Almost one quarter of FSW in this study had cervicitis, second only to vaginal discharge as the most common syndrome. Cervicitis in this study was predominantly non-gonococcal, non-chlamydial in etiology, and no pathogen was detected in cervical samples in over 90% of participants with cervicitis. Cervicitis that is not associated with chlamydial or gonoccocal infections is the most common type of cervicitis overall and is referred to as ‘non-specific cervicitis’ (NSC) . The rate of NSC determined here was higher than some rates reported in non-FSW women .
Studies in other FSW populations have demonstrated a strong association between gonoccoal, chlamydial or Trichomonas infection with clinical manifestations of cervicitis [8, 9]. No such association was found in the women studied here, and this likely reflects the low overall prevalence of STI diagnosed, in contrast to the higher STI prevalence reported in FSW in other Latin American countries, Asia and Africa [8, 9, 11, 16, 17].
Other potential reasons for the high frequency of NSC and lack of association with typical cervicitis-causing organisms may include ongoing inflammation of the cervix after previously treated chlamydial or gonorrhoeal infections, perhaps mediated by an abnormal immune response . Data was unfortunately not collected on prior antimicrobial treatment for cervicitis or other genital tract syndromes in these women, which is a significant limitation to this study.
Cervical irritation due to douches and spermicides may also have contributed to high NSC rates . While no data was collected on the use of spermicides or frequency of douching, douching is common in this population (personal observation by authors). Additionally, testing for other potential pathogens associated with cervicitis such as HSV-2 and M. genitalium were not performed in this study . Furthermore, microscopy was used for the detection of trichomoniasis in this study, a method that is less sensitive compared to culture-based, molecular and immunochromatographic methods . This relatively insensitive method of TV detection is a limitation of this study, and future studies should consider the use of newer generation diagnostic methods such as PCR.
Bacterial vaginosis may play a causative role in some NSC cases. BV was the second most common genital tract infection in our study and was present in over a third (36.9%) of cervicitis cases. On bivariate analysis, the association between BV and cervicitis failed to reach significance, but this may reflect insufficient power due to the number of FSW enrolled. There is growing evidence from other studies that BV is an independent risk factor for cervicitis . Bacterial vaginosis could lead to cervicitis through a loss of bactericidal H202-producing lactobacilli, reduced levels of protective vaginal mucins, and increased pro-inflammatory enzymes and cytokines, which in turn may decrease the cervical mucus barrier .
Regular clinic attendance was associated with a 46% reduced risk of cervicitis, possibly due to the reduced rates of STI and BV noted in the regular clinic attendees. This may reflect frequent and early antibiotic treatment of genital tract syndromes and infections, although the exact frequency of antibiotic treatment was not determined. Self-treatment with antimicrobials was also considered as a confounding factor in women who attended clinics, however only one participant reported receiving treatment outside of clinics (data not shown). Preventative STI education delivered during clinic attendance may also contribute to the protective effect associated with regular clinic attendance. Regardless of the mechanism, the current Peruvian Ministry of Health program of free monthly health checks for FSW may be effective for reducing rates of cervicitis, BV and cervicitis-causing STI noted in FSW with regular clinic attendance.
Ecuadorian nationality was also protective against cervicitis, even after controlling for regular clinic attendance, which was more common in the Ecuadorian participants. The effect of Ecuadorian nationality may reflect unmeasured cultural differences in sexual practices, douching or other risk behaviors for cervicitis and STI.