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Cervicitis Treatment & Management

  • Author: Arthur T Ollendorff, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Nov 03, 2014
 

Approach Considerations

Admit women to the hospital if pelvic inflammatory disease [PID] is suspected and the patient is unable to take oral medications, is pregnant or immunocompromised, has failed prior outpatient therapy, has a tubo-ovarian abscess, or if the diagnosis is uncertain (e.g. appendicitis cannot be ruled out). If disseminated infection is suspected, intensive monitoring and parenteral medication are needed, as patients may quickly become unstable.

If the patient is unable to take oral medication because of intractable nausea, vomiting, or abdominal pain, then hospitalization for intravenous medication is warranted.

In most cases, test-of-cure is not necessary, because of the high efficacy of the medications used. In the case of persistent symptoms or pregnancy, follow-up testing is recommended.

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Antimicrobial Management

Treatment of all causes of cervicitis is medical and can be done presumptively (treatment with azithromycin or doxycycline) in infectious cases or with specific antibiotic treatment once the etiology is known; however, empiric treatment for cervicitis can also include coverage for gonorrhea if there is clinical suspicion for this condition.

Provide presumptive therapy to women at increased risk for chlamydial infection, particularly in cases in which follow-up is uncertain or in which a relatively insensitive diagnostic test is used instead of nucleic acid amplification testing (NAAT), as well as in patients who have been diagnosed with trichomoniasis and bacterial vaginosis.[1]

Treatment must also include the patient's sexual partners to prevent reinfection. In addition, all [#TreatmentConsultations] sexual activity must cease for 7 days until the completion of therapy; that is: (1) after initiating treatment in the patient and (2) until the partner has also been treated.

Chlamydial cervicitis

The CDC recommends the following regimens for presumptive treatment of chlamydial cervicitis[1] :

  • Azithromycin 1 g oral (PO) in a single dose, OR
  • Doxycycline 100 mg PO twice daily (bid) for 7 days

These patients should also be treated concurrently for gonococcal infection in areas with high gonorrhea prevalence or if the individual’s personal risk is high. Effective alternative agents to azithromycin and doxycycline include erythromycin, levofloxacin, and ofloxacin, as follows[1, 10] :

  • Erythromycin base 500 mg PO four times daily (qid) for 7 days, OR
  • Erythromycin ethylsuccinate 800 mg PO qid for 7 days, OR
  • Levofloxacin 500 mg PO daily (qd) for 7 days, OR
  • Ofloxacin 300 mg PO bid for 7 days

In women who defer presumptive treatment, the need for therapy depends on the results of sensitive tests for chlamydia and gonorrhea.[1]

Gonococcal cervicitis

For uncomplicated gonococcal infections of the cervix, the CDC updated their recommendations in August 2012, as follows[24] :

  • Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS
  • Azithromycin 1 g PO in a single dose (preferred, owing to tetracycline resistance) or doxycycline 100 mg PO bid for 7 days

Alternatively, if ceftriaxone is not an option, the following regimens are recommended[24] :

  • Single-dose injectable cephalosporin regimens, PLUS
  • Azithromycin 1 g PO in a single dose (preferred) or doxycycline 100 mg PO bid for 7 days, PLUS
  • Test-of-cure in 1 week (with culture, including phenotypic antimicrobial susceptibility; if culture is unavailable, obtain NAAT)

If the patient has a severe cephalosporin allergy, azithromycin 2 g PO in a single dose plus test-of-cure in 1 week are recommended.[24]

Trichomoniasis

The CDC recommends metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose for T vaginalis infections.[20] Alternatively, metronidazole 500 mg PO bid for 7 days can be given.

Patients must avoid alcohol consumption during treatment with metronidazole or tinidazole, as well as for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.[20] Topically applied antimicrobials are not as effective as the oral doses (eg, metronidazole) and should be avoided.

Lactating women who are administered metronidazole should withhold breastfeeding during treatment and for 12-24 hours after the last dose.[20] Women treated with tinidazole should also withhold breastfeeding during treatment, as well as for 3 days after the last dose.

