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PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 72, MAY 2006
Vaginitis
Vaginal symptoms are common in the general population and are one of the
This Practice Bulletin was most frequent reasons for patient visits to obstetriciangynecologists (1).
developed by the ACOG Com- Vaginitis may have important consequences in terms of discomfort and pain,
mittee on Practice Bulletins
days lost from school or work, and sexual functioning and self-image. Vaginitis
Gynecology with the assistance
is associated with sexually transmitted diseases and other infections of the
of Paul Nyirjesy, MD. The in-
formation is designed to aid female genital tract, including human immunodeficiency virus (HIV) (2, 3), as
practitioners in making deci- well as adverse reproductive outcomes in pregnant and nonpregnant women.
sions about appropriate obstet- Treatment usually is directed to the specific causes of vaginal symptoms, which
ric and gynecologic care. These most commonly include bacterial vaginosis, vulvovaginal candidiasis, and tri-
guidelines should not be con- chomoniasis. The purpose of this document is to provide information about the
strued as dictating an exclusive diagnosis and treatment of vaginitis.
course of treatment or proce-
dure. Variations in practice may
be warranted based on the
needs of the individual patient,
Background
resources, and limitations Vaginitis is defined as the spectrum of conditions that cause vulvovaginal
unique to the institution or type symptoms such as itching, burning, irritation, and abnormal discharge. The
of practice. most common causes of vaginitis are bacterial vaginosis (2250% of sympto-
matic women), vulvovaginal candidiasis (1739%), and trichomoniasis
(435%); 772% of women with vaginitis may remain undiagnosed (4). In the
undiagnosed group of women, symptoms may be caused by a broad array of
conditions, including atrophic vaginitis, various vulvar dermatologic condi-
tions, and vulvodynia. Vaginitis has a broad differential diagnosis, and success-
ful treatment frequently rests on an accurate diagnosis.
Estrogen status plays a crucial role in determining the normal state of the
vagina. In the prepubertal and postmenopausal states, the vaginal epithelium is
thinned, and the pH of the vagina usually is elevated (4.7 or greater). A routine
bacterial culture will demonstrate a broad variety of organisms, including skin
and fecal flora. During the reproductive years, the presence of estrogen increas-
es glycogen content in vaginal epithelial cells, which in turn encourages colo-
nization of the vagina by lactobacilli. This increased level of colonization leads
women with recurrent vulvovaginal candidiasis second- mg weekly or 200 mg twice a week, are acceptable
ary to C albicans, after initial intensive therapy for 714 options (9). Candida species colonization and sympto-
days to achieve mycologic remission, prolonged antifun- matic vulvovaginal candidiasis may occur more com-
gal treatment with fluconazole, 150 mg weekly (7) for 6 monly in pregnant women (10). Although low-dose
months, will successfully control more than 90% of short-term fluconazole use is not associated with known
symptomatic episodes and will lead to a prolonged pro- birth defects (11), higher doses of 400800 mg/d have
tective effect in approximately 50% of women. Although been linked to birth defects (12). Thus, treatment of vul-
daily oral ketoconazole was previously described as an vovaginal candidiasis in pregnancy should consist of one
effective suppressive therapy in women with recurrent of the topical imidazole therapies listed in Table 1, prob-
vulvovaginal candidiasis (8), weekly fluconazole has a ably for 7 days (13).
lower risk of liver toxicity and should be used instead of Although much less common than C albicans, vul-
ketoconazole (9). For patients who are unable or unwill- vovaginal candidiasis caused by non-albicans Candida
ing to take fluconazole, prolonged maintenance therapy species are less likely to respond to azole antifungal
with intermittent topical agents, such as clotrimazole, 500 therapy (6). Current experience consists exclusively of
VOL. 107, NO. 5, MAY 2006 ACOG Practice Bulletin Vaginitis 1197
descriptions of case series of patients seen at centers spe- Following treatment, bacterial vaginosis may recur
cializing in the treatment of vaginitis. A standard course in up to 30% of women within 3 months (24). Possible
of topical imidazole therapy may be effective in up to mechanisms include persistence of pathogenic bacteria,
50% of such cases (14). Therapy with vaginal boric acid, reinfection from exogenous sources, including a sexual
600-mg capsules daily for a minimum of 14 days, seems partner, or failure of the normal lactobacillus-dominant
to be effective for azole failures (15). Patients with non- flora to reestablish themselves. Studies of partner treat-
albicans Candida vulvovaginal candidiasis in whom ment have failed to show a protective effect (25, 26).
