Cases/Sexual Health

New Vaginal Discharge After A New Partner — Free SCA Practice Case

Woman with new vaginal discharge after a new partner

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Anneka Hollis

Age

27 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I've had a smelly discharge for about a week and I'd like to get a cream from the pharmacy."

Medical Records

●PMH: Nil significant. No previous gynaecological problems.
●Medications: Combined oral contraceptive pill.
●Allergies: NKDA.
●Sexual health: Chlamydia and gonorrhoea screen 7 months ago via online kit, both negative.
●Social: Veterinary nurse. Lives with a friend. Smokes 5 a day.

Patient Script

For the friend playing the patient role

Character Overview: You are Anneka Hollis, a 27 year old veterinary nurse at a busy small animal practice. You live in a shared flat with a friend, Ashleigh. You are cheerful and chatty, but you get quieter and speak more quickly when the talk turns to sex. You are embarrassed about the discharge and have decided it is probably thrush, because that is what your friends always get. You started seeing Elias, a 29 year old physiotherapist, about a month ago and you really like him. You do not want anything to complicate it. You are not hostile to the doctor, you just want something simple from the pharmacy and you do not want a test. You will agree to a sensible plan if the doctor is kind, explains clearly and gives you a way to deal with Elias.

Opening Sentence: "Hi, doctor. I've had a bit of a smelly discharge for about a week and I think it's thrush. Can I just get a cream from the pharmacy? I'd rather not have any tests or anything."

History if Asked (Data Gathering Phase)

●Onset and course: "It started about a week ago and it hasn't gone away. It's about the same each day, maybe a bit more noticeable than at the start."
●What the discharge is like: "Thin and watery, a greyish white colour. There's a fishy smell, mostly noticeable after sex and for a few days after my period. It's not thick or lumpy."
●Itch and soreness: "No itching and no soreness. That's what makes me not sure it's thrush, if I'm honest, but the smell is what bothers me."
●Pain or urinary symptoms: "No pain passing urine and no burning. No pelvic or tummy pain and no pain during sex."
●Bleeding: "No bleeding between periods or after sex. My periods are normal and regular. The last one finished about two weeks ago."
●Fever or feeling unwell: "No, I feel fine otherwise."
●Treatments tried: "I have used a scented intimate wash every day for the last ten days, to try to get rid of the smell, and I have started using a bit of shower gel as well. I haven't bought any cream yet."
●Previous episodes: "Never had anything like this before. A friend of mine had thrush last year and I assumed it was the same."
●Contraception: "I take the combined pill, every day, no missed pills. No coil. I'm not worried about pregnancy."
●Other medical history and medicines: "Nothing, just the pill. No allergies, and I've never had a problem with antibiotics."
●Alcohol and smoking: "I smoke about five a day. I drink most weekends, three or four glasses of wine on a Friday and Saturday, so around 15 units a week."

Ideas, Concerns, Expectations

Gating note: Anneka does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She believes it is thrush, or that she has not been washing enough, and she thinks the smell is her fault. "I just assumed it was thrush. Or maybe I'm not keeping myself clean enough, that's why I started with the wash."
●Concerns: Her main worry is Elias. She fears that if she has a test and it shows something, he will think she was unfaithful or that he caught something from her, and that it would end things. She also dislikes the idea of an examination and "a swab". "If I get tested and something comes up, how do I even tell him? It's only been a month. I don't want him to think I've been sleeping around."
●Expectations: She wants a cream from the pharmacy and no test. "I just want a cream and to get on with it. I really don't want an examination or a swab. Isn't thrush cream something you can just buy?"

Sexual History (Only if Asked)

Gating note: Anneka answers sexual history questions readily if the doctor explains why they are asking and asks sensitively. If the doctor asks bluntly with no explanation, she goes quiet and gives short answers.

