SIM 5 Jessica Whitaker Vaginal Odor: activity report:
Women's Health GYN | 2026 update | 100% correct
-American Sentinel University.
1. A 32-year-old woman presents with a 5-day history of thin, grayish vaginal discharge
with a fishy odor. She has no dysuria or pruritus. On examination, the vaginal pH is 5.2,
and a whiff test (10% KOH) produces a strong amine odor. A saline wet mount shows
numerous clue cells. Which of the following best explains the pathophysiology of this
condition?
A. Overgrowth of Lactobacillus species with decreased vaginal pH
B. Reduction in hydrogen peroxide-producing lactobacilli and overgrowth of anaerobic bacteria such
as Gardnerella vaginalis
C. Primary infection with Trichomonas vaginalis causing inflammation and alkalinity
D. Allergic reaction to semen or personal care products leading to histamine release
Answer: B
Rationale: Bacterial vaginosis (BV) results from a decrease in Lactobacillus dominance and an
increase in anaerobic bacteria (e.g., Gardnerella, Prevotella). The fishy odor is due to amines
produced by anaerobes. Option A is incorrect because Lactobacillus is decreased, not
overgrown. Option C describes trichomoniasis, which typically presents with frothy discharge
and pruritus. Option D describes non-infectious vaginitis, which lacks clue cells and elevated
pH.
2. A 45-year-old woman with recurrent bacterial vaginosis (4 episodes in the past year) is
seeking management. She has a history of type 2 diabetes and uses a copper IUD for
contraception. According to the 2026 CDC STI treatment guidelines, which of the following
is the most appropriate initial suppressive regimen?
A. Metronidazole gel 0.75% once weekly for 6 months
B. Oral metronidazole 500 mg twice daily for 7 days, then 500 mg once daily for 4 months
C. Oral tinidazole 2 g single dose followed by boric acid 600 mg intravaginally nightly for 14 days
D. Clindamycin ovules 100 mg daily for 3 days each month for 6 months
Answer: B
Rationale: For recurrent BV, the 2026 CDC guidelines recommend oral metronidazole 500 mg
twice daily for 7 days, followed by suppressive therapy with oral metronidazole 500 mg once
daily for 4 months. Option A (metronidazole gel weekly) is not recommended due to poor
adherence and lower efficacy. Option C (tinidazole + boric acid) may be considered for
refractory cases but is not first-line. Option D (clindamycin ovules) may be used but is less
preferred due to risk of Clostridium difficile and resistance.
Page 1
,3. A 28-year-old woman presents with a 3-day history of greenish-yellow, frothy vaginal
discharge with a strong odor, vulvar pruritus, and dysuria. On speculum exam, the cervix
appears erythematous with punctate hemorrhages ('strawberry cervix'). A saline wet
mount reveals motile flagellated organisms. Which of the following additional findings is
most likely to be present?
A. Vaginal pH < 4.5
B. Positive whiff test with 10% KOH
C. Elevated vaginal pH > 5.0 and numerous white blood cells on microscopy
D. Pseudohyphae on KOH preparation
Answer: C
Rationale: Trichomoniasis typically causes a vaginal pH > 5.0 and an inflammatory response
with many WBCs. The whiff test (option B) is characteristic of BV, not trichomoniasis (though
amines may be present, it's not typically positive). Option A (pH < 4.5) is normal or seen in
candidiasis. Option D (pseudohyphae) indicates Candida infection.
4. A 26-year-old woman with a history of recurrent vulvovaginal candidiasis (RVVC)
presents with intense pruritus, thick white discharge, and erythema. She has been using
over-the-counter clotrimazole intermittently. A KOH preparation shows budding yeast and
pseudohyphae. She is not pregnant and has no known drug allergies. According to the 2026
IDSA guidelines for RVVC, which of the following induction and maintenance regimens is
recommended?
