• • Inflammatory condition of the cervix defined by the presence of mucopurulent endocervical discharge, easily induced endocervical friability, or edematous cervical ectopy.
  
• • Most often a result of chlamydia, gonorrhea, trichomoniasis, or genital herpes infection.
  
• • Associated with an increased risk of upper genital tract infection, adverse pregnancy outcomes, and HIV acquisition.

Cervicitis is typically the consequence of infection with sexually acquired pathogens, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae and, occasionally, Trichomonas vaginalis or herpes simplex virus (HSV). The diagnosis is made when either mucopurulent discharge or easily induced bleeding (friability) is present at the endocervical os; more subtle signs include edema of the cervical ectropion (edematous ectopy). Recent data suggest that disruption of normal vaginal flora, most often manifesting as bacterial vaginosis, may also promote cervicitis. Although C trachomatis is probably the most common cause of cervicitis, and N gonorrhoeae is also implicated, the majority of women (80–90%) infected with these pathogens have no signs of cervicitis.

The cervix consists of an underlying connective tissue matrix overlaid by two types of distinct epithelium, each of which is vulnerable to infection by distinct pathogens. The endocervical canal and ectropion (cervical ectopy), if present, are lined by columnar epithelial cells. These cells, which line what is commonly called the endocervix, provide vulnerable targets for infections with C trachomatis and N gonorrhoeae. The ectocervix, in contrast, is lined by squamous epithelium that is contiguous with the vaginal mucosa. For this reason, the ectocervix is susceptible to T vaginalis, an agent more commonly associated with vaginitis.

Estrogen, produced endogenously or administered exogenously, promotes the formation and maintenance of cervical ectopy, which is present in adolescents, pregnant women, and women who take estrogen-containing contraceptives. Estrogen is also needed to maintain adequate thickness of the squamous cervicovaginal epithelium (≥20 cell layers). This promotes sustenance of a healthy population of hydrogen peroxide-producing Lactobacillus species, which maintain normal (acidic) vaginal pH. The quality of endocervical mucous is also affected by these hormones. Relatively high levels of estrogen during the follicular phase leading up to ovulation thin the endocervical mucous; this can result in elaboration of so-called physiologic discharge. In the luteal phase of the cycle, progesterone increases the viscosity and reduces the volume of endocervical mucous.

Recently, some investigators have proposed a direct role for these hormones in modulating the balance of cell-mediated (Th1) and humoral (Th2) immune responses, with estrogen predominance promoting Th2 and progesterone augmenting Th1 responses. Because endocervical mucous possesses intrinsic antimicrobial activity by virtue of lactic acid, low pH, and antimicrobial peptides, these hormonal changes are potentially important in mediating susceptibility to and natural history of cervical infection. For example, it is not at all clear why only a subset of women develops inflammatory signs of cervicitis when infected by chlamydia, gonorrhea, or trichomoniasis.

Acquisition of the sexually transmitted diseases (STDs) that cause cervicitis—in particular, chlamydia, gonorrhea, trichomoniasis, and genital herpes—is markedly reduced when condoms are used consistently and correctly. No data speak to the effect of condoms on cervicitis in which no microbiologic etiology is apparent.

History

A thorough sexual history—including assessment of number and gender of recent partners, specific sexual practices (oral, anal, vaginal sex), whether sex partners are symptomatic or have been recently diagnosed with an STD or STD-related syndrome, recent Papanicolaou (Pap) smear history, and use of condoms or other prevention methods—should be obtained from women who present with cervicitis.

Symptoms referent to the lower genital tract that should be elicited include dysuria, urinary hesitancy or frequency, and abnormal vaginal discharge. Elements of the history that might suggest upper genital tract involvement should be assessed, including lower abdominal or pelvic pain or cramping, right upper quadrant pain, and pain or bleeding with intercourse or other penetrative sex.

Patients should be specifically queried about a history of douching and any use of intravaginal products, including lubricants, over-the-counter therapeutic preparations (especially antifungal products), and so-called feminine deodorants, all of which can cause a chemical or allergic mucosal reaction. Information about these factors can help to narrow the differential diagnosis considerably and direct subsequent management.

