A 19-year-old woman comes to the office due to increasing vaginal discharge. The discharge began 6 months ago when she started taking a combined estrogen/progestin contraceptive pill. Since then, she has had multiple episodes of thin discharge accompanied occasionally by mild vulvar irritation. The discharge improves with probiotics and douches but then recurs after a week. She recently became sexually active and has had 2 lifetime partners.
Vital signs are normal. BMI is 22 kg/m². Pelvic examination reveals a thin, slightly malodorous, clear, yellow discharge throughout the vaginal vault. There is no discharge from the cervical os and no cervical friability. Bimanual examination demonstrates no cervical motion tenderness.
Wet mount microscopy shows numerous epithelial cells and occasional polymorphonuclear leukocytes, and the pH of the discharge is 4.2. Urine pregnancy test is negative.
Which of the following is the most likely diagnosis in this patient?

Question

Quizplus · Accepted Answer

Physiologic leukorrhea occurs due to elevated estrogen levels and results in episodic, thin vaginal discharge. In patients taking combined estrogen/progestin oral contraceptives, physiologic leukorrhea occurs while taking the active pills (high estrogen) and resolves during the week of placebo pills (low estrogen). This discharge is also common at other times of elevated estrogen levels, including ovulation and pregnancy. Patients with physiologic leukorrhea typically have a thin vaginal discharge with minimal vulvar irritation and odor. Pelvic examination of these patients is unremarkable, vaginal pH is normal (4-4.5), and microscopy shows only vaginal epithelial cells. Patients do not require further evaluation or treatment. (Choice A) Acute cervicitis typically presents with mucopurulent discharge, cervical friability (ie, cervix bleeds on contact), and an abundance of polymorphonuclear leukocytes on microscopy. Acute cervicitis (Choice B) Bacterial vaginosis presents with a thin, gray, malodorous vaginal discharge. Evaluation shows an elevated pH (>4.5), an amine odor (eg, whiff test), and clue cells (epithelial cells covered with coccobacilli) on microscopy. clue cells (Choice C) Candidal vulvovaginitis typically presents with vulvar pruritus, vulvovaginal erythema, and a thick, white discharge. Hyphae and pseudohyphae are seen on microscopy. (Choice E) Trichomoniasis presents with a green, frothy vaginal discharge and protozoa on microscopy. protozoa Educational objective: Physiologic leukorrhea occurs due to elevated estrogen levels associated with combination hormonal contraceptive use. Patients typically have a normal pelvic examination, pH, and microscopy. Physiologic leukorrhea does not require treatment. __________ References: Effects of hormonal contraception on vaginal flora. (http://www.ncbi.nlm.nih.gov/pubmed/22520642) Vaginitis. (http://www.ncbi.nlm.nih.gov/pubmed/21524046)

A 19-Year-Old Woman Comes to the Office Due to Increasing