Clinical Topic A-Z Clinical Speciality

Vaginal discharge

Vaginal discharge
D019522Vaginal Discharge
Infections and infestationsSexual healthWomen's health
2013-05-01Last revised in May 2013

Vaginal discharge - Summary

Normal physiological vaginal discharge changes with the menstrual cycle. It is thick and sticky for most of the cycle, but becomes clearer, wetter, and stretchy for a short period around the time of ovulation.

Abnormal vaginal discharge is characterized by a change of colour, consistency, volume, or odour, and may be associated with symptoms such as itch, soreness, dysuria, pelvic pain, or intermenstrual or post-coital bleeding.

Abnormal vaginal discharge is most commonly caused by infection; however, there can be non-infective causes, such as retained foreign body, inflammation due to allergy or irritation, tumours, atrophic vaginitis, and cervical ectopy or polyps.

In women with abnormal vaginal discharge, the risk of sexually transmitted infection (STI) and symptoms suggestive of an infective cause of vaginal discharge should be assessed.

Vaginal candidiasis (fungal infection with Candida albicans) is characterized by an odourless, white, curdy discharge with a pH of less than 4.5. Vulval satellite lesions of erythema may occur in addition to vaginal erythema.

Bacterial vaginosis (overgrowth of aerobic bacteria, particularly Gardnerella vaginalis) is characterized by a white/grey homogeneous coating of the vaginal walls and vulva that has a fishy odour and a pH of > 4.5.

Trichomoniasis (a sexually transmitted infection caused by the protozoan Trichomonas vaginalis) is not always symptomatic; however, when symptomatic, it is characterized by a yellow-green, frothy discharge with a fishy odour and a pH of > 4.5.

Cervicitis caused by chlamydia (or less commonly by gonorrhoea) is characterized by an inflamed cervix which bleeds easily and may be associated with a mucopurulent discharge.

Pelvic inflammatory disease caused by chlamydia (or less commonly gonorrhoea) is characterized by lower abdominal pain, with or without fever. Cervicitis may be seen, and adnexal tenderness and cervical excitation found on bimanual palpation.

Examination is advised for most women, but may be omitted for women with a history suggestive of physiological discharge, or for some women presenting with classical symptoms of vaginal candidiasis or bacterial vaginosis, depending on their history.

If an examination is advised, a speculum examination, bimanual palpation, pH testing of vaginal discharge and swabs (if indicated) should be undertaken.

While awaiting swab results, empirical antibiotic treatment should be started in women with:

Cervicitis (they should be treated for chlamydia).

Suspected bacterial vaginosis.

Suspected vaginal candidiasis.

Pelvic inflammatory disease (if same day treatment in a genito-urinary clinic is not possible).

Trichomoniasis, for confirmation of diagnosis (if referral to genito-urinary medicine is not acceptable or feasible).

Urgent referral to a gynaecologist is indicated if gynaecological cancer is suspected.

Referral to a genito-urinary clinic for partner notification is indicated if there is microbiologically-confirmed gonorrhoea, chlamydia, or trichomoniasis.

Referral to a genito-urinary clinic for investigation and management is recommended for women with suspected pelvic inflammatory disease (same-day assessment) or suspected trichomoniasis.

Have I got the right topic?

144months3060monthsFemale

This CKS topic is based on guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency (HPA)[HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC][FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

This CKS topic covers the diagnosis of the causes of abnormal vaginal discharge.

This CKS topic does not cover the management of the causes of abnormal vaginal discharge.

There are separate CKS topics on Bacterial vaginosis, Candida - female genital, Chlamydia - uncomplicated genital, Gonorrhoea, Pelvic inflammatory disease, and Trichomoniasis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in May 2013

May 2013 — reviewed. A literature search was conducted in March 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No major changes to clinical recommendations have been made.

Previous changes

January 2009 — minor typographical correction. Issued in February 2009.

October 2008 to January 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2013.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2013.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2013.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2013.

