What is the recommended treatment for a perimenopausal female with vulvar itching and a rancid vaginal discharge?

In cases of vulvar itching accompanied by rancid vaginal discharge in a perimenopausal female, the likely underlying issue is a bacterial vaginosis or a vaginitis condition that may require an antibiotic treatment. Oral metronidazole is a well-established treatment for bacterial vaginosis, which is characterized by a fishy or rancid smelling discharge and can also present with itching.

Vaginal atrophy, which is common in perimenopausal women due to decreased estrogen levels, can cause similar symptoms such as itching and discomfort. However, this tends to produce a different type of discharge, often non-offensive. While topical estradiol cream can be beneficial for symptoms related to vaginal atrophy, it would not directly address an infection or a condition like bacterial vaginosis that causes rancid discharge.

Oral fluconazole is used to treat yeast infections, which typically present with a thick, white discharge rather than a rancid one. On the other hand, topical metronidazole may not be as effective as the oral formulation for systemic treatment of bacterial vaginosis and may not adequately address the symptoms if the condition is more extensive.

Thus, the choice of oral metronidazole is particularly appropriate in this scenario due to