GPAtlas🧭 When to suspect
Suspect a pathological cause when:
• There is a change in the amount, consistency, colour or odour of vaginal discharge.
• The discharge is associated with itch, soreness, dysuria or pelvic pain.
The first task is to separate this from physiological discharge:
• Clear or white and non-offensive.
• Varies cyclically: clearer and stretchy around ovulation, thicker and white pre-menstrually.
The three common infective causes can usually be triangulated at the bedside by discharge character, odour, itch and vaginal pH. Only one of them – trichomonas – is a sexually transmitted infection, which is what drives partner notification and screening.
| Likely cause | Typical discharge and clinical clues | Vaginal pH |
|---|---|---|
| Physiological | • Clear/white, non-offensive, no itch • Varies with cycle, pregnancy, COC |
≤ 4.5 |
| Bacterial vaginosis | • Thin grey/white, fishy odour, coats vaginal walls • No soreness or itch • ~50% asymptomatic • Not an STI |
> 4.5 |
| Candidiasis (thrush) | • Thick white ‘cottage cheese’, itch and soreness, vulval erythema/fissures • Often minimal odour • Not an STI |
≤ 4.5 |
| Trichomonas | • Frothy yellow/green, offensive • Vulvitis, dysuria • Classic ‘strawberry cervix’ (seen in a minority) • An STI |
> 4.5 |
Source: BASHH
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