●Current partner: "Elias. We've been together about a month. He's a man, he's 29. We've been having sex since about two weeks after we met. We don't have any other partners."
●Condom use: "We used condoms the first few times, then we got a bit lazy. Probably about half the time now. We haven't had anything go wrong with a condom."
●Type of sex: "Vaginal and oral. No anal sex."
●Elias's sexual history and symptoms: "He says he's had a few girlfriends before me. I haven't asked if he's been tested, and he hasn't said anything. He hasn't said he has any symptoms."
●Her previous partner: "Lachlan. We split up about seven months ago, after two years together. I had a test at that point, using an online kit, and it was all negative. I've had no other partners since Lachlan apart from Elias."
●Previous infections and other risks: "I've never had an STI. No injecting drugs, and neither has Elias that I know of. I have not had a blood test for HIV."
●Consent: "Everything has been completely consensual. I feel safe with him."
●Sexual health clinic experience: "I've never been to a clinic. I've only done the online kit."
●Vaccination: "I had the HPV jab at school."

Social History and Practicalities

●Work: Veterinary nurse. Full time, works some Saturdays, finishes at 5.30 pm most days. She could attend an appointment tomorrow after work or on Thursday morning on her day off.
●Home: Shares a flat with Ashleigh. She has not told Ashleigh about the discharge.
●Confidentiality: Anneka asks, if the doctor mentions letters or texts, who would see her results. She would prefer a phone call or text on her mobile rather than anything that goes to the flat.
●Attending: She would rather go to her own surgery than a clinic, as she has never been to a sexual health clinic, but would consider it if the doctor explains what to expect.
●Examination: If the doctor asks to examine her, she is nervous but will agree if the doctor explains what it involves and says she can stop at any time. If asked to self swab, she says she thinks that would be fine.

Responses to Management (The Negotiation Phase)

●
If the doctor says the cream from the pharmacy is not the right treatment, or asks to confirm the cause first:
- ●Reaction: Hesitant. "But thrush cream is what you get for this, isn't it? Why wouldn't it work?" She accepts if told that thrush usually itches and has no strong smell, that her symptoms do not look like thrush, and that the right treatment depends on finding out what it is. "So it might not be thrush. What else could it be?"
●
If the doctor explains why a test and examination are advised, or offers a self swab, a clinic or a surgery visit:
- ●Reaction: Anxious. "I knew you'd say that. Why do I need to be swabbed if it's only a smell?" She settles when told that a new partner means a small chance of an infection that causes no symptoms, and that finding out is better than guessing. She asks what the test involves, how long it takes and when she will find out. She agrees to attend tomorrow after work if offered, or to do a swab herself.
●
If the doctor explains that it is probably a common vaginal imbalance (bacterial vaginosis) and not a sign of being unclean:
- ●Reaction: Relieved but surprised. "So it's not because I'm dirty? I thought the wash would help." She asks whether it is an infection and whether Elias gave it to her. If told it is common, not caused by poor hygiene and not an STI, and that a scented wash can make it worse, she says, "Right, I'll stop using the wash and the shower gel."
●
If the doctor offers antibiotic tablets or gel, or says to wait for the swab results first:
- ●Reaction: Practical. "Will they work? And I'm on the pill, does that matter?" If told alcohol should be avoided: "I've got a night out on Saturday. How long do I have to avoid it?" She accepts any reasonable plan once she knows how to take it and what side effects to expect.
●
If the doctor discusses Elias, testing him or telling him:
- ●Reaction: Worried. "Does he have to be treated for this? How do I even bring it up?" If told that he does not need treatment for the discharge itself, but that both of them having a sexual health check is sensible: "Okay. I can tell him I'm having a check up before we stop using condoms altogether. That's not a lie." She asks whether the clinic can help if something does show up.
●
If the doctor discusses results, confidentiality, follow up or safety netting:
- ●Reaction: Wants specifics. "Will it go on my record? Who sees it? Will you phone or will it be a letter?" If told it will be a phone call or text and she should come back if the smell returns or she gets pain, fever, or bleeding, she repeats it back correctly. If the safety net is vague, she asks, "How bad is bad? What would I actually notice?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Anneka has a week of thin, grey white, fishy smelling discharge with no itch or soreness, and has self diagnosed thrush. She wants a pharmacy cream and does not want a test. The pattern is typical of bacterial vaginosis (BV), but she started a new relationship a month ago, uses condoms about half the time, and has not been tested. The station tests whether the candidate treats the likely cause while still offering proper sexual health testing, and does so without shaming her or losing her.
●The model plan has six parts. Take a sensitive sexual history. Recognise that BV is the likely diagnosis but that an STI cannot be excluded by phone. Explain why an antifungal cream will not help. Arrange an in person assessment with swabs (or a self taken swab) and STI testing. Offer treatment for BV. Give partner advice, self care advice and specific safety netting.
●Acceptable alternatives: examination and swabs at the surgery or at a sexual health clinic; a self taken vulvovaginal swab; starting metronidazole once swabs have been taken, rather than after the results; or waiting for the results before prescribing. A candidate who takes the swabs the next day, and prescribes then, also passes. Declining to prescribe over the phone with no swabs taken is also reasonable, because there is a recent new partner.

