Endocervicitis: inflammation of the cervix, treatment

Endocervicitis is an inflammation of the columnar epithelium of the endocervix, the internal canal of the cervix. The term is often considered more broadly as "cervicitis," as the inflammation can also involve the external cervix. Acute conditions are usually associated with infection, while chronic conditions can be fueled by both infectious and non-infectious factors, including microbiota imbalances, chemical irritants, and atrophic changes. The clinical presentation ranges from asymptomatic to mucus- and purulent-mixed discharge, intermenstrual bleeding, and dyspareunia. [1]

The main infectious causes are Chlamydia trachomatis and Neisseria gonorrhoeae; Trichomonas vaginalis and Mycoplasma genitalium are also detected in some patients. However, a significant proportion of cases have no proven chlamydial or gonococcal etiology, highlighting the role of bacterial vaginosis and M. genitalium in the pathogenesis. This is important for the choice of tactics: standard empirical therapy for chlamydia and gonorrhea does not always cover M. genitalium. [2]

Endocervicitis is closely associated with the risk of ascending infection: cervical inflammation may precede endometritis and pelvic inflammatory disease. Timely diagnosis and appropriate treatment reduce the risk of complications, including infertility and chronic pelvic pain. Concomitant infections, including syphilis and human immunodeficiency virus, should also be considered in accordance with current guidelines. [3]

Current guidelines emphasize targeted diagnostic testing using nucleic acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae, and in cases of persistent inflammation, testing for Mycoplasma genitalium and evaluation for bacterial vaginosis. The choice of an empirical regimen depends on the clinical presentation, risk factors, and availability of tests and resistance. [4]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, cervicitis and endocervicitis are coded as N72 "Inflammatory diseases of the cervix uteri." This code includes endocervicitis and exocervicitis, with or without erosion. If necessary, an additional pathogen code from the range B95-B97 is indicated. Postpartum cervicitis (O86.11) is separately identified. [5]

In the eleventh version of the classification (ICD-11), cervicitis is classified under the heading "Inflammatory diseases of the female genital organs" and has the code GA04 "Cervicitis." If the etiology is tuberculous, the corresponding category for tuberculosis of the cervix is used. The advantage of ICD-11 is its more detailed stratification by location and cause. [6]

The choice of a specific code depends on clinical data: pregnancy, postpartum period, identified pathogen, and associated conditions. Correct coding is important for statistical purposes, patient routing, and insurance purposes. [7]

When cervicitis is combined with vaginitis or pelvic inflammatory disease, codes reflecting the underlying clinical syndrome are used, with the addition of codes for associated conditions and the pathogen. This facilitates surveillance and quality of care auditing. [8]

Epidemiology

Cervicitis is a common condition in reproductive age, with a significant proportion of cases being asymptomatic. According to reviews, chlamydial cervicitis is several times more common than gonococcal cervicitis, but in many cohorts, up to 75 percent of cases are not associated with chlamydia or gonococcus, reflecting the multifactorial nature of the condition. [9]

Globally, hundreds of millions of new cases of curable sexually transmitted infections, including chlamydia, gonorrhea, and trichomoniasis, are reported annually. In 2020, 374 million new cases of the four curable infections were estimated, and the prevalence of chlamydia among women aged 15-49 was approximately 4 percent. These figures are important for screening and prevention programs. [10]

National reports show persistently high rates of chlamydial infection and concomitant gonorrhea; in the United States, more than 2.5 million cases of these infections will be reported in 2022. Young women under 25 constitute a high-risk group, which correlates with characteristics of cervical ectopia and behavioral factors. [11]

Recent studies also note an increase in the detection of Mycoplasma genitalium and an association between cervicitis and bacterial vaginosis. This impacts empirical treatment decisions and highlights the need for greater access to nucleic acid diagnostics. [12]

Reasons

Infectious causes include Chlamydia trachomatis and Neisseria gonorrhoeae as the most common pathogens, as well as Trichomonas vaginalis and Mycoplasma genitalium. The latter is particularly relevant in cases of persistent symptoms and negative tests for chlamydia and gonorrhea. In some cases, herpes simplex virus and human papillomavirus with secondary inflammation are detected. [13]

Non-infectious causes include chemical irritation (spermicides, local antiseptics), mechanical trauma, foreign bodies, mucosal atrophy due to low estrogen levels, and dysbiosis. Such factors can maintain chronic inflammation even after eradication of the primary pathogen. [14]

A combination of infectious and non-infectious triggers is common. For example, bacterial vaginosis alters the acidity and microbial community, facilitating colonization by pathogens. Therefore, treatment should include restoring the vaginal microbiota and modifying behavioral factors. [15]

Special causes include cervical tuberculosis and rare specific infections associated with immunosuppression. These situations require extensive diagnostics and individualized therapy with the participation of specialized specialists. [16]

