> Table of Contents > Cervicitis, Ectropion, and True Erosion
Cervicitis, Ectropion, and True Erosion
Cecilia M. Kipnis, MD
Gillian R. Wackowski, DO
image BASICS
DESCRIPTION
  • Cervicitis is an acute or chronic cervical inflammation; can be infectious or noninfectious.
  • Ectropion is the eversion of the endocervix, exposing the columnar cells to the vaginal environment. This is more common in adolescents and pregnancy and can be confused for cervicitis.
  • A true erosion occurs with the loss of overlying cervical epithelium due to trauma (e.g., forceful insertion of vaginal speculum in patient with atrophic mucosa).
  • System(s) affected: reproductive
Geriatric Considerations
  • Chronic cervicitis or a true erosion in postmenopausal women may be related to low levels of estrogen.
  • Infectious cervicitis should not be overlooked in geriatric patients as many remain sexually active.
Pregnancy Considerations
All pregnant women should be screened for infectious cervicitis at the first prenatal visit by screening for chlamydia, and those with new or multiple sexual partners should also be screened for gonorrhea a (1).
Pediatric Considerations
Infectious cervicitis in children should lead to an investigation of possible sexual abuse.
EPIDEMIOLOGY
Incidence
  • Cervicitis: most commonly due to infectious etiologies, including, but not limited to the following:
    • Chlamydia: 1,401,906 cases were reported to the CDC in 2013, 67% of reported cases occurring among 15- to 24-year-olds (2). Actual incidence is significantly higher.
    • Gonorrhea: second most commonly reported notifiable disease after chlamydia in the United States; 333,004 cases reported to the CDC in 2013 (2)
    • HSV and Trichomonas: these are not routinely reported to CDC but trend data show Trichomonas infections are up for a third year in a row (3).
    • Mycoplasma genitalium: increasingly recognized as a common sexually transmitted pathogen among high-risk, sexually active women (4)
  • Ectropion: typically related to higher levels of estrogen; ectropion is common among adolescents, women using combined oral contraceptive pills (OCPs), and pregnant women.
    • Present in 14-37% of outpatients (5)
  • True erosion: can be seen in women with cervical trauma
ETIOLOGY AND PATHOPHYSIOLOGY
  • Cervicitis: Often, no specific etiology is identified.
    • Infectious: Chlamydia trachomatis, Neisseria gonorrhoeae are the most commonly identified pathogens; they affect the columnar epithelium of the endocervix. Trichomonas vaginalis and herpes simplex virus (HSV; especially primary infections of HSV-2) affect the squamous epithelium. Mycoplasmas (e.g., M. genitalium) are becoming increasingly recognized as causative organism.
    • Noninfectious: physical or chemical irritation (e.g., douching, latex exposure, contraceptive creams, or vaginal foreign bodies such as tampons, cervical caps), radiation therapy, inflammatory diseases, malignancy
  • Ectropion
    • Hormonal changes with puberty, oral contraceptive use, or pregnancy
    • Resulting from cervical laceration during childbirth
  • True erosion: injury to atrophic epithelium; estrogen-deficient states such as menopause
RISK FACTORS
  • Infectious cervicitis (6)
    • Ages 15 to 25 is strongest predictor of risk
    • Multiple sexual partners
    • New sexual partner
    • Unprotected sex or sporadic use of condoms
    • History of sexually transmitted infection (STI)
    • Exchanging sex for money or drugs
    • Black and Hispanic race
    • Other reproductive tract infections: bacterial vaginitis, pelvic inflammatory disease (PID)
  • Noninfectious cervicitis
    • Foreign objects: pessary, diaphragm, cervical cap, and so forth.
  • Ectropion: adolescence, pregnancy, use of OCP
  • True erosion: estrogen deficiency, trauma from foreign body
GENERAL PREVENTION
  • STIs (chlamydia, gonorrhea, trichomoniasis)
  • Advise use of condoms and safer sexual practices to prevent STIs. Follow USPTF-recommended screening measures (6)[A]:
  • Annual screening for C. trachomatis infection of all sexually active women ≤25 years and all older women at increased risk. Screen all pregnant women at the first prenatal visit.
  • Annual screening for N. gonorrhoeae among sexually active women ≤25 years and all older women at increased risk (new or multiple partners, from communities with high prevalence). Screen among pregnant women at risk early in pregnancy (4).
  • At least annual screening of trichomoniasis among HIV-positive women
  • Treat sexual partners of infected women.
  • Estrogen deficiency: estrogen replacement therapy
image DIAGNOSIS
PHYSICAL EXAM
  • Cervicitis: most evident is mucopurulent/purulent discharge from cervix and/or cervical friability (4)
  • Other symptoms: erythema, ulceration (HSV), punctate hemorrhage (“strawberry” cervix appearance in trichomoniasis). Consider coexistence with PID with cervical motion tenderness on bimanual exam (6).