boric acid therapy is ineffective should be referred to a Studies of recolonization with lactobacillus supplements
specialist experienced in handling such cases. have used nonvaginal strains of lactobacillus and have
failed to show a clear benefit (24). Prolonged antibiotic
Bacterial Vaginosis therapy may be useful in women with recurrent bacterial
Bacterial vaginosis is a polymicrobial infection marked vaginosis; however, further investigation is warranted.
by a lack of hydrogen peroxide-producing lactobacilli Nonpregnant women with bacterial vaginosis can be
and an overgrowth of facultative anaerobic organisms. treated with the alternatives listed in Table 1. Although
Organisms that are found with greater frequency and clindamycin use may be associated with in vitro anti-
numbers in women with bacterial vaginosis include microbial resistance (21), the listed alternatives seem to
G vaginalis, Mycoplasma hominis, Bacteroides species, have comparable clinical efficacy and safety (2729).
Peptostreptococcus species, Fusobacterium species, Generally, topical therapy is more expensive than gener-
Prevotella species, Atopobium vaginae, and other anaer- ic oral metronidazole, although the latter may be asso-
obes (16, 17). Because these organisms are part of the ciated with significant gastrointestinal symptoms.
normal flora, the mere presence of these organisms, espe- Disulfiramlike reactions may occur with both oral and
cially G vaginalis, on a culture does not mean that the topical metronidazole. As with the treatment of vulvo-
patient has bacterial vaginosis. Patients with bacterial vaginal candidiasis, treatment for BV should be individ-
vaginosis, when symptomatic, may complain of an ualized to the patient after considering multiple clinical
abnormal vaginal discharge and a fishy odor. A clinical factors.
diagnosis of bacterial vaginosis requires the presence of In several epidemiologic studies, bacterial vaginosis
three out of four Amsels criteria: abnormal gray dis- has been associated with low birth weight, premature
charge, vaginal pH greater than 4.5, a positive amine test, rupture of membranes (PROM), and prematurity
and more than 20% of the epithelial cells being clue cells. (3032). Standard antibiotic therapy seems to effectively
In research settings, the Nugent score (18), which assigns eradicate bacterial vaginosis in pregnant women (33, 34),
a value to different bacterial morphotypes seen on Gram and those with symptomatic bacterial vaginosis should be
stain of vaginal secretions, is considered the current cri- treated. Neither metronidazole nor clindamycin have
terion standard for diagnosing bacterial vaginosis. known teratogenic effects (35). Studies have been con-
Compared to Nugent scoring, Amsels criteria have a sen- ducted to determine whether treating asymptomatic bac-
sitivity of 92% and specificity of 77% (19). However, a terial vaginosis in an uncomplicated pregnancy will
similar sensitivity and specificity have been demonstrat- decrease the risk of adverse outcomes. They have yield-
ed by using any combination of only two clinical criteria ed conflicting results and have shown no clear benefit to
(20). routine screening and treatment in U.S. populations (36).
In nonpregnant women, bacterial vaginosis has been However, in women with high-risk pregnancies, particu-
associated with a number of infections of the female larly those with prior preterm deliveries, some studies
reproductive tract, including pelvic inflammatory disease have shown that screening for and treating bacterial vagi-
(PID), postprocedural gynecologic infections, and acqui- nosis with oral metronidazole may decrease the risk of
sition of HIV and herpes simplex virus (HSV)-2 infec- preterm PROM and preterm delivery (37, 38), but others
tions (21). Treatment for bacterial vaginosis before have not (36).
