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Cervicitis

Cervicitis is an inflammation of the cervix, the lower, narrow end of the uterus that opens into the vagina, and it can be acute or chronic depending on duration and cause.^[1]^[2] It most frequently affects sexually active women aged 15–24, with an estimated prevalence of 30–40% among patients attending sexually transmitted infection (STI) clinics.^[2] The condition is often caused by infectious agents, particularly STIs such as Chlamydia trachomatis and Neisseria gonorrhoeae, which account for 30–50% of cases, while other pathogens like herpes simplex virus (HSV), Trichomonas vaginalis, and Mycoplasma genitalium are also implicated.^[2]^[3] Noninfectious etiologies include allergic reactions to substances like spermicides or latex, mechanical trauma from devices such as diaphragms, bacterial vaginosis, or hypoestrogenic states leading to atrophy.^[1]^[2] Risk factors encompass high-risk sexual behaviors, multiple sexual partners, early onset of sexual activity, and a history of prior STIs.^[1] Many cases of cervicitis are asymptomatic, but when symptoms occur, they may include abnormal vaginal discharge that is mucopurulent, pain during urination or sexual intercourse, bleeding between menstrual periods, or spotting after sex.^[1]^[3] Diagnosis typically involves clinical evaluation for signs like endocervical exudate or friability, supplemented by nucleic acid amplification tests (NAATs) for common pathogens such as chlamydia and gonorrhea, with additional testing for trichomoniasis or bacterial vaginosis if indicated.^[2]^[3] Treatment is guided by the underlying cause and often starts empirically in high-risk individuals with antibiotics such as doxycycline (100 mg orally twice daily for 7 days) or azithromycin (1 g single dose) to cover chlamydia, alongside ceftriaxone for gonorrhea if suspected.^[3]^[2] Partner notification and treatment are essential to prevent reinfection, with recommendations for expedited partner therapy where feasible.^[3] Untreated cervicitis can lead to complications including pelvic inflammatory disease, infertility, or increased susceptibility to HIV.^[1] Prevention strategies emphasize consistent condom use, limiting sexual partners, and routine STI screening in at-risk populations.^[1]

Overview

Definition and Pathophysiology

Cervicitis is defined as an inflammation of the cervix uteri, primarily affecting the columnar epithelium lining the endocervical canal, though it may also involve the squamous epithelium of the ectocervix.^[2] This condition typically centers on the transformation zone, the dynamic area where the squamous epithelium of the ectocervix meets the columnar epithelium at the squamous-columnar junction, making this junction particularly susceptible to inflammatory processes due to its exposure to vaginal flora and mechanical irritants.^[2]^[4] The endocervical glands, embedded within the cervical stroma, can also become involved, leading to glandular inflammation that contributes to overall tissue disruption.^[5] The pathophysiology of cervicitis involves a cascade of inflammatory responses that result in mucosal edema, characterized by fluid accumulation in the cervical tissues, and hyperemia, marked by increased blood flow causing erythema and congestion.^[6]^[7] This is accompanied by cellular infiltration, where immune cells migrate into the cervical stroma and epithelium, disrupting the protective cervical mucus barrier and potentially leading to epithelial injury or ulceration.^[2] Proinflammatory cytokines play a key role in recruiting these cells, amplifying the inflammatory milieu and promoting tissue damage without necessarily involving deeper stromal layers unless chronicity develops.^[2] Cervicitis is differentiated into acute and chronic forms based on duration and histological features, with acute cervicitis presenting a sudden onset and characterized by prominent neutrophilic infiltration, epithelial erosion, and purulent exudate formation in the endocervical canal.^[2]^[8] In contrast, chronic cervicitis persists for three months or longer and features a predominance of lymphocytes, plasma cells, and macrophages in the superficial cervical stroma, often with lymphoid follicle formation and possible squamous metaplasia in the transformation zone.^[2]^[9] These histological changes reflect a shift from acute neutrophilic response to a sustained lymphocytic infiltration, which may lead to stromal remodeling but rarely progresses to severe glandular destruction in isolation.^[8]

