Cervicitis is a process characterised by inflammation of the cervix.

It was
recognised for the first time as an important clinical condition in 1984, described
as “the counterpart in women of urethritis in men”.1 Inflammation is localised
mainly in the columnar epithelial cells of the endocervical glands, but it can also
affect the squamous epithelium of the ectocervix.

It is usually caused by an infectious agent, generally transmitted sexually.

On many occasions it does not cause noticeable symptoms and the importance
of its detection and correct treatment lies in the fact that silent infection can result
in complications such as salpingitis, endometritis and pelvic inflammatory
disease (PID) and have severe consequences in pregnant women.

Despite the fact that there are not many studies which have evaluated the
frequency of cervicitis, it is estimated that it is a common condition, with
prevalence’s as high as 20–40% in women seen in consultations for sexually
transmitted infections (STIs).

Anatomy and physiology of the cervix

The cervix consists of a matrix of connective tissue covered by two different

types of epithelium: columnar and squamous. The columnar epithelial cells line
the endocervical canal and form the target for the pathogens most frequently
associated with cervicitis, such as Chlamydia trachomatis and Neisseria
gonorrhoeae. On the other hand, the ectocervix is lined with squamous
epithelium, which is adjacent to the vaginal mucosa and, consequently,
susceptible to pathogens associated with vaginitis, including Trichomonas
vaginalis and Candida spp. Both epithelia differ, not only in the susceptibility to
certain microorganisms, but also in the endogenous defence mechanisms, their
response to hormonal changes, their secretory capacity and their vulnerability to
HIV.

Hormones have multiple effects on the cervicovaginal mucosa. Thus, oestrogens

(both endogenous and exogenous) promote cervical ectropion, i.e. the protrusion
of the columnar epithelium of the endocervix towards the visible ectocervix,

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present in adolescents, pregnant women and women who take
oestrogencontaining contraceptives. In addition, they are fundamental for the
maintenance of an appropriate thickness of the cervicovaginal squamous
epithelium. On the contrary, progesterone may cause this epithelium to become
thinner. The quality of the endocervical mucus is also influenced by these
hormones, and a direct modulator role has even been proposed for them in
humoral and cell-mediated immune responses. Furthermore, endocervical mucus
has considerable intrinsic antimicrobial activity provided by lactic acid, a low pH
and the presence of antimicrobial peptides.

Signs and symptoms

From the clinical point of view, cervicitis tends to classified as acute or chronic,
with the latter being responsible for a large number of cases. Inflammation of the
cervix is frequently asymptomatic, and in symptomatic women the symptoms are
often nonspecific, with the most significant being the presence of increased
vaginal discharge and/or intermenstrual bleeding, usually related to sexual
intercourse.

In gynaecological examination, cervicitis is typically manifested by the presence

of mucopurulent endocervical exudate in the endocervical canal (“mucopurulent
cervicitis”) and/or bleeding, which is easily induced by light rubbing with a
cotton swab through the external cervical os (“friability”). Both signs can be
present or there may only be one of them, and friability is as common, or even
more so, than the presence of exudate. Therefore, although the oldest works refer
to the term “mucopurulent cervicitis”, this terminology is not precise and the
clinical practice guidelines have used the term “cervicitis” since 2006 to include
all cases.

Chronic cervicitis, generally asymptomatic, is very common in adult women (at

least that which can be seen only microscopically) and its importance lies in the
fact that subclinical infection can extend to the upper genital tract, resulting in
complications such as endometritis, salpingitis and PID. It can also lead to
adverse effects in pregnant women and in newborns. The sequelae of PID include

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chronic abdominal pelvic pain, infertility and increased risk of ectopic
pregnancy. In addition, chronic inflammation of the cervix could contribute to
the development of cervical cancer.

Aetiology

There are multiple agents, both infectious and non-infectious, potentially

involved in cervicitis. Current availability of molecular techniques is
increasing the number of microorganisms recognised as potential aetiological
agents.

