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Vaginitis and cervicitis are undoubtedly linked in many instances, to some degree. When considering cervicitis as a discrete entity, the most common causes are infections due to Chlamydia trachomatis and Neisseria gonorrheae. Other causes of cervicitis are human papillomavirus (HPV) and infrequently considered are herpes simplex virus (HSV), Mycoplasma, and Ureaplasma. The two latter bacteria are commonly found colonizing the lower genital tract in sexually active women and their role in the disease of female pelvic organs is not well understood. However, recent data have implicated the mycoplasmas and ureaplasmas in both obstetric and gynecologic pelvic infections. Other causes of cervicitis have been documented throughout the