Epidemiology and Risk Factors

Cervicitis is a common condition among sexually active women, with exact global prevalence difficult to ascertain due to varying diagnostic criteria and underreporting. Estimates suggest that it affects 30% to 40% of women attending sexually transmitted infection (STI) clinics, while population-based studies indicate higher rates in high-risk groups such as female sex workers, where prevalence can reach up to 25% in low-resource settings like parts of Africa and Latin America.^[2]^[10] The World Health Organization (WHO) reports that curable STIs like chlamydia and gonorrhea, which are leading causes of infectious cervicitis, resulted in 129 million and 82 million new cases globally as of 2020, respectively, with prevalence rates of 4.0% for chlamydia and 1.8% for gonorrhea among women aged 15–49 years.^[11]^[12] Regional disparities are pronounced, with higher incidence in low- and middle-income countries due to limited access to screening and treatment, compared to high-income settings where rates are lower but still significant among at-risk populations.^[6] Demographically, cervicitis predominantly impacts women aged 15 to 24 years, who account for the highest incidence due to increased sexual activity and biological susceptibility.^[2] Associations exist with early sexual debut, multiple sexual partners, and single marital status, particularly in urban areas.^[6] Socioeconomic disparities exacerbate vulnerability, as low socioeconomic status correlates with higher exposure to STIs through factors like inconsistent healthcare access and higher rates of transactional sex.^[6] In the United States, for example, chlamydia rates among women were 610.7 cases per 100,000 in 2023, with elevated risks in underserved communities.^[13] Key risk factors include unprotected sexual intercourse, a history of prior STIs, and having a partner with concurrent sexual partners or known infection.^[3] Additional modifiable risks encompass inconsistent condom use, frequent douching, and use of intrauterine devices (IUDs), which may facilitate bacterial ascension if hygiene is compromised.^[3]^[14] Hormonal influences, such as oral contraceptive use, have been linked to increased cervical chlamydia infection risk, potentially due to altered cervical mucus.^[15] Non-modifiable factors include younger age and HIV co-infection, which heightens susceptibility.^[2] In recent years (2022–2024), reported STI incidence has declined in high-income countries, such as a 9% decrease in the US from 2023 to 2024, attributed to widespread STI screening programs targeting young women, though rates remain higher than in the early 2000s and global trends in low-resource areas continue to rise without such interventions. Provisional 2024 data indicate further declines, with chlamydia cases down 8% and gonorrhea down 10% from 2023 in the US.^[3]^[13]^[16]

Clinical Features

Symptoms

Cervicitis commonly manifests through patient-reported symptoms such as abnormal vaginal discharge, which is often mucopurulent, yellow or gray, and increased in volume compared to normal.^[1]^[2] Vaginal bleeding, particularly after sexual intercourse (postcoital) or between menstrual periods (intermenstrual), is another frequent complaint.^[3]^[17] Dyspareunia, or pain during sexual intercourse, and dysuria, or painful urination, are also prevalent subjective experiences.^[4]^[14] Less common symptoms include lower abdominal pain and urinary frequency, which may accompany the more typical presentations.^[2] Many cases of cervicitis are asymptomatic, with studies estimating that 70% to 80% of affected individuals report no noticeable complaints.^[2] These symptoms can vary in onset and duration; acute cervicitis often involves sudden appearance of discharge or bleeding, whereas chronic forms may feature milder, persistent discomfort lasting months or longer.^[4]^[14] The variability of these symptoms means they can sometimes mimic those of other gynecological conditions, such as bacterial vaginosis or early pelvic inflammatory disease, complicating self-recognition.^[2] Symptoms like dyspareunia and abnormal bleeding frequently interfere with sexual activity, while dysuria and discharge can disrupt daily functioning and overall comfort, thereby impacting quality of life.^[1]^[4]