Primary evidence

No new randomized controlled trials published in the major journals since 1 March 2013.

New policies

No new national policies or guidelines since 1 March 2013.

New safety alerts

No new safety alerts since 1 March 2013.

Changes in product availability

No changes in product availability since 1 March 2013.

Goals and outcome measures

Goals

To identify women who require examination and vaginal swabs

To identify women who can be treated empirically without swabs

To identify women who require referral

Background information

Definition

What is it?

Normal physiological discharge changes with the menstrual cycle. It is thick and sticky for most of the cycle, but becomes clearer, wetter, and stretchy for a short period around the time of ovulation. These changes do not occur in women using oral contraceptives.

Abnormal vaginal discharge is characterized by a change of colour, consistency, volume, or odour, and may be associated with symptoms such as itch, soreness, dysuria, pelvic pain, or intermenstrual or post-coital bleeding.

Causes

What causes it?

Abnormal vaginal discharge is most commonly caused by infection.

Vaginal infections include:

Bacterial vaginosis caused by an overgrowth of anaerobic bacteria, particularly Gardnerella vaginalis.

Vaginal candidiasis caused by fungal infection with Candida albicans.

Trichomoniasis, a sexually transmitted infection caused by the protozoan Trichomonas vaginalis.

Herpes Simplex, a sexually transmitted infection. If it causes cervicitis, women can present with vaginal discharge.

Endocervical infections caused by sexual transmission of chlamydia or gonorrhoea. Infection may remain localized causing cervicitis, or ascend to cause pelvic inflammatory disease.

Less commonly, abnormal vaginal discharge has a non-infective cause:

A retained foreign body such as a tampon, condom, or vaginal sponge.

Inflammation due to allergy or irritation caused by substances such as deodorants, lubricants, and disinfectants.

Tumours of the vulva, vagina, cervix, and endometrium.

Atrophic vaginitis in post-menopausal women.

Cervical ectopy or polyps.

Fistulae

[HPA, 2011; FSRH, 2012; Lazaro, 2013]

Diagnosis

Diagnosis of the underlying cause of vaginal discharge

Who to examine

Do I need to examine a woman with abnormal vaginal discharge?

Assess:

Risk of a sexually transmitted infection (STI). Women are considered at increased risk if they are less than 25 years of age or have had a new sexual partner in the last 12 months.

Symptoms of infective causes of vaginal discharge:

Cervicitis or pelvic inflammatory disease — vaginal discharge associated with post-coital or intermenstrual bleeding, dysuria, deep dyspareunia, or lower abdominal pain.

Vaginal candidiasis — a white odourless discharge that may be associated with itching and superficial soreness.

Bacterial vaginosis (BV) — a fishy-smelling discharge, not associated with itching or soreness.

Trichomoniasis — a fishy-smelling discharge that may be associated with itching, soreness, and dysuria.

Whether a non-infective cause of vaginal discharge is likely.

Examination may be omitted and empirical treatment prescribed, for women with:

A history suggestive of physiological discharge.

Characteristic symptoms of vaginal candidiasis if:

She is at low risk of an STI, and

She does not have symptoms of other conditions causing vaginal discharge, and

Symptoms have not developed following a gynaecological procedure, and

This is a first episode of suspected vaginal candidiasis, or if recurrent, recurrence is infrequent (less than four times a year).

See the CKS topic on Candida - female genital for further information on treatment.

Characteristic symptoms of BV if:

She is at low risk of an STI, and

She does not have symptoms of other conditions causing vaginal discharge, and

Symptoms have not developed following a gynaecological procedure, and

She is not pregnant, and

She is not post-natal, post-miscarriage, post-termination, and

This is a first episode of suspected BV, or if recurrent, a previous episode of recognizably similar symptoms was previously diagnosed to be BV following examination. See Additional information for when it is reasonable to assume that a previous diagnosis of BV was reliable.