Infectious agents

Sexually transmitted pathogens

 C. trachomatis and N. gonorrhoeae. These are pathogens typically

associated with cervicitis, although both microorganisms are detected in
less than half of cases. The rest can be produced by other pathogens, by
non-infectious agents and, occasionally, by systemic inflammatory
processes. C. trachomatis is the most frequently identified cause in women
with cervicitis, with a frequency of isolation that varies from 10 to 50% in
the published studies, depending on the population studied, the criteria used
in the case definition and the methods used for diagnosis. Nevertheless,
only 10–20% of cases of C. trachomatis infection in women are associated
with clinical signs of cervicitis, which could be due to both differences in
susceptibility of the host and to variability in the pathogenicity of the
strains. The percentage of cases of cervicitis due to N. gonorrhoeae is highly
variable in relation to the marked differences in the prevalence of this
infection in the populations studied.

 T. vaginalis. Other pathogens which typically cause STIs may also lead to
cervicitis. Among them, T. vaginalis has been associated with cervical
inflammation and with an increased risk of HIV transmission. T. vaginalis
can cause erosive inflammation of the ectocervical epithelium which can
result in a wide range of epithelial alteration, from small petechiae to large

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 haemorrhages. The pathogenesis of these lesions could be due, at least
partly, to cytotoxic factors produced by T. vaginalis, such as proteases
capable of degrading some endogenous factors that protect the integrity of
the cervicovaginal epithelium, mainly the socalled secretory leucocyte
protease inhibitor. Similar to what happens with C. trachomatis, the reason
for which trichomoniasis only causes evident signs of inflammation of the
cervix in some women is unknown. Among the possible causes could be
the greater pathogenicity of some strains, the number of microorganisms
present or intrinsic factors of the host that could increase its susceptibility.

 Mycoplasma genitalium. Another possible aetiological agent involved in

cervicitis is M. genitalium. This microorganism was identified for the first
time in 1980 in the urethra of two patients with non-gonococcal urethritis.
The frequency of M. genitalium as a pathogen causing an STI is still not
well known, due in particular to the difficulty of its detection, since it is a
bacterium which does not grow well in conventional culture media and it
is necessary to resort to nucleic acid amplification (NAA) techniques for its
diagnosis. Nevertheless, it is estimated that it is one of the microorganisms
most commonly associated with genital tract infections, with a prevalence
in men with urethritis of up to 30–40%.

 Its potential as a sexually transmitted pathogen has been confirmed in

studies that demonstrate the presence of the microorganism in the sexual
partners of infected patients and the concordance of the genotypes present
in members of the couple. Most prevalence studies have been carried out in
risk populations, mainly in patients from STI clinics, which implies a bias
and limits the conclusions with respect to the frequency of M. genitalium
infection in the general population. Some authors have estimated its overall
prevalence in women between 1 and 6.4%, and in studies carried out in
women seen in STI clinics the frequency varies from 0.1% found in
asymptomatic women up to 20% in the study by Gaydos et al., in which
almost 70% of patients presented signs or symptoms of cervicitis. After the

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 discovery of M. genitalium, the capacity of this bacterium to infect the
female genital tract was revealed, causing an inflammatory response, via
its inoculation in small apes. Acute infection of the endocervical mucosa is
able to destroy the microvilli and cause an increase in the formation of
secretory vesicles. Furthermore, infection of the endocervical cells in vitro
by M. genitalium causes a proinflammatory response with secretion of
several interleukins and other substances related to inflammation. Levels of
proinflammatory cytokines are elevated in women with chronic M.
genitalium infection, which could give the idea that, similar to what occurs
with C. trachomatis, persistent, untreated infection could lead to chronic
inflammation, with harmful effects for the female reproductive system.

With regard to its pathogenic role in women, Manhart et al. analysed by PCR a
total of 719 endocervical samples from a collection from patients who had been
seen in an STI clinic and found that women infected by M. genitalium had a three
times greater likelihood of presenting with mucopurulent cervicitis. Subsequent
studies have confirmed this connection. Furthermore, M. genitalium infection in
women can cause complications which affect the upper genital tract, such as
endometritis and PID, infertility and adverse effects in pregnancy and birth.