Physical Signs and Complications

Physical signs of cervicitis are primarily identified during pelvic examination and include visible inflammation of the cervix, such as cervical ectropion where the columnar epithelium is exposed on the ectocervix, giving a reddened appearance.^[5] Friability of the cervical tissue, characterized by easy bleeding upon gentle swabbing or contact, is a common finding, as is the presence of mucopurulent or purulent discharge emanating from the endocervical os.^[3]^[5] Additional objective features may include edema of the ectropion or punctate hemorrhages, particularly in cases associated with specific pathogens like Trichomonas, which can produce a "strawberry cervix" appearance with red spots.^[2] During speculum examination, these signs—mucopurulent discharge, friability, and ectropion—are directly observed, often prompting further evaluation for upper genital tract involvement. Bimanual palpation may reveal cervical motion tenderness or adnexal tenderness, indicating possible extension of inflammation beyond the cervix.^[3]^[2] These findings are present in many cases, though up to 80% of cervicitis instances may lack overt symptoms, underscoring the importance of routine screening.^[2] Untreated cervicitis can lead to short-term complications such as progression to pelvic inflammatory disease (PID), which involves ascent of infection to the upper genital tract and manifests with abdominal or adnexal tenderness on examination.^[3]^[5] Long-term consequences include infertility due to tubal scarring from PID, ectopic pregnancy, and chronic pelvic pain.^[2] Additionally, cervicitis increases susceptibility to HIV acquisition through enhanced viral shedding and mucosal disruption, and in pregnancy, it raises risks of preterm birth, premature rupture of membranes, and intrauterine growth restriction.^[3]^[2] Rare sequelae of persistent cervicitis include neoplastic changes, including an elevated risk of squamous intraepithelial lesions that may progress to cervical cancer.^[2] These complications highlight the need for timely identification of physical signs to mitigate adverse outcomes.^[2]

Etiology

Infectious Causes

Infectious causes of cervicitis are predominantly sexually transmitted infections (STIs) that target the cervical epithelium, leading to inflammation through direct microbial invasion or immune response. The most common bacterial pathogens include Chlamydia trachomatis and Neisseria gonorrhoeae, which together account for 30% to 50% of infectious cases, with C. trachomatis being 4 to 5 times more prevalent than N. gonorrhoeae.^[2] These obligate intracellular bacteria infect the columnar epithelium of the endocervix, often resulting in mucopurulent discharge due to cytokine-mediated neutrophil recruitment. Transmission occurs primarily through unprotected sexual contact, with asymptomatic carriage common; for instance, C. trachomatis prevalence in sexually active young women ranges from 5% to 10%, facilitating silent spread.^[18]^[2] Other bacterial agents include Mycoplasma genitalium, which contributes to 10% to 30% of cases, particularly in persistent or non-gonococcal, non-chlamydial cervicitis, while the role of Ureaplasma urealyticum remains less established and lacks convincing evidence as a primary cause.^[2]^[3] M. genitalium, a cell-wall-deficient bacterium, adheres to mucosal surfaces via adhesins and induces inflammation through toxin production. These pathogens are also transmitted sexually and frequently asymptomatic, mirroring patterns seen in chlamydial infections.^[2] Bacterial vaginosis (BV) is associated with cervicitis through disruption of vaginal flora, including absence of lactobacilli and overgrowth of anaerobes that degrade cervical mucus.^[2]^[3] Viral causes include herpes simplex virus (HSV-1 and HSV-2), which accounts for a smaller proportion of cases but can produce ulcerative cervicitis during primary infection. HSV targets squamous epithelium, replicating in sensory neurons and causing recurrent outbreaks via latency in sacral ganglia. Certain high-risk human papillomavirus (HPV) types, such as HPV-16 and HPV-18, may contribute to chronic inflammation by integrating into host DNA and disrupting epithelial differentiation, though they are less directly linked to acute cervicitis. Cytomegalovirus (CMV) rarely causes cervicitis except in immunocompromised patients, where it leads to necrotizing infection of endothelial cells.^[2]^[1] Viral transmission occurs via sexual contact or close mucosal exposure, with high rates of asymptomatic shedding—up to 80% for HSV and widespread subclinical HPV carriage in sexually active adults.^[2] Protozoan infections, notably Trichomonas vaginalis, represent another key etiology, affecting squamous epithelium and potentially causing a characteristic "strawberry" appearance due to petechiae from microhemorrhages. This flagellated parasite adheres to vaginal and cervical mucosa via surface proteins, evading host immunity through antigenic variation. All these infectious agents spread mainly through vaginal or anal intercourse, with asymptomatic carriage prevalent in 50% to 70% of cases, underscoring the role of routine screening in at-risk populations.^[2]

