Excerpt from Cervicitis

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Background

Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV), or human papillomavirus (HPV). Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted diseases (STDs). This article focuses on the infectious etiologies of cervicitis.

Pathophysiology

Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvovaginitis and cervicitis. Vulvovaginitis and cervicitis are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article.

Frequency

United States

The Centers for Disease Control and Prevention (CDC) estimates that 19 million STD infections occur annually, almost half of them among those aged 15-24 years. In addition to potentially severe health consequences, STDs pose a tremendous economic burden, with direct medical costs as high as $15.5 billion in a single year.

Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men. In 2003, 877,478 chlamydial infections were reported to the CDC, up from 834,555 cases reported in 2002. Because many cases are not reported or even diagnosed, it is estimated that actually 2.8 million new cases of chlamydia occur each year. Gonorrhea is the second most commonly reported infectious disease in the United States, with 335,104 cases reported in 2003. Much like chlamydia, gonorrhea is believed to be underreported. An estimated 718,000 new infections occur each year.

The annual rate of infection by HSV and HPV is difficult to estimate because the vast majority of initial infections are asymptomatic or unrecognized. In the United States, seroprevalence studies show that 22% of adults have HSV type 2 antibodies, and currently, it is believed that over 500,000 new cases of genital herpes occurs annually. Approximately 20 million people are currently infected with HPV. At least 50% of sexually active men and women acquire a genital HPV infection at some point in their lives. By age 50 years, at least 80% of women will have acquired genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

International

Worldwide, more than 400 million adults become infected with an STD every year. Four STDs that are spread primarily through sexual contact are completely curable—trichomoniasis, chlamydia, syphilis, and gonorrhea. These infections account for 333 million STD infections, or about 80% of the worldwide total. Approximately 9% of all persons aged 15-44 years in North America contract 1 of these STDs annually, but the rate rises to 25% in sub-Saharan Africa.

Worldwide, over 170 million cases of trichomoniasis are reported each year. Infection rates have been reported as high as 67% in Mongolia in 1988, 40-60% in Africa, and 40% in indigenous Australians older than age 40.

Chlamydia is the next most common STD with approximately 92 million cases a year. Prevalence of chlamydia varies enormously across the world. In the 1990s, rates amongst pregnant women in Europe ranged from 2.7% in Italy to 8.0% in Iceland, while studies in South America found rates of 1.9% amongst teenagers in Chile and 2.1% amongst pregnant women in Brazil. In Asia, rates among pregnant women tend to be much higher: up to 17% in India and 26% in rural Papua New Guinea. In Africa, studies amongst pregnant women have revealed rates from 6% in Tanzania to 13% in Cape Verde.

HPV, HSV, and gonorrhea each account for roughly 20-60 million cases of STDs per year.

The prevalence of HPV, a cause of cervical cancer, varies roughly 20-fold internationally. Among the countries evaluated, Spain had the lowest prevalence of HPV; only 1.4% of women in Spain tested positive for HPV. The highest prevalence of HPV was seen in sub-Saharan Africa; 26% of the women in Nigeria tested positive for HPV. South America tended to have rates that were in between those of Europe and sub-Saharan Africa, while rates in Asia varied widely (with the lowest rates in Hanoi, Vietnam, and the highest in India and Korea).

In a variety of studies, the seroprevalence of HSV-2 is higher in the United States (13-40%) than in Europe (7-16%), and the highest is in Africa (30-40%).

Studies of pregnant women in Africa have found rates for gonorrhea ranging from 0.02% in Gabon to 3.1% in Central African Republic and 7.8% in South Africa. In the Western Pacific in the 1990s, the highest prevalence rates (>3%) were in Cambodia and Papua New Guinea. Other areas such as China, Vietnam, and the Philippines had rates of 1% or less. Between 1995 and 1999, a significant increase in gonorrhea incidence occurred in Eastern Europe, with the highest rates in Estonia, Russia, and Belarus.

Mortality/Morbidity

Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease (PID), infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race

No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex

Male urethritis is more often symptomatic; therefore, diagnosis is usually made earlier in males than in females. Females with cervicitis are most often asymptomatic, so they do not seek evaluation or treatment as readily.

Age

Individuals younger than age 25 and single marital status are both risk factors for cervicitis. Both biological (eg, postulated immaturity of the female reproductive tract) and behavioral factors (eg, greater number of partners, low awareness of acquired immunodeficiency syndrome (AIDS) and other STDs, and limited use of protection against STDs) are thought to contribute to this risk. Routine screening of sexually active adolescents and young adults is therefore recommended.

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