Risk factors

Risk factors include early sexual debut, frequent partner changes, unprotected sex, and a history of sexually transmitted infections. Young age (under 25 years) is particularly prevalent due to the larger area of ectopia and the greater vulnerability of the columnar epithelium. [17]

Indirect factors include bacterial vaginosis, disruption of the vaginal microbiota after antibacterial therapy, and the use of irritating intimate hygiene products. Cervicitis is more common in individuals with human immunodeficiency virus infection. [18]

Smoking, intrauterine procedures without adequate antisepsis, and the postpartum period can also increase the risk of cervical inflammation. Considering these factors helps guide targeted prevention and determine the scope of testing. [19]

The presence of concomitant infections such as chlamydia and gonorrhea increases the risk of ascending infection and pelvic inflammatory disease, requiring active identification and treatment of partners. [20]

Pathogenesis

The primary target for Chlamydia trachomatis and Neisseria gonorrhoeae is the columnar epithelium of the endocervix. Attachment and invasion of epithelial cells trigger an inflammatory cascade with cytokine production, clinically manifested by mucopurulent discharge and contact bleeding. Involvement of innate immune receptor pathways determines the intensity of the local response. [21]

Trichomonas vaginalis and herpes simplex virus most often affect the stratified squamous epithelium of the exocervix but can maintain inflammation in the cervical canal. Mycoplasma genitalium has pronounced adhesiveness and forms persistent forms, which complicates eradication and contributes to chronicity. [22]

Vaginal dysbiosis with a predominance of anaerobes (bacterial vaginosis) alters pH and reduces colonization resistance, facilitating pathogen access to the endocervix. This explains the association of cervicitis with bacterial vaginosis and the need for microbiota correction. [23]

If left untreated, the inflammation can spread to the endometrium and tubes, resulting in endometritis and pelvic inflammatory disease. Repeated episodes increase the risk of tubal infertility and chronic pelvic pain. [24]

Symptoms

Some patients present asymptomatically, and the inflammation is detected during a routine examination or screening. Symptomatic forms include mucopurulent discharge, intermenstrual or postcoital bleeding, dyspareunia, and dysuria. Contact bleeding and cervical redness may be present during examination. [25]

Pain during cervical movement or palpation may indicate upward spread of inflammation and requires the exclusion of pelvic inflammatory disease. Systemic symptoms, such as fever, are less common and usually indicate a more severe course. [26]

The spectrum of symptoms may overlap with vaginitis and urethritis, necessitating a combined diagnosis. Some patients report a connection between symptoms and the menstrual cycle or sexual intercourse. [27]

The absence of pronounced symptoms does not exclude the risk of complications: asymptomatic chlamydial infection remains an important source of ascending infection and transmission to partners. [28]

Forms and stages

Cervicitis is conventionally classified as acute or chronic. The acute form is often infectious, with pronounced symptoms, while the chronic form can last for months due to persistent pathogens or non-infectious triggers. A duration of more than three months is often considered a chronic condition. [29]

By etiology, the disease is classified as infectious (chlamydial, gonococcal, trichomonas, associated with Mycoplasma genitalium) and non-infectious. Combined forms are common, reflecting the role of dysbiosis and behavioral factors in maintaining inflammation. [30]

Depending on the extent of the process, endocervicitis is differentiated from exocervical involvement. If signs of ascending infection are present, the transition to endometritis and pelvic inflammatory disease is discussed, which affects the scope of therapy and monitoring. [31]

Clinical classification helps to standardize diagnosis, select empirical treatment, and determine indications for advanced investigations, including pelvic ultrasound. [32]

Complications and consequences

The main complications are endometritis and pelvic inflammatory disease, followed by tubal factor infertility and an increased risk of ectopic pregnancy. Repeated episodes of cervicitis increase the likelihood of chronic pelvic pain. The risk of complications is particularly high with untreated chlamydial and gonococcal infections. [33]

Cervicitis is associated with adverse pregnancy outcomes, including chorioamnionitis and preterm birth; postpartum endocervicitis may occur in the postpartum period. Correction of infection before pregnancy planning and screening in at-risk groups improve prognosis. [34]

Persistence of Mycoplasma genitalium is associated with refractory forms of inflammation and decreased efficacy of standard regimens, increasing the burden of re-visits and symptom duration. This justifies targeted testing after treatment failure. [35]

Psychosocial consequences include anxiety, stigma, and impact on sexual functioning. Education, counseling on partner notification, and safe sex are essential elements of management. [36]

When to see a doctor

Seek immediate medical attention if you experience purulent discharge, intermenstrual or postcoital bleeding, pelvic pain, fever, or painful intercourse or urination. These symptoms may indicate cervicitis or ascending inflammation. [37]