Non-Infectious Causes

Non-infectious cervicitis arises from mechanical, chemical, physiological, or systemic factors that irritate or inflame the cervical tissue without involvement of pathogens. These causes are particularly relevant in low-risk populations and can mimic infectious presentations, necessitating careful differential diagnosis. Studies indicate that non-infectious etiologies account for a substantial proportion of cervicitis cases, with over 50% of clinical presentations testing negative for common sexually transmitted infections.^[2] Mechanical causes include trauma to the cervix from sexual intercourse, which can lead to micro-abrasions and subsequent inflammation, especially in cases of vigorous activity or inadequate lubrication. Foreign bodies such as retained tampons, pessaries, or barrier contraceptives like diaphragms and cervical caps can cause prolonged irritation if left in place too long, promoting local edema and erythema. Additionally, gynecologic procedures, including cervical biopsy, cone biopsy, or dilation and curettage, may induce iatrogenic trauma, resulting in acute or chronic inflammatory changes.^[2]^[7]^[4] Chemical and irritant causes often stem from allergic reactions or direct exposure to substances that disrupt the cervical mucosa. Common triggers include spermicides, latex in condoms, and vaginal douches, which can provoke hypersensitivity responses manifesting as redness and discharge. Feminine hygiene products, such as scented soaps or deodorants, may alter the vaginal pH, leading to irritation, while contraceptive creams or gels can similarly cause contact dermatitis-like effects on the cervix. These reactions are more prevalent in individuals with sensitivities to such agents.^[1]^[7]^[4] Physiological and hormonal factors contribute to non-infectious cervicitis through changes in cervical epithelium. Estrogen-related cervical ectropion, characterized by the eversion of columnar epithelium onto the ectocervix, is common during adolescence, pregnancy, or oral contraceptive use due to elevated estrogen levels; this exposes sensitive tissue to the vaginal environment, potentially causing chronic inflammation. Conversely, hypoestrogenic states, such as those in menopause or post-oophorectomy, can lead to atrophic changes in the vaginal and cervical lining, mimicking cervicitis with friability and spotting.^[19]^[2] Rarely, non-infectious cervicitis associates with autoimmune or systemic inflammatory conditions, where immune-mediated damage affects cervical tissue. Examples include links to lichen planus, lupus, or sarcoidosis. These cases often present in the context of broader autoimmune disease and require multidisciplinary evaluation.^[2]

Diagnosis

Clinical Evaluation

The clinical evaluation of cervicitis begins with a detailed patient history to identify potential risk factors and symptoms suggestive of the condition. Key components include obtaining a comprehensive sexual history, such as the number of recent sexual partners (e.g., within the past 60 days), types of sexual practices (vaginal, anal, or oral), condom use, and any prior sexually transmitted infections (STIs) in the patient or partners.^[3]^[20] Menstrual patterns should be assessed, including any intermenstrual or postcoital bleeding, while obstetric history encompasses current pregnancy status, prior pregnancies, and deliveries. The duration and nature of associated symptoms, such as abnormal vaginal discharge, dyspareunia, or dysuria, are also documented to gauge acuity and progression.^[21]^[3] Risk assessment for STIs is integral and typically employs standardized approaches like the CDC's "Five P's" framework (Partners, Practices, Protection from STIs, Past STI history, and Prevention of pregnancy) to screen for behavioral and biologic risks.^[20] This involves nonjudgmental questioning to evaluate factors such as new or multiple partners, inconsistent condom use, history of exchanging sex for money or drugs, and community STI prevalence, particularly in women under 25 years or those with other vulnerabilities.^[20]^[3] Such screening helps prioritize empiric management while informing the need for further evaluation. The physical examination focuses on a pelvic assessment performed in a comfortable setting. A speculum examination is conducted to visualize the vagina and cervix, allowing inspection for signs of inflammation, such as ectropion, friability, or mucopurulent discharge from the endocervical os.^[21]^[3] Bimanual palpation evaluates for cervical tenderness, uterine or adnexal masses, or pain suggestive of upper tract involvement. Sampling techniques, including gentle passage of a swab along the endocervix to check for induced bleeding, are employed during this exam to collect specimens for subsequent testing.^[3]^[21] Differential diagnosis considerations during evaluation aim to distinguish cervicitis from other pelvic pathologies based on history and exam findings. For instance, a history of abnormal discharge without cervical friability may point toward vaginitis, while lower abdominal pain or fever could suggest endometritis; persistent bleeding or irregular patterns warrant exclusion of cervical cancer through targeted questioning on risk factors like HPV exposure or abnormal Pap history.^[21]^[3] Clinical findings guide the selection of diagnostic tests for confirmation.^[21]