A. Fluconazole 150 mg single dose, then 150 mg weekly for 6 months
B. Fluconazole 150 mg every 72 hours for 3 doses, then 150 mg weekly for 6 months
C. Itraconazole 200 mg daily for 7 days, then 200 mg weekly for 6 months
D. Boric acid 600 mg intravaginally daily for 14 days, then twice weekly for 6 months
Answer: B
Rationale: For RVVC, the 2026 IDSA guidelines recommend an induction phase of fluconazole
150 mg every 72 hours for 3 doses, followed by a maintenance phase of 150 mg weekly for 6
months. Option A (single dose) is insufficient for induction. Option C (itraconazole) is a
second-line alternative. Option D (boric acid) is used for azole-resistant cases but is not
first-line.
5. A 34-year-old woman with a history of recurrent UTIs and on suppressive nitrofurantoin
presents with vaginal irritation and a thin, watery discharge. She reports using a vaginal
estrogen cream for atrophic vaginitis. On exam, the vaginal mucosa is pale, dry, and
friable. Vaginal pH is 6.0. Microscopy shows parabasal cells and numerous white blood
cells, but no clue cells, trichomonads, or yeast. Which of the following is the most likely
diagnosis?
A. Bacterial vaginosis
B. Desquamative inflammatory vaginitis
C. Cytolytic vaginosis
Page 2
,D. Allergic contact dermatitis
Answer: B
Rationale: Desquamative inflammatory vaginitis (DIV) is an uncommon condition characterized
by purulent discharge, elevated pH, parabasal cells, and inflammation without specific
pathogens. It is often associated with estrogen deficiency or autoimmune processes. Option A
(BV) would show clue cells and amine odor. Option C (cytolytic vaginosis) presents with normal
pH and Lactobacillus overgrowth. Option D (allergic contact) would have pruritus and
erythema, not parabasal cells.
6. A 30-year-old woman with symptomatic bacterial vaginosis is being treated with oral
metronidazole. She reports that she is currently breastfeeding a 2-month-old infant.
According to the 2026 CDC guidelines and AAP recommendations, which of the following
statements is most accurate regarding the safety of this treatment?
A. Metronidazole is contraindicated during breastfeeding due to high levels in breast milk and risk of
carcinogenicity
B. Metronidazole is safe; the infant should be monitored for diarrhea and oral thrush, and the mother
should avoid breastfeeding for 12-24 hours after a single 2g dose
C. Metronidazole is safe; the mother should pump and discard milk for 5 days after the last dose
D. Metronidazole is safe; no precautions are needed as levels in breast milk are negligible
Answer: B
Rationale: The AAP considers metronidazole compatible with breastfeeding. However, after a
single 2g dose, high levels in milk may cause side effects in the infant; thus, the CDC
recommends interrupting breastfeeding for 12-24 hours. For multiple-dose therapy (e.g., 500 mg
BID), levels are lower, and no interruption is needed, but monitoring for diarrhea/thrush is
prudent. Option A overstates risk. Option C is unnecessary. Option D is incorrect for the
single-dose scenario.
7. A 38-year-old woman with recurrent bacterial vaginosis and a history of pelvic
inflammatory disease (PID) is being evaluated. She has a new sexual partner and uses
condoms inconsistently. Which of the following strategies is most effective in reducing the
risk of BV recurrence?
A. Daily probiotic Lactobacillus capsules containing L. rhamnosus GR-1 and L. reuteri RC-14
B. Use of male condoms consistently with all sexual encounters
C. Monthly intravaginal boric acid 600 mg for 6 months
D. Treatment of male partners with oral metronidazole
Answer: B
Rationale: Consistent condom use has been shown to reduce BV recurrence by preventing
exposure to semen and new bacterial strains. Option A (probiotics) has mixed evidence and is
not as effective as condoms. Option C (boric acid) may help but is not first-line for prevention.
Option D (partner treatment) is not recommended by the CDC as it does not reduce recurrence
in women.
Page 3
, 8. A 42-year-old woman undergoing chemotherapy for breast cancer presents with severe
vulvar pain, erythema, and copious purulent discharge. She is on high-dose corticosteroids
and broad-spectrum antibiotics. KOH preparation reveals pseudohyphae. Culture grows
Candida glabrata resistant to fluconazole (MIC > 64 g/mL). Which of the following is the
most appropriate treatment?
