoples are 10–30 times those of non-Indigenous Australians, with the highest burden in the Northern Territory and remote Western Australia.
Chlamydia notification rates are 3–5 times higher in Aboriginal and Torres Strait Islander populations, with the greatest disparity in the 15–24-year age group.
Recurrent BV and trichomoniasis contribute to higher rates of PID, tubal infertility, and adverse pregnancy outcomes in Aboriginal and Torres Strait Islander women.

Access & remoteness

Many remote communities have limited access to primary care clinicians with gynaecological skills. Point-of-care testing (e.g., BVBlue®, rapid NAAT platforms) can reduce diagnostic delays. Telehealth sexual health consultations with remote specialists are increasingly available.

Cultural safety

Vaginal discharge is a sensitive topic. Use plain, non-judgemental language. Offer a female clinician where possible. Involve Aboriginal and Torres Strait Islander health workers (AHPs/AHWs) in health promotion and follow-up. Avoid assumptions about sexual behaviour.

Partner notification

Partner notification in small communities requires particular sensitivity to avoid stigma and breaches of confidentiality. Patient-delivered partner therapy (PDPT) may improve treatment uptake where partner attendance is difficult. Involve sexual health services and AHPs.

Antimicrobial access

Medication access in remote communities may depend on Health Centre stock. Oral metronidazole and azithromycin are commonly stocked. Ensure adequate supply for complete courses. Supervised dosing may be appropriate if desired by the patient.

Screening & follow-up

Opportunistic screening for chlamydia should be offered at every health assessment, antenatal visit, and contraception consultation. Annual chlamydia screening is recommended for sexually active women under 30. Follow-up for test of cure requires recall systems — use electronic health records and community health worker follow-up.

Social determinants

Overcrowded housing, limited access to water and sanitation, and disrupted health literacy pathways are upstream drivers of higher STI and BV rates. Holistic, trauma-informed care that addresses these determinants alongside clinical treatment is essential.

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Strengths-based approach: Aboriginal and Torres Strait Islander health workers and community-controlled health organisations (ACCHOs) are central to culturally safe STI management. Support existing community-led sexual health programs (e.g., the BBV & STI Strategy for Aboriginal and Torres Strait Islander People). Engage with local communities to co-design health promotion messaging.

📚 References

1. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Australian STI Management Guidelines for Use in Primary Care. Sydney: ASHM; 2023. Available at: www.sti.guidelines.org.au.
2. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th edn. Melbourne: RACGP; 2016 (updated 2023).
3. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187.
4. Sobel JD. Vaginitis in adults: initial evaluation. UpToDate. Wolters Kluwer; 2024.
5. Bradshaw CS, Morton AN, Hocking J, et al. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis. 2006;193(11):1478–1486.
6. Sobel JD, Kapernick PS, Zervos M, et al. Treatment of complicated Candida vaginitis: comparison of single and sequential doses of fluconazole. Am J Obstet Gynecol. 2001;185(2):363–369.
7. Australian Institute of Health and Welfare (AIHW). Sexually Transmitted Infections and Blood-borne Viruses in Aboriginal and Torres Strait Islander People. AIHW; 2023.
8. Silver BJ, Guy RJ, Kaldor JM, et al. Trichomonas vaginalis as a cause of perinatal morbidity: a systematic review and meta-analysis. Sex Transm Dis. 2014;41(3):190–196.
9. Australian Government Department of Health. Fifth National Aboriginal and Torres Strait Islander Blood-borne Viruses and Sexually Transmissible Infections Strategy 2018–2022. Canberra: Commonwealth of Australia; 2018.
10. Donders GGG, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic vaginitis: no longer a stranger. Res Microbiol. 2017;168(9–10):832–838.
11. Ong JJ, Fethers K, Fairley CK, et al. Trichomonas vaginalis in Australia: epidemiology, clinical features, and management. Sex Health. 2020;17(2):121–129.
12. Centers for Disease Control and Prevention (CDC). Diseases Characterized by Vaginal Discharge — 2021 STI Treatment Guidelines. Atlanta: CDC; 2021.
13. Marrazzo JM, Donders G, Lusk J, et al. Bacterial vaginosis is associated with Mycoplasma genitalium and Ureaplasma urealyticum: a systematic review and meta-analysis. PLoS One. 2021;16(3):e0248835.
14. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of Genital Chlamydia Trachomatis Infection in Pregnancy. RANZCOG College Statement C-Obs 53. Melbourne; 2017.
15. Nyirjesy P, Brookhart C, Lasy P, et al. Randomized trial of intravaginal boric acid versus nystatin for vulvovaginal candidiasis. Am J Obstet Gynecol. 2018;219(6):584.e1–584.e7.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).