Cervicitis – Causes, Symptoms, Diagnosis, Treatment - Health

Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections. Non-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms. Cervicitis affects over half of all women during their adult life.^[rx]

Vaginitis and cervicitis are undoubtedly linked in many instances, to some degree. When considering cervicitis as a discrete entity, the most common causes are infections due to Chlamydia trachomatis and Neisseria gonorrheae. Other causes of cervicitis are human papillomavirus (HPV) and infrequently considered are herpes simplex virus (HSV), Mycoplasma, and Ureaplasma. The two latter bacteria are commonly found colonizing the lower genital tract in sexually active women and their role in the disease of female pelvic organs is not well understood. However, recent data have implicated the mycoplasmas and ureaplasmas in both obstetric and gynecologic pelvic infections.

Causes of Cervicitis

Cervicitis can be caused by any of a number of infections – of which the most common are chlamydia and gonorrhea, with chlamydia accounting for approximately 40% of cases.^[rx] Other causes include Trichomonas vaginalis, herpes simplex virus, and Mycoplasma genitalium.^[rx]Infectious agents include Neisseria gonorrhea, Chlamydia trachomatis, and less commonly, herpes simplex, Trichomonas vaginalis, and Mycoplasma genitalium. Neisseria and chlamydia primarily infect the columnar epithelium of the endocervix, whereas HSV and trichomonas affect the squamous epithelium of the ectocervix.[rx][rx] Bacterial vaginosis has also been associated with cervicitis.[rx]
Non-infectious causes – include mechanical and chemical irritants. Surgical instruments or foreign objects like pessaries, condoms, diaphragms, cervical caps, or tampons can cause mechanical trauma. Chemical irritants cause allergic reactions and include soaps, laundry products, spermicides, latex, vaginal douches, and contraceptive creams.[rx][rx]
Systemic inflammatory diseases – like lichen planus and Behcet syndrome have also been implicated in cervicitis. The hypoestrogenic state seen with natural or surgical menopause can mimic cervicitis. This is due to the atrophy of the vaginal and uterine lining.[rx] However, the exact etiology cannot be determined in more than half the cases.[rx] It is not clinically possible to differentiate the inflammation caused by mechanical or chemical irritants from that caused by infectious etiologies.
Sexually transmitted infections – Most often, the bacterial and viral infections that cause cervicitis are transmitted by sexual contact. Cervicitis can result from common sexually transmitted infections (STIs), including gonorrhea, chlamydia, trichomoniasis and genital herpes.
Allergic reactions – An allergy, either to contraceptive spermicides or to latex in condoms, may lead to cervicitis. A reaction to feminine hygiene products, such as douches or feminine deodorants, also can cause cervicitis.
Bacterial overgrowth – An overgrowth of some of the bacteria that are normally present in the vagina (bacterial vaginosis) can lead to cervicitis.
Irritation or injury – from tampons, pessaries, or from birth control devices like diaphragms
Bacterial imbalance – normal, healthy bacteria in the vagina are overwhelmed by unhealthy or harmful bacteria. This is also called bacterial vaginosis.
Hormonal imbalance – having relatively low estrogen or high progesterone may interfere with the body’s ability to maintain healthy cervical tissue.
Cancer or cancer treatment – rarely, radiation therapy or cancer may cause changes to the cervix consistent with cervicitis.

There are also certain behaviors that can place individuals at a higher risk for contracting cervicitis. High-risk sexual behavior, a history of STIs, many sexual partners, sex at an early age, and sexual partners who engage in high-risk sexual behavior or have had an STI can increase the likelihood of contracting cervicitis.^[rx]

Symptoms of Cervicitis

Cervicitis may have no symptoms.^[rx] If symptoms do manifest, they may include:

Abnormal vaginal bleeding that occurs after intercourse, or between periods
Unusual vaginal discharge that does not go away: discharge may be gray, white or yellow in color
Painful sexual intercourse
Pain in the vagina
Pressure or heaviness in the pelvis
Painful urination
Vaginal itching
Large amounts of unusual vaginal discharge
Frequent, painful urination
Bleeding between menstrual periods
Vaginal bleeding after intercourse, not associated with a menstrual period
Abnormal vaginal bleeding after intercourse between periods
Unusual gray, white, or yellow vaginal discharge
Pressure or heaviness in the pelvis^[rx]

Diagnosis of Cervicitis

To diagnose cervicitis a clinician will perform a pelvic exam. This exam includes a speculum exam with a visual inspection of the cervix for abnormal discharge, which is usually purulent or bleeding from the cervix with little provocation.^[rx]

A pelvic exam – During this exam, your doctor checks your pelvic organs for areas of swelling and tenderness. He or she may also place a speculum in your vagina to view the upper, lower, and sidewalls of the vagina and the cervix.
A specimen collection – In a process similar to a Pap test, your doctor uses a small cotton swab or a brush to gently remove a sample of cervical and vaginal fluid. Your doctor sends the sample to a lab to test for infections. Lab tests may also be performed on a urine sample.
Mucopurulent cervicitis – is diagnosed on the basis of its clinical appearance, and the purulent appearance on an endocervical swab. The two most common causes of mucopurulent cervicitis are chlamydia trachomatis and Neisseria gonorrhoeae.
Culture – is no longer routinely used for diagnosis but has been replaced usually by DNA probes or polymerase chain reaction (PCR) technology.
For screening – urine can be used for PCR testing with a sensitivity of 98-100%. A positive screening test mandates treatment. Nevertheless, a positive screening test from urine does not replace the evaluation of the cervix.