abortion or hysterectomy significantly decreases the risk
of postoperative infectious complications (22). Treatment Trichomoniasis
helps women to resolve concurrent mucopurulent cer- Vaginal trichomoniasis is a common sexually transmitted
vicitis (23). There are no current data on the treatment of disease with an estimated annual incidence of 7.4 million
bacterial vaginosis to decrease acquisition of PID, HIV, cases in the United States (39). Symptomatic women
or HSV-2, and the role of treatment of asymptomatic bac- with trichomoniasis may have an abnormal discharge,
terial vaginosis to prevent these associated morbidities is itching, burning, or postcoital bleeding. Although many
unclear. women with trichomoniasis will have an elevated vaginal
VOL. 107, NO. 5, MAY 2006 ACOG Practice Bulletin Vaginitis 1199
health care provider to visualize yeast on microscopy. result, is frequently isolated in women with vaginal
Furthermore, compared with culture and yeast poly- symptoms as well. However, a casecontrol study of 118
merase chain reaction, false-positive rates of up to 50% women with GBS found no association between women
have been reported (53). Because they can pick up small- with GBS and vulvovaginal symptoms (56). Similarly,
er numbers of organisms, yeast cultures are considered lactobacilli are part of the vaginal flora. Although it has
the criterion standard in confirming the presence of yeast. been hypothesized that an overgrowth of lactobacilli can
They are not routinely performed because of their cost, cause vaginal symptoms (57), such a syndrome is poor-
the delay involved in obtaining results, and the fact that ly characterized, and controlled studies confirming the
many women may be asymptomatically colonized with existence of such a syndrome are lacking. Thus, the pres-
yeast. Nevertheless, yeast cultures should be obtained in ence of large numbers of lactobacilli on either
cases of recurrent vulvovaginal candidiasis or possible microscopy or vaginal culture should be considered a
non-albicans Candida infection; the latter should be sus- normal finding.
pected if microscopy reveals only blastospores or the
patient with vulvovaginal candidiasis has persistent When is it appropriate to provide treatment
symptoms after antifungal therapy. Yeast cultures also for vaginitis without an examination?
should be considered in symptomatic women with nega-
tive microscopy, those with signs of vulvovaginal can- Over the past decade, women have increasingly relied on
didiasis, or multiple symptoms but negative microscopy self-diagnosis and self-treatment of vulvovaginal can-
results (54). didiasis. An estimated $275 million is spent annually on
Because microscopy has a fairly limited sensitivity, nonprescription antifungals, and the drugs number in the
culture or trichomonas antigen testing should be obtained top 10 of all nonprescription medications sold in the
in situations where trichomoniasis is suspected but not United States (58). With topical antimycotic agents
proved. However, health care providers may have diffi- approved for nonprescription use, it is assumed that
culty finding a laboratory that can provide a culture women with a prior episode of vulvovaginal candidiasis
medium and perform the test. There are currently no clear can self-diagnose accurately (59). The perceived benefits
criteria or studies to assess which patients should under- of nonprescription antifungals include convenience, the
go trichomonas cultures. Their use should be considered ability to rapidly initiate antimycotic therapy, and the
in patients with a negative wet mount test result and any potential to reduce health care costs significantly (1).
of the following circumstances: a history of trichomonia- However, the reliability of self-diagnosis may be
sis with persistent symptoms after therapy, a high vaginal poorer than previously suggested. In a study of 601
pH and microscopy that reveals leukocytes, a Pap test women recruited from a variety of medical and commu-
result with trichomonas, or patient desire for trichomonas nity sites in Georgia, investigators found that only 11%
screening because of a possible exposure. of women with no prior diagnosis and 34.5% of women
Mucopurulent cervicitis, which is sometimes caused with a prior diagnosis of vulvovaginal candidiasis accu-
by Neisseria gonorrheae or C trachomatis (55), may rately recognize the classic scenario for candidiasis (60).
present as an abnormal yellow discharge. Therefore, Both groups were particularly poor at recognizing bacte-
DNA tests or cultures for these two organisms should be rial vaginosis, with an accuracy of 3.2% and 4.4%,
obtained in patients with a purulent discharge, cervical respectively. In a prospective study of 95 symptomatic
friability, any symptoms suggestive of PID, or leukocytes women purchasing nonprescription antifungal products,
on microscopy. Such tests also should be performed in only 34% had pure vulvovaginal candidiasis, and self-
women who fall into higher risk groups where annual treatment with a topical antifungal agent would have
screening is recommended (9). been inappropriate or inadequate therapy in the remain-
Because the normal vaginal flora is very heteroge- ing 66% (61). In a longitudinal study of women who
neous, routine bacterial cultures of the vagina have no submitted yeast cultures every 4 months for a year,
use in diagnosing bacterial vaginosis. They may have a researchers found no correlation between antecedent
limited role in diagnosing suspected cases of group A Candida species colonization and subsequent antifungal
streptococcal vaginitis, but this condition is considered use (62). Finally, a telephone diagnosis of vaginal symp-
rare. In patients with symptoms suggestive of bacterial toms seemed to correlate poorly with the actual diagno-
vaginosis that do not fulfill Amsels criteria, a Gram stain sis (63). Given the nonspecific nature of vulvovaginal
is considered the criterion standard for diagnosis. Other symptoms (19), patients who are already in the office
organisms routinely found on vaginal culture include should not be treated for vaginitis without an examina-
GBS and lactobacilli. Group B streptococci is part of the tion. Whenever possible, patients requesting treatment
normal flora in approximately 25% of women and, as a by telephone should be asked to come in for evaluation;
How should patients be evaluated in the rate home tests for vaginitis ultimately may help to min-
absence of a microscope? imize these effects.