Reasons for a routine consultation include changes in the nature of discharge, an unpleasant odor, recurring symptoms after self-treatment, and known contact with a partner who has been infected. Women under 25 are recommended to undergo screening tests for chlamydia and gonorrhea when changing partners. [38]

Pregnant women with suspected cervicitis should seek medical attention immediately to ensure safe treatment. In the postpartum period, the appearance of foul-smelling discharge and fever requires ruling out infectious complications. [39]

If symptoms persist after standard treatment, testing for Mycoplasma genitalium and evaluation for bacterial vaginosis should be discussed, as these conditions often explain treatment failure.[40]

Diagnostics

Basic diagnostics include a physical examination with an assessment of discharge and contact bleeding, as well as collection of material from the cervical canal or vagina for nucleic acid amplification tests for Chlamydia trachomatis and Neisseria gonorrhoeae. If trichomoniasis is suspected, amplification tests are preferred due to their higher sensitivity compared to microscopy. [41]

In cases of persistent or recurrent inflammation, testing for Mycoplasma genitalium with macrolide resistance testing, if available, is recommended. Bacterial vaginosis is also assessed using clinical criteria or the Nugent score. This helps select targeted therapy and avoid ineffective courses. [42]

Additionally, screening for syphilis and human immunodeficiency virus is performed, as well as, if indicated, testing for herpes simplex virus. If signs of ascending infection are detected, a pelvic ultrasound is considered to rule out complications. [43]

Criteria for cervicitis include mucopurulent endocervical discharge and/or mild induced bleeding upon probe contact. However, a definitive diagnosis relies on laboratory confirmation and exclusion of alternative causes of symptoms.[44]

Table 1. Diagnostic tests and their role

Test	What does it reveal?	When is it prescribed?	Features of interpretation
NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae	Etiology of cervicitis	At the first contact	High sensitivity; material - vaginal swab or endocervical swab
NAAT for Mycoplasma genitalium	Persistent atypical infection	In case of relapse or ineffectiveness of therapy	Preferably with a macrolide resistance test
NAAT for Trichomonas vaginalis	Trichomoniasis	With foamy discharge, itching	Higher sensitivity than microscopy
Assessment for bacterial vaginosis (A msel/Nagent criteria)	Dysbiosis	If there is a characteristic discharge/odor	Helps explain symptoms without chlamydia/gonorrhea
Screening for syphilis and human immunodeficiency virus	Co-infections	All patients with cervicitis	Affects the management and notification of partners

Differential diagnosis

First, cervicitis and vaginitis are differentiated: with vaginitis, symptoms are more often associated with itching, burning, and changes in the vaginal microbiota, while with cervicitis, endocervical mucopurulent discharge and contact bleeding predominate. However, these conditions often coexist, requiring simultaneous examination. [45]

Differentiation with pelvic inflammatory disease is important: the presence of pelvic pain, tenderness with cervical motion, and systemic symptoms increases the likelihood of ascending infection and requires expanded therapy. Endometritis, polyps, cervical effusion with ectropion, and neoplastic processes are also excluded. [46]

Specific infections and dermatological diseases of the vulva and vagina, as well as traumatic and chemical causes, are taken into account. In cases of atypia of cervical cytology, additional examination is carried out according to oncological protocols. [47]

Table 2. Distinguishing features

State	Discharge	Pain	Objective signs	Tactics
Cervicitis	Mucopurulent	Dyspareunia is possible	Contact bleeding, hyperemia of the cervix	NAAT, etiology-based therapy
Vaginitis	Thick/foamy, itchy	Itching/burning	pH changes, 'key cells' in bacterial vaginosis	Treatment of vaginitis
Pelvic inflammatory disease	May be	Pelvic pain, fever	Pain in the appendages, positive cervical motion symptom	Wide antibacterial coverage

Treatment

Empirical therapy for confirmed cervicitis in non-pregnant women often includes coverage for chlamydial and gonococcal infections pending test results: ceftriaxone intramuscularly once for Neisseria gonorrhoeae plus oral doxycycline for 7 days for Chlamydia trachomatis. Adjustments to the regimen are made based on NAAT results and local resistance guidelines. [48]

When Mycoplasma genitalium is detected, a strategy targeting macrolide resistance mutations is preferred. In Europe, an extended course of azithromycin is recommended in the absence of resistance, and moxifloxacin is recommended as a second-line therapy in cases of resistance or persistence. In the absence of resistance testing, a 7-day regimen of doxycycline followed by 7 days of moxifloxacin increases the likelihood of eradication. [49]

Pregnant women are treated according to the regimens for chlamydia and gonorrhea, using medications safe for pregnancy; doxycycline is contraindicated, and azithromycin and ceftriaxone remain options. Management includes partner testing and follow-up monitoring as indicated. [50]