See the CKS topic on Bacterial vaginosis for further information on treatment.

Examination is advised for all other women.

Additional information

Additional information

A previous diagnosis of BV can be assumed to be reliable if:

Characteristic symptoms and signs of BV were present.

Symptoms and signs of other conditions causing vaginal discharge were absent and there was no microbiological evidence of their presence from swabs of vaginal discharge.

Symptoms and signs cleared following antibiotic treatment.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency[HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC][FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

Examination advised

If necessary, what examination is advised?

Undertake:

An inspection of the vulva for lesions, discharge, vulvitis, ulcers and any other changes.

A speculum examination to visualize the cervix and vagina to look for signs of cervicitis, vaginal discharge, and any possible foreign body.

Ideally, pH testing of vaginal discharge from the lateral wall of the vagina with narrow-range pH paper (pH 4–7).

Swabs, if indicated by clinical findings — see Who to swab.

Bi-manual palpation for cervical motion tenderness, adnexal tenderness, and abnormal masses if the history is suggestive of pelvic inflammatory disease.

Offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia.

Look for characteristic signs that may indicate the infective cause of vaginal discharge:

Vaginal candidiasis is characterized by an odourless, white, curdy discharge with a pH of less than 4.5. Vulval satellite lesions of erythema may occur in addition to vaginal erythema.

Bacterial vaginosis is characterized by a white/grey homogeneous coating of the vaginal walls and vulva that has a fishy odour and a pH of more than 4.5.

Trichomoniasis, when symptomatic, is characterized by a yellow-green, frothy discharge with a fishy odour and a pH of more than 4.5.

Cervicitis caused by chlamydia (or less commonly by gonorrhoea) is characterized by an inflamed cervix which bleeds easily and may be associated with a mucopurulent discharge.

Pelvic inflammatory disease caused by chlamydia (or less commonly by gonorrhoea) is characterized by lower abdominal pain, with or without fever. Cervicitis may be seen, and adnexal tenderness and cervical excitation found on bimanual palpation.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency (HPA) [HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC] [FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

Who to swab

Who needs a swab?

Swabs may be omitted and empirical treatment prescribed:

For women with characteristic signs of vaginal candidiasis if:

There is a low risk of a sexually transmitted infection (STI), and

There are no signs of other conditions, and

Symptoms have not developed following a gynaecological procedure, and

This is a first episode of suspected vaginal candidiasis, or if recurrent, recurrence is infrequent (less than four times a year).

For women with characteristic signs of bacterial vaginosis (BV) if:

There is a low risk of an STI, and

There are no signs of other conditions causing vaginal discharge, and

Symptoms have not developed following a gynaecological procedure, and

She is not post-natal, post-miscarriage, or post-termination, and

She is not pregnant, and

This is a first episode of suspected BV, or

This is suspected recurrent BV, and a previous episode was reliably diagnosed to be BV following examination. See Additional information for when it is reasonable to assume that a previous diagnosis of BV was reliable.

For women with characteristic features of trichomoniasis or pelvic inflammatory disease (PID), swabs may be omitted if they are being referred to genito-urinary medicine (GUM) for confirmation of the diagnosis.

Take swabs from all other women with a suspected infective cause of abnormal vaginal discharge. This includes women with abnormal vaginal discharge who are:

At high risk of an STI.

Presenting with symptoms of an upper genital tract infection, when same-day assessment is not possible at a GUM clinic.

Requesting investigation or STI screening.

Post-partum, post-miscarriage, post-abortion, or post-instrumentation.

Presenting due to failure of treatment or recurrent infection.

Presenting with vaginitis without discharge or symptoms not characteristic of BV or candida.

Found to have cervicitis on examination.

Presenting with vaginal discharge of uncertain cause.

Additional information

Additional information

Risk of an STI — women are considered at increased risk if they are less than 25 years of age or have had a new sexual partner in the last 12 months or have had a STI in the past.