There may be times when patients can only be evaluated
For symptomatic patients with a high pH but
without microscopy. Because there are currently no rapid
tests for yeast, testing for vulvovaginal candidiasis with- normal microscopy, what is appropriate man-
out a microscope will consist of history, examination, agement?
and culture. An elevated vaginal pH will determine Testing of the vaginal pH and amine testing are part of a
which patients may need further testing for bacterial battery of tests that are used to diagnose vulvovaginal
vaginosis or trichomoniasis. Testing for trichomoniasis symptoms. When pH is abnormally elevated in a symp-
can be performed with point-of-care tests for tri- tomatic patient, it is usually associated with microscopic
chomonas antigen (the OSOM Trichomonas Rapid Test) findings that help to establish a diagnosis. Depending on
or culture. Point-of-care tests for pH and amines the cause of symptoms, findings such as trichomonads,
(QuickVue Advance pH and Amines test), G vaginalis clue cells, or immature epithelial cells may be seen.
proline iminopeptidase activity (QuickVue Advance G.
However, recent intercourse, menses, sampling of cervi-
vaginalis test) and vaginal sialidases (OSOM BVBlue
cal mucus, or recent treatment with a medication also
test) are all FDA-approved to aid in the diagnosis of bac-
can alter the pH of the vagina. In the presence of com-
terial vaginosis. Although their exact role in current
pletely normal microscopy (including vaginal cytology),
diagnostic algorithms is unclear, their use should be con-
there is no evidence that a high pH alone causes vaginal
sidered when a microscope is unavailable. When possi-
symptoms. Thus, the symptomatic patient should be
ble, a slide of vaginal secretions should be obtained for
treated in a manner similar to other women with vagini-
future Gram stain.
tis where the diagnosis is unclear, including obtaining
cultures for yeast and trichomonas.
VOL. 107, NO. 5, MAY 2006 ACOG Practice Bulletin Vaginitis 1201
ture should be performed. If culture is unavailable, the In adolescent patients, the causes of vaginitis are
least expensive approach is to treat the patient with similar to an adult population of reproductive age (72).
metronidazole. In populations with a low prevalence of In sexually active adolescents with vaginitis, screening
trichomoniasis (5% or less), this approach may lead to for gonorrhea and chlamydia also should be performed.
unnecessary treatment in more than 50% of patients (67). In adolescents who wish to avoid a speculum examina-
tion, examination of swabs obtained blindly from the
What nonmedical approaches are effective? vagina have a sensitivity similar to speculum examina-
tions (72) for diagnosing causes of vaginitis, and urine
Complementary and alternative therapies are commonly testing can be performed for gonorrhea and chlamydia if
used to treat vulvovaginal symptoms (68). Such thera- indicated.
pies include lactobacilli, yogurt, garlic, tea tree oil, a low
carbohydrate diet, desensitization to Candida species
How should patients be counseled?
