What does a strawberry cervix indicate and how is it treated?

Strawberry Cervix: Clinical Significance and Management

A "strawberry cervix" is a pathognomonic sign of Trichomonas vaginalis infection, appearing as red punctate lesions on the cervix, and requires treatment with metronidazole regardless of symptoms. 1

What the Finding Indicates

Strawberry cervix (colpitis macularis) is highly specific for trichomoniasis, though it is only visible in a minority of infected patients:

• The appearance consists of red punctate hemorrhagic lesions creating a characteristic stippled pattern on the cervical surface 1
• This finding has an odds ratio of 241 for trichomoniasis when present, making it one of the most specific clinical signs in gynecology 2
• However, the sensitivity is low—most women with trichomoniasis will NOT have a visible strawberry cervix 2
• When present, it strongly indicates the need for wet mount examination and/or culture to confirm T. vaginalis infection 2

Associated Clinical Features

When strawberry cervix is identified, expect to find other manifestations of trichomoniasis:

• Purulent vaginal discharge (yellow-green in color) with odds ratio of 8.0 2
• Vaginal erythema (odds ratio 4.3) and vulvar erythema (odds ratio 2.5) 2
• Symptoms of yellow vaginal discharge (odds ratio 2.4) and vulvar itching (odds ratio 3.0) 2
• Abnormal vaginal odor may be present 2

Diagnostic Confirmation

While the strawberry cervix appearance is highly suggestive, confirmation is essential:

• Wet mount microscopy showing motile trichomonads is the traditional diagnostic method, though sensitivity is limited 3
• Culture provides higher sensitivity than wet mount and should be used when clinical suspicion is high but wet mount is negative 2, 3
• DNA amplification techniques have good sensitivity but are not yet universally approved for diagnostic purposes 3

Treatment Protocol

Single-dose metronidazole 2g orally is the treatment of choice for confirmed trichomoniasis:

• This regimen is effective in the majority of cases 3
• Concurrent partner treatment is mandatory as trichomoniasis is a sexually transmitted infection 4, 3
• Unlike bacterial vaginosis or candidiasis, trichomoniasis requires treatment even if asymptomatic once diagnosed, due to its role as an STI and potential complications 4
• Outside the United States, other nitroimidazoles may be used with equivalent efficacy 3

Critical Clinical Implications

The presence of trichomoniasis has important health consequences beyond vaginal symptoms:

• Associated with increased HIV transmission and acquisition 3
• Linked to pelvic inflammatory disease, though less commonly than chlamydia or gonorrhea 4, 3
• Associated with adverse birth outcomes in pregnant women 3
• Screen for concurrent STIs, particularly Chlamydia trachomatis and Neisseria gonorrhoeae, as coinfection is common 2

Common Pitfalls to Avoid

• Do not assume absence of strawberry cervix rules out trichomoniasis—the finding has high specificity but low sensitivity 2
• Failing to treat sexual partners leads to reinfection and treatment failure 3
• Metronidazole resistance is emerging; if treatment fails, consider higher doses or longer duration regimens 3
• Do not confuse strawberry cervix with cervical ectropion (normal finding in adolescents) or friability from other STIs 1