- Jeanne Marrazzo, MD, MPH
Jeanne Marrazzo, MD, MPH
- Professor, Division of Allergy & Infectious Diseases
- Medical Director, Seattle STD/HIV Prevention Training Center
- University of Washington
- Section Editors
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics/Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Noreen A Hynes, MD, MPH, DTM&H
Noreen A Hynes, MD, MPH, DTM&H
- Section Editor — Sexually Transmitted Diseases
- Associate Professor of Infectious Diseases; International Health; and Population, Family, and Reproductive Health
- Johns Hopkins University Schools of Medicine and Public Health
Cervicitis refers to inflammation of the uterine cervix. The inflammation primarily affects the columnar epithelial cells of the endocervical glands, but can also affect the squamous epithelium of the ectocervix. It may be due to an infectious or noninfectious etiology and may be acute or chronic. Acute cervicitis is usually due to infection (eg, chlamydia, gonorrhea), although a specific infection cannot be determined in a large proportion of cases. Chronic cervicitis usually has a noninfectious source.
Cervical infection is clinically important because it can ascend and cause endometritis or pelvic inflammatory disease (PID); the pathogens involved can be transmitted to sexual partners; and, in pregnant women, it may cause pregnancy and/or neonatal complications as a result of infection of the fetus, placenta, amniotic fluid, decidua, or membranes. In addition, cervicitis appears to be associated with a significant increase in risk of HIV-1 acquisition and shedding . Sequelae of PID include chronic pelvic pain, infertility, and an increased risk of ectopic pregnancy. (See "Long-term complications of pelvic inflammatory disease".)
Infection — When an infectious etiology can be documented, Chlamydia trachomatis (typically serovars D-K) and Neisseria gonorrhoeae are the most common organisms identified, even though a relatively small proportion of women with these infections develop cervicitis. Chlamydial cervicitis occurs more often than gonococcal, and both primarily affect the columnar epithelium of the endocervix.
Herpes simplex virus (HSV) and Trichomonas vaginalis account for a few cases, but primarily affect the squamous epithelium of the ectocervix. Tuberculosis involves the cervix in a small proportion of women with tuberculous endometritis (see "Endometritis unrelated to pregnancy", section on 'Tuberculous endometritis') . Mycoplasma genitalium may be an important pathogen, as well [3-5]. Bacterial vaginosis and streptococci (group A) have also been implicated as causative agents of acute cervicitis [6-10]. Bacterial vaginosis is unlikely to be a cause of isolated cervicitis, without concurrent vaginal findings.
Mycoplasma hominis, Ureaplasma urealyticum, and group B beta-hemolytic streptococci are commonly found in the genital tract, but there is little evidence that they cause cervicitis [11,12]. Case reports have described cervicitis associated with other infectious agents (bacteria, viruses, fungi, parasites).
- Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis. Sex Transm Dis 2008; 35:946.
- Samantaray S, Parida G, Rout N, et al. Cytologic detection of tuberculous cervicitis: a report of 7 cases. Acta Cytol 2009; 53:594.
- Rodrigues MM, Fernandes PÁ, Haddad JP, et al. Frequency of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis and Ureaplasma species in cervical samples. J Obstet Gynaecol 2011; 31:237.
- Gaydos C, Maldeis NE, Hardick A, et al. Mycoplasma genitalium as a contributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics. Sex Transm Dis 2009; 36:598.
- Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Am J Obstet Gynecol 2012; 206:476.e1.
- Paraskevaides EC, Wilson MC. Fatal disseminated intravascular coagulation secondary to streptococcal cervicitis. Eur J Obstet Gynecol Reprod Biol 1988; 29:39.
- Manhart LE, Critchlow CW, Holmes KK, et al. Mucopurulent cervicitis and Mycoplasma genitalium. J Infect Dis 2003; 187:650.
- Marrazzo JM. Mucopurulent cervicitis: no longer ignored, but still misunderstood. Infect Dis Clin North Am 2005; 19:333.
- Marrazzo JM, Wiesenfeld HC, Murray PJ, et al. Risk factors for cervicitis among women with bacterial vaginosis. J Infect Dis 2006; 193:617.
- McGowin CL, Anderson-Smits C. Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women. PLoS Pathog 2011; 7:e1001324.
- Nugent RP, Hillier SL. Mucopurulent cervicitis as a predictor of chlamydial infection and adverse pregnancy outcome. The Investigators of the Johns Hopkins Study of Cervicitis and Adverse Pregnancy Outcome. Sex Transm Dis 1992; 19:198.
- Paavonen J, Critchlow CW, DeRouen T, et al. Etiology of cervical inflammation. Am J Obstet Gynecol 1986; 154:556.