antigen, hormonal manipulation with depot medroxy-
progesterone, and douching. Current data are insufficient Several specific myths may need to be addressed in
regarding either efficacy or safety to support recommen- counseling patients about vaginitis. Following is a dis-
dation of these nonmedical treatments for bacterial vagi- cussion of some common questions that may arise dur-
nosis or vulvovaginal candidiasis (69). ing counseling:
Which types of vaginitis are sexually transmitted
For vaginitis in pediatric or adolescent diseases (STDs) and which are not? Did I get this
patients, what is appropriate management, from my current sexual partner? Trichomoniasis is
and are there any special considerations? an STD. However, because asymptomatic carriage
can occur for prolonged periods in both men and
Vulvovaginitis is one of the most common gynecologic women, a recent diagnosis of trichomoniasis does
problems in prepubertal girls. However, because of the not necessarily establish recent acquisition, unless
lack of estrogenization of the vagina and resulting vagi- the patient has had documented negative tri-
nal atrophy and alkalinic pH, the causes seem to be quite chomonas cultures in the past. Because men can
different from an adult population. Most cases are thought harbor T vaginalis, a woman with trichomoniasis
to be noninfectious in origin, secondary to a broad range should refrain from intercourse until both she and
of conditions, many of them dermatologic (eg, contact her partner(s) have been treated. Although bacterial
dermatitis). Those cases with specific bacterial causes vaginosis is associated with sexual activity (73), it
typically have an acute onset of a visible discharge. also has been described in virginal women (74) and
Respiratory organisms such as group A streptococci is not considered an STD. However, in female part-
and Hemophilus influenzae are the most common infec- ners of lesbians with bacterial vaginosis, there is a
tious causes (70), as well as enteric and sexually trans- higher incidence of bacterial vaginosis (75); no
mitted pathogens; Candida species is rarely found. Lichen studies address whether simultaneous treatment of
sclerosis and atrophic vaginitis also may be present in both women in a lesbian couple will decrease recur-
prepubertal girls. Pinworms may cause perianal and vul- rence rates. Although vulvovaginal candidiasis also
var itching. A pediatric patient with vulvovaginal symp- is associated with sexual factors, such as oral recep-
toms should undergo a careful vulvar examination to look tive sex, it does not seem to be an STD (76). With
for evidence of a dermatologic cause and for vaginal dis- both bacterial vaginosis and vulvovaginal candidia-
charge. Vaginal secretions should be evaluated by sis in heterosexual couples, randomized studies of
microscopy to look for leukocytes (70), and a bacterial partner treatment have failed to show a decrease in
culture should be obtained by introducing a swab through the risk of recurrence (22, 77).
the hymen. Therapy depends on the results of the What is the role of douching in the prevention or
microscopy and culture. An examination for pinworms treatment of vaginitis? No studies show any benefit
may demonstrate the presence of pinworm eggs. In cases to douching as a treatment for vaginitis. The associ-
of a possible foreign body, the discharge often will have ation of douching with bacterial vaginosis (73) and
an abnormal odor and be associated with some vaginal bacterial vaginosisassociated flora (16), although
bleeding. Vaginal irrigation may lead to expulsion of the not a clear demonstration of cause and effect, sug-
foreign body; if not, vaginoscopy should be performed. If gests that douching should not be used as a treat-
sexual abuse is suspected, child protective services ment for vaginitis and actually may exacerbate
should be notified and the child referred to a professional symptoms. In addition, douching has been associat-
trained in the management of such cases (71). ed with increased risk of cervicitis, PID, and tubal
To prevent reinfection, women with trichomoniasis zole. Am J Obstet Gynecol 2001;185:3639. (Level I)
should avoid intercourse until they and their partner
7. Sobel JD, Wiesenfeld HC, Martens M, Danna P, Hooton
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vaginal candidiasis and trichomoniasis. In selected Centers for Disease Control and Prevention. MMWR
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Epidemiology and outcomes associated with moderate to
VOL. 107, NO. 5, MAY 2006 ACOG Practice Bulletin Vaginitis 1203
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Group. N Engl J Med 1995;333:173742. (Level II-2)
17. Burton JP, Devillard E, Cadieux PA, Hammond JA, Reid
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18. Nugent RP, Krohn MA, Hillier SL. Reliability of diag- cervical cytokine response to treatment with oral or vagi-
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Hillier SL. Predictive value of the clinical diagnosis of oral clindamycin on late miscarriage and preterm delivery
lower genital tract infection in women. Am J Obstet in asymptomatic women with abnormal vaginal flora and
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2003;361:9837. (Level I)
20. Gutman RE, Peipert JF, Weitzen S, Blume J. Evaluation of
clinical methods for diagnosing bacterial vaginosis. 35. Diav-Citrin O, Shechtman S, Gotteiner T, Arnon J, Ornoy
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metronidazole: a prospective controlled cohort study.