Recently, Lis et al. carried out a meta-analysis in which they analysed the link
between M. genitalium infection and several female genital tract syndromes. The
study concluded that M. genitalium infection was significantly linked to
cervicitis, PID, preterm pregnancy and spontaneous abortion. The risk of
infertility in infected women was also found to be high. In addition, co-infection
of M. genitalium with C. trachomatis has been documented in women with
cervicitis. In the study by Bjartling et al., 5% of patients infected with C.
trachomatis were also infected with M. genitalium. Similar results were found
by Gaydos et al., who found a high percentage of co-infections in women with
cervicitis, with the most common being M. genitalium with C. trachomatis
(5.3%) and M. genitalium with T. vaginalis (4.5%).

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 •
Herpes simplex virus. Genital infection by the herpes simplex virus (HSV)
types 1 and 2 can be the cause of cervicitis, most commonly in women with
apparent clinical symptoms of primary HSV-2 infection. In these patients,
cervicitis is typically characterised by the presence of erosive and diffuse
haemorrhages, usually in the ectocervical epithelium, which is frequently
accompanied by ulceration. It is estimated that cervicitis occurs in
approximately 15–20% of women with primary HSV-2 genital infection with
clinically evident symptoms. In these cases, the manifestations of primary
HSV-2 infection are usually visible in the vulvar epithelium and/or the
introitus. Cervicitis can also occur during clinical recurrences of genital HSV-
2 infection, but with less severe manifestations than those produced during
the primary infection. Asymptomatic excretion of HSV2 does not seem to be
directly related to cervicitis. HSV-1 can also cause cervicitis, although the
clinical manifestations are less severe and are generally produced only during
the primary genital infection.

Other potentially involved genital tract microorganisms

 Mycoplasma hominis. This microorganism is frequently found in the female

genital tract of sexually active women, and some studies suggest a
pathogenic role for this microorganism in some symptoms of cervicitis and
PID. In a study conducted in pregnant women, it was found that the detection
of M. hominis was frequently linked to the presence of cervicitis. Other
authors have found a high prevalence of M. hominis (26%) in women with
cervicitis. Nevertheless, since this microorganism is frequently present in the
healthy population, as well as in the symptoms of bacterial vaginosis, it is
difficult to determine its pathogenic role in this context.

 Ureaplasma spp. Both Ureaplasma parvum and Ureaplasma urealyticum are

detected frequently in the cervix of patients with cervicitis of unknown
cause, but its aetiological role is controversial. It is possible that a high
bacterial load may contribute to the development of cervicitis. However, it

6
 seems that at least U. urealyticum has a limited role as a pathogen in the
female genital tract.

 Bacterial vaginosis (BV)-associated bacteria. A possible link between BV

and cervicitis has been the subject of study in some works. BV is a frequent
cause of vaginal infection and is characterised by an imbalance in the vaginal
microbiota, with an overgrowth of the anaerobic bacteria and a reduction of
the hydrogen-peroxide (H2O2)-producing lactobacilli, which are the
predominant vaginal flora in normal conditions. There is evidence of the link
between BV and N. gonorrhoeae and C. trachomatis infection, which makes
the demonstration of a possible relationship between BV and cervicitis
difficult, regardless of other co-pathogens. Furthermore, BV has been
associated with an increase in the risk of gynaecological complications
which involve the upper genital tract, including PID, and bacteria which
characterise BV can cross the endocervical mucus barrier and lead to a local
inflammatory response. Marrazzo et al. studied 424 women with BV and
found that 63 (15%) of them had cervicitis. Only in eight of the 63 (13%)
was there evidence of a concomitant infection with C. trachomatis or
gonococcus. The authors concluded that in women with BV it is common to
find cervicitis, and that this is associated with different risk factors to those
existing in cervical infection caused by N. gonorrhoeae or C. trachomatis.
An aspect to be highlighted from this study is the conclusion that the absence
of H2O2-producing lactobacilli can contribute to the development of
cervicitis. Furthermore, in another study carried out in women who presented
with BV and cervicitis, the addition of metronidazole in the form a vaginal
gel to the conventional treatment of cervicitis with doxycycline and
ofloxacin improved the cure rates. All these data suggest that some BV-
associated bacteria can contribute to the development of cervical
inflammation. Mageeibacillus indolicus is a bacterium of the Clostridiales
order which has been linked to failures in the treatment of women with BV
and was detected recently in men with non-gonococcal urethritis. Data
available to date suggest the hypothesis that this bacterium could be a

