Cervicitis and pelvic inflammatory disease

• Cervicitis is inflammation of the cervix, usually from a sexually transmitted infection; pelvic inflammatory disease (PID) is inflammation of the upper genital tract (endometrium, fallopian tubes, ovaries and pelvic peritoneum) that most often ascends from the cervix.
• Presumptive treatment should be started when pelvic pain plus cervical, uterine or adnexal tenderness cannot be explained by another cause, because delay risks infertility, ectopic pregnancy and chronic pelvic pain.
• Cervicitis is treated with doxycycline 100 mg by mouth twice a day for 7 days, adding cover for gonorrhoea where risk is high; PID needs broad-spectrum antibiotics for 14 days, given by mouth or intravenously depending on severity.^[1][2][3]
• Every patient with PID needs testing for gonorrhoea, chlamydia, HIV and syphilis, and her recent sex partners need evaluation and treatment.
• Complications include tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome (perihepatitis with right upper quadrant pain), infertility and ectopic pregnancy. ^[1]

By the end of this page you should be able to:

1. Define cervicitis and PID and place each in the spectrum of upper and lower genital tract infection. ^[1]
2. List the organisms most often responsible and the risk factors for ascending infection.
3. Explain how infection moves from the cervix to the tubes and peritoneum.
4. Diagnose cervicitis and PID using the clinical criteria and the investigations that support them.
5. Choose and dose outpatient and inpatient antibiotic regimens from the current CDC and BASHH guidance. ^[1]
6. Recognise the complications, arrange follow-up and manage sex partners.
7. Describe the care of pregnant women, adolescents and women using an intrauterine device (IUD).

Cervicitis is the lower-tract infection; PID is the upper-tract consequence. A woman with cervicitis may have no upper-tract disease, but cervicitis can be the first sign of an ascending infection, so patients are always assessed for PID. A further useful distinction is between acute PID, with pain, fever and tenderness, and subclinical or silent PID, in which tubal damage occurs without symptoms. Both matter, because even mild or asymptomatic disease can damage fertility.

Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are the classic causes. The proportion of cases attributable to either organism is falling, and of women diagnosed with acute PID about 50% test positive for one of them.^[1] Organisms that make up the normal vaginal flora, such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods and Streptococcus agalactiae, are also associated with PID, as are Mycoplasma genitalium, Trichomonas vaginalis, cytomegalovirus and Mycoplasma hominis.

For cervicitis, C. trachomatis and N. gonorrhoeae are the most common identifiable causes. Chlamydial infection is often silent in women, which is why it and gonorrhoea are screened for before symptoms develop. Trichomoniasis, genital herpes (especially primary herpes simplex virus type 2 infection) and M. genitalium are also associated with cervicitis. No organism is isolated in many women, particularly those above 30 years with a lower risk of recent sexually transmitted infection; in these, bacterial vaginosis or chemical irritation may contribute.

Risk factors for PID include:

• Age under 25 years, the age group in whom chlamydia and gonorrhoea are most prevalent.
• A new sex partner, a partner with concurrent partners, or a partner with a sexually transmitted infection.
• Previous sexually transmitted infection or PID.
• Insertion of an intrauterine device, but mainly in the first 3 to 6 weeks after insertion (CDC says the first 3 weeks; BASHH says 4 to 6 weeks), and mainly when gonorrhoea or chlamydia is already present.^{[1][3] [2]}
• Lack of or inconsistent barrier contraception.

PID is the most serious infection of sexually active young women in most settings. In one synthesis, up to about one third of female infertility worldwide is attributed to one or more episodes of PID, with salpingitis as the key step.^[5]

Infection ascends from the endocervix to the endometrium, fallopian tubes and peritoneum. The factors that break the cervical barrier include menstruation, which removes the mucus plug and allows bacteria to pass, and the mechanical disruption of procedures such as insertion of an IUD or instrumentation of the uterus.

Once the tubes are infected, inflammation damages the tubal epithelium. Neutrophils, macrophages and lymphocytes release enzymes and reactive oxygen species that destroy ciliated cells. Healing produces fibrosis and adhesions, and chronic inflammation makes the environment hostile to gametes and embryos. Ciliary loss and partial blockage slow or stop movement of sperm, ova and embryos. This is why PID leads to infertility and ectopic pregnancy even after the original infection has cleared.