21. Beigi RH, Austin MN, Meyn LA, Krohn MA, Hillier SL.
Teratology 2001;63:18692. (Level II-2)
Antimicrobial resistance associated with the treatment
of bacterial vaginosis. Am J Obstet Gynecol 2004;191: 36. Carey JC, Klebanoff MA, Hauth JC, Hillier SL, Thom
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delivery in pregnant women with asymptomatic bacterial
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38. Hauth JC, Goldenberg RL, Andrews WW, DuBard MB,
25. Vejtorp M, Bollerup AC, Vejtorp L, Fanoe E, Nathan E, Copper RL. Reduced incidence of preterm delivery with
Reiter A, et al. Bacterial vaginosis: a double-blind ran- metronidazole and erythromycin in women with bacterial
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39. Weinstock H, Berman S, Cates W Jr. Sexually transmitted
26. Colli E, Landoni M, Parazzini F. Treatment of male part- diseases among American youth: incidence and preva-
ners and recurrence of bacterial vaginosis: a randomised lence estimates, 2000. Perspect Sex Reprod Health 2004;
trial. Genitourin Med 1997;73:26770. (Level I) 36:610. (Level III)
27. Ferris DG, Litaker MS, Woodward L, Mathis D, Hendrich 40. Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J,
J. Treatment of bacterial vaginosis: a comparison of oral Kiviat NB, et al. Diagnosis of trichomoniasis. Compari-
metronidazole, metronidazole vaginal gel, and clin- son of conventional wet-mount examination with cytolog-
damycin vaginal cream. J Fam Pract 1995;41:4439. ic studies, cultures, and monoclonal antibody staining of
(Level I) direct specimens. JAMA 1988;259:12237. (Level II-3)
28. Hanson JM, McGregor JA, Hillier SL, Eschenbach DA, 41. Pastorek JG 2nd, Cotch MF, Martin DH, Eschenbach DA.
Kreutner AK, Galask RP, et al. Metronidazole for bacter- Clinical and microbiological correlates of vaginal tri-
ial vaginosis. A comparison of vaginal gel vs. oral thera- chomoniasis during pregnancy. The Vaginal Infections
py. J Reprod Med 2000;45:88996. (Level I) and Prematurity Study Group. Clin Infect Dis 1996;23:
29. Paavonen J, Mangioni C, Martin MA, Wajszczuk CP. 107580. (Level II-2)
Vaginal clindamycin and oral metronidazole for bacterial 42. Soper D. Trichomoniasis: under control or undercon-
vaginosis: a randomized trial. Obstet Gynecol 2000;96: trolled? Am J Obstet Gynecol 2004;190:28190. (Level
25660. (Level I) III)
30. Gravett MG, Hummel D, Eschenbach DA, Holmes KK. 43. Huppert JS, Batteiger BE, Braslins P, Feldman JA, Hobbs
Preterm labor associated with subclinical amniotic infec- MM, Sankey HZ, et al. Use of an immunochromato-
VOL. 107, NO. 5, MAY 2006 ACOG Practice Bulletin Vaginitis 1205
75. Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K,
Stine K, Hillier SL. Characterization of vaginal flora and The MEDLINE database, the Cochrane Library, and the
bacterial vaginosis in women who have sex with women. American College of Obstetricians and Gynecologists own
J Infect Dis 2002;185:130713. (Level II-2) internal resources and documents were used to conduct a
literature search to locate relevant articles published be-
76. Geiger AM, Foxman B. Risk factors in vulvovaginal can- tween January 1985 and February 2006. The search was re-
didiasis: a case-control study among university students. stricted to articles published in the English language.
Epidemiology 1996;7:1827. (Level II-2) Priority was given to articles reporting results of original
77. Fong IW. The value of treating the sexual partners of research, although review articles and commentaries also
women with recurrent vaginal candidiasis with ketocona- were consulted. Abstracts of research presented at sympo-
zole. Genitourin Med 1992;68:1746. (Level I) sia and scientific conferences were not considered adequate
for inclusion in this document. Guidelines published by or-
78. Scholes D, Stergachis A, Ichikawa LE, Heidrich FE,
ganizations or institutions such as the National Institutes of
Holmes KK, Stamm WE. Vaginal douching as a risk fac- Health and ACOG were reviewed, and additional studies
tor for cervical Chlamydia trachomatis infection. Obstet were located by reviewing bibliographies of identified arti-
Gynecol 1998;91:9937. (Level II-3) cles. When reliable research was not available, expert opin-
79. Ness RB, Hillier SL, Kip KE, Richter HE, Soper DE, ions from obstetriciangynecologists were used.
Stamm CA, et al. Douching, pelvic inflammatory disease, Studies were reviewed and evaluated for quality according
and incident gonococcal and chlamydial genital infection to the method outlined by the U.S. Preventive Services Task
in a cohort of high-risk women. Am J Epidemiol Force:
2005;161:18695. (Level II-2)
I Evidence obtained from at least one properly de-
signed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon-
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and consis-
tent scientific evidence.
Level BRecommendations are based on limited or incon-
sistent scientific evidence.
Level CRecommendations are based primarily on con-
sensus and expert opinion.