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.

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Confirmed chlamydia: doxycycline 100 mg PO bd for 7 days (first line per current guidance, having largely superseded single-dose azithromycin given superior efficacy, particularly for rectal infection); azithromycin 1 g PO single dose, then 500 mg PO od for 2 further days, is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.

Endometriosis

Endometriosis is the presence of endometrial-like tissue outside the uterine cavity, most commonly on the ovaries (endometriomas, "chocolate cysts"), pelvic peritoneum, and uterosacral ligaments, less commonly the bowel, bladder, or, rarely, distant sites.

This ectopic tissue responds to cyclical hormonal changes, causing local inflammation, fibrosis, and adhesion formation, which together drive the characteristic pain and subfertility associated with the condition.

It affects roughly 10% of women of reproductive age, and diagnostic delay from symptom onset to confirmed diagnosis remains a well recognized problem, often spanning several years.

Secondary dysmenorrhoea, often severe and progressively worsening
Deep dyspareunia, particularly with deep penetration, reflecting uterosacral or pouch of Douglas involvement
Chronic pelvic pain, not confined to menstruation
Cyclical or perimenstrual bowel or bladder symptoms (dyschezia, hematochezia, or dysuria/hematuria) where bowel or bladder involvement is present
Subfertility, present in a substantial proportion of affected women, from a combination of anatomical distortion, adhesions, and altered pelvic and ovarian environment
Examination may reveal a fixed, retroverted uterus, uterosacral nodularity or tenderness, or a palpable adnexal mass (endometrioma), though examination is frequently normal, particularly in earlier or more superficial disease

Transvaginal ultrasound is useful for identifying endometriomas and deep infiltrating disease involving the bowel or bladder, but has limited sensitivity for superficial peritoneal disease, which represents a large proportion of cases
MRI provides further characterization, particularly for deep infiltrating disease and pre-surgical planning
Laparoscopy with histological confirmation remains the diagnostic gold standard, though current guidelines increasingly support starting empirical treatment based on clinical history and examination alone (without requiring laparoscopic confirmation first) in women with a classic presentation, given the diagnostic delay and morbidity associated with waiting for surgical confirmation
No blood test (including CA-125) has adequate sensitivity or specificity for diagnosis

Analgesia: NSAIDs as per the Dysmenorrhoea entry, though often insufficient alone in significant disease
Hormonal suppression is first line medical management and can be started empirically without a laparoscopic diagnosis: combined oral contraceptive (continuous/extended cycle use often more effective for pain control than cyclical use), the levonorgestrel-releasing IUD, or progestogen-only options (desogestrel pill, or medroxyprogesterone acetate injection)
GnRH agonists (e.g. goserelin depot injection) induce a temporary medical menopause and are highly effective for pain, but are generally reserved for second line use given menopausal side effects, and are typically used with "add-back" HRT to mitigate bone density loss and vasomotor symptoms if used beyond 6 months
GnRH antagonists (e.g. elagolix, where available) offer an oral alternative with a different side effect profile
Surgical management (laparoscopic excision or ablation of endometriotic deposits, with excision generally preferred given better evidence for symptom and fertility outcomes) is considered for confirmed disease not responding to medical therapy, significant endometriomas, or where fertility is a priority and anatomical distortion is contributing to subfertility
Endometrioma management: surgical excision (cystectomy) is generally preferred over drainage/ablation alone given lower recurrence rates, though this carries a small risk of reducing ovarian reserve, a discussion particularly relevant where fertility preservation is a priority
Fertility considerations: referral to fertility services (including consideration of IVF) is appropriate where subfertility is present and conservative or surgical management has not achieved pregnancy within a reasonable timeframe
Severe, deep infiltrating disease (bowel, bladder, or ureteric involvement) requires management at a specialist endometriosis center with multidisciplinary surgical input

Referral: gynecology for suspected endometriosis based on clinical history, even without imaging confirmation; specialist endometriosis center for deep infiltrating disease or complex surgical needs; fertility services where subfertility is a concern.

Cervicitis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management