A. Intravaginal clotrimazole 100 mg daily for 7 days
B. Oral fluconazole 150 mg daily for 14 days
C. Intravaginal boric acid 600 mg daily for 14 days
D. Intravenous amphotericin B deoxycholate 0.3 mg/kg/day
Answer: C
Rationale: Candida glabrata is often resistant to azoles. Boric acid is recommended as first-line
for azole-resistant Candida vaginitis. Option A (clotrimazole) is an azole and likely ineffective.
Option B (fluconazole) is inappropriate due to resistance. Option D (amphotericin B) is reserved
for severe systemic infections; topical boric acid is preferred for localized disease.
9. A 25-year-old woman with a history of recurrent BV and trichomoniasis presents for
follow-up after completing treatment for trichomoniasis with oral tinidazole 2 g single dose.
She is asymptomatic now. A test of cure is performed using a nucleic acid amplification test
(NAAT) for Trichomonas vaginalis. According to the 2026 CDC guidelines, when should
this test be performed?
A. Immediately after completion of treatment
B. 2 weeks after treatment
C. 3 months after treatment
D. Only if symptoms recur
Answer: B
Rationale: The CDC recommends a test of cure for trichomoniasis at 2 weeks after treatment due
to the high rate of reinfection and resistance. NAAT is more sensitive than microscopy. Option A
(immediately) would not detect persistent infection due to residual DNA. Option C (3 months) is
too late; reinfection may have occurred. Option D (only if symptoms recur) misses asymptomatic
persistent infection.
10. A 36-year-old woman with recurrent bacterial vaginosis and a history of multiple
sexual partners is concerned about HIV risk. She has no known HIV exposure. Which of
the following statements regarding the association between BV and HIV acquisition is most
accurate based on current evidence?
A. BV is not associated with HIV acquisition; the correlation is due to confounding by sexual behavior
B. BV increases the risk of HIV acquisition by disrupting the vaginal epithelial barrier and recruiting
HIV target cells
C. Treatment of BV with metronidazole reduces the risk of HIV acquisition by 50%
D. HIV-positive women are less likely to develop BV due to antiretroviral therapy
Page 4
Women's Health GYN | 2026 update | 100% correct
-American Sentinel University.
1. A 32-year-old woman presents with a 5-day history of thin, grayish vaginal discharge
with a fishy odor. She has no dysuria or pruritus. On examination, the vaginal pH is 5.2,
and a whiff test (10% KOH) produces a strong amine odor. A saline wet mount shows
numerous clue cells. Which of the following best explains the pathophysiology of this
condition?
A. Overgrowth of Lactobacillus species with decreased vaginal pH
B. Reduction in hydrogen peroxide-producing lactobacilli and overgrowth of anaerobic bacteria such
as Gardnerella vaginalis
C. Primary infection with Trichomonas vaginalis causing inflammation and alkalinity
D. Allergic reaction to semen or personal care products leading to histamine release
Answer: B
Rationale: Bacterial vaginosis (BV) results from a decrease in Lactobacillus dominance and an
increase in anaerobic bacteria (e.g., Gardnerella, Prevotella). The fishy odor is due to amines
produced by anaerobes. Option A is incorrect because Lactobacillus is decreased, not
overgrown. Option C describes trichomoniasis, which typically presents with frothy discharge
and pruritus. Option D describes non-infectious vaginitis, which lacks clue cells and elevated
pH.
2. A 45-year-old woman with recurrent bacterial vaginosis (4 episodes in the past year) is
seeking management. She has a history of type 2 diabetes and uses a copper IUD for
contraception. According to the 2026 CDC STI treatment guidelines, which of the following
is the most appropriate initial suppressive regimen?
A. Metronidazole gel 0.75% once weekly for 6 months
B. Oral metronidazole 500 mg twice daily for 7 days, then 500 mg once daily for 4 months
C. Oral tinidazole 2 g single dose followed by boric acid 600 mg intravaginally nightly for 14 days
D. Clindamycin ovules 100 mg daily for 3 days each month for 6 months
Answer: B
Rationale: For recurrent BV, the 2026 CDC guidelines recommend oral metronidazole 500 mg
twice daily for 7 days, followed by suppressive therapy with oral metronidazole 500 mg once
daily for 4 months. Option A (metronidazole gel weekly) is not recommended due to poor
adherence and lower efficacy. Option C (tinidazole + boric acid) may be considered for
refractory cases but is not first-line. Option D (clindamycin ovules) may be used but is less
preferred due to risk of Clostridium difficile and resistance.