Swabs can be used to collect a sample of this discharge for inspection under a microscope and/or lab testing for gonorrhea, chlamydia, and Trichomonas vaginalis. A bimanual exam in which the clinician palpates the cervix to see if there is any associated pain should be done to assess for pelvic inflammatory disease.^[rx]

Treatment of Cervicitis

The resolution of symptoms is dependent on the etiology of cervicitis. According to the CDC guidelines, empiric treatment is recommended for women at higher risk of STIs, which include women <25, those with a new sexual partner, a partner with an STI, or multiple concurrent sexual partners. For these women, antimicrobials to cover for chlamydia and gonorrhea is given. Empiric treatment is also suggested for women with no identifiable pathogen on testing. Treatment can be deferred until the confirmatory tests are available for women at lower risk of STIs. According to the guidelines published by Institut national d’excellence en Sante et en services sociaux (INESSS), the empiric regimens are as follows:

1g single oral dose azithromycin PLUS either 800 mg cefixime in a single oral dose or 250 mg intramuscular ceftriaxone in a single dose
100 mg oral doxycycline twice daily for 7 days PLUS either 800 mg cefixime in a single oral dose or 250 mg intramuscular ceftriaxone in a single dose
For severe allergy to penicillins/cephalosporins: 2g oral azithromycin in a single dose[rx][rx][rx]

For infectious agents identified by laboratory investigations, the treatment is as follows:

Chlamydia: A single oral dose of 1g azithromycin OR 100mg doxycycline twice daily for 7 days
Gonorrhea: 250mg intramuscular ceftriaxone PLUS a single oral dose of 1g azithromycin
Mycoplasma: 400mg moxifloxacin after treatment failure with 1g oral azithromycin
Trichomonas: A single oral 2g dose of metronidazole OR tinidazole. Trichomoniasis is treated with the antibiotic metronidazole. If you are allergic to any of these antibiotics, an alternative can be prescribed.
Bacterial vaginosis: Twice daily 500mg metronidazole for 7 days OR intravaginal 0.75% metronidazole gel once daily for 5 days
HSV: Oral 400mg acyclovir three times daily for 7 to 10 days

Gonorrhea is usually treated with an injection of the antibiotic ceftriaxone (Rocephin) and one dose of oral azithromycin. Chlamydia is typically treated with oral antibiotics such as azithromycin (Zithromax), doxycycline (sold under several brand names), ofloxacin (Floxin) or levofloxacin (Levaquin).

If you have genital herpes, an antiviral medication can be prescribed. This could be acyclovir (Zovirax), valacyclovir (Valtrex) or famciclovir (Famvir). You will need to take the medication for up to 10 days the first time you develop genital herpes. For recurrent herpes outbreaks, you can take the medication for three to five days.

Treatment of sexual partners is also recommended, and sexual activity should be stopped until the completion of therapy and resolution of treatment.[rx] HIV positive women with cervicitis are given the same treatment as HIV negative. Prompt treatment in these women reduces viral shedding and may reduce the risk of HIV transmission.[rx]

Natural treatment options

Acute cervicitis that is caused by an infection is best treated medically, as it is essential to clear up the infection. If a woman has chronic cervicitis with mild symptoms, she may choose to use home remedies to help ease the symptoms. A person should always use home remedies alongside medical treatments. They are not intended to replace them.

Home remedies that may help treat cervicitis include:

Traditional Chinese medicine: A 2014 study found that traditional Chinese medicinal treatments, including specific Chinese herbs, may be effective in the treatment of cervicitis. The herbs were reported to have an anti-inflammatory effect.
Eating yogurt or taking probiotic supplements: Yogurt contains healthful bacteria called probiotics. Probiotics are also available in supplement form and are available to buy online. A 2014 study suggests that probiotics may help treat bacterial vaginosis, which is one cause of cervicitis.
Eating garlic or taking a garlic supplement: Garlic has strong antibacterial properties. Another 2014 study found that taking garlic supplements may also help treat bacterial vaginosis.

It is a good idea to seek a diagnosis and advice from a doctor before deciding on a course of treatment. These alternative treatments need further studies as they are not considered first-line treatment for cervicitis or vaginal infections at this time.

Home remedies that support vaginal and cervical health and may prevent cervicitis include:

Drinking green tea: A 2014 study suggested green tea may have a protective role in reducing the risk of ovarian and endometrial cancers.
Avoiding irritants: Avoiding douches, tampons, diaphragms, and scented soaps reduce the risk of irritation.
Wearing loose cotton underwear: Breathable underwear reduces the buildup of moisture and bacteria that can lead to infection.
Using condoms during sex: This reduces the risk of STIs, one of the leading causes of cervicitis.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down the questions you want to be answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also, write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.

References