Chronic Cervicitis

Chronic cervicitis is persistent inflammation of the cervix lasting longer than 3 months. It is often non-infectious or follows incompletely treated infection.

• Causes include persistent Chlamydia, Mycoplasma genitalium, bacterial vaginosis, herpes, trichomoniasis, irritants (douching, spermicides, latex, tampons), intrauterine devices and cervical ectropion.
• The cervix may look normal or hyperaemic with discharge.
• Cervical neoplasia must be excluded before attributing symptoms to inflammation.

Persistent mucoid or purulent discharge, intermenstrual or post-coital bleeding, dyspareunia and lower abdominal ache.

• The cervix is red, granular or friable, with mucopus at the os; nabothian cysts may be present.
• Differential diagnosis: cervical ectropion, cervical intraepithelial neoplasia, cervical cancer, cervical tuberculosis, atrophic cervicitis, cervical polyp, endometritis.
• Complications: chronic pelvic pain, pelvic inflammatory disease, infertility, persistent contact bleeding and anxiety.

Diagnosis is by speculum examination, with testing for infection and exclusion of neoplasia.

• Speculum examination.
• NAAT for chlamydia, gonorrhoea, Mycoplasma genitalium and trichomonas; HSV PCR if lesions.
• Cervical screening with HPV test, cytology or VIA; colposcopy and biopsy for abnormal areas.
• Vaginal pH, wet mount; HIV and syphilis tests.
• Xpert MTB/RIF on a cervical tissue sample when tuberculosis is suspected.

Treat the cause found, remove irritants, and consider cautery only after neoplasia is excluded.

• Supportive: remove irritants (douches, spermicides, scented products); partner testing and treatment; condoms.
• Pharmacological: treat the cause found. Chlamydia: doxycycline 100 mg oral 12-hourly for 7 days. Gonorrhoea: ceftriaxone 500 mg IM single dose. Trichomoniasis or bacterial vaginosis: metronidazole 400 mg oral 12-hourly for 7 days. Mycoplasma genitalium: doxycycline 100 mg oral 12-hourly for 7 days, followed by azithromycin 1 g oral on the first day then 500 mg oral daily for 2 days. For atrophic cervicitis: oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly. Without a cause, an empirical course of doxycycline 100 mg oral 12-hourly for 14 days may be used.
• Procedures: cryotherapy, electrocautery or laser of a persistent inflamed ectropion after neoplasia is excluded.
• Special groups: in pregnancy use azithromycin 1 g oral single dose instead of doxycycline and avoid oestrogen cream. In HIV infection ensure antiretroviral treatment is optimised.
• Red flags: friable irregular cervix, post-coital bleeding with positive screening, weight loss, night sweats, foul discharge.
• Follow-up: review at 4 to 6 weeks; test of cure where indicated; repeat screening and examination at 3 months.