Symptoms and Signs

Symptoms of cervicitis include abnormal vaginal discharge (increase in amount; change in color [often yellow, green, or brown] or odor [malodorous]), intermenstrual bleeding, and bleeding that occur after intercourse or other penetrative sexual contact. However, most women with cervicitis do not complain of symptoms, and even when symptoms are present, they are nonspecific and may indicate vaginitis without cervical involvement. If endometritis or other pelvic inflammatory disease (PID) accompanies cervicitis, lower abdominal pain or cramping, often exacerbated with intercourse, may be present.

Mucopurulent discharge issuing from the endocervical canal and easily induced bleeding are the most easily recognized signs of endocervicitis. Both may be present simultaneously. Edematous ectopy is a more subtle sign and is characterized by a swollen, irregular mucosal surface to the ectropion. Signs of infection affecting the ectocervix depend on the responsible pathogen. T vaginalis can cause an erosive inflammation of the ectocervical epithelium, classically manifest as “strawberry cervix” or colpitis macularis. This process may appear as a range of epithelial disruption, from small isolated petechiae to large punctuate hemorrhages with surrounding areas of pale mucosa.

Genital infection with HSV types 1 and 2 can cause cervicitis, particularly in the case of women who experience severe clinical manifestations of primary infection with HSV-2. Although most primary HSV-2 infections are asymptomatic, some women (15–20%) experience a severe primary infection that may include cervicitis. Cervicitis in this setting is characterized by diffuse erosive and hemorrhagic lesions, usually in the ectocervical epithelium, and often accompanied by frank ulceration. Other manifestations of primary HSV-2 genital infection are usually evident, including external herpetic lesions, neurologic manifestations (including aseptic meningitis, urinary retention, and lumbosacral radiculitis), fever, and inguinal lymphadenopathy. Cervicitis may recur with clinical recurrences of genital HSV-2; however, it is typically not severe. Subclinical shedding of HSV-2 does not appear to be directly related to cervicitis. HSV-1 may also cause cervicitis similar to that described for HSV-2; however, the manifestations are typically less severe, and usually occur only during the primary genital infection with HSV-1. As with genital herpes, other causes of genital ulcer disease can cause lesions on the cervix; these include the chancre of primary syphilis and ulcers of chancroid.

Mycoplasma genitalium has recently been implicated as a sexually transmissible cause of cervicitis, but its exact prevalence, incidence, and natural history are not known; prospective studies are underway. Various case reports have attributed cervicitis to infection with certain Streptococcus species—most notably, S agalactiae (group B streptococcus) and S pyogenes—but reliable estimates of how commonly this might occur, if a causal relationship exists, are not available, nor is the approach to treating these agents if they are suspected etiologies of cervicitis clear.

Apart from the previously noted infections, numerous noninfectious and infectious systemic inflammatory processes and local insults can precipitate cervical inflammation that may present clinically as apparent cervicitis. The former group includes Behçet syndrome, sarcoidosis, ligneous conjunctivitis, and tuberculosis. Substances that either erode the endocervical mucous plug or cause an irritant mucositis can also cause signs of cervicitis. Commonly used, commercially available douching and feminine deodorant preparations often include detergents that have surfactant properties, and many include various chemicals such as antihistamines and cornstarch. In one large study in which commercial sex workers were randomized to use vaginal sponges impregnated with 1 g of nonoxynol-9 (N-9), cervical erosions as assessed by colposcopy were seen more commonly among N-9 users, who were also more likely to acquire HIV infection during the course of the study than were nonusers. Because N-9 has shown no benefit in reducing acquisition of HIV and STDs, it is no longer recommended for this purpose.

Even seemingly obvious signs of endocervical inflammation may have variable precision for chlamydia and gonorrhea, because the predictive value of individual cervical findings suggestive of cervicitis may vary with patients’ age and other STD-related risk factors. For example, the presence of easily induced endocervical bleeding in a 16-year-old girl who reports recent unprotected sex with a new male partner is highly predictive of chlamydial infection; the predictive value of this sign is much lower for chlamydia in a 35-year-old woman in a long-term, monogamous relationship.

Laboratory Findings