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 sexually transmitted agent, which is able to play a pathogenic role both in
the female genital and male genital tract. In a recent study, Gorgos et al.
analysed BV-associated bacteria as potential causes of cervicitis. By
studying the samples of a cohort of women, the authors found that M.
indolicus could be detected in a significantly higher percentage in the cervix
(42.9% vs 11.9%) and in the vagina (42.9 % vs 16.7%) of women with
cervicitis, compared to women without cervicitis. Therefore, they conclude
that the colonisation of the endocervix by M. indolicus may contribute to the
manifestations of cervicitis. In this study, an inverse relationship was also
found between the detection of Lactobacillus jensenii and the presence of
signs of cervicitis (52.4% in the cervix of women without cervicitis
compared to 14.3% in women with cervicitis). This relationship had already
been reported in previous studies. Given that the strain L. jensenii TL2937
has proven to have a mitigating role in the inflammatory response in an
animal model, the potential beneficial effect of L. jensenii in cervicitis could
derive from the capacity of some strains of this species present in the vaginal
microbiota to deactivate the immune response, thereby reducing cervical
inflammation. Another possible explanation would be that this bacterium
acts by simply promoting the resistance to vaginal colonisation by BV-
producing bacteria. Furthermore, glycosidases and proteinases produced in
abundance by the flora associated with BV can degrade the cervicovaginal
mucus, altering its protective role, both physical and immunological, thereby
contributing to the pathogenesis of cervicitis.

Other microorganisms

There are other microorganisms which have been potentially linked to cervicitis,
but there is little evidence available to date of this association. Cytomegalovirus
can be transmitted sexually and has been detected in a limited number of patients
with cervicitis. The presence of human T-cell lymphotropic virus type 1
(HTLV1) in cervical secretions of women with cervicitis has also been reported.

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However, it is difficult to establish the aetiological role of both viruses in this
context.

Isolated cases of cervicitis attributed to species of the genus Streptococcus

(mainly S. agalactiae and S. pyogenes) have been published, but there is no
concrete data available on their frequency or if there is a clear causal relationship.

Non-infectious agents

The etiology in a high percentage of women in whom none of the known

pathogens are found is still unknown. Endocervical inflammation can be
measured through numerous metabolic pathways. A local inflammatory process
could be induced or maintained through different paths, including the effects of
a persistent infection due to an unknown pathogen, a persistently altered vaginal
microbiota or an exaggerated immune response (Table 1). Such processes are
probably modulated by the effect of endogenous and exogenous hormones,
including the hormonal changes that occur during the menstrual cycle and with
the use of contraceptives. Endogenous hormones, as has already been mentioned,
have a clear role in the maintenance of the integrity of cervicovaginal mucus.
Local immune response is regulated by oestrogens (they increase the response)
and progesterone (it decreases it). Women with low oestrogen levels (post-
menopausal, post-partum, very low body fat or on treatment with androgenic
drugs) have a greater risk of atrophic vaginitis, and their incapacity to maintain
a normal vaginal pH (<4.5) may cause a gradual erosion of the endocervical
mucus. Progesterone has proven to increase susceptibility to simian
immunodeficiency virus infection in animal models and may increase the risk of
cervicitis in women, as some studies in women who used it as a contraceptive
seem to conclude.

Table 1

Factors potentially involved in cervicitis with negative microbiological studies

and possible mechanisms.

