Cervicitis, Ectropion, and True Erosion

Cervicitis, Ectropion, and True Erosion is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Cervicitis is 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).
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 because 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 (1)[A]. Pregnant women should have test of cure for chlamydia >3 weeks from treatment and rescreened for gonorrhea in 3 months or in 3rd trimester.

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: 1.7 million cases were reported to the CDC in 2017, with actual incidence estimated to be >3 million yearly. About 5% of sexually active women between the ages of 14 and 39 years have chlamydia infection with substantial variation by region and ethnicity/race (2).
    • Gonorrhea: second most commonly reported notifiable disease after chlamydia in the United States; 468,514 cases reported to the CDC in 2016 (1), with 91.9% of cases in persons aged 15 to 44 years; isolates showing elevated ceftriaxone MICS indicating resistance fluctuated between 0.05% and 0% (2).
    • Herpes simplex virus (HSV): >700,000 new cases per year in the United States
    • Trichomonas: not routinely reported to CDC, but trend data show Trichomonas infection overall prevalence of 3.1% with specific prevalence of 13.3% among non-Hispanic black persons (2)
    • Mycoplasma genitalium: increasingly common sexually transmitted pathogen among high-risk, sexually active women, detected in 10–30% of women with cervicitis (1)
    • Human papillomavirus (HPV): the most common sexually transmitted infection (STI) in the United States with prevalence 42.5% among U.S. adults (2)
  • Ectropion: typically related to higher levels of estrogen; ectropion is common among adolescents, women using combined oral contraceptive pills (OCPs), and pregnant women.

Prevalence
Present in 14–37% of outpatients (3)

Etiology and Pathophysiology

  • Cervicitis: Often, no specific etiology is identified.
    • Infectious: Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly identified pathogens; they affect the columnar epithelium of the endocervix. Trichomonas vaginalis, HSV (especially primary infections of HSV-2), and HPV affect the squamous epithelium. Mycoplasmas (e.g., M. genitalium) are becoming increasingly recognized as causative organisms.
    • 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
    • Ages 15 to 25 years is strongest predictor of risk.
    • Multiple or new sexual partners
    • Unprotected sex or inconsistent condom use
    • History of 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, etc.
  • Ectropion: adolescence, pregnancy, use of OCP
  • True erosion: hypoestrogenism, trauma from foreign body

General Prevention

Advise use of condoms and safer sexual practices to prevent STIs. Follow USPSTF-recommended screening measures (4)[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 (1).
  • At least annual screening of trichomoniasis among HIV-positive women
  • Treat sexual partners of infected women.
  • Hypoestrogenism: estrogen replacement therapy

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