Evaluate male partners and treat them with either tinidazole in a single dose of 2 g PO or metronidazole 500 mg PO bid for 7 days.[20]

Treatment during pregnancy

Do not treat pregnant women with doxycycline, ofloxacin, and levofloxacin.[10] Pregnant women with chlamydial cervicitis may be treated with azithromycin as above or with amoxicillin 500 mg PO three times daily (tid) for 7 days. Erythromycin may be an alternative regimen, as follows[10] :

  • Erythromycin base 500 mg PO qid for 7 days, OR
  • Erythromycin base 250 mg PO qid for 14 days, OR
  • Erythromycin ethylsuccinate 800 mg PO qid for 7 days, OR
  • Erythromycin ethylsuccinate 400 mg PO qid for 14 days

Pregnant women with gonococcal cervicitis should undergo the same treatment as nonpregnant women. In those who cannot tolerate a cephalosporin, consider azithromycin 2 g PO.[11]

Pregnant women with trichomoniasis can be treated with 2 g metronidazole in a single dose at any stage of pregnancy.[20] The safety of tinidazole in pregnant women has not been well evaluated.

Cervicitis and HIV coinfection

In women with concurrent cervicitis and HIV infection, the treatment regimen is the same as that for women not infected with HIV.[1] It is essential for these women to receive treatment to reduce cervical HIV shedding, which is increased in cervicitis, and thus reduce the potential for HIV transmission to their sex partners.[1]

In patients with trichomoniasis and HIV coinfection, the CDC recommends considering a multidose treatment regimen of metronidazole PO, as a study indicated the single dose of metronidazole 2 g PO was not as effective as 500 mg bid for 7 days.[20]

Recurrent/persistent cervicitis

Aside from reevaluation for reexposure to a sexually transmitted infection (STI), there are currently no defined treatment options for women found to have recurrent and persistent cervicitis despite the exclusion of relapse/reinfection with a specific STI, the absence of bacterial vaginosis, and the evaluation and treatment of the patient’s sex partner(s).[1] The efficacy of repeated or prolonged antibiotic therapy in these women is also unclear. Consider referring women with persistent symptoms clearly caused by cervicitis to gynecologic specialists.[1]

Women with trichomoniasis, treatment failure using metronidazole 2 g single dose, and exclusion of reinfection should be treated with metronidazole 500 mg PO bid for 7 days.[20] If retreatment is unsuccessful, consider tinidazole or metronidazole at 2 g PO for 5 days. If none of these treatment strategies are effective, consult with an infectious disease specialist to determine the susceptibility of the T vaginalis infection to metronidazole and tinidazole. The CDC also provides consultation (telephone: 404-718-4141; Web site: http://www.cdc.gov/std) and T vaginalis susceptibility testing.[20]

Antimicrobial-resistant gonorrhea

Consult an infectious disease specialist for suspected treatment failure or for the management of patients infected with a microbial strain that has demonstrated in vitro resistance.[11] Perform culture and susceptibility testing, retreat the patient with at least 250 mg of ceftriaxone intramuscular/intravenous (IM/IV), and treat the patient’s sex partners. In addition, notify the CDC through state and local public health authorities.[11]

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions (eg, pelvic inflammatory disease [PID]), owing to the ability of N gonorrhoeae to develop resistance to microbial therapies.[25] The guidelines no longer recommended fluoroquinolone antibiotics to treat gonorrhea in the United States.

This change was based on analysis of new data from the CDC’s Gonococcal Isolate Surveillance Project (GISP). The GISP data showed that the proportion of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men had reached 7.9% in 2010, a 13-fold increase from 0.6% in 2001.[25, 26]

As a result of another update of the CDC’s treatment guidelines, in August 2012, oral cephalosporins are no longer recommended for gonococcal infections.[24] Thus, cefixime at any dose is no longer a first-line treatment for such infections.[24]

Treatment of gonorrhea is now limited to ceftriaxone 125 mg IM once as a single dose plus a second antibiotic. Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.

For more information, see the CDC’s Antibiotic-Resistant Gonorrhea Web site, the Gonococcal Isolate Surveillance Project (GISP) Web site, or the May 18, 2012, video presentation, The Growing Threat of Multidrug Resistant Gonorrhea.

