Inflammatory vaginitis is vaginal inflammation without evidence of the usual infectious causes of vaginitis. It occurs most commonly after menopause or in other hypoestrogenic states. Symptoms include a purulent vaginal discharge, dyspareunia, dysuria, and vaginal irritation. Diagnosis is with pelvic examination, vaginal pH, and wet mount. Treatment is with clindamycin vaginal cream.
(See also Overview of Vaginitis.)
In patients with inflammatory vaginitis, vaginal epithelial cells slough superficially, and streptococci overgrow.
Inflammatory vaginitis occurs and recurs most commonly in patients who become hypoestrogenic due to menopause or primary ovarian insufficiency (premature ovarian failure—eg, due to autoimmune disease, oophorectomy, pelvic radiation, or chemotherapy). The etiology may be autoimmune.
Symptoms and Signs of Inflammatory Vaginitis
Purulent vaginal discharge, dyspareunia, dysuria, and vaginal irritation are common. Vaginal pruritus and erythema may occur. Burning, pain, or mild bleeding occurs less often. Vaginal tissue may appear thin and dry. Vaginitis may recur.
Patients who are postmenopausal or those with premature ovarian insufficiency may also have signs and symptoms of genitourinary syndrome of menopause (eg, vulvovaginal atrophy, urinary urgency, dysuria).
Diagnosis of Inflammatory Vaginitis
Vaginal pH and wet mount
Symptoms of inflammatory vaginitis overlap with other forms of vaginitis, and a general evaluation (eg, vaginal fluid pH measurement, microscopy, whiff test) should be performed.
Inflammatory vaginitis is diagnosed if
Vaginal fluid pH is > 6.
Whiff test is negative.
Microscopy shows predominantly white blood cells and parabasal cells.
The pelvic examination should include evaluation for characteristic findings of vulvovaginal atrophy (eg, labia minora resorption or fusion, tissue fragility, pallor, loss of vaginal rugae).
Treatment of Inflammatory Vaginitis
Clindamycin 2% vaginal cream
Treatment of inflammatory vaginitis is with clindamycin 2% vaginal cream 5 g every evening for 2 weeks.
Genital atrophy, if present, can be treated with topical estrogen such as the following:
0.01% estradiol vaginal cream 2 to 4 g (once a day for 1 to 2 weeks), followed by 1 to 2 g (once a day for 1 to 2 weeks), then 1 g (1 to 3 times weekly)
Estradiol vaginal tablets 4 or 10 mcg twice a week
Estradiol ring (releases approximately 7.5 mcg/d) every 3 months
Topical estrogen therapy is usually preferred for genitourinary syndrome of menopause, because it is more effective for this indication and has lower risk of adverse effects than systemic menopausal hormone therapy.