There is a wide variation in what women and physicians consider normal vaginal discharge. Many of the symptoms associated with vaginal abnormality are present in healthy women, and healthy women experience vaginal discharge. The quantity of discharge appears to vary from woman to woman, as well as throughout an individual woman's menstrual cycle. Normal vaginal fluid may have an unpleasant odor. There is some evidence that healthy women can experience irritative symptoms.

It is troubling that these conclusions challenge some of what is written in textbooks. Physicians who are misinformed about the nature of vaginal wetness, odor, and irritation may impose the diagnosis of vaginitis on healthy women who would then be subject to needless worry and unnecessary medication. If true, this would be consistent with medicine's historical tendency to interpret the normal functions of the female reproductive system as diseased (29).

Although vaginal discharge, odor, and irritation may be normal, they may also be legitimate indicators of disease. Given the prevalence of vaginal symptoms, it is important for primary care researchers to develop clinically useful ways of making the distinction between normal and pathologic discharge and establish some criteria for "normality." Existing studies typically classify women as normal if either they had been examined thoroughly and no disease was found ("clinically normal") or if they declared themselves normal ("self-report"). There are other possible definitions of normality, including those based on a statistically derived norm or on a threshold value beyond which diagnosis and treatment become beneficial (30).

In addition, future studies will require more clinically useful measures. Measuring grams of discharge or milliliters of cervical mucus is not practical during a pelvic examination. If there is a wide variation in normal, it may be impossible to provide precise measures of normality for measures such as quantity of discharge. Alternative definitions of normal, such as change from usual pattern (31) or functional difficulties, may be more useful. Indeed, for patients, social factors may play a key role in determining what is or is not normal. Some patients with vaginal symptoms seek medical consultation when the discharge interferes with function, either during sexual relations or in the ability to perform activities of daily living. "Symptoms" are a nearly ubiquitous human experience, yet the decision to seek medical consultation is often triggered by some social difficulty (32).

Although vaginal symptoms portend serious disease only rarely, they are distressing to patients. Unfortunately, a good evidence base upon which to decide when discharge indicates pathology is lacking. Both clinicians and their patients would benefit from a better understanding of the range of normal as well as what constitutes a meaningful departure from that range.

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