In their article on chronic vaginal discharge, Bradford and Fischer1 have highlighted an area of women’s health that often fails to receive the attention it deserves. I believe the aspect of the subject that causes our colleagues the greatest difficulty is making an accurate diagnosis or diagnoses. It is common for our patients with vulvovaginal complaints to have more than one diagnosis; a feature that may complicate their management.2
Of all the diagnostic techniques applicable to female lower genital tract, the one I have found most useful is microscopy of the stained vaginal smear as described in The Vulva &Vagina Manual.3 To put the subject in perspective, the following are the findings made on 1000 consecutive stained smears obtained from patients complaining of discharge and/or pruritus/vulvodynia and/or dyspareunia and as a means of assessing treatment response in my private practice between 2014 and 2018. Fifty per cent were considered normal (including cervical eversion). The remaining diagnoses were atrophy (menopausal, lactational and prepubertal) 15 per cent, Candida albicans 12 per cent, erosive vaginitis (desquamative inflammatory vaginitis and vaginal lichen planus) eight per cent, vaginitis requiring further investigation six per cent, atrophic vaginitis four per cent, bacterial vaginosis one per cent and non-albicans yeast one per cent. Three per cent of the slides revealed the following diagnoses: radiation vaginitis, ulcer, malignancy, graft versus host disease, herpes simplex, cervicitis and chemical vaginitis.
Treatment of these disorders is relatively simple and effective when diagnosed accurately. For example, when the excessive secretions have been confirmed physiological, the patient will almost certainly benefit from a change of contraception to depot medroxyprogesterone acetate, which reduces physiological secretions by means of progestogen-only ovulation suppression. An additional bonus from its use is the prevention of candidiasis.4
The finding of no abnormality (the largest group above) included treatment follow up and symptomatic patients with sexual problems, physiological discharge and vulvar dermatoses who may have received inappropriate medication without the smear diagnosis. Our patients would benefit from increased emphasis on training in this relatively simple diagnostic technique as well as the management of vulvovaginal disorders in general.