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three studies reported the safety and efficacy of intravaginal 2% or 3% estriol (544,912,1093) in the treatment of t. vaginalis-induced vaginitis among pregnant women. two studies of t. vaginalis-induced vaginitis among pregnant women reported no serious adverse effects (910,912). additionally, 2 of these 3 studies noted improvements in vaginal discharge and vulvovaginal symptoms (1093,912), although more studies are needed for definitive conclusions (912). no data are available about the use of estriol in the treatment of t. vaginalis-induced vaginitis during pregnancy, although a nonnested study and a nested study reported that the use of intravaginal estriol with metronidazole was well tolerated by pregnant women (912,1093). finally, a nonnested study and a nested study found that intravaginal estriol is well tolerated (915,912) during the third trimester of pregnancy.
vaginitis is the most common symptom prompting gynecological care. despite the high prevalence and impact of this condition, many physicians (including those who provide prenatal care) appear to be unaware of the correct management of this condition. careful history taking (notably regarding the presence of physical signs) and the prompt performance of appropriate tests are essential to making the correct diagnosis and management decisions. treatment for cervicitis is intended to relieve symptoms without altering the vaginal flora or facilitating the acquisition of sexually transmitted diseases. the key roles of antifungal treatments and metronidazole are to prevent vaginitis and candidiasis, and to treat bacterial vaginosis. the use of contraceptive or other interventions should be based on a careful assessment of the patient’s risk and benefits and should be tailored to the patient. the use of non-hormonal medications or vaginal douching as treatment for vaginitis or candidiasis is discouraged.
the antibiotic of choice for treatment of chlamydia trachomatis is amoxicillin, which eradicates the organism from 95% of infected cases. metronidazole should not be used to treat c. trachomatis because of the risk for adverse pregnancy outcomes. benzoyl peroxide creams (e.g., clinique mild, keratoya regular, lactina cooling regular, obagi perfection regular, and obagi perfection intensive) are first-line treatment of bacterial vaginosis, but they do not clear the vaginal flora. vaginal antifungal therapy (e., clotrimazole cream) is sometimes effective for treating vaginal candidiasis but is best reserved for patients with extensive or persistent symptoms. systemic corticosteroids are effective treatment for the symptoms of allergic or fungal vaginitis, but their use is not recommended because of the potential for adverse pregnancy outcomes. vaginal douches (1320, 1321, 1322, 1323) for treating vaginitis are not recommended because they can mask symptoms, can be absorbed into the bloodstream, and may change the vaginal flora. finally, locally available treatments, such as aloe vera, can have some effectiveness; however, their role in therapy is not established (1318).
some studies suggest that hiv infection may be more prevalent among women with bv compared with uninfected women with bv (1008). according to the most recent data, c. trachomatis and n. gonorrhoeae have been detected in the genital tracts of approximately 5% to 30% of women with bv (1008). although hiv has not been isolated from vaginas of asymptomatic women, some studies suggest that hiv infection and bv occur together, but no specific associations have been made (1007). recent data indicate that some c. gonorrhoeae strains that are resistant to at least one of the antibiotics used to treat bv (i.e., metronidazole, tinidazole, or clindamycin) have emerged (1009). this raises the possibility that treatment of bv may be ineffective for women infected with antibiotic-resistant strains of c. trachomatis or n. gonorrhoeae.