Cervicitis itself is the first visible stage of this process: inflammation and fragility of the cervical epithelium, with mucopurulent discharge and bleeding on contact. Organisms that infect the columnar cells of the cervix can move upward through the uterine cavity into the tubes, especially during menstruation.

Cervicitis may cause no symptoms. When symptoms occur they include an abnormal vaginal discharge, intermenstrual bleeding and bleeding after intercourse, often with mild pelvic discomfort. PID more often causes bilateral lower abdominal or pelvic pain, usually of recent onset, with deep dyspareunia and abnormal bleeding (postcoital, intermenstrual or heavy periods). Vaginal discharge is often purulent. Low-grade fever, nausea or vomiting occur in more severe disease.

A good history also asks about fever, urinary symptoms, vomiting, date of the last period and pregnancy risk, because ectopic pregnancy, urinary infection and appendicitis can mimic PID. An IUD insertion in the previous 6 weeks raises the possibility of PID.^[1][3]

General and abdominal examination look for fever and rebound or guarding, which suggest peritonitis or a surgical abdomen. Pelvic examination is essential. Cervicitis is suggested by a purulent or mucopurulent endocervical exudate and easily induced bleeding. The three minimum clinical criteria for diagnosing PID are cervical motion tenderness, uterine tenderness and adnexal tenderness; one is enough to raise suspicion.^[1][3] In BASHH guidance, fever greater than 38°C is a sign that supports the diagnosis.^[3]

Other signs that support PID are lower abdominal tenderness, usually bilateral, cervical motion tenderness, adnexal tenderness, mucopurulent cervical discharge and fever. The absence of vaginal or cervical pus cells has a good negative predictive value for PID, while their presence is non-specific. ^[3]

Women with cervicitis should be assessed for signs of PID, tested for C. trachomatis and N. gonorrhoeae by NAAT on a vaginal, cervical or urine sample, and evaluated for bacterial vaginosis and trichomoniasis. Diagnosis of PID remains clinical because symptoms and signs overlap with other pelvic conditions; a clinical diagnosis has a positive predictive value for salpingitis of 65 to 90% compared with laparoscopy.^[1][3]

Other causes of pelvic pain (ectopic pregnancy, acute appendicitis, ovarian cyst torsion or rupture, endometriosis, urinary tract infection, functional pain) are unlikely to be harmed by starting empiric antibiotics for PID, and early treatment reduces the risk of long-term damage.^[1][3]

The guiding principle is to treat early, because preventing long-term sequelae depends on prompt antibiotics. All regimens are broad-spectrum, covering N. gonorrhoeae, C. trachomatis and anaerobes. After deciding to treat, the main question is whether the woman can be managed as an outpatient or needs admission.

Admission is recommended when any of the following apply: a surgical emergency cannot be excluded, a tubo-ovarian abscess is present, the woman is pregnant, she is severely ill with nausea and vomiting or temperature greater than 38.5°C, she cannot follow or tolerate an oral regimen, or there is no clinical response to oral treatment.^[1]

The archived RCOG Green-top Guideline No. 32 directs readers to the BASHH guideline.^[4]

CDC 2021 recommends 14 days of oral therapy with a single intramuscular dose of a cephalosporin plus doxycycline and metronidazole. The regimens are: ^[1][2]

• Ceftriaxone 500 mg intramuscularly in a single dose, plus doxycycline 100 mg by mouth twice daily for 14 days, with metronidazole 500 mg by mouth twice daily for 14 days.^[1]
• Cefoxitin 2 g intramuscularly in a single dose plus probenecid 1 g by mouth in a single dose, plus doxycycline 100 mg by mouth twice daily for 14 days, with metronidazole 500 mg by mouth twice daily for 14 days.^[1]
• Another parenteral third-generation cephalosporin plus the same doxycycline and metronidazole backbones. ^[1]