Telling BV, Thrush and STIs Apart

●NICE Clinical Knowledge Summaries (CKS, vaginal discharge, revised February 2024) describe discharge as physiological or pathological. Non sexually transmitted infective causes are BV and vulvovaginal candidiasis. Sexually transmitted causes include chlamydia, gonorrhoea and trichomoniasis. Non infective causes include a retained foreign body, dermatitis and gynaecological cancer.
●BV (CKS, last revised July 2023) is an overgrowth of mainly anaerobic organisms with loss of lactobacilli, raising vaginal pH above 4.5. About half of women have no symptoms. When present, it is a fishy smelling, thin white or grey discharge, usually without soreness, itch or irritation. Thrush is typically itchy, with a thick white discharge that has little smell. Chlamydia and gonorrhoea often cause no symptoms, or a change in discharge, bleeding between periods or after sex, or pelvic pain.
●Anneka's features (fishy smell, thin grey discharge, worse after sex and after menstruation, no itch) favour BV. Semen and menstrual blood raise vaginal pH, which explains the timing. Different infections can coexist, so the history alone cannot exclude an STI.

Why a New Partner Changes the Plan

●CKS BV allows empirical treatment without examination only when all of the following apply: low risk of an STI, no symptoms of other conditions, first episode or a previously confirmed similar episode, not pregnant, not postnatal and no recent gynaecological procedure. A new partner a month ago with inconsistent condom use means she is not at low risk. That is why testing is needed.
●CKS vaginal discharge advises that women at increased risk of an STI should be offered testing for chlamydia, gonorrhoea, trichomoniasis, HIV and syphilis, ideally in a genitourinary medicine (GUM) clinic, to facilitate treatment and partner notification, but that testing in primary care is acceptable if she cannot or will not attend a clinic.
●The BASHH BV guideline (2012) states that routine STI screening should be offered in accordance with current testing guidelines for women with BV, and that BV may coexist with candidiasis, trichomoniasis and cervicitis.

Why Not the Pharmacy Cream

●Antifungal creams and pessaries treat thrush. They do not treat BV, so using one would delay the right treatment. Her scented wash and shower gel are likely to worsen the problem.
●A good explanation is short: the symptoms point away from thrush, so the cream is unlikely to help, and the best treatment depends on confirming the cause.

Testing and Examination

●Examination is advised for most women with abnormal discharge. It can be omitted only if the history indicates BV or thrush, the STI risk is low, and there is no suggestion of upper tract infection. Neither applies here, and discharge cannot be examined or swabbed over the phone.
●Offer a vulvovaginal swab for chlamydia and gonorrhoea (NAAT), testing for trichomonas, and blood tests for HIV and syphilis. Vaginal pH and microscopy support the diagnosis of BV. Self taken swabs are accepted and may be easier for her. A sexual health clinic can offer one stop testing, treatment and partner notification.
●Window periods apply: NHS advice is that some infections can take up to 7 weeks after sex to show on a test, so symptomatic testing now is right, and the sexual health service will advise when to repeat HIV and syphilis blood tests.