Page 1
,3. A 28-year-old woman presents with a 3-day history of greenish-yellow, frothy vaginal
discharge with a strong odor, vulvar pruritus, and dysuria. On speculum exam, the cervix
appears erythematous with punctate hemorrhages ('strawberry cervix'). A saline wet
mount reveals motile flagellated organisms. Which of the following additional findings is
most likely to be present?
A. Vaginal pH < 4.5
B. Positive whiff test with 10% KOH
C. Elevated vaginal pH > 5.0 and numerous white blood cells on microscopy
D. Pseudohyphae on KOH preparation
Answer: C
Rationale: Trichomoniasis typically causes a vaginal pH > 5.0 and an inflammatory response
with many WBCs. The whiff test (option B) is characteristic of BV, not trichomoniasis (though
amines may be present, it's not typically positive). Option A (pH < 4.5) is normal or seen in
candidiasis. Option D (pseudohyphae) indicates Candida infection.
4. A 26-year-old woman with a history of recurrent vulvovaginal candidiasis (RVVC)
presents with intense pruritus, thick white discharge, and erythema. She has been using
over-the-counter clotrimazole intermittently. A KOH preparation shows budding yeast and
pseudohyphae. She is not pregnant and has no known drug allergies. According to the 2026
IDSA guidelines for RVVC, which of the following induction and maintenance regimens is
recommended?
A. Fluconazole 150 mg single dose, then 150 mg weekly for 6 months
B. Fluconazole 150 mg every 72 hours for 3 doses, then 150 mg weekly for 6 months
C. Itraconazole 200 mg daily for 7 days, then 200 mg weekly for 6 months
D. Boric acid 600 mg intravaginally daily for 14 days, then twice weekly for 6 months
Answer: B
Rationale: For RVVC, the 2026 IDSA guidelines recommend an induction phase of fluconazole
150 mg every 72 hours for 3 doses, followed by a maintenance phase of 150 mg weekly for 6
months. Option A (single dose) is insufficient for induction. Option C (itraconazole) is a
second-line alternative. Option D (boric acid) is used for azole-resistant cases but is not
first-line.
5. A 34-year-old woman with a history of recurrent UTIs and on suppressive nitrofurantoin
presents with vaginal irritation and a thin, watery discharge. She reports using a vaginal
estrogen cream for atrophic vaginitis. On exam, the vaginal mucosa is pale, dry, and
friable. Vaginal pH is 6.0. Microscopy shows parabasal cells and numerous white blood
cells, but no clue cells, trichomonads, or yeast. Which of the following is the most likely
diagnosis?
A. Bacterial vaginosis
B. Desquamative inflammatory vaginitis
C. Cytolytic vaginosis
Page 2
,D. Allergic contact dermatitis
Answer: B
Rationale: Desquamative inflammatory vaginitis (DIV) is an uncommon condition characterized
by purulent discharge, elevated pH, parabasal cells, and inflammation without specific
pathogens. It is often associated with estrogen deficiency or autoimmune processes. Option A
(BV) would show clue cells and amine odor. Option C (cytolytic vaginosis) presents with normal
pH and Lactobacillus overgrowth. Option D (allergic contact) would have pruritus and
erythema, not parabasal cells.
6. A 30-year-old woman with symptomatic bacterial vaginosis is being treated with oral
metronidazole. She reports that she is currently breastfeeding a 2-month-old infant.
According to the 2026 CDC guidelines and AAP recommendations, which of the following
statements is most accurate regarding the safety of this treatment?