For women weighing more than 150 kg with documented gonococcal infection, CDC advises ceftriaxone 1 g.^[1] If the community risk of gonorrhoea is low and the patient has a severe cephalosporin allergy, alternative oral combinations are levofloxacin 500 mg once daily with metronidazole 500 mg twice daily for 14 days, moxifloxacin 400 mg once daily for 14 days, or an azithromycin-based regimen.^{[1] [3]}

BASHH (2019 interim update) uses the same structure but different doses in the UK: ^[3]

• Intramuscular ceftriaxone 1000 mg in a single dose, plus doxycycline by mouth twice daily for 14 days, plus metronidazole by mouth twice daily for 14 days.^[3]
• Oral ofloxacin twice daily for 14 days, plus metronidazole twice daily for 14 days.^[3]
• Oral moxifloxacin once daily for 14 days.^[3]

BASHH also lists an alternative outpatient regimen of intramuscular ceftriaxone 1000 mg immediately, plus azithromycin 1 g weekly for 2 weeks.^[3] Quinolones are reserved because of tendon and nerve adverse effects, and ofloxacin and moxifloxacin should be avoided when gonococcal PID is likely because of UK quinolone resistance. Moxifloxacin has the best activity against M. genitalium among the suggested regimens.

Parenteral therapy is continued until 24 hours after clinical improvement, then switched to oral medication to complete 14 days. CDC recommends any of: ^[1][3]

• Ceftriaxone 1 g intravenously every 24 hours, plus doxycycline 100 mg by mouth or intravenously every 12 hours, plus metronidazole 500 mg by mouth or intravenously every 12 hours.^[1]
• Cefotetan 2 g intravenously every 12 hours, plus doxycycline 100 mg by mouth or intravenously every 12 hours.^[1]
• Cefoxitin 2 g intravenously every 6 hours, plus doxycycline 100 mg by mouth or intravenously every 12 hours.^[1]

Metronidazole can be given by mouth because it is well absorbed, and doxycycline is given orally when possible. After improvement the oral continuation is doxycycline 100 mg twice daily plus metronidazole 500 mg twice daily to complete 14 days. Alternatives are ampicillin-sulbactam plus doxycycline, or clindamycin plus gentamicin.^[1]

BASHH recommends:

• Intravenous ceftriaxone 2 g daily, plus intravenous doxycycline (oral if tolerated), followed by oral doxycycline twice daily plus oral metronidazole to complete 14 days.^[3]
• Intravenous clindamycin 900 mg three times daily, plus intravenous gentamicin with a loading dose of 2 mg/kg then 1.5 mg/kg three times daily with drug-level monitoring, followed by oral clindamycin 450 mg four times daily or oral doxycycline, plus oral metronidazole, to complete 14 days.^{[3] [1]}

Alternative inpatient regimens in the BASHH guidance use intravenous ofloxacin or ciprofloxacin plus metronidazole.^[3]

The main differences to remember are that the UK regimens use higher-dose intramuscular ceftriaxone (1000 mg rather than 500 mg) and a lower metronidazole dose (rather than 500 mg twice daily), reflecting local epidemiology and formularies. Which you follow depends on where you practise and local resistance patterns.

Cervicitis is treated presumptively when the woman is at increased risk (age under 25 years, new sex partner, a partner with concurrent partners, or a partner with an infection), when follow-up cannot be ensured, or when NAAT testing is not available. Trichomoniasis and bacterial vaginosis are treated if found; women at lower risk may wait for test results. ^[2]

• Recommended regimen: doxycycline 100 mg by mouth twice daily for 7 days.^[2]
• Alternative regimen: azithromycin 1 g by mouth as a single dose.^[2]

Empiric cover for gonococcal infection should be added when the woman is at risk of gonorrhoea or lives where prevalence is high, as in the gonococcal infection guidance. Persistent or recurrent cervicitis needs re-evaluation for reinfection, treatment failure and non-infectious causes such as cervical dysplasia, cervical polyps or chemical irritation. After excluding reinfection, untreated bacterial vaginosis and untreated partners, there is no defined further antibiotic strategy, and M. genitalium may be considered in women who fail azithromycin or doxycycline without clear re-exposure. ^[2]

