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Adolescent Gynecology

Cervicitis and Sexually Transmitted Infections in the Adolescent Population

Akilah Weber-LaShore, MD; Frank M. Biro, MD

The Centers for Disease Control and Prevention (CDC) estimates about 19 million new sexually transmitted infections (STIs) occur annually, half of which are among people aged 15 to 24 years.1 A national survey of 9th through 12th grade students in public and private schools showed that 47.8% of those surveyed in 2007 had experienced sexual intercourse, and 35% were currently sexually active. Only 61.5% reported use of a condom during their last sexual encounter.2 All health care professionals—especially those who serve an adolescent population—should be knowledgeable about the most common STIs. Two of the most common symptomatic presentations are cervicitis and genital lesions. This article will review the symptoms, risks, and treatment recom-mendations for the most common STIs, with a focus on those that cause cervicitis.

Chlamydia

Chlamydia trachomatis (CT) is the most commonly reported STI in the United States. It is estimated that there are 2.8 million new cases annually (Figure).1 In 2006, the greatest incidence occurred in 15- to 19-year-olds, and the rate in black women was 8 times higher than in white women.3 The majority of chlamydial infections are asymptomatic, a fact not known by most adolescents. Only about 30% of those infected will have a mucopurulent cervical discharge. In some cases, the cervix will appear edematous and/or friable. Pelvic inflammatory disease (PID) and peri-hepatitis (Fitz-Hugh-Curtis syndrome) are potential complications of chlamydial infections. Long-term sequelae include ectopic pregnancy and infertility, even without recognized PID.4

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FIGURE. CDC 2006 sexually transmitted diseases surveillance: gonorrhea and chlamydia rates. GC = gonococcus; CT = chlamydia trachomatis.

The US Preventive Services Task Force (USPSTF) recommends annual screening for chlamydia in all sexually active women aged 25 years and younger.5 Testing methods include culture, direct immunofluorescense, nucleic acid hybridization, and enzyme immunoassay, all of which require a pelvic examination to collect cervical epithelial cells. The most sensitive and specific test is the nucleic acid amplification test (NAAT), which can detect chlamydia from cervical swab or urine sample. The recommended antibiotic options for treatment of chlamydial infections include doxycycline 100 mg orally bid for 7 days or azithromycin 1 gm orally (single dose).6

If there is a high rate of gonorrhea in the patient population, concurrent treatment for gonorrhea should be considered. All sexual partners within the previous 60 days require treatment. Performing a test of cure is not recommended for nonpregnant adolescent females. However, due to the high rate of re-infection, a repeat test is recommended 3 to 5 months after treatment.

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Gonorrhea

Gonorrhea, caused by the bacteria Neisseria gonorrhoeae (GC), is the second most commonly reported STI in the United States. In 2006, there were more than 358,000 cases of gonorrhea reported, which is believed to represent about half of the actual cases that year.3 Similar to chlamydia, gonorrhea is prevalent in the adolescent population and disproportionally affects minority groups. The rate of gonococcal infections in black women is 18 times higher than in white women.3 Symptoms associated with infections include vaginal discharge, dysuria, metrorrhagia and postcoital bleeding. A significant number of gonorrheal infections are asymptomatic and if untreated can develop into PID, and rarely, disseminated GC.

The USPSTF recommends annual screening of all women 25 years old and younger.7 Screening options include culture, nucleic acid hybridization test, and NAAT. Again, either cervical swab or urine can be used as the specimen for NAAT. In 2006, more than 13% of gonorrhea isolates showed resistance to fluoroquinolones and thus, that class of antibiotics has been removed as a recommended treatment option.8 The current CDC recommended treatment options are ceftriaxone 125 mg IM–single dose, or cefixime 400 mg orally–single dose.