  • Ectropion: Cervix appears red due to the color of the columnar epithelium.
  • True erosion: vaginal bleeding, sharply defined ulcers of cervix
DIFFERENTIAL DIAGNOSIS
  • Cervical dysplasia
  • Cervical neoplasm
  • Cervical polyp or fibroid
  • Ruptured nabothian cyst
  • Postcervical procedure (biopsy, LEEP, IUD insertion/removal, aggressive pap smear)
  • Bacterial vaginosis (discharge is noninflammatory)
DIAGNOSTIC TESTS & INTERPRETATION
  • Nucleic acid amplification test (NAAT) is the recommended test by USPTF and CDC for C. trachomatis/N. gonorrhoeae detection (6)[A].
  • Urine specimens are slightly less sensitive than clinical endocervical or self-collected vaginal swabs (4).
  • NAAT is also the most sensitive test for M. genitalium, although testing for this is not widely available (4).
  • Cultures may be used when evaluating a potential N. gonorrhoeae treatment failure (7).
  • Vaginal wet mount for T. vaginalis
    • Culture, antigen assays, and NAAT should be considered when microscopy is unavailable or inconclusive. Sensitivity for microscopy is low (˜50%).
    • Pap smears should not be used to diagnose trichomoniasis.
  • If ulcerations are present, culture for HSV.
Diagnostic Procedures/Other
Colposcopy may be helpful in cases of chronic inflammation, with biopsy of suspicious areas.
image TREATMENT
MEDICATION
First Line
  • If infectious cervicitis suspected in high-risk patient, presumptive treatment is appropriate: ceftriaxone 250 mg single dose IM, followed by either azithromycin 1 g single dose or doxycycline 100 mg PO BID × 7 days. Option of ceftriaxone and azithromycin removes patient-compliance factor because they are 1-time doses and can be administered in office.
  • Chlamydia: for nonpregnant women, azithromycin 1 g PO single dose or doxycycline 100 mg BID PO × 7 days; for pregnant women, azithromycin 1 g single dose or erythromycin base 500 mg QID PO × 7 days or erythromycin ethylsuccinate 800 mg QID × 7 days
  • Gonorrhea: Due to increased resistance to antibiotics, the CDC currently recommends ceftriaxone 250 mg single dose IM, followed by either azithromycin 1 g PO single dose or doxycycline 100 mg PO BID × 7 days regardless of the chlamydial coinfection status.
  • Trichomoniasis: metronidazole 2 g PO single dose or 500 mg PO BID × 7 days. A single oral dose of 2 g of tinidazole is also effective (6)[A].
  • \M. genitalium: azithromycin 1 g PO as a single dose or 500 mg PO once followed by 250 mg PO daily × 4 days
  • Ectropion: none, unless patient is extremely symptomatic with copious discharge. In that case, acid-buffered vaginal jelly can be used to decrease discharge.
  • True erosion: conjugated estrogen cream applied vaginally daily for 1 to 2 weeks, followed by maintenance dosing twice weekly or oral hormone replacement therapy (HRT)
  • Contraindications:
    • Metronidazole: The manufacturer states that metronidazole is contraindicated in the 1st trimester in pregnancy but more recent meta-analyses suggest absence of teratogenicity.
    • P.183

    • Doxycycline: do not use during pregnancy or lactation
    • Estrogen: See extended list of contraindications to estrogen use in standard texts.
  • Precautions:
    • Metronidazole and tinidazole: Avoid alcohol and breastfeeding during treatment and 12 to 24 hours after completion of treatment with metronidazole and 72 hours after completion of treatment with tinidazole (4)[A].
    • Doxycycline: possible fetal harm if used during pregnancy; staining of the infant's teeth if used during breastfeeding; allergy; photosensitization
    • Erythromycin: nausea or vomiting
    • Estrogens: history of estrogen-dependent neoplasms; history of thromboembolic diseases. See extended list of contraindications to estrogen therapy in standard texts.
  • Significant possible interactions:
    • Metronidazole: ethanol
    • Doxycycline: dairy products, iron preparations, warfarin, and oral contraceptives (advise use of alternative contraceptive method)
    • Erythromycin: theophylline (elevated theophylline level)
    • Estrogen: N/A
Second Line
  • Chlamydia
    • Levofloxacin 500 mg PO daily × 7 days
    • Ofloxacin 300 mg PO BID × 7 days (4)[A]
  • Gonorrhea: If an injectable cephalosporin is not an option, oral cephalosporin therapy with azithromycin or doxycycline can be considered as 2nd-line therapy:
    • Cefixime: 400 mg PO single dose is an acceptable alternative to ceftriaxone, (however, necessitates that the patient return in 1 week for a test of cure) plus azithromycin 1 g single dose or doxycycline 100 mg PO BID × 7 days (8)[A].
