Cervicitis and Sexually Transmitted Infections in the Adolescent ...

ADOLESCENT
GYNECOLOGY
CONTRIBUTED BY THE
NORTH AMERICAN SOCIETY FOR
PEDIATRIC AND 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 9 th through 12 th 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 recommendations
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
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.
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
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
ABOUT NASPAG
The North American Society for Pediatric and
Adolescent Gynecology (NASPAG) is a nonprofit
organization dedicated to educating
health care professionals in pediatric and
adolescent gynecology.
For more information, contact NASPAG:
www.naspag.org
NASPAG
409 12th Street, SW
P.O. Box 96920
Washington, D.C. 20090-6920
34 The Female Patient | VOL 34 JUNE 2009 www.femalepatient.com

Weber-LaShore and Biro
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 reinfection,
a repeat test is recommended 3 to 5
months after treatment.
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.
TRICHOMONIASIS
Trichomonas vaginalis is a protozoan characterized
by flagellated motility. An estimated 7.4 million
cases are seen annually in the United States. 1
Rate per 100,000 sexually active women
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
1,409
6,224
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
681
3,143
15-19 20-24 25-29
Age group (y)
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.
GC
CT
1,189
307
FIGURE. CDC 2006 sexually transmitted diseases surveillance: gonorrhea
and chlamydia rates.
GC = gonococcus; CT = chlamydia trachomatis.
FOCUSPOINT
The majority
of chlamydial
infections are
asymptomatic,
a fact not known
by most
adolescents.
The Female Patient | VOL 34 JUNE 2009 35

ADOLESCENTGYNECOLOGY
Cervicitis and Sexualy Transmitted Infections
FOCUSPOINT
PELVIC INFLAMMATORY
DISEASE
Pelvic inflammatory disease can
be caused by STIs (ie, gonorrhea,
Patients with
chlamydia) but can also be associated
with organisms from the
gonorrhea are
often also infected
vaginal flora (ie, G. vaginalis,
anaerobes, gram negative rods). It
with chlamydia,
has the potential to infect the
and thus dual
uterus, tubes, and ovaries. Symptoms
include abdominal pain,
treatment might
fever, menorrhagia, vaginal discharge,
and vomiting, and can
be warranted.
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.
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.
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.
36 The Female Patient | VOL 34 JUNE 2009 www.femalepatient.com