Diagnostic Tests

Diagnosis of cervicitis relies on laboratory and imaging methods to confirm inflammation and identify etiological pathogens, particularly in cases suspected based on clinical findings such as mucopurulent discharge or cervical friability.^[3] Microbiological testing is the cornerstone for detecting infectious causes, with nucleic acid amplification tests (NAATs) recommended as the preferred method for identifying Chlamydia trachomatis and Neisseria gonorrhoeae, the most common bacterial pathogens. NAATs demonstrate high sensitivity, typically exceeding 95% for both organisms when using cervical or vaginal specimens, and offer superior specificity compared to traditional culture methods. For Trichomonas vaginalis, wet mount microscopy of vaginal or cervical secretions can provide rapid detection but has limited sensitivity of approximately 50-60%, necessitating confirmatory NAAT if initial results are negative. Cultures remain useful for herpes simplex virus (HSV) in cases with ulcerative cervical lesions, though they are less sensitive than NAATs and are not routinely employed for asymptomatic or mild cervicitis.^[3]^[22]^[23]^[24] Cytological evaluation via Pap smear may reveal signs of inflammation, such as increased metaplastic cells or reactive changes, and koilocytosis suggestive of human papillomavirus (HPV) involvement, but it is not suitable for primary diagnosis of cervicitis due to its low specificity for active infection. Abnormal Pap results can prompt further investigation but should not replace targeted pathogen testing.^[4] Additional diagnostic modalities include colposcopy, which allows magnified visualization of cervical abnormalities like acetowhite epithelium or vascular changes in persistent or atypical cases, often guiding targeted biopsies. Endocervical biopsy is indicated for chronic or refractory cervicitis to assess for plasma cell infiltration or exclude neoplasia, with histological findings commonly confirming chronic inflammation. Multiplex PCR panels enable simultaneous detection of multiple pathogens, including Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium, improving efficiency in high-risk populations.^[25]^[9]^[26] According to the Centers for Disease Control and Prevention (CDC) STI Treatment Guidelines updated in 2021, women with suspected cervicitis should undergo routine NAAT screening for chlamydia, gonorrhea, and trichomoniasis, with consideration for Mycoplasma genitalium in persistent cases; the American College of Obstetricians and Gynecologists (ACOG) endorses these recommendations for high-risk groups, emphasizing annual screening in sexually active women under 25 or those with multiple partners.^[27]

