GPAtlas🧭 When to suspect
Suspect a pathological cause when there is a change in the amount, consistency, colour or odour of vaginal discharge, or when it is associated with itch, soreness, dysuria or pelvic pain. The first task is to separate this from physiological discharge – clear or white, non-offensive, and varying 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. Crucially, 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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