Physiological Vaginal Discharge

Physiological vaginal discharge consists of normal secretions from the cervix, vaginal wall transudate, shed epithelial cells, and normal flora (mainly Lactobacillus species), changing with the menstrual cycle, pregnancy, arousal, contraception and age.

• Normal discharge is typically clear, white or off white (turns yellow on drying), non-offensive, not itchy, varying in volume, with a pH of 3.8 to 4.5.
• Variation:
  • Early cycle: scanty and thick.
  • Mid-cycle at ovulation: clear, stretchy and abundant (similar to egg white).
  • Luteal phase: thicker, whiter and less abundant.
  • Pregnancy: increased, thin and milky (leucorrhoea) because of oestrogen.
  • Combined contraceptive pill, vaginal ring, implant: change in quantity.
  • Sexual arousal: increased lubrication.
  • Neonates: transient, from maternal oestrogen; puberty: whitish discharge (physiological leucorrhoea) 6 to 12 months before menarche.
  • Postmenopause: scanty.
• It requires no treatment. The main task is to exclude pathological discharge and reassure.

• Mild to moderate, odourless, non-irritant discharge, with cyclical changes and no associated itching, soreness, dysuria, dyspareunia or pelvic pain.
• Examination (if needed): healthy vulva, normal vagina and cervix, normal discharge, normal pH, no clue cells.
• Signs of pathological discharge: change in colour (green, yellow, grey), odour, froth, curd like, blood stained, itch, soreness, abdominal pain, fever, dyspareunia, post-coital or intermenstrual bleeding, sexual risk, pregnancy with fluid leak, foreign body, prepubertal child with offensive discharge.

• Clinical, from history and cyclical pattern.
• When doubt exists: vaginal pH (normal 3.8 to 4.5), saline and potassium hydroxide microscopy, swabs for bacterial vaginosis, candidiasis, Trichomonas, chlamydia and gonorrhoea; pregnancy test.
• Speculum and bimanual examination for blood stained, persistent or recurrent discharge; cervical screening if due.
• In pregnancy, test for rupture of membranes if watery leakage is suspected.

• Reassurance and explanation of the normal cycle related changes.
• Hygiene advice: wash the vulva with water, avoid douching, perfumed products, bubble baths, antiseptics and vaginal deodorants (they disturb normal flora and can cause infection or dermatitis); change underwear daily, cotton; panty liners can be used but changed often and avoided if they cause irritation.
• Avoid unnecessary antibiotics and antifungals.
• For women who dislike a hormone related increase in discharge: review contraceptive choice (a lower oestrogen product), though increased discharge is not harmful.
• Advise attending if discharge changes: colour, smell, itch, soreness, bleeding or pain.
• No follow up needed for confirmed physiological discharge.