Management

Treatment Approaches

Treatment of cervicitis is tailored to the underlying etiology, with empiric antimicrobial therapy recommended for cases presumed to be infectious, particularly those involving sexually transmitted infections like Chlamydia trachomatis and Neisseria gonorrhoeae.^[28] The Centers for Disease Control and Prevention (CDC) guidelines emphasize dual therapy to cover both pathogens when gonococcal infection is suspected.^[28] For presumed chlamydial cervicitis, the preferred regimen is doxycycline 100 mg orally twice daily for 7 days, as it demonstrates superior efficacy compared to single-dose alternatives in reducing reinfection risk.^[2] An alternative for patients unable to tolerate doxycycline is azithromycin 1 g orally in a single dose.^[2] When gonorrhea is likely, ceftriaxone 500 mg intramuscularly as a single dose (or 1 g if patient weight exceeds 150 kg) is added to the chlamydial regimen.^[2] Alternatives for ceftriaxone, such as in cases of cephalosporin allergy, include gentamicin 240 mg intramuscularly once plus azithromycin 2 g orally once.^[28] For viral causes, such as herpes simplex virus (HSV), antiviral therapy is indicated to reduce symptoms and transmission. Acyclovir 400 mg orally three times daily for 7-10 days is the standard initial treatment for first-episode genital HSV infection associated with cervicitis.^[2] In cases of suspected Mycoplasma genitalium, which may contribute to persistent cervicitis, initial treatment with doxycycline 100 mg orally twice daily for 7 days is followed by moxifloxacin 400 mg orally daily for 7 days if resistance is confirmed or suspected.^[2] Non-infectious cervicitis, often due to chemical irritants, allergic reactions, or cervical ectropion, requires identification and elimination of the offending agent, such as spermicides, douches, or latex products.^[21] For allergic cases, avoidance of allergens typically resolves symptoms without further intervention.^[21] Persistent symptoms from cervical ectropion may be managed with cryotherapy, which freezes and ablates the ectopic columnar epithelium, leading to symptom relief in most cases.^[29] Follow-up evaluation is essential to confirm resolution, with repeat testing for chlamydia, gonorrhea, or trichomoniasis recommended at 3 months post-treatment due to high reinfection rates.^[28] Partner notification and treatment are critical to prevent reinfection, following CDC protocols that encourage expedited partner therapy where legally permissible.^[28] For high-risk infections like gonorrhea, a test-of-cure at 7-14 days may be considered if symptoms persist or resistance is a concern.^[2]

Prevention Strategies

Prevention of cervicitis primarily focuses on reducing exposure to infectious agents, particularly sexually transmitted infections (STIs) like chlamydia and gonorrhea, which account for the majority of cases.^[3] Consistent and correct use of condoms during sexual intercourse significantly lowers the risk of acquiring STIs that cause cervicitis.^[1] Limiting the number of sexual partners further decreases transmission risk by reducing opportunities for exposure to infected individuals.^[30] STI education programs, including school-based interventions, promote these safe sex practices and have been shown to reduce STI incidence through evidence-based approaches that encourage delayed sexual debut and consistent barrier use.^[31] Vaccination against human papillomavirus (HPV) plays a key role in preventing HPV-related cervicitis, as certain HPV types can lead to cervical inflammation and precancerous lesions.^[3] The 9-valent HPV vaccine (Gardasil 9) protects against nine HPV strains, including those responsible for most cervical cancers and genital warts, and is recommended routinely at ages 11–12 years, with catch-up vaccination through age 26 for those not adequately vaccinated earlier.^[32] Regular screening protocols are essential for early detection and treatment of asymptomatic infections that could progress to cervicitis. The Centers for Disease Control and Prevention (CDC) recommends annual screening for chlamydia and gonorrhea using nucleic acid amplification tests for all sexually active women under 25 years, as well as for older women at increased risk, such as those with new or multiple partners.^[33] These guidelines align with U.S. Preventive Services Task Force (USPSTF) recommendations for screening sexually active women aged 24 years and younger, and those 25 years and older at elevated risk.^[34] Public health measures, including partner management, help curb reinfection and community spread. When cervicitis due to chlamydia or gonorrhea is diagnosed, all sex partners from the preceding 60 days should be referred for evaluation, testing, and presumptive treatment through contact tracing efforts.^[3] Expedited partner therapy (EPT), where medication is provided to partners without an in-person visit, is recommended by the CDC to treat chlamydia and gonorrhea efficiently and reduce transmission.^[35] For non-infectious cervicitis, avoiding vaginal hygiene practices like douching or using scented products prevents irritation from chemical irritants.^[21]

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