Can Bacterial Vaginosis (BV) cause cervicitis?

Bacterial Vaginosis and Cervicitis: Relationship and Clinical Implications

Yes, bacterial vaginosis (BV) can cause cervicitis, as evidenced by multiple clinical guidelines and research studies showing a clear association between BV and inflammation of the cervix. 1, 2, 3

Pathophysiological Relationship

BV is characterized by a shift from the normal lactobacillus-dominant vaginal flora to an overgrowth of anaerobic bacteria. This alteration in vaginal microbiota can lead to cervical inflammation through several mechanisms:

1. Direct pathogenic effect: The CDC guidelines note that limited data indicate BV can cause cervicitis 1

2. Microbial association: The organisms involved in BV are similar to the nongonococcal, nonchlamydial bacteria frequently isolated from the upper genital tract of women with inflammatory conditions 1

3. Absence of protective bacteria: Research shows that the absence of H₂O₂-producing Lactobacillus species (which are depleted in BV) is associated with a 2.7 times higher risk of cervicitis 4

Evidence of Causation

Several key findings support the causal relationship between BV and cervicitis:

• In a controlled study, treatment of BV with metronidazole gel was associated with significantly higher resolution of cervicitis (88.9%) compared to placebo (62.5%) 2

• Among women with BV, approximately 15% have concurrent cervicitis, even in the absence of chlamydial or gonococcal infection 4

• BV is recognized as an antecedent to lower genital tract infections that can lead to cervicitis and potentially to upper genital tract infections 1

Clinical Approach to BV-Associated Cervicitis

When evaluating a patient with cervicitis, clinicians should:

1. Test for BV: Women with cervicitis should be evaluated for BV, and if present, it should be treated 1

2. Consider multiple etiologies: While C. trachomatis and N. gonorrhoeae are common causes of cervicitis, BV should be considered when these pathogens are not detected 1, 5

3. Treat appropriately:

   • For BV: Metronidazole 500mg orally twice daily for 7 days (95% cure rate) 6
   • Alternative regimens: Metronidazole gel 0.75% intravaginally once daily for 5 days or clindamycin cream 2% intravaginally at bedtime for 7 days 6

Clinical Implications

The relationship between BV and cervicitis has important clinical implications:

• Risk of ascending infection: Cervicitis may be a sign of upper genital tract infection (endometritis), so women with cervicitis should be assessed for signs of pelvic inflammatory disease (PID) 1

• Persistent cervicitis: In women with persistent cervicitis where STIs have been excluded, reassessment of vaginal flora for BV is recommended 1

• Preventive measures: Consistent condom use may help prevent recurrence of BV and associated cervicitis 6

Diagnostic Considerations

When evaluating a patient with suspected cervicitis:

• Look for endocervical mucopurulent discharge or easily induced bleeding 4
• Measure vaginal pH (typically >4.5 in BV) 6
• Perform microscopic examination for clue cells and decreased lactobacilli 6
• Test for other potential causes of cervicitis (C. trachomatis, N. gonorrhoeae, trichomoniasis, HSV) 1

The evidence clearly demonstrates that BV is not only associated with cervicitis but can directly contribute to its development, and treating BV can lead to resolution of cervicitis in many cases.