Factor Mechanism

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 Persistent alteration of the vaginal Uncertain mechanism (glycosidases produced
microbiota by bacterial vaginosis-associated bacteria)
Hypoestrogenism Involvement of the local immune response
(post-menopausal, post-partum, very Greater risk of atrophic vaginitis and inability
low body fat or on treatment with to maintain a normal vaginal pH (<4.5), which
androgenic drugs) can cause erosion of
the endocervical mucus
Inflammatory/autoimmune Excessive immune response
diseases (Behc¸ et’s disease,
sarcoidosis, ligneous conjunctivitis)
Use of potentially irritant products They alter or irritate the cervicovaginal
(vaginal soaps, spermicides, deodorants, mucus
etc.)
Persistent infection with an unidentified The use of molecular techniques is expanding
pathogen the spectrum of new

In addition to the aetiological agents mentioned, there is a variety of systemic

inflammatory processes, both infectious and non-infectious, as well as some
agents or local factors that can cause endocervical inflammation, resulting in
the onset of clinical signs of cervicitis. Among the inflammatory- or immune-
based processes that can occur with cervicitis are Behc¸ et’s disease,
sarcoidosis and ligneous conjunctivitis. The local agents that can cause
irritation and/or erosion of the cervicovaginal mucosa include soaps used in
vaginal washes, chemical deodorants and some spermicides (Table 2).

Complications

The main complications of cervicitis are endometritis, PID and possible

adverse effects in pregnancy. The clinical signs of cervicitis and/or
endometritis may be the only ones present in patients with PID. In women with
lower genital tract infections the risk of developing PID is estimated to be
between 20 and 80% depending on the delay in the diagnosis, the presence of
co-infection and other host-dependent factors.

Furthermore, it is accepted that the presence of cervical inflammation may play

a role in the transmission of HIV, increasing both the susceptibility to the
infection by the virus and the excretion of it. Mechanisms by which cervicitis
may favour the transmissibility of HIV include an increase in viral replication

10
in the context of infection or inflammation, particularly in the presence of
elevated proinflammatory cytokines, the disruption of cervical mucus and the
greater number of HIV-infected cells in cervical secretions. A correlation
between the presence of the HIV genome in cervical secretions and evidence
of cervicitis has been demonstrated. In addition, the expression of HIV in the
genital tract could be altered in a different way depending on the etiology of
the cervicitis.

There is also evidence of the involvement of chronic inflammation of the

cervix in the pathogenesis of cervical cancer. Some genotypes of the human
papillomavirus (HPV), particularly 16 and 18, are involved in the development
of most of the genital cancers. The role of these viruses in cervicitis is more
uncertain. In some studies, a direct relationship has been found between the
degree of cervical inflammation and the presence of squamous intraepithelial
lesions.

Complications in pregnant women

The repercussions that cervicitis can have in pregnancy and the possible
adverse effects in the neonate are still subject to controversy. Most of the works
published which have evaluated these effects include only the cases of
cervicitis produced by classic pathogens (gonococcus and Chlamydia). In
pregnant women, C. trachomatis infection has been linked to an increase in the
risk of ectopic pregnancy, premature birth, premature rupture of membranes,
spontaneous abortion and childhood morbidity. However, some studies do not
find statistically significant differences between the risk of premature birth or
premature rupture of membranes in women with cervicitis caused by
Chlamydia and gonococcus and pregnant women without infection, while in
others there is a statistically significant association between C. trachomatis
infection and the risk of spontaneous abortion in a population with a high
prevalence of infection due to this bacterium (17.4%).

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In the case of M. genitalium, a significant association has been found between
infection due to this bacterium and the risk of spontaneous abortion and
premature birth.

Diagnosis

Clinical diagnosis of cervicitis was traditionally made based on the presence of

suggestive findings in the clinical examination with a speculum: an oedematous
and friable cervix with the presence of cervical secretion of mucopurulent
appearance. Nevertheless, both the degree of cervical inflammation and the
accompanying signs and symptoms can be highly variable, and the predictive
value of the cervical signs suggestive of cervicitis can also vary depending on
age and other risk factors related to STIs. A microscopic examination using
Gram stain can also be performed to confirm the existence of cervical
inflammation, quantifying the polymorphonuclear leukocytes (PMN) in the
endocervical secretion. A count >30 PMN/field is considered significant.