Patients with gonorrhea are often also infected with chlamydia, and thus dual treatment might be warranted. If a NAAT test was performed and is negative for chlamydia, there is no need to treat for chlamydia. However, if a non-NAAT test was negative for chlamydia, or a test for chlamydia was not done, then the patient should also receive treatment for chlamydia.6 Sex partners also require treatment. There is no recommendation as to whether a patient should be tested for re-exposure after initial treatment.

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Trichomoniasis

Trichomonas vaginalis is a protozoan characterized by flagellated motility. An estimated 7.4 million cases are seen annually in the United States.1 Infection with trichomoniasis has been shown to increase the risk of HIV transmission. Patients may complain of a vaginal discharge that is often frothy and yellow-greenish in nature with an odor. They may also have vaginal irritation, dysuria, and dysparunia. On exam, small red ulcerations in the vagina or on the cervix (strawberry cervix) may be seen. The vaginal pH is usually >5.

Trichomoniasis can be diagnosed by viewing the motile trichomonads from the vaginal secretions on a wet prep. It can also be detected by performing the rapid trichomoniasis test (results available in 10 minutes), or by performing the Affirm VP III test (results available in 45 minutes). The most sensitive and specific method of diagnosis of trichomoniasis is by performing a culture.6 The recommended treatment options are metronidazole 2gm orally–single dose, or tinidazole 2 gm orally–single dose.

Patients should be instructed to avoid alcohol for 24 hours after taking metronidazole or for 72 hours after taking tinidazole to prevent a disulfiram-like reaction. No follow-up is necessary for patients who were initially asymptomatic or who became asymptomatic after treatment. Sex partners should also be treated to prevent reinfection.

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Pelvic Inflammatory Disease

Pelvic inflammatory disease can be caused by STIs (ie, gonorrhea, chlamydia) but can also be associated with organisms from the vaginal flora (ie, G. vaginalis, anaerobes, gram negative rods). It has the potential to infect the uterus, tubes, and ovaries. Symptoms include abdominal pain, fever, menorrhagia, vaginal discharge, and vomiting, and can range from mild to severe on presentation. As a result of this wide variation in type and severity of symptoms, PID can be difficult to diagnose. Because of the serious consequences to the patient’s future reproductive potential if PID is not treated, a low threshold for diagnosis and treatment is recommended. Empiric treatment may be given to any sexually active woman who presents with pelvic pain with no other identifiable cause and has cervical motion tenderness, adnexal tenderness, or uterine tenderness. Antibiotic treatment should cover both gonorrhea and chlamydia organisms and possibly anerobic organisms.6

Hospitalization of all adolescent females with PID has not been shown to have any beneficial effect; thus, hospitalization should occur using the same criteria in adolescents as adults.6 Patients who receive outpatient treatment should demonstrate improvement within 72 hours. If this does not occur, re-evaluation for possible admission and further diagnostic testing should be considered.

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CONCLUSION

Cervicitis caused by STIs in the adolescent population is a continuing problem for their current health as well as their reproductive potential. Early recognition and treatment is imperative.

Neither author reports any actual or potential conflicts of interest in relation to this article.

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Akilah Weber-LaShore, MD, is Fellow, Pediatric and Adolescent Gynecology; Frank M. Biro, MD, is Professor of Pediatrics, Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

References

1. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36(1):6–10.
2. Eaton DR, Kann L, Kinchen S, et al. Youth risk behavior surveillance-United States, 2007. MMWR Surveill Summ. 2008; 57(4):1–131.
3. Centers for Disease Control and Prevention: Trends in reportable sexually transmitted diseases in the United States, 2006. www.cdc.gov/std/stats/trends2006.htm. Accessed May 11, 2009.
4. Cates W Jr, Wasserheit JN. Genital chlamydial infections: epidemiology and reproductive sequale. Am J Obstet Gynecol. 1991; 164(6 Pt 2):1771–1781.
5. US Preventive Services Task Force. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med. 2001;20(3 Suppl.):90–94.
6. Centers for Disease Control and Prevention, Workowski A, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1–94.
7. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med. 2005;3(3):263–267.
8. Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007; 56(14):332–336.

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