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Long-Term Monitoring

Follow up with women treated for cervicitis according to recommendations for the specific etiology to determine whether the condition has resolved.[1] Routine test-of-cure (ie, repeat testing 3-4 wk following treatment completion) is not recommended following treatment, except in the following situations[1, 10] :

  • The patient is pregnant
  • Symptoms persist
  • Suspicion of reinfection exists
  • There is questionable treatment compliance

Women with persistent symptoms following gonococcal or chlamydial infection should be reevaluated owing to the increased risk of reinfection within 6 months following treatment; ie, repeat testing should be performed 3-6 months after the initial treatment, whether or not a patient’s sex partner(s) underwent treatment.[1] Women treated for trichomoniasis should also be rescreened at 3 months following treatment due to the high risk for reinfection.[20]

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Contributor Information and Disclosures
Author

Arthur T Ollendorff, MD Director of Medical Education, Department of Obstetrics/Gynecology, Mountain Area Health Education Center; Clinical Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine

Arthur T Ollendorff, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North Carolina Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Acknowledgements

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Jeffrey B Garris, MD Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine

Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Sabrina R Kendrick, MD, FACP Assistant Professor, Department of Internal Medicine, Rush University Medical Center; Director, Screening Clinic, The CORE Center; Consulting Staff, Division of Infectious Diseases, John H Stroger Hospital of Cook County

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Anita B Varkey, MD Assistant Professor, Department of Medicine, Loyola University Medical Center; Associate Program Director, Internal Medicine Residency; Medical Director, General Internal Medicine Clinic, Loyola Outpatient Center

Anita B Varkey, MD is a member of the following medical societies: American College of Physicians and Society of General Internal Medicine

Disclosure: Nothing to disclose.

References
  1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010: diseases characterized by urethritis and cervicitis. Available at http://www.cdc.gov/std/treatment/2010/urethritis-and-cervicitis.htm. Accessed: May 17, 2012.

  2. Paavonen J. Chlamydia trachomatis infections of the female genital tract: state of the art. Ann Med. 2012 Feb. 44(1):18-28. [Medline].

  3. Taylor BD, Darville T, Ferrell RE, Kammerer CM, Ness RB, Haggerty CL. Variants in toll-like receptor 1 and 4 genes are associated with Chlamydia trachomatis among women with pelvic inflammatory disease. J Infect Dis. 2012 Feb 15. 205(4):603-9. [Medline]. [Full Text].

  4. Oakeshott P, Aghaizu A, Hay P, Reid F, Kerry S, Atherton H. Is Mycoplasma genitalium in women the "New Chlamydia?" A community-based prospective cohort study. Clin Infect Dis. 2010 Nov 15. 51(10):1160-6. [Medline].

  5. Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Am J Obstet Gynecol. 2012 Jun. 206(6):476.e1-8. [Medline].

  6. McGowin CL, Anderson-Smits C. Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women. PLoS Pathog. 2011 May. 7(5):e1001324. [Medline]. [Full Text].

  7. Centers for Disease Control and Prevention. STD trends in the United States: 2010 national data for gonorrhea, chlamydia, and syphilis. Available at http://www.cdc.gov/std/stats10/trends.htm. Accessed: October 24, 2012.

  8. Centers for Disease Control and Prevention. Trichomoniasis – CDC fact sheet. Available at http://www.cdc.gov/std/trichomonas/STDFact-trichomoniasis.htm. Accessed: October 24, 2012.

  9. Centers for Disease Control and Prevention. Genital HPV infection – CDC fact sheet. Available at http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed: October 24, 2012.

  10. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010: chlamydial infections. Available at http://www.cdc.gov/std/treatment/2010/chlamydial-infections.htm. Accessed: May 18, 2012.

  11. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010: gonococcal infections. Available at http://www.cdc.gov/std/treatment/2010/gonococcal-infections.htm. Accessed: May 18, 2012.

  12. Burnett AM, Anderson CP, Zwank MD. Laboratory-confirmed gonorrhea and/or chlamydia rates in clinically diagnosed pelvic inflammatory disease and cervicitis. Am J Emerg Med. 2012 Sep. 30(7):1114-7. [Medline].

  13. Centers for Disease Control and Prevention. Seroprevalence of herpes simplex virus type 2 among persons aged 14-49 years--United States, 2005-2008. MMWR Morb Mortal Wkly Rep. 2010 Apr 23. 59(15):456-9. [Medline].

  14. World Health Organization. Sexually Transmitted Infections. October 2007. Available at http://www.who.int/mediacentre/factsheets/fs110/en/index.html.

  15. Clifford GM, Gallus S, Herrero R, Munoz N, Snijders PJ, Vaccarella S. Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis. Lancet. 2005 Sep 17-23. 366(9490):991-8. [Medline].