There is a need to agree on some diagnostic criteria for cervicitis that make it
possible to establish a uniform case definition that can be applied in clinical
practice and in epidemiological studies. The most frequently used criteria for the
case definition in studies published in recent years have been the existence of
mucopurulent discharge or the presence of >30 PMN/field in the endocervical
secretion. In an extensive study conducted recently, three possible case
definitions were evaluated: a “clinical” (presence of mucopurulent discharge),
another “microscopic” (>30 leukocytes/high-power field) and a combined
“microscopic and clinical” definition. The exclusively “clinical” and the

12
“combined” definition were the most used for the prediction of infection. With
the combined “microscopic and clinical” case definition, the highest positive
predictive value and the highest specificity was obtained, although with a lower
sensitivity to predict infection caused by the most common pathogens.

The aetiological diagnosis can be performed by studying a sample of

endocervical exudate, carefully obtained using a speculum during the
gynaecological examination. Vaginal secretions should be removed using a dry
swab, which is then disposed of. Subsequently, the cervix should be gently
compressed with the speculum and a thin swab should be inserted into the
endocervical canal. Swabs of calcium alginate or with a wooden stick should not
be used, as they can inhibit both the growth in cell culture and the NAA
techniques. It is advisable to soak at least two swabs to allocate one of them to
the microscopic examination and the cultures and the other swab to NAA tests.

The Gram stain of the endocervical exudate can be useful in the diagnosis of
gonococcal cervicitis (presence of Gram-negative diplococci), although it has a
low sensitivity and specificity and its results can be influenced both by the
experience of the observer and by the possible interference with the microbiota
or leukocytes of the vagina itself and not of the cervical mucus.

The sample of endocervical exudate should be cultured in normal media,

including a selective medium for N. gonorrhoeae (Thayer-Martin or Martin-
Lewis) and T. vaginalis. General media, such as blood agar and chocolate agar
should also be used, for the recovery of less common bacteria, as there are some
strains of N. gonorrhoeae that can be inhibited in selective media.

NAA techniques should be used for the diagnosis of C. trachomatis since, as it is

an intracellular bacterium, it requires cell cultures and antigen detection
techniques lack sufficient sensitivity. There are different platforms on the market
for the joint detection of C. trachomatis and N. gonorrhoeae in the same sample,
using NAA techniques. These systems differ in their amplification methods and
in the sequences used as target, and, in general, they all offer a high sensitivity

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(>90%) and a very high specificity (>99%). Due to its high sensitivity, it is
important to adjust the working conditions to prevent contamination.

Despite the advantages offered by the NAA techniques, it is recommended not

to disregard cultures, as the detection of N. gonorrhoeae may have important
connotations, even of a judicial nature, and because the recovery of the strains
allows their antibiotic resistance profiles to be studied.

Cell cultures for Chlamydia should also be maintained in reference centres, both
to monitor the onset and the evolution of resistances over time and to be able to
study and characterise the strains with epidemiological and research purposes
(e.g. strains associated with lymphogranuloma venereum and other rare
infections caused by variants or mutant strains).

Vaginal samples show a sensitivity and specificity comparable to endocervical

samples when NAA techniques are used, and, therefore, can be a valid alternative
for the diagnosis of cervicitis in women who cannot have a full gynaecological
examination. In these cases, the vaginal exudate can be obtained by the patient
herself (self-exam) with good results. On the contrary, fractional urethral urine
is a less useful sample for the diagnosis of cervicitis due to C. trachomatis and
N. gonorrhoeae as it provides a lower sensitivity.

Serological tests for detecting an immune response are not useful in the diagnosis
of active C. trachomatis infections.

T. vaginalis infection can be diagnosed by means of a fresh microscopic

examination of the cervical secretion, but the sensitivity of this technique is low,
meaning that for its diagnosis it is necessary to perform a culture in the
appropriate media or to use a NAA technique.