    • In the case of a true penicillin allergy, alternative regimens include the following:
      • Azithromycin: 2 g PO as a single dose; however, due to evidence of increasing resistance to macrolides, use should be limited. Test of cure is recommended
      • CDC no longer recommends fluoroquinolones for treatment of gonorrhea due to emergence of fluoroquinolone-resistant N. gonorrhoeae in United States (8)[A].
      • M. genitalium: moxifloxacin 400 mg PO daily × 7 to 10 days (7)[C] in patients with persistent M. genitalium despite azithromycin treatment, although studies are limited
  • Estrogen deficiency: A number of estrogen vaginal preparations are available commercially.
Pregnancy Considerations
Doxycycline and the quinolones are contraindicated in pregnancy.
SURGERY/OTHER PROCEDURES
  • Ectropion: Symptomatic lesions can be treated with silver nitrate, or cryo and electrocautery (5).
  • Chronic cervicitis with negative cultures and treatment failure may be treated with cryosurgery, electrocautery, or loop excision.
  • Surgical management and cautery is generally considered overly invasive and should only be used in select patients with severe/significant symptoms who do not respond to other treatments. Adverse effects can include continued or increased discharge, recurrence of lesion, and cervical stenosis which may affect fertility.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Test of cure for C. trachomatis is recommended in pregnant patients to document eradication of infection; perform at least 3 weeks following treatment.
  • Reinfection with Trichomonas, gonorrhea, and chlamydia is common; repeat screening should be performed routinely for all patients 3 to 4 months following treatment (4)[A].
  • Estrogen deficiency: Reexamine in 1 month to confirm healing.
PATIENT EDUCATION
If the etiology of cervicitis is a confirmed STI, the patient's sex partners within the preceding 60 days must be evaluated for N. gonorrhoeae or C. trachomatis and treated accordingly. Patient should abstain from sexual intercourse for 7 days after a single-dose regimen or after completion of a 7-day regimen to avoid reinfection.
PROGNOSIS
  • Cervicitis: excellent after bacterial infection is eradicated
  • Ectropion: spontaneous regression postpartum and with cessation of use of oral contraceptives
  • True erosion: spontaneous healing
REFERENCES
1. Centers for Disease Control and Prevention; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (United States). Incidence, prevalence, and cost of sexually transmitted infections in the United States; CDC fact sheet. http://www.cdc.gov/std/stats/sti-estimates-fact-sheet-feb-2013.pdf.
2. Centers for Disease Control and Prevention. Reported STDs in the United States: 2013 national data for chlamydia, gonorrhea and syphilis; CDC fact sheet. http://www.cdc.gov/nchhstp/newsroom/docs/STD-Trends-508.pdf.
3. Centers for Disease Control and Prevention. 2013 sexually transmitted diseases surveillance Table 45. Selected STDs and complications—initial visits to physicians' offices, National Disease and Therapeutic Index, United States, 1966-2013. http://www.cdc.gov/std/stats13/tables/45.htm.
4. Workowski K, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
5. Wan YL, Edmondson RJ, Crosbie EJ. Intermenstrual and postcoital bleeding. Obstet Gynaecol Reprod Med. 2015;25(4):106-112.
6. U.S. Preventive Services Task Force. Final Recommendation Statement: Chlamydia and Gonorrhea: Screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and-gonorrhea-screening?ds=1&s=chlamydia%20and%20gonorrhea%20screening. Accessed July 25, 2015
7. Manhart LE, Broad JM, Golden MR. Mycoplasma genitalium: should we treat and how? Clin Infect Dis. 2011;53(Suppl 3):S129-S142.
8. Centers for Disease Control and Prevention. 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(31):590-594.
Additional Reading
  • Cazanave C, Manhart LE, Bébéar C. Mycoplasma genitalium, an emerging sexually transmitted pathogen. Med Mal Infect. 2012;42(9):381-392.
  • Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep. 2014:63(RR-02):1-19.
  • Cook RL, Hutchison SL, Østergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142(11):914-925.
  • Gülmezoglu AM, Azhar M. Interventions for trichomoniasis in pregnancy. Cochrane Database Syst Rev. 2011;(5):CD000220.
  • Haggerty CL, Taylor BD. Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2011;2011:959816.
  • 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(11):946-959.
  • Wilson JF. In the clinic. Vaginitis and cervicitis. Ann Intern Med. 2009;151(5):ITC3-1-ITC3-15.
Codes
ICD10
  • N72 Inflammatory disease of cervix uteri
  • N86 Erosion and ectropion of cervix uteri
Clinical Pearls
  • If infectious cervicitis is suspected, treatment of choice is ceftriaxone 250 mg IM plus azithromycin 1 g PO × 1 dose. Do not wait for test results.
  • Sexual partner(s) need to be treated.
  • Positive results for N. gonorrhoeae or chlamydia should be reported to local or state health department.