- Marrazzo JM, Handsfield HH, Whittington WL. Predicting chlamydial and gonococcal cervical infection: implications for management of cervicitis. Obstet Gynecol 2002; 100:579.
- Koelle DM, Benedetti J, Langenberg A, Corey L. Asymptomatic reactivation of herpes simplex virus in women after the first episode of genital herpes. Ann Intern Med 1992; 116:433.
- Huppert JS, Mortensen JE, Reed JL, et al. Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women. Sex Transm Dis 2008; 35:250.
- Short VL, Totten PA, Ness RB, et al. Clinical presentation of Mycoplasma genitalium Infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease. Clin Infect Dis 2009; 48:41.
- Marrazzo JM, Martin DH. Management of women with cervicitis. Clin Infect Dis 2007; 44 Suppl 3:S102.
- Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59:1.
- Hobbs MM, van der Pol B, Totten P, et al. From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections. Sex Transm Dis 2008; 35:8.
- Sellors J, Howard M, Pickard L, et al. Chlamydial cervicitis: testing the practice guidelines for presumptive diagnosis. CMAJ 1998; 158:41.
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
- Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_e (Accessed on August 09, 2012).
- http://www.cdc.gov/std/treatment/2010/default.htm (Accessed on January 13, 2011).
- Centers for Disease Control and Prevention (CDC). Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep 2012; 61:590.
- Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep 2007; 56:332.
- Wang SA, Harvey AB, Conner SM, et al. Antimicrobial resistance for Neisseria gonorrhoeae in the United States, 1988 to 2003: the spread of fluoroquinolone resistance. Ann Intern Med 2007; 147:81.
- Whittington WL, Kent C, Kissinger P, et al. Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study. Sex Transm Dis 2001; 28:117.
- Paavonen J, Roberts PL, Stevens CE, et al. Randomized treatment of mucopurulent cervicitis with doxycycline or amoxicillin. Am J Obstet Gynecol 1989; 161:128.
- Chandeying V, Sutthijumroon S, Tungphaisal S. Evaluation of ofloxacin in the treatment of mucopurulent cervicitis: response of chlamydia-positive and chlamydia-negative forms. J Med Assoc Thai 1989; 72:331.
- Schwebke JR, Weiss HL. Interrelationships of bacterial vaginosis and cervical inflammation. Sex Transm Dis 2002; 29:59.
- Parsons WL, Godwin M, Robbins C, Butler R. Prevalence of cervical pathogens in women with and without inflammatory changes on smear testing. BMJ 1993; 306:1173.
- Nyirjesy P. Nongonococcal and Nonchlamydial Cervicitis. Curr Infect Dis Rep 2001; 3:540.
- Purola E, Paavonen J. Routine cytology as a diagnostic aid in chlamydial cervicitis. Scand J Infect Dis Suppl 1982; 32:55.
- Hare MJ, Toone E, Taylor-Robinson D, et al. Follicular cervicitis--colposcopic appearances and association with Chlamydia trachomatis. Br J Obstet Gynaecol 1981; 88:174.
- Dunlop EM, Garner A, Darougar S, et al. Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis. Genitourin Med 1989; 65:22.
- Paavonen J, Vesterinen E, Meyer B, Saksela E. Colposcopic and histologic findings in cervical chlamydial infection. Obstet Gynecol 1982; 59:712.
- Mena LA, Mroczkowski TF, Nsuami M, Martin DH. A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Clin Infect Dis 2009; 48:1649.
- Schwebke JR, Rompalo A, Taylor S, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens--a randomized clinical trial. Clin Infect Dis 2011; 52:163.
- Jernberg E, Moghaddam A, Moi H. Azithromycin and moxifloxacin for microbiological cure of Mycoplasma genitalium infection: an open study. Int J STD AIDS 2008; 19:676.
- Jensen JS, Bradshaw CS, Tabrizi SN, et al. Azithromycin treatment failure in Mycoplasma genitalium-positive patients with nongonococcal urethritis is associated with induced macrolide resistance. Clin Infect Dis 2008; 47:1546.
- Bradshaw CS, Chen MY, Fairley CK. Persistence of Mycoplasma genitalium following azithromycin therapy. PLoS One 2008; 3:e3618.
- Noninfectious causes
- CLINICAL FINDINGS
- Signs and symptoms
- Physical examination
- DETERMINING THE CAUSE
- Less useful - unnecessary tests
- Empiric therapy
- Treatment of specific infections
- - Gonorrhea, chlamydia
- - Bacterial vaginosis
- - Trichomonas vaginalis
- - Herpes simplex virus
- Sex partners
- Women with no identifiable pathogen
- Women with a foreign body/substance
- Asymptomatic women with inflammation on histology or cytology
- RECURRENT OR PERSISTENT DISEASE
- CHRONIC CERVICITIS
- SUMMARY AND RECOMMENDATIONS