Treating BV

●CKS and BASHH recommend treatment for symptomatic women. Oral metronidazole is the treatment of choice. Intravaginal metronidazole gel and intravaginal clindamycin cream are alternatives. Oral clindamycin and tinidazole are less preferred.
●The BNF lists oral metronidazole for BV as 400 to 500 mg twice daily for 5 to 7 days, or 2 g as a single dose, and metronidazole vaginal gel as one applicatorful at night for 5 days. BASHH notes that the 2 g single dose may be slightly less effective and that the 5 to 7 day course is preferred.
●BASHH advises avoiding alcohol with oral metronidazole because of a possible disulfiram like reaction, and, as a precaution, with the vaginal gel. The BNF interaction entry says the manufacturer advises avoiding alcohol for at least 48 hours after stopping oral treatment, which answers her question about Saturday night. Clindamycin cream can weaken latex condoms, so she should not rely on them during treatment.
●The combined pill is not affected by metronidazole. Pregnancy should be considered before prescribing: her last period was two weeks ago and she takes the pill correctly, so pregnancy is very unlikely.
●A test of cure is not required if symptoms resolve (BASHH).

Self Care, Prevention and Recurrence

●Advise avoiding vaginal douching, shower gel, antiseptic products and perfumed products, and washing with water or a simple emollient. CKS lists douching, vaginal washes, smoking, copper coils, menstruation and semen as factors that raise the risk of BV, and hormonal contraception, consistent condom use and a circumcised partner as factors that reduce it.
●Recurrence of BV is common. If symptoms persist or return, check adherence, reconsider the diagnosis, check for continued exposure to contributing factors and consider referral to a sexual health clinic. Probiotic and lactic acid products have not shown consistent benefit.
●Women with BV are at a higher risk of acquiring STIs including HIV, which is another reason for condoms and for testing.

Partner Management

●BASHH (2012) found no reduction in relapse when male partners were treated, so routine screening and treatment of a male partner for BV is not indicated. Elias does not need treatment for the discharge itself.
●Elias should still be encouraged to have a sexual health check as a new partner, ideally at the same time. If an STI is found, partner notification should be arranged, and the sexual health service can do this for her, which many patients find easier than telling a partner themselves. Avoid sex or use condoms until both have been tested, and until any treatment has been completed.
●If a woman with BV has a female partner, BASHH notes a high rate of BV in female partners, but no study has tested treating them together.
●Help her to plan what to say to Elias. Many patients fear that a test implies infidelity. BV is not an STI, and a joint check up is routine in a new relationship.

Safety Netting and Follow Up

●Review urgently, or the same day, for lower abdominal or pelvic pain, fever, bleeding between periods or after sex, pain during sex, or feeling generally unwell, because pelvic inflammatory disease (PID) needs prompt treatment. CKS advises a low threshold for empirical treatment of PID.
●Agree how results will be given (phone or text, per her wishes). Plan GUM referral if an STI is found, if symptoms persist or recur, or if the cause is in doubt.

Common Mistakes in This Station

●Agreeing to a pharmacy antifungal cream, or diagnosing thrush from the call.
●Prescribing metronidazole without any assessment, swab or STI offer, even though she has a new partner.
●Lecturing her about STIs when she refuses a test, instead of asking why and responding to the fear about Elias.
●Forgetting alcohol advice with metronidazole, or the condom warning with clindamycin cream.
●Telling her that Elias must be treated for BV, or giving no partner advice.
●Telling her BV is caused by poor hygiene, or failing to tell her to stop the wash.
●Vague safety netting that does not name pelvic pain, fever or bleeding.

Mapped to the RCGP curriculum topic: Sexual Health.

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