THE ENIGMATIC CERVIX

Although mucopurulent cervicitis (MPC) is not a reportable disease in the United States, it is believed to be one of the most frequent genital infections in women. 14 Brunham et al 1 reported that the prevalence of MPC was 29% in women screened at a sexually transmitted disease (STD) clinic and 8% at a student health service. Cervicitis, especially MPC, is a major public health problem. 1,7,12,18 Unfortunately, infection of the cervix is often asymptomatic and clinical diagnosis has been hindered by the lack of reproducible objective criteria for cervicitis. 18 Even the nomenclature is confusing, including acute and chronic cervicitis, cervical erosion, hypertropic cervicitis, follicular cervicitis, papillary cervicitis, and most recently MPC. Further compounding our difficulty in managing cervicitis is the lack of understanding of the etiologic agents. Infectious cervicitis is a major cause of sexual and perinatal transmission of pathogenic microorganisms and can lead to significant complications. 7,14,18 The complications of cervicitis fall into three major groups: pelvic inflammatory disease, adverse pregnancy outcome, and cervical neoplasia. The first group, pelvic inflammatory disease (PID), occurs as the result of ascending intraluminal spread of pathogens from the cervix to the endometrium and fallopian tubes. PID is the most serious health problem associated with cervicitis resulting in tubal factor infertility, ectopic pregnancies, and chronic pelvic pain. 25 Over 25% of women who develop acute clinically evident PID suffer from these long term complications. 25 Plasma cell endometritis is an excellent indicator for acute salpingitis (PID) and has been demonstrated by Paavonen and co-workers to be present in approximately 40% of women with MPC who had no signs of PID on examination. 17 These authors proposed that MPC may be the only sign of upper genital tract infection in many young women who may ultimately develop tubal damage. It has been recognized that many women (maybe equal in number to clinically apparent) suffer from asymptomatic or subclinical PID. The prognosis for fertility in women with unrecognized PID appears to be similar to that for clinically apparent PID. 25 Multiple studies have demonstrated that bacterial vaginosis (BV) is a risk factor for nongonococcal nonchlamydial PID, 25 as well as the better known agents Chlamydia trachomatis and Neisseria gonorrhoeae . The second major complication and public health problem associated with cervicitis is adverse pregnancy outcome. Infection ascending from the cervix into the intrauterine compartment during pregnancy can result in chorioamnionitis, preterm premature rupture of the membranes, amniotic fluid infection (amnionitis), preterm labor and delivery, and puerperal and neonatal infections. 7,14,18 Thirdly, infection of the cervix may initiate or promote cervical neoplasia. 28 As discussed later in text, human papillomavirus (HPV) (especially types 16 and 18) and BV have been associated with cervical intraepithelial neoplasia (CIN). HPV has also been clearly implicated in the etiology of cervical cancer. 28 In developing countries, cervical cancer is the leading cause of death from genital tract cancer. The high risk for significant complications and adverse effects on the health of young women and their newborns associated with cervicitis demonstrates the importance of detecting symptomatic and asymptomatic cervicitis in nonpregnant and pregnant women. Accomplishment of this goal requires an understanding of the etiology, pathogenesis, diagnosis, and management of cervicitis.