After starting PID treatment, reassess within 72 hours. Women should show clinical improvement, with defervescence and reduced abdominal, uterine, adnexal and cervical motion tenderness, within 3 days.^[1][3] Lack of improvement at 72 hours calls for hospitalisation, review of the antibiotic regimen and further investigation, including laparoscopy if needed.^[1][3]

Women with moderate or severe PID should be reviewed at 72 hours and again at 2 to 4 weeks, checking clinical response, compliance, partner screening and treatment, awareness of the long-term risks and a repeat pregnancy test if needed. Further testing for gonorrhoea or chlamydia at 2 to 4 weeks is recommended if symptoms persist or compliance was poor.^[3] Women with chlamydial or gonococcal PID are retested at 3 months, regardless of whether their partners were treated.^[1]

For PID, sex partners during the 60 days before symptom onset are evaluated, tested and presumptively treated for chlamydia and gonorrhoea, regardless of the organism eventually identified. If the last intercourse was more than 60 days before onset, the most recent partner is treated.^[1] BASHH extends contact tracing for partners within 6 months of symptom onset, tailored to the sexual history, and recommends empirical broad-spectrum treatment for male partners, for example doxycycline 100 mg twice daily for 1 week, because many cases are not attributable to N. gonorrhoeae, C. trachomatis or M. genitalium.^[3]

Where M. genitalium is confirmed, male partners are tested and treated, and partners are advised to avoid intercourse until both patient and partner have completed treatment.

For cervicitis, partners during the previous 60 days are referred for evaluation, testing and presumptive treatment if chlamydia, gonorrhoea or trichomoniasis was identified. Expedited partner therapy and other partner-referral strategies are acceptable alternatives.^[2]

All women treated for PID or cervicitis are advised to avoid sexual intercourse until therapy is complete, symptoms have resolved and partners have been treated.

All women diagnosed with PID are tested for gonorrhoea, chlamydia, HIV and syphilis, and for M. genitalium where testing is available. All contraceptive methods can be continued during treatment. An IUD in a woman who develops PID does not usually need to be removed; she is treated and followed closely, and removal is considered if there is no improvement within 48 to 72 hours.^[1][3]

• Tubo-ovarian abscess: a collection of pus in the fallopian tube or ovary, usually requiring intravenous antibiotics and more than 24 hours of inpatient observation. Surgical or radiological drainage is sometimes needed.^[1]
• Fitz-Hugh-Curtis syndrome: perihepatitis with inflammation and adhesions around the liver capsule, presenting as right upper quadrant pain that worsens with breathing and movement. It has been reported as a complication of PID in about a quarter of cases in some series.^[6]
• Infertility: one synthesis attributes up to about a third of female infertility worldwide to episodes of PID, and the more episodes a woman has had, the higher her risk of tubal-factor infertility.^[5]
• Ectopic pregnancy: women with previous PID or salpingitis are at a two- to six-fold increased risk of ectopic pregnancy compared with unaffected women.^[5]
• Chronic pelvic pain: recurrent or chronic salpingitis can cause scarring, hydrosalpinx and ongoing pain.
• Recurrence: treating the first episode and the partners reduces the risk of recurrence; non-adherence increases it.

An open-access review (2026) that pooled published ranges gives representative long-term outcomes by number of episodes: no prior episode baseline infertility about 0.9%, ectopic pregnancy 1.3% and chronic pelvic pain 5%; one episode 12%, 8% and 25%; two episodes 25%, 15% and 30%; three or more episodes 50%, 28% and 40%.^[5] These are pooled estimates rather than measurements from a single population, so they describe risk rather than predict it.

With prompt treatment most women recover fully. Early antibiotics reduce the risk of permanent tubal damage and the long-term sequelae of infertility, ectopic pregnancy and chronic pelvic pain. The risk of damage rises with every episode and with delayed treatment, which is why empiric treatment at the first presentation is justified even though the clinical diagnosis is imprecise.

Women who have had a tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome or severe disease may have more scarring and a higher risk of recurrence. Long-term follow-up and repeat testing where indicated help detect reinfection before further damage occurs.

