Cervicitis, Ectropion, and True Erosion
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- 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).
- System(s) affected: reproductive
- 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.
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].
Infectious cervicitis in children should lead to an investigation of possible sexual abuse.
- Cervicitis: most commonly due to infectious etiologies, including, but not limited to, the following:
- Chlamydia: 1,441,789 cases were reported to the CDC in 2014, 65% 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; 350,062 cases reported to the CDC in 2014 (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 infections are up for a 3rd year in a row, significantly higher in African American women (3).
- 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): >5,000,000 new cases per year in the United States
- 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 (4)
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 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
- 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
- Infectious cervicitis (3)
- Ages 15 to 25 years is strongest predictor of risk.
- Multiple sexual partners
- New sexual partner
- Unprotected sex or inconsistent condom use
- 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
- 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.
- Estrogen deficiency: estrogen replacement therapy