When combined with bacterial vaginosis, treatment for bacterial vaginosis is prescribed, which reduces inflammation and the risk of recurrence. Safe sex counseling, abstinence from sexual intercourse until completion of treatment, and testing and treatment of sexual partners are important, especially for chlamydia, gonorrhea, and Mycoplasma genitalium. [51]

Table 3. Examples of etiotropic therapy in non-pregnant women

Suspected/confirmed etiology	Recommended scheme	Comments
Chlamydial cervicitis	Doxycycline 100 mg 2 times a day for 7 days	An alternative in case of intolerance is azithromycin according to local recommendations.
Gonococcal cervicitis	Ceftriaxone intramuscularly once; + doxycycline for 7 days if chlamydia co-infection is suspected	The dose and need for combination are determined by local protocols.
Mycoplasma genitalium without resistance mutations	Extended course of azithromycin 5 days	Preferred with proven sensitivity
Mycoplasma genitalium with resistance/persistence	Moxifloxacin 400 mg once a day for 7-10 days	Consider 14 days in case of complications
Trichomonas vaginalis	Nitroimidazole drugs according to standard regimens	Treatment of partners is mandatory

Table 4. Management of special groups

Situation	Peculiarities	Approach
Pregnancy	Drug restrictions	Use pregnancy-safe chlamydia/gonorrhea regimens
Postpartum period	Risk of postpartum cervicitis	Treatment according to the pathogen, monitoring for endometritis
Persistent symptoms	Suspected Mycoplasma genitalium, bacterial vaginosis	Testing and adjustment of therapy
HIV infection	Higher incidence of cervicitis	A diagnosis and treatment strategy similar to that for HIV-negative individuals, with an emphasis on partner notification

Table 5. Supportive measures and relapse prevention

Measure	Target	Evidence base
Abstain from sexual intercourse until the end of treatment	Reduction of reinfection	Recommendations from the Centers for Disease Control and Prevention
Examination and treatment of partners	Transmission interruption	Standards of European and national guidelines
Correction of bacterial vaginosis	Reducing the persistence of inflammation	Observational study data
Safe sex education	Reducing the risk of new infections	Public health recommendations

Prevention

Primary prevention includes the use of barrier methods of contraception, limiting the number of partners, and regular screening for women under 25 and older when changing partners. Education and counseling are key to sustainably reducing the prevalence of sexually transmitted infections. [52]

Secondary prevention focuses on early detection and treatment of cervicitis and co-infections, as well as partner notification. Access to nucleic acid testing and referral of patients from primary care to specialized services are important. [53]

Risk factor modification—avoiding irritating intimate hygiene products, rational use of antibacterial drugs, and microbiota adjustments for bacterial vaginosis—reduces the likelihood of recurrence. [54]

For pregnant women and women planning pregnancy, preconception screening and treatment are recommended if infection is detected, which reduces the risk of complications during pregnancy and the postpartum period. [55]

Forecast

With timely diagnosis and adequate etiotropic treatment, the prognosis is favorable, with symptoms typically resolving within weeks. Lack of treatment or frequent relapses increase the risk of pelvic inflammatory disease and infertility, which worsens the long-term outcome. [56]

The presence of Mycoplasma genitalium and bacterial vaginosis is associated with a prolonged and recurrent course, requiring targeted diagnostics and escalated therapy. Individualized treatment in such cases improves outcomes. [57]

Pregnant women achieve good outcomes with timely treatment, but require more careful monitoring and selection of safe regimens. Follow-up visits are mandatory as indicated. [58]

Comprehensive prevention, screening and partner notification programs reduce the burden of disease and the risk of complications at the population level. [59]

FAQ

• What is the difference between cervicitis and vaginitis?

Cervicitis is an inflammation of the cervical canal, most often characterized by mucopurulent endocervical discharge and contact bleeding; vaginitis is an inflammation of the vagina with itching, burning, and changes in the microbiota. These conditions often coexist and require simultaneous diagnosis. [60]

• Is it possible to be treated without tests?

Empirical therapy is acceptable when the probability of chlamydia/gonorrhea is high and prompt testing is not possible, but it is preferable to confirm the etiology with nucleic acid tests to avoid treatment failure and relapse. [61]

• What if symptoms persist after the standard course?

Testing for Mycoplasma genitalium and evaluation for bacterial vaginosis should be discussed; if M. genitalium is confirmed, resistance-guided regimens or a doxycycline to moxifloxacin sequence should be considered.[62]

• Should sexual partners be treated?

Yes, if chlamydia, gonorrhea, trichomoniasis, or Mycoplasma genitalium are detected, partners are tested and treated to reduce the risk of reinfection and transmission. Abstinence from contact is recommended for all participants until the course is completed. [63]

• Is cervicitis dangerous during pregnancy?

Untreated cervicitis increases the risk of pregnancy complications; pregnant women are prescribed safe regimens to eliminate pathogens according to guidelines. Early presentation and treatment improve outcomes for both mother and fetus. [64]