A previous diagnosis of BV can be assumed to be reliable if:

Characteristic symptoms and signs of BV were present.

Symptoms and signs of other conditions causing vaginal discharge were absent and there was no microbiological evidence of their presence from swabs of vaginal discharge.

Symptoms and signs cleared following antibiotic treatment.

Basis for recommendation

Basis for recommendation

These recommendations are largely based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency (HPA)[HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), (formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC]);[FSRH, 2012]and the British Association for Sexual Health and HIV [Lazaro, 2013].

There is good evidence that a combination of clinical features and a measurement of vaginal pH is a sensitive, although not very specific, predictor of the cause of vaginal discharge. Using these criteria, the diagnosis is missed in only a few people with BV or vaginal candidiasis. However, a moderate number of women who do not have vaginal candidiasis or BV will be incorrectly diagnosed with these conditions.

The addition of high vaginal swabs and endo-cervical swabs produces a more accurate final diagnosis. Swabbing is therefore recommended when clinical features are not clearly suggestive of either BV or vaginal candidiasis.

Women with suspected trichomoniasis should be referred to a GUM clinic as the swabs needs to reach the laboratory within 6 hours.

How to swab

How do I test pH and take high vaginal and endocervical swabs?

Following insertion of a vaginal speculum:

To test the pH of vaginal discharge: rub a swab along the lateral wall of the vagina to collect some discharge then rub this onto narrow range pH paper. Narrow range pH paper (range 4 to 5) is available from medical laboratory suppliers.

To take a high vaginal swab: swab discharge from the lateral vaginal wall and posterior fornix.

To take an endocervical swab: clean the cervical os with a large sterile swab and discard. Insert a new swab into the endocervix and rotate 360 degrees.

Submit swabs with appropriate clinical information to guide laboratory testing. Include the nature of the vaginal discharge, any risk or suspicion of sexually transmitted disease, and associated symptoms.

Refrigerate swabs at 4°C if they are not to be immediately sent to the laboratory:

High vaginal swabs for suspected trichomoniasis should arrive and be examined in the laboratory within 6 hours. It is therefore recommended that women with suspected trichomoniasis are referred to genito-urinary medicine for further investigation.

Other swabs should be received by the laboratory within 48 hours.

The swabs required for investigation of suspected chlamydia or gonorrhoea vary around the country:

It is therefore recommended that you discuss taking swabs for vaginal infections with your local laboratory.

For chlamydia, follow the manufacturers instructions on the chlamydia collecting kit that is provided by the local laboratory. Some laboratories also test the same sample for gonorrhoea using nucleic acid amplification tests (NAATs).

For laboratories that do not test for gonorrhoea and chlamydia using NAATs, send suspected Neisseria gonorrhoeae culture in a charcoal-based transport medium, and transport to the laboratory as soon as possible.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency (HPA) [HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC] [FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

Management

Management

Scenario: Management : covers the management of women and girls (12 years of age or older) with vaginal discharge.

Scenario: Management

Scenario: Management of vaginal discharge

144months3060monthsFemale

Who to refer

Who should I refer for abnormal vaginal discharge?

Arrange urgent admission for women with pelvic inflammatory disease who are:

Pregnant.

Pyrexial and unwell, or unable to take oral fluids or medications.

For further information see the CKS topic on Pelvic inflammatory disease.

Referral to a genito-urinary medicine clinic for investigation and management is recommended for women with:

Suspected pelvic inflammatory disease, for same day assessment.

Suspected trichomoniasis.

Referral to a genito-urinary medicine clinic for partner notification is recommended for anyone with microbiologically confirmed:

Gonorrhoea.

Chlamydia.

Trichomoniasis.

Consider urgent referral to a gynaecologist for women with suspected gynaecological cancer. For further information see the CKS topic on Gynaecological cancer - suspected.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency[HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC][FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

Who to treat

Who should I treat while awaiting swab results?

