What is follicular cervicitis in young to middle-aged women with a history of cervical abnormalities or infections?

What is Follicular Cervicitis?

Follicular cervicitis is a specific colposcopic appearance of cervical inflammation characterized by visible lymphoid follicles on the cervix, creating a hypertrophic follicular pattern that is strongly associated with Chlamydia trachomatis infection. 1

Clinical Appearance and Pathophysiology

• Follicular cervicitis presents as a distinctive hypertrophic follicular appearance on colposcopy, with visible lymphoid follicles creating a characteristic pattern on the cervical surface 1, 2
• The cervix typically shows severe edema, erythema, friability, and endocervical mucopurulent discharge 2
• An atypical transformation zone is frequently observed on colposcopic examination 2
• The follicular pattern represents lymphoid tissue hyperplasia in response to chronic antigenic stimulation from infection 1

Strong Association with Chlamydia

• In women who are sexual partners of men with non-gonococcal urethritis, follicular cervicitis was identified in 44% of cases, and C. trachomatis was isolated from 45% of those with follicular cervicitis compared to only 7% without this finding 1
• This follicular appearance is particularly characteristic of chlamydial infection and does not show similar correlation with Mycoplasma hominis or Ureaplasma urealyticum 1
• The presence of follicular cervicitis should prompt immediate testing for C. trachomatis using nucleic acid amplification tests (NAATs) 3

Diagnostic Implications for Young to Middle-Aged Women

• Women with cervical abnormalities or prior infections who present with follicular cervicitis are at high risk for C. trachomatis and should be tested for both chlamydia and N. gonorrhoeae 3
• Risk factors that increase likelihood of chlamydial infection include age <25 years, new or multiple sex partners, unprotected sex, and use of oral contraceptives 3, 2
• The presence of cervical ectopy (columnar epithelium on the ectocervix) is an important risk factor for chlamydial infection and may coexist with follicular changes 2

Clinical Significance and Cytological Concerns

• Papanicolaou smears from women with C. trachomatis-positive follicular cervicitis often reveal benign atypias and dyskaryotic changes 2
• Women with follicular cervicitis and cytological atypias should be tested for C. trachomatis, as this intracellular organism may play a role in the development of cervical intraepithelial neoplasia (CIN) 2
• Follow-up cytology after adequate treatment of chlamydial infection is warranted to assess resolution of atypias 2

Treatment Approach

• If follicular cervicitis is identified in a high-risk woman (age <25, new/multiple partners), empiric treatment covering C. trachomatis and N. gonorrhoeae should be initiated immediately: azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days 4
• All women with follicular cervicitis should be assessed for pelvic inflammatory disease, as subclinical upper reproductive tract infection may already be present 3
• Sex partners must be notified, examined, and treated for chlamydia and gonorrhea to prevent reinfection 4
• Patients and partners should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimens 4

Critical Pitfalls to Avoid

• Do not dismiss follicular cervicitis as benign—it is a marker of likely chlamydial infection requiring treatment to prevent serious sequelae including pelvic inflammatory disease, ectopic pregnancy, and infertility 5
• Do not rely solely on symptoms, as chlamydial cervicitis is frequently asymptomatic despite the presence of follicular changes 6
• Do not fail to treat sex partners, as untreated partners will lead to reinfection 4
• In women over 30 years old in stable relationships, follicular cervicitis is less common, and if present with negative STD testing, consider non-infectious causes such as inflammation in the zone of ectopy 3, 7