Equity, Accuracy, and Stewardship: Rethinking Vaginitis Diagnosis for Women Everywhere

Vaginitis remains a leading cause of gynecologic-related primary care visits in the United States, yet the approach to diagnosis and treatment continues to present significant challenges for clinicians and public health professionals. Recent studies underscore persistent gaps in diagnostic testing and highlight the consequences for antimicrobial stewardship and patient outcomes.

An analysis of healthcare resource utilization revealed that among more than 4 million patients presenting with vaginitis symptoms between 2018 and 2022, only about a quarter of non-pregnant women and half of pregnant women received any diagnostic testing at their initial visit.¹ The majority were treated empirically without laboratory confirmation of the underlying cause. Advanced molecular diagnostics, such as nucleic acid amplification tests (NAATs), were used in less than 10% of cases, despite their superior sensitivity and specificity. This underutilization persists despite updated guidelines from the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM) recommending multiplex NAATs for vaginitis diagnosis.²

This diagnostic gap has far-reaching implications. When treatment is based solely on symptoms, the risk of misdiagnosis and inappropriate therapy increases. One study found that nearly half of women with laboratory-confirmed vaginitis received inappropriate prescriptions, and a third of women without any infectious cause were still given antibiotics or antifungals.³ Those treated empirically without confirmation were much more likely to return with persistent symptoms within three months, contributing to increased healthcare utilization and patient frustration. Access to advanced diagnostics may be restricted by cost, availability, and insurance coverage, particularly in resource-limited settings.

Several factors contribute to these gaps. Clinical practice often favors traditional methods—wet mount microscopy, pH testing, or visual inspection—because they are quick, familiar, and usually easily available. However, these methods lack the sensitivity and specificity of molecular diagnostics. Practical barriers also play a role: NAATs may not be available in every clinic, turnaround times can be slow, and insurance coverage varies. Furthermore, billing and reimbursement issues further complicate the picture, as some low-cost or point-of-care tests may not be billed or captured in claims data, leading to underreporting and possibly underuse.⁴

From an antimicrobial stewardship perspective, these findings are concerning. Prescribing antibiotics or antifungals without confirming the diagnosis contributes to the growing problem of antimicrobial resistance. Organisms associated with vaginitis are not immune to this trend, and overuse of empiric therapy risks making future infections more difficult to treat. Recent data from another study showed that concurrent treatment of male partners—using both oral and topical antimicrobials—alongside standard therapy for women with bacterial vaginosis (BV) significantly reduces BV recurrence rates compared to treating women alone.⁵ By targeting both partners, the cycle of reinfection is interrupted, thereby decreasing the overall need for repeated antimicrobial courses in women. Such a strategy not only improves clinical outcomes but also aligns with antimicrobial stewardship principles by minimizing unnecessary antibiotic exposure, reducing the risk of development of resistance, and preserving the efficacy of available therapies.

The path forward involves broader adoption of molecular diagnostics, especially multiplex NAATs, which are now recommended by society guidelines. Stewardship efforts must focus on ensuring that every patient receives the right treatment, at the right time, for the right reason. Provider education is also critical; clinicians must be aware of the limitations of traditional methods and the benefits of targeted diagnostics. Policy initiatives should support stewardship, reduce disparities, and improve outcomes for women nationwide. Investment in rapid, accurate point-of-care testing and equitable access across all patient populations will be essential to improving the standard of care for vaginitis nationwide.

References:

1. Chen J, Tse J, Shi L, Cheng MM, Lillis R, Near AM. Real-world clinical burden of patients presenting with vaginitis symptoms in the United States. AJOG Global Reports. 2025;5:100504. doi:10.1016/j.xagr.2025.100504.
2. Broache, Molly BSN, MSN; Cammarata, Catherine L. BS; Stonebraker, Elizabeth BS; Eckert, Karen MS; Van Der Pol, Barbara PhD, MPH; Taylor, Stephanie N. MD. Performance of a Vaginal Panel Assay Compared With the Clinical Diagnosis of Vaginitis. Obstetrics & Gynecology 138(6):p 853-859, December 2021
3. Hillier SL, Austin M, Macio I, Meyn LA, Badway D, Beigi R. Diagnosis and Treatment of Vaginal Discharge Syndromes in Community Practice Settings. Clinical Infectious Diseases. 2021;72(9):1538–43. doi:10.1093/cid/ciaa260.
4. Heidt B, Siqueira WF, Eersels K, Diliën H, van Grinsven B, Fujiwara RT, Cleij TJ. Point of Care Diagnostics in Resource-Limited Settings: A Review of the Present and Future of PoC in Its Most Needed Environment. Biosensors (Basel). 2020 Sep 24;10(10):133. doi: 10.3390/bios10100133. 
5. Vodstrcil LA, Plummer EL, Fairley CK, Hocking JS, Law MG, Petoumenos K, Bateson D, Murray GL, Donovan B, Chow EPF, Chen MY, Kaldor J, Bradshaw CS; StepUp Team. Male-Partner Treatment to Prevent Recurrence of Bacterial Vaginosis. N Engl J Med. 2025 Mar 6;392(10):947-957. doi: 10.1056/NEJMoa2405404.