Abnormal vaginal discharge — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 9: Genito-urinary diseases · Médecins Sans Frontières, Current online edition, last updated August 2022

Syndromic management of abnormal vaginal discharge including cervicitis, vaginitis and trichomoniasis for clinicians in resource-limited settings.

In one sentenceWomen with abnormal vaginal discharge and risk factors receive dual treatment for chlamydia (azithromycin 1 g or doxycycline 100 mg twice daily × 7 days) and gonorrhoea (ceftriaxone 500 mg IM); partner treatment essential.

Issuer: Médecins Sans Frontières
Edition: Current online edition, last updated August 2022
Audience: Clinicians in resource-limited and humanitarian settings
Evidence: Expert consensus based on field experience and international guidance
Reviewed: 21 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 21 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline section addresses the diagnosis and syndromic management of abnormal vaginal discharge, defined as discharge different from usual in colour, odour or consistency. The guideline emphasises that abnormal discharge may indicate vaginitis (caused by Gardnerella vaginalis, Trichomonas vaginalis or Candida albicans) or cervicitis (caused by Neisseria gonorrhoeae or Chlamydia trachomatis), and requires clinical confirmation through speculum examination and bimanual pelvic examination to rule out upper genital tract infection.

The core recommendation is risk-based syndromic treatment: women with abnormal vaginal discharge and risk factors (urethral discharge in partner, sexual violence or prostitution context, new partner or more than one partner in preceding 3 months) should receive empirical treatment for cervicitis covering both chlamydia and gonorrhoea. Specific treatment regimens are provided for cervicitis, bacterial vaginosis/trichomoniasis and vulvovaginal candidiasis, with separate recommendations for pregnant women. Partner treatment is routinely recommended for vaginitis and cervicitis.

The guideline supports laboratory confirmation where available (Xpert PCR for C. trachomatis and N. gonorrhoeae, wet smear microscopy for T. vaginalis and Candida) but provides practical syndromic algorithms for settings without diagnostic capacity. Treatment failure protocols and guidance on extensive vulvar involvement are included.

Key points

For clinicians — doses and thresholds as stated in the guideline

Cervicitis treatment (non-pregnant): azithromycin 1 g PO single dose OR doxycycline 100 mg PO twice daily for 7 days PLUS ceftriaxone 500 mg IM single dose OR cefixime 400 mg PO single dose
Cervicitis treatment (pregnant): azithromycin 1 g PO single dose OR erythromycin 1 g PO twice daily or 500 mg 4 times daily for 7 days PLUS ceftriaxone 500 mg IM single dose OR cefixime 400 mg PO single dose
Bacterial vaginosis and trichomoniasis: tinidazole 2 g PO single dose OR metronidazole 2 g PO single dose; treatment failure: tinidazole 500 mg twice daily for 5 days OR metronidazole 400–500 mg twice daily for 7 days
Vulvovaginal candidiasis: clotrimazole 500 mg vaginal tablet, single dose inserted deep at bedtime; add miconazole 2% cream twice daily for 7 days if extensive vulvar involvement
Risk factors for empirical cervicitis treatment: urethral discharge in partner, sexual violence or prostitution context, new partner or more than one partner in preceding 3 months
All women with vaginal discharge require abdominal and bimanual pelvic examination to rule out upper genital tract infection (lower abdominal pain and cervical motion tenderness)
Partner treatment: same regimen as patient for vaginitis or cervicitis whether or not symptomatic; for candidiasis, treat partner only if symptomatic with miconazole 2% cream twice daily for 7 days
Xpert molecular (PCR) tests recommended for detection of C. trachomatis and N. gonorrhoeae; Gram-stained smear not sensitive for N. gonorrhoeae in women

Treatment of cervicitis by pregnancy status

Table extracted from the guideline

Population	Treatment for chlamydia		Treatment for gonorrhoea
Non-pregnant women	azithromycin PO: 1 g single dose OR doxycycline PO: 100 mg 2 times daily for 7 days	PLUS	ceftriaxone IM: 500 mg single dose OR cefixime PO: 400 mg single dose
Pregnant women	azithromycin PO: 1 g single dose OR erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 7 days	PLUS	ceftriaxone IM: 500 mg single dose OR cefixime PO: 400 mg single dose

Source: Médecins Sans Frontières, Abnormal vaginal discharge — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“When in doubt, administer treatment for cervicitis to women with abnormal vaginal discharge and any of the following risk factors: Urethral discharge in the partner, Context of sexual violence or prostitution, New partner or more than one partner in the preceding 3 months”

— Médecins Sans Frontières, Abnormal vaginal discharge — MSF Clinical guidelines, Case management section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As we work to strengthen Georgia's sexual and reproductive health services, this MSF guideline provides a pragmatic syndromic approach particularly valuable for our primary health care settings where laboratory confirmation is not always immediately available. The risk-based algorithm for cervicitis treatment addresses a critical gap in our national STI protocols, especially for managing vulnerable populations including sex workers and survivors of gender-based violence. I would emphasise to Georgian clinicians the absolute requirement for partner treatment—our experience shows this remains the weakest link in STI control despite improvements in patient management. Implementation will require addressing the practical challenge of ceftriaxone availability in rural health posts and ensuring that primary care providers are trained and confident in performing speculum and bimanual pelvic examinations, which remains inconsistent across our regions.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus, where sexually transmitted infections remain a public health concern and laboratory diagnostic capacity varies significantly between urban tertiary centres and rural primary care settings. The syndromic management approach is particularly valuable for Georgian primary health care settings where Xpert PCR testing may not be available, though national STI programmes should work towards expanding laboratory confirmation capacity. Georgia’s universal health coverage programme has improved access to STI treatment since 2013, but implementation of partner notification and treatment remains challenging and would benefit from the structured approach outlined in this guideline. National programmes should consider local antimicrobial resistance patterns, particularly for gonorrhoea, when adapting these treatment protocols.

Questions this guideline answers

Quick answers

When should I treat empirically for cervicitis in a woman with abnormal vaginal discharge?

Treat for cervicitis when the woman has abnormal vaginal discharge (clinically confirmed by speculum exam) AND any of these risk factors: urethral discharge in her partner, context of sexual violence or prostitution, new partner or more than one partner in the preceding 3 months. Always treat for both chlamydia AND gonorrhoea.

Can I use doxycycline for chlamydia treatment in pregnant women?

No. For pregnant women with cervicitis, use azithromycin 1 g PO single dose OR erythromycin (1 g twice daily or 500 mg 4 times daily for 7 days). Doxycycline is only recommended for non-pregnant women.

Should I always treat the partner of a woman with abnormal vaginal discharge?

Yes, for vaginitis or cervicitis, the partner receives the same treatment as the patient whether or not symptoms are present. For vulvovaginal candidiasis only, treat the partner only if symptomatic (itching and redness of glans/prepuce) with miconazole 2% cream twice daily for 7 days.

What should I do if single-dose treatment for bacterial vaginosis or trichomoniasis fails?

In case of treatment failure, use tinidazole 500 mg twice daily for 5 days OR metronidazole 400–500 mg twice daily for 7 days (longer multi-day regimen rather than single dose).

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Acute diarrhoea — MSF Clinical guidelinesChapter 3: Gastrointestinal disorders

Abnormal vaginal discharge — MSF Clinical guidelines

What this guideline says

Key points

Treatment of cervicitis by pregnancy status

From the guideline