• Screening sexually active women for chlamydia and gonorrhoea reduces their risk of PID, and treatment of infected women prevents upper-tract spread. ^[1]
• The value of screening for bacterial vaginosis or M. genitalium in preventing PID is not established.
• Partner evaluation, testing and treatment prevent reinfection and onward transmission.
• Advice after treatment: abstain from intercourse until treatment is complete, symptoms have resolved and partners have been treated; complete the full antibiotic course.
• Condom use and reductions in number of sexual partners lower the risk of acquiring the infections that lead to PID.
• Before inserting an IUD, consider screening for C. trachomatis and N. gonorrhoeae in women at increased risk, because the risk of PID is highest in the first weeks after insertion when an infection is already present.

Pregnant women with suspected PID are at high risk of maternal morbidity and preterm delivery. They should be admitted and treated with intravenous antibiotics, in consultation with an infectious disease specialist. BASHH notes that in very early pregnancy, before a pregnancy test is positive, using the standard regimens is justified because the benefits outweigh the potential risks. For cervicitis in pregnancy, diagnosis and treatment follow the specific guidance for chlamydia and gonorrhoea rather than the standard doxycycline regimen. ^[2][3]

Adolescent women are at high risk of chlamydia and gonorrhoea and so of PID. Hospitalisation decisions use the same criteria as for older women; there is no evidence that routine admission improves outcomes.

PID becomes less common after the menopause, but the risk of other causes of pelvic pain increases. Cervicitis in women above 30 years is less often due to a recently acquired sexually transmitted infection and more often persistent or non-infectious in origin.

Women with HIV infection and PID or cervicitis receive the same regimens as women without HIV. Those with HIV are more likely to have a tubo-ovarian abscess, but respond to standard therapy. ^[1][2][3]

The risk of PID associated with an IUD is confined mainly to the first 3 weeks after insertion (CDC) or 4 to 6 weeks (BASHH). If PID develops in a user, the IUD does not usually need to be removed; treatment is given and close follow-up arranged. Removal is considered if there is no improvement within 48 to 72 hours. ^[1][3]

• Doxycycline, metronidazole and a single intramuscular dose of ceftriaxone are the core of empiric treatment and are usually available.
• If transvaginal ultrasound is unavailable, rely on clinical criteria and start treatment early rather than delaying.
• Partner notification is often the hardest step; use expedited partner therapy where it is permitted by law, and explain why completing treatment prevents permanent damage and future ectopic pregnancy.
• IUD insertion services should include screening or presumptive treatment for women at high risk when testing is unavailable only after considering local guidance; never withhold an effective contraceptive solely because of theoretical infection risk.
• Refer or arrange surgery for suspected tubo-ovarian abscess or for women who do not improve within 72 hours.

• Cervicitis is inflammation of the cervix, most often from C. trachomatis or N. gonorrhoeae; PID is the ascending infection that produces endometritis, salpingitis, tubo-ovarian abscess or pelvic peritonitis.
• Cervicitis is diagnosed by mucopurulent cervical discharge or easy cervical bleeding; PID is diagnosed clinically, with cervical, uterine or adnexal tenderness as the minimum criterion.
• Treat early and empirically: about 50% of women diagnosed with acute PID test positive for gonorrhoea or chlamydia, so a negative swab does not exclude disease.^[1]
• Cervicitis: doxycycline 100 mg twice daily for 7 days, or azithromycin 1 g as a single dose, with added gonococcal cover where indicated.^[2]
• PID: 14 days of a cephalosporin plus doxycycline plus metronidazole, intramuscular or oral for mild to moderate disease, intravenous for severe disease or pregnancy.^[1][3]
• Hospitalise for suspected abscess, pregnancy, severe illness or inability to tolerate oral therapy.
• Review within 72 hours; improvement should be evident within 3 days.
• Screen and treat contacts from the previous 60 days, and longer where the sexual history warrants.
• Complications are tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome, infertility, ectopic pregnancy and chronic pelvic pain; risk rises with each episode.
• Women with HIV are treated with the same regimens, and an IUD does not usually need removal.

Plain-text links (no TopicLink): chlamydia, gonorrhoea, bacterial vaginosis, trichomoniasis, mycoplasma genitalium, urinary tract infection, ectopic pregnancy, infertility, endometriosis, appendicitis, caesarean section and episiotomy, contraception, postpartum infection.