NAA techniques are the techniques of choice for the diagnosis of M. genitalium
and HSV types 1 and 2. Some of the molecular techniques currently marketed
allow the joint detection of M. genitalium and of mutations associated with
macrolide resistance. Various commercial systems based on NAA techniques (
generally multiplex PCR), which include almost all of the known pathogens

14
associated with cervicitis and other STIs, are available. The cervical sample
collected in transport medium for liquid-based cytology (e.g. ThinPrep or
SurePath ) can be used in some of these pieces of equipment, which is beneficial
when the detection of HPV needs to be done simultaneously.

Treatment

The decision to perform empirical or targeted treatment of women with cervicitis

should be taken after considering factors such as age, the epidemiological context
and the availability of rapid diagnostic tests. It is advisable to start empirical
treatment that includes C. trachomatis and N. gonorrhoeae in the case of women
with a high risk of infection due to these pathogens (age <25 and those with a
new sexual partner or with a partner diagnosed with an STI), especially if follow-
up is not guaranteed or if appropriate diagnostic tests are not available (e.g. NAA
tests not available). For women with a low risk of STI the treatment can be
delayed, awaiting the results of the diagnostic tests.

The empirical treatment regimen recommended in most guidelines is

azithromycin, 1 g orally in a single dose, or doxycycline, 100 mg orally, twice
daily for seven days. If the patient has a high risk of gonococcal infection, this
pathogen should also be covered, preferably with ceftriaxone 500–1000 mg,
intramuscularly, in a single dose.

Azithromycin is also the treatment of choice if the pathogen identified is M.

genitalium, but resistant strains associated with clinical failure have been
reported. In these cases, the recommended treatment is moxifloxacin, 400
mg/day for 7–14 days. Carrying out a test of cure (repetition of the diagnostic
tests one month after finishing treatment) is not necessary unless the symptoms
persist or in pregnant patients.

In the follow-up of patients in whom the aetiological agent is a sexually

transmitted pathogen, screening for HIV and syphilis and contact tracing should
be performed.

15
The management of patients with cervicitis in whom no pathogenic agent can be
identified is controversial. For these cases, there is not sufficient scientific
evidence that justifies a treatment alternative, and each case should be assessed
according to the clinical context and the presence of other non-infectious factors.

Management of contacts (sexual partners)

Sexual contacts from the last 60 days of women with cervicitis must be assessed
and treated with the same antibiotic regimen recommended for the identified or
suspected sexually transmitted pathogen.

To minimize the risk of contagion and reinfection, patients should be advised to

abstain from having sexual intercourse until the symptoms have resolved and
their sexual partner(s) have also been duly treated.

Special considerations for treatment

HIV infection

Women with cervicitis and HIV infection should be treated with the same
antibiotic regimen as those not infected. It has been suggested that cervical
inflammation increases the elimination of HIV; consequently, appropriate
treatment of cervicitis in HIV-infected patients could reduce the excretion of the
virus and reduce the risk of it being transmitted to sexual partners.

Pregnancy

The diagnosis and treatment of cervicitis in pregnant women does not differ from
that of non-pregnant women.

Chronic cervicitis (persistent or recurrent)

Cervicitis can persist or recur after completing one or several cycles of

antibiotic treatment. In these cases, it is recommended that patients be re-
assessed after ruling out possible re-exposure or treatment failure.

As has been mentioned in previous sections, the importance of chronic

cervicitis lies in the fact that it can result in complications such as endometritis,

16
salpingitis, PID, chorioamnionitis and other adverse effects in pregnancy. It
can also play a role in the initiation or promotion of cervical cancer.

In these cases, potential microorganisms involved less frequently and not

covered by the treatment administered ( e.g. Trichomonas or BV agents)
should be ruled out. Most of the guidelines recommend a full gynaecological
review to rule out signs of malignancy and consider non-infectious agents,
such as some chemical substances that may erode the cervicovaginal mucus or
cause irritative mucositis (vaginal douches, spermicides and chemical
deodorants).

In cases of chronic cervicitis in which it is not possible to find an aetiological

agent, ablation therapy can be considered, although studies which evaluate its
effectiveness are limited. This option should be considered as a last resort, and
before its application it is necessary to always rule out a possible malignancy.

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