  16. American College of Obstetricians and Gynecologists. New cervical cancer screening recommendations from the U.S. Preventive Services Task Force and the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology. Available at http://www.acog.org/About ACOG/Announcements/New Cervical Cancer Screening Recommendations.aspx. Accessed: October 24, 2012.

  17. American Cancer Society. American Cancer Society guidelines for the early detection of cancer. Available at http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed: October 24, 2012.

  18. US Preventive Services Task Force. Screening for cervical cancer. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm. Accessed: October 24, 2012.

  19. Prentiss KA, Newby PK, Vinci RJ. Adolescent female with urinary symptoms: a diagnostic challenge for the pediatrician. Pediatr Emerg Care. 2011 Sep. 27(9):789-94. [Medline].

  20. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010: diseases characterized by vaginal discharge. Available at http://www.cdc.gov/std/treatment/2010/vaginal-discharge.htm. Accessed: May 18, 2012.

  21. Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. 2004 Apr. 103(4):619-31. [Medline].

  22. {Guideline} American College of Obstetricians and Gynecologists. Practice bulletin no. 140: management of abnormal cervical cancer screening test results and cervical cancer precursors. Obstet Gynecol. 2013 Dec. 122(6):1338-67. [Medline].

  23. Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol. 2013 Apr. 121(4):829-46. [Medline].

  24. 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 Aug 10. 61(31):590-4. [Medline]. [Full Text].

  25. Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].

  26. Centers for Disease Control and Prevention. 2010 sexually transmitted diseases surveillance. Available at http://www.cdc.gov/std/stats10/gonorrhea.htm. Accessed: November 6, 2012.

  27. Centers for Disease Control and Prevention. Chlamydia screening among sexually active young females enrollees of health plans - United States, 2000-2007. MMWR Weekly. April 17, 2009. 58(14):362-365. [Full Text].

  28. Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Contraception. 2005 Jul. 72(1):60-4. [Medline].

  29. Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Mosby; 2007. 598-600.

  30. Kirkcaldy RD, Augostini P, Asbel LE, et al. Trichomonas vaginalis antimicrobial drug resistance in 6 US cities, STD Surveillance Network, 2009-2010. Emerg Infect Dis. 2012 Jun. 18(6):939-43. [Medline]. [Full Text].

  31. Schiffman M, Khan MJ, Solomon D, Herrero R, Wacholder S, Hildesheim A. A study of the impact of adding HPV types to cervical cancer screening and triage tests. J Natl Cancer Inst. 2005 Jan 19. 97(2):147-50. [Medline].

 
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Normal cervix
Cervix of a lactating woman without sexually transmitted infections. The patient had twice given birth vaginally.
Cervical cellularity (ectopy), which is often present in adolescents, allows for greater adherence of infectious organisms in the cervix. The risk of acquiring acute salpingitis for a sexually active 15-year-old is 1:8, compared with 1:80 for women aged 24 years and older.
Signs of chlamydial cervicitis on speculum examination may include mucopurulent endocervical discharge and spontaneous or easily induced endocervical bleeding or any zones of ectopy.
In women with gonococcal cervicitis, the cervix may show mucopurulent or purulent cervical discharge and easily induced cervical bleeding.
Herpes simplex virus (HSV) cervicitis may involve the exocervix or endocervix, and it may be symptomatic or asymptomatic. Usually, the cervix appears abnormal to inspection, with diffuse vesicular lesions, ulcerative lesions, erythema, or friability.
T vaginalis can have a characteristic "frothy" gray or yellow-green vaginal discharge and pruritus. The occurrence of cervical petechiae, or "strawberry cervix," is a classic presentation that is seen in less than 2% of cases. T vaginalis may also infect the Skene glands and the urethra and may be asymptomatic in women.
Papanicolaou (Pap) stain, high power, showing the Herpes simplex virus (HSV) infecting cells with multiple nuclei, intranuclear inclusions, and margination of the chromatin to the outer portion of the nuclei.
Pap stain, high power, showing human papillomavirus (HPV) infecting a cell with a dark, wrinkled nucleus surrounded by a clear cytoplasmic halo.
Pap stain, high power (under oil immersion), showing 2 pear-shaped structures representing Trichomonas. Small, pale nuclei and cytoplasmic granules are present.
 
 
 
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