Cervicitis 

Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae,herpes simplex virus (HSV), or human papillomavirus (HPV). Trichomonas vaginalis, technically a vaginal infection, is commonly discussed when discussing cervicitis. Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted infections (STIs). This article focuses on the infectious etiologies of cervicitis.

Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvovaginitis and cervicitis. Vulvovaginitis and cervicitis are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article.

Frequency

United States

The Centers for Disease Control and Prevention (CDC) estimates that over 19 million STI infections occur annually, almost half of them among those aged 15-24 years. In addition to potentially severe health consequences, STIs pose a tremendous economic burden, with direct medical costs as high as $16 billion in a single year.

Trichomonas is the most common curable STI in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men. In 2007, 1.1 million chlamydial infections were reported to the CDC, up from 877,478 cases reported in 2003.^[1] Because many cases are not reported or even diagnosed, 2.8 million new cases of chlamydia are actually estimated to occur each year. Gonorrhea is the second most commonly reported infectious disease in the United States, with 355,991 cases reported in 2007.^[1] Much like chlamydia, gonorrhea is believed to be underreported.

The annual rates of infection by HSV and HPV are difficult to estimate because the vast majority of initial infections are asymptomatic or unrecognized.^[1] In the United States, seroprevalence studies show that 22% of adults have HSV type 2 antibodies; currently, over 500,000 new cases of genital herpes are believed to occur annually. Approximately 20 million people are currently infected with HPV. At least 50% of sexually active men and women acquire a genital HPV infection at some point in their lives. By age 50 years, at least 80% of women will have acquired a genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

International

Worldwide, more than 400 million adults become infected with an STI every year. Four STIs that are spread primarily through sexual contact are completely curable—trichomoniasis, chlamydia, syphilis, and gonorrhea. These infections account for 340 million STI infections, or about 80% of the worldwide total. Approximately 9% of all persons aged 15-44 years in North America contract 1 of these STIs annually, but the rate rises to 25% in sub-Saharan Africa.

Worldwide, over 170 million cases of trichomoniasis are reported each year. Infection rates have been reported as high as 67% in Mongolia in 1988, 40-60% in Africa, and 40% in indigenous Australians older than 40 years.

Chlamydia is the next most common STI, with approximately 92 million cases a year. Prevalence of chlamydia varies enormously across the world. In the 1990s, rates among pregnant women in Europe ranged from 2.7% in Italy to 8.0% in Iceland, while studies in South America found rates of 1.9% among teenagers in Chile and 2.1% among pregnant women in Brazil. In Asia, rates among pregnant women tend to be much higher: up to 17% in India and 26% in rural Papua New Guinea. In Africa, studies of pregnant women have revealed rates from 6% in Tanzania to 13% in Cape Verde.

HPV, HSV, and gonorrhea each account for roughly 20-60 million cases of STIs per year.

The prevalence of HPV, a cause of cervical cancer, varies roughly 20-fold internationally. An analysis of worldwide prevalence was published in 2005.^[2] Among the countries evaluated, Spain had the lowest prevalence of HPV; only 1.4% of women in Spain tested positive for HPV. The highest prevalence of HPV was seen in sub-Saharan Africa; 26% of the women in Nigeria tested positive for HPV. South America tended to have rates that were in between those of Europe and sub-Saharan Africa, while rates in Asia varied widely (with the lowest rates in Hanoi, Vietnam, and the highest in India and Korea).

In various studies, the seroprevalence of HSV-2 is higher in the United States (13-40%) than in Europe (7-16%) and is highest in Africa (30-40%).

Studies of pregnant women in Africa have found rates for gonorrhea ranging from 0.02% in Gabon to 3.1% in Central African Republic and 7.8% in South Africa. In the Western Pacific in the 1990s, the highest prevalence rates (≥ 3%) were in Cambodia and Papua New Guinea. Other areas such as China, Vietnam, and the Philippines had rates of 1% or less. Between 1995 and 1999, a significant increase in gonorrhea incidence occurred in Eastern Europe, with the highest rates in Estonia, Russia, and Belarus.

Mortality/Morbidity

Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease (PID), infertility, ectopic pregnancy, chronic pelvic pain, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race

No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex

Male urethritis is more often symptomatic; therefore, diagnosis is usually made earlier in males than in females. Females with cervicitis are most often asymptomatic, so they do not seek evaluation or treatment as readily.

Age

Age younger than 25 years, single marital status, and a new sexual partner within the past 6 weeks are risk factors for cervicitis. Both biological (eg, postulated immaturity of the female reproductive tract) and behavioral factors (eg, greater number of partners, low awareness of acquired immunodeficiency syndrome [AIDS] and other STIs, and limited use of protection against STIs) are thought to contribute to this risk. Routine screening of sexually active adolescents and young adults is therefore recommended.

Routine chlamydia screening of sexually active young women is recommended by the US Preventive Services Task Force to prevent consequences of untreated chlamydial infection (eg, pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain). Fewer than half of young, sexually active females in the United States are screened for chlamydia, according to the Morbidity and Mortality Weekly Report (MMWR). Nationally, the annual screening rate increased from 25.3% in 2000 to 43.6% in 2006, and then decreased slightly to 41.6% in 2007.^[1]