A. Metronidazole is contraindicated during breastfeeding due to high levels in breast milk and risk of
carcinogenicity
B. Metronidazole is safe; the infant should be monitored for diarrhea and oral thrush, and the mother
should avoid breastfeeding for 12-24 hours after a single 2g dose
C. Metronidazole is safe; the mother should pump and discard milk for 5 days after the last dose
D. Metronidazole is safe; no precautions are needed as levels in breast milk are negligible
Answer: B
Rationale: The AAP considers metronidazole compatible with breastfeeding. However, after a
single 2g dose, high levels in milk may cause side effects in the infant; thus, the CDC
recommends interrupting breastfeeding for 12-24 hours. For multiple-dose therapy (e.g., 500 mg
BID), levels are lower, and no interruption is needed, but monitoring for diarrhea/thrush is
prudent. Option A overstates risk. Option C is unnecessary. Option D is incorrect for the
single-dose scenario.
7. A 38-year-old woman with recurrent bacterial vaginosis and a history of pelvic
inflammatory disease (PID) is being evaluated. She has a new sexual partner and uses
condoms inconsistently. Which of the following strategies is most effective in reducing the
risk of BV recurrence?
A. Daily probiotic Lactobacillus capsules containing L. rhamnosus GR-1 and L. reuteri RC-14
B. Use of male condoms consistently with all sexual encounters
C. Monthly intravaginal boric acid 600 mg for 6 months
D. Treatment of male partners with oral metronidazole
Answer: B
Rationale: Consistent condom use has been shown to reduce BV recurrence by preventing
exposure to semen and new bacterial strains. Option A (probiotics) has mixed evidence and is
not as effective as condoms. Option C (boric acid) may help but is not first-line for prevention.
Option D (partner treatment) is not recommended by the CDC as it does not reduce recurrence
in women.
Page 3
, 8. A 42-year-old woman undergoing chemotherapy for breast cancer presents with severe
vulvar pain, erythema, and copious purulent discharge. She is on high-dose corticosteroids
and broad-spectrum antibiotics. KOH preparation reveals pseudohyphae. Culture grows
Candida glabrata resistant to fluconazole (MIC > 64 g/mL). Which of the following is the
most appropriate treatment?
A. Intravaginal clotrimazole 100 mg daily for 7 days
B. Oral fluconazole 150 mg daily for 14 days
C. Intravaginal boric acid 600 mg daily for 14 days
D. Intravenous amphotericin B deoxycholate 0.3 mg/kg/day
Answer: C
Rationale: Candida glabrata is often resistant to azoles. Boric acid is recommended as first-line
for azole-resistant Candida vaginitis. Option A (clotrimazole) is an azole and likely ineffective.
Option B (fluconazole) is inappropriate due to resistance. Option D (amphotericin B) is reserved
for severe systemic infections; topical boric acid is preferred for localized disease.
9. A 25-year-old woman with a history of recurrent BV and trichomoniasis presents for
follow-up after completing treatment for trichomoniasis with oral tinidazole 2 g single dose.
She is asymptomatic now. A test of cure is performed using a nucleic acid amplification test
(NAAT) for Trichomonas vaginalis. According to the 2026 CDC guidelines, when should
this test be performed?
A. Immediately after completion of treatment
B. 2 weeks after treatment
C. 3 months after treatment
D. Only if symptoms recur
Answer: B
Rationale: The CDC recommends a test of cure for trichomoniasis at 2 weeks after treatment due
to the high rate of reinfection and resistance. NAAT is more sensitive than microscopy. Option A
(immediately) would not detect persistent infection due to residual DNA. Option C (3 months) is
too late; reinfection may have occurred. Option D (only if symptoms recur) misses asymptomatic
persistent infection.
10. A 36-year-old woman with recurrent bacterial vaginosis and a history of multiple
sexual partners is concerned about HIV risk. She has no known HIV exposure. Which of
the following statements regarding the association between BV and HIV acquisition is most
accurate based on current evidence?
A. BV is not associated with HIV acquisition; the correlation is due to confounding by sexual behavior
B. BV increases the risk of HIV acquisition by disrupting the vaginal epithelial barrier and recruiting
HIV target cells
C. Treatment of BV with metronidazole reduces the risk of HIV acquisition by 50%
D. HIV-positive women are less likely to develop BV due to antiretroviral therapy
Page 4