Give empirical antibiotics to women with:

Cervicitis — treat for chlamydia while awaiting swab results. For further information see the CKS topic on Chlamydia - uncomplicated genital.

Suspected pelvic inflammatory disease — if same day treatment in a genito-urinary clinic is not possible. For further information on treatment, see the CKS topic on Pelvic inflammatory disease.

Suspected trichomoniasis — if referral to genito-urinary medicine is not acceptable or feasible, for confirmation of the diagnosis. For further information on treatment, see the CKS topic on Trichomoniasis.

Suspected bacterial vaginosis — for further information on treatment, see the CKS topic on Bacterial vaginosis.

Suspected vaginal candidiasis — for further information on treatment, see the CKS topic on Candida - female genital.

Empirical antibiotics while awaiting swab results are not required for women at increased risk of a sexually transmitted infection, if they do not have any clinical features suggestive of infection.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion and conform to guidelines for the management of abnormal vaginal discharge issued by the Health Protection Agency[HPA, 2011]; the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC][FSRH, 2012]; and the British Association for Sexual Health and HIV [Lazaro, 2013].

Evidence

Evidence

Supporting evidence

Evidence on diagnostic criteria for abnormal vaginal discharge

There is a high sensitivity but only moderate specificity for diagnosing bacterial vaginosis and candidiasis based on clinical features and pH alone. Specificity is significantly increased when results of endo-cervical swabs for chlamydia and gonorrhoea and high vaginal swabs are available.

A randomized controlled crossover trial examined the sensitivity and specificity of diagnostic strategies used in family planning clinics and genito-urinary medicine (GUM) clinics [Melville et al, 2005].

Population: 200 women presenting with a primary complaint of vaginal discharge, of which 100 women were recruited from a family planning clinic and 100 women from a GUM clinic.

Intervention: each woman was assessed separately using typical diagnostic strategies:

Family planning clinic: history, examination, vaginal pH; and high vaginal swabs and endo-cervical swabs for chlamydia and gonorrhoea.

GUM clinic: history, examination, vaginal pH; high vaginal swabs and endo-cervical swabs for chlamydia; microscopy and direct inoculation of gonococcal plates by samples taken from the endocervix and urethra.

Comparison: a comprehensive range of microbiological tests for all types of infective causes of pelvic and vaginal infections.

Outcomes:

On day 1, the family planning clinic strategy over diagnosed 27 cases of candidiasis, 14 cases of bacterial vaginosis, and 1 case of trichomoniasis. These infections were shown not to be present when test results were reviewed on the seventh day.

On day 1, the GUM clinic failed to diagnose 21 cases of candidiasis and 1 case of bacterial vaginosis, which were shown to be present when test results were reviewed on the seventh day.

How does this study support recommendations?

This study supports the recommendation to use clinical features alone to diagnose bacterial vaginosis and vaginal candidiasis in women at low risk of having a more serious infection. Investigations are indicated to increase the certainty of the diagnosis when infections are recurrent.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of vaginal discharge.

Search dates

September 2008 - March 2013.

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Vaginal Discharge/, vaginal discharge$.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Topic specific literature search sources

BASHH

RCOG

Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

FSRH (2012) Management of vaginal discharge in non-genitourinary medicine settings. ..Faculty of Sexual and Reproductive Healthcare.www.fsrh.org [Free Full-text]

HPA (2011) Management of abnormal vaginal discharge in women. Quick reference guide for primary care: for consultation and local adaptation. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]

Lazaro, N. (2013) Sexually transmitted infections in primary care. .2nd edn.Royal College of General Practitioners and British Association for Sexual Health and HIV.www.bashh.org [Free Full-text]

Melville, C., Nandwani, R., Bigrigg, A. and McMahon, A.D. (2005) A comparative study of clinical management strategies for vaginal discharge in family planning and genitourinary medicine settings. Journal of Family Planning and Reproductive Health Care 31(1), 26-30. [Abstract]