A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?

Acyclovir & elective cesarean section (C-section)

Acyclovir & allow spontaneous progression of labor

A 25-year-old woman presents with thin, gray-white vaginal discharge and mild itching. Microscopy shows clue cells and pH is 5.5. What is the most appropriate treatment?

Metronidazole 500mg BD for 7 days

Metronidazole gel 0.75% for 5 days

Clindamycin cream 2% for 7 days

Weekly fluconazole 150mg for 6 months

Fluconazole 150mg orally as single dose

Topical clotrimazole for 7 days

Metronidazole 500mg orally twice daily for 7 days

Reinfection from untreated partner

Positive whiff test and vaginal pH > 4.5

Inflammation/infection of vulva and/or vagina; a common gynecological complaint causing discomfort.
Cardinal Symptoms:
- Pruritus (itching): Often the most prominent symptom.
- Vaginal discharge: Altered color, consistency, volume, or odor.
- Vulvar soreness, irritation, or burning.
- Dyspareunia; external dysuria (pain with urination).
Initial Diagnostic Workup:
- Focused history and pelvic examination.
- Vaginal pH assessment: Crucial first step.
- Office microscopy: Saline wet mount (clue cells, trichomonads), 10% KOH prep (hyphae, whiff test).
Core Pathophysiology: Disruption of normal vaginal flora (Lactobacilli maintain acidic pH) allows pathogen overgrowth.

⭐ Normal vaginal pH is 3.8-4.5; disruption is key to many vulvovaginitis types.

Bacterial Vaginosis: Symptoms, Risk Factors, Diagnosis

Etiology: Polymicrobial; shift from Lactobacillus to ↑ Gardnerella vaginalis, anaerobes.
Clinical Features: Thin, homogenous, grey-white discharge; characteristic fishy odor. Pruritus/inflammation often mild or absent.
Diagnosis: 📌 Amsel's Criteria (need 3 of 4):
- Thin, white, homogenous discharge.
- Vaginal pH > 4.5.
- Positive Whiff-amine test (fishy odor with 10% KOH).
- Clue cells (>20% of epithelial cells) on wet mount microscopy.
⭐ Clue cells on microscopy are virtually pathognomonic for Bacterial Vaginosis.
Microscopy Findings:
- Clue cells: Squamous epithelial cells studded with coccobacilli, obscuring cell borders.
Treatment (Non-pregnant):
- Metronidazole 500mg PO BID for 7 days.
- Metronidazole gel 0.75% intravaginally OD for 5 days.
- Clindamycin cream 2% intravaginally HS for 7 days.
Complications: ↑ Risk of PID, preterm labor, postoperative infections, HIV acquisition/transmission.

Feature	Vulvovaginal Candidiasis (VVC)	Trichomoniasis
Etiology	Candida albicans (yeast); Risk: Diabetes, Antibiotics, ↑Estrogen	Trichomonas vaginalis (flagellated protozoan, STI)
Discharge	Thick, white, curdy ("cottage cheese"); non-odorous	Profuse, thin, frothy, yellow-green; malodorous (fishy)
Symptoms	Intense vulvar pruritus, burning, soreness, dyspareunia; vulvar erythema, edema	Vulvovaginal irritation, pruritus, dysuria, dyspareunia; postcoital bleeding
Vaginal pH	Normal ($pH \le \mathbf{4.5}$)	Elevated ($pH > \mathbf{4.5}$, often $\mathbf{5.0-6.0}$)
Microscopy	10% KOH: Pseudohyphae, budding yeast (spaghetti & meatballs)	Saline wet mount: Motile, pear-shaped flagellated organisms
Treatment	Topical azoles. Oral: Fluconazole 150mg single dose.	Metronidazole 2g single dose (treat partner). Alt: Tinidazole 2g.
Mnemonic	📌 Candida: Cottage cheese, $pH < \mathbf{5}$.	📌 Trich: Think Treats (Strawberry), $pH > \mathbf{5}$.

⭐ 'Strawberry cervix' (colpitis macularis) is a classic, though not always present, sign of Trichomoniasis.

Atrophic Vaginitis:
- Cause: ↓ Estrogen (e.g., menopause, lactation).
- Sx: Vaginal dryness, dyspareunia, itching.
- Signs: Pale, thin, friable mucosa; loss of rugae; petechiae. Vaginal pH > 5.0.
- Dx: Clinical; wet mount: ↑parabasal cells.
- Rx: Lubricants, moisturizers, topical estrogen.
⭐ Atrophic vaginitis is primarily due to estrogen deficiency and responds well to topical estrogen therapy.
Other Non-Infectious Causes:
- Irritant/Allergic Contact Dermatitis:
  - Cause: Soaps, detergents, spermicides.
  - Sx: Vulvar erythema, edema, intense itching/burning; often spares vagina.
  - Rx: Avoid irritant, topical low-potency corticosteroids.
- Lichen Sclerosus:
  - Sx: Intense pruritus; thin, white, crinkled ("cigarette paper") vulvar plaques; figure-of-eight pattern.
  - Rx: High-potency topical corticosteroids. ⚠️ ↑ SCC risk.

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