Cervicitis

Cervicitis is inflammation of the uterine cervix, most commonly infectious, principally Chlamydia trachomatis and Neisseria gonorrhoeae, though also Mycoplasma genitalium, Trichomonas vaginalis, and herpes simplex virus. Non-infectious causes include chemical irritation, mechanical trauma (from an IUD or barrier device), and, in some cases, no organism is identified despite a clearly inflamed cervix.

Often asymptomatic. When symptomatic: mucopurulent or purulent cervical discharge, intermenstrual or postcoital bleeding (from friable, inflamed cervical epithelium), dyspareunia, and, on examination, a cervix that is edematous, friable, and bleeds easily on contact, with visible mucopurulent discharge from the os.

• NAAT testing for chlamydia and gonorrhea (endocervical or self-taken vaginal swab, or first-void urine) is essential in every case, given how commonly these are the underlying cause
• Testing for Mycoplasma genitalium where available, particularly if chlamydia and gonorrhea are negative and symptoms persist
• Wet mount and pH assessment for trichomoniasis and BV as co-existing or alternative causes
• Speculum examination assessing cervical appearance, and a pregnancy test in any woman of reproductive age with abnormal bleeding
• HIV and syphilis screening should be offered as part of a full STI screen given the shared risk context

• Empirical treatment while awaiting results is reasonable in high risk women or where follow-up cannot be assured, covering the most likely and most consequential causes: a single regimen commonly used is doxycycline 100 mg PO bd for 7 days (covering chlamydia and, empirically, Mycoplasma genitalium to some degree), with gonorrhea cover added (ceftriaxone 1 g IM single dose) if local gonorrhea prevalence is significant or risk factors are present
• Confirmed chlamydia: doxycycline 100 mg PO bd for 7 days (first line per current guidance, having largely superseded single-dose azithromycin given superior efficacy, particularly for rectal infection); azithromycin 1 g PO single dose, then 500 mg PO od for 2 further days, is an alternative, particularly in pregnancy where doxycycline is avoided
• Confirmed gonorrhea: ceftriaxone 1 g IM single dose (dose increased from older regimens given rising resistance concerns; local antimicrobial guidance should be checked given evolving resistance patterns)
• Confirmed Mycoplasma genitalium: doxycycline 100 mg PO bd for 7 days followed by azithromycin 1 g PO then 500 mg PO od for 2 days, or, where resistance testing is available and shows macrolide resistance, moxifloxacin 400 mg PO od for 7 to 14 days
• Trichomoniasis or BV as the identified cause: managed per those respective entries
• Sexual partner notification and treatment for the preceding 3 to 6 months (per organism-specific guidance) is essential for all confirmed STI-related cervicitis, with abstinence advised until both partners have completed treatment
• Persistent cervicitis despite treatment and confirmed cure of identified organisms warrants further evaluation, including consideration of non-infectious causes and, in postmenopausal women or where malignancy is a concern, cervical biopsy

Referral: sexual health services for full STI screening and partner notification; gynecology for persistent cervicitis of uncertain cause or where malignancy needs to be excluded.