Atrophic Vaginitis Estrogen plays an important role in the maintenance of normal vaginal ecology. Women undergoing menopause, either naturally or secondary to surgical removal of the ovaries, may develop inﬂammatory vaginitis, which may be accompanied by an increased, purulent vaginal discharge. In addition, they may have dyspareunia and postcoital bleeding resulting from atrophy of the vaginal and vulvar epithelium. Examination reveals atrophy of the external genitalia, along with a loss of the vaginal rugae. The vaginal mucosa may be somewhat friable in areas. Microscopy of the vaginal secretions shows a predominance of parabasal epithelial cells and an increased number of leukocytes.
Atrophic vaginitis is treated with topical estrogen vaginal cream. Use of 1 g of conjugated estrogen cream intravaginally each day for 1 to 2 weeks generally provides relief. Maintenance estrogen therapy, either topical or systemic, should be considered to prevent recurrence of this disorder.
Cervicitis The cervix is made up of two different types of epithelial cells: squamous epithelium and glandular epithelium. The cause of cervical inﬂammation depends on the epithelium affected. The ectocervical epithelium can become inﬂamed by the same micro-organisms that are responsible for vaginitis. In fact, the ectocervical squamous epithelium is an extension of and is continuous with the vaginal epithelium. Trichomonas, candida, and herpes simplex virus (HSV) can cause inﬂammation of the ectocervix. Conversely, N. gonorrhoeae and C. trachomatis infect only the glandular epithelium (29).
Diagnosis The diagnosis of cervicitis is based on the finding of a purulent endocervical discharge, generally yellow or green in color and referred to as “mucopus” (30).
1.
After removal of ectocervical secretions with a large swab, a small cotton swab is placed into the endocervical canal and the cervical mucus is extracted. The cotton swab is inspected against a white or black background to detect the green or yellow color of the mucopus. In addition, the zone of ectopy (glandular epithelium) is friable or easily induced to bleed. This characteristic can be assessed by touching the ectropion with a cotton swab or spatula.
2.
Placement of the mucopus on a slide that can be Gram stained will reveal the presence of an increased number of neutrophils (>30 per high-power field). The presence of intracellular gram-negative diplococci, leading to the presumptive diagnosis of gonococcal endocervicitis, may be detected. If the Gram stain results are negative for gonococci, the presumptive diagnosis is chlamydial cervicitis.
3.
Tests for gonorrhea and chlamydia, preferably using nucleic acid amplification tests, should be performed. The microbial etiology of endocervicitis is unknown in about 50% of cases in which neither gonococci nor chlamydia is detected.
Treatment Treatment of cervicitis consists of an antibiotic regimen recommended for the treatment of uncomplicated lower genital tract infection with both chlamydia and gonorrhea (16) (Table 18.3). Fluoroquinolone resistance is common in Neisseria gonorrhoeae isolates, and, therefore, these agents are no longer recommended for the treatment of women with gonococcal cervicitis. It is imperative that all sexual partners be treated with a similar antibiotic regimen. Cervicitis is commonly associated with BV, which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis.
Table 18.3 Treatment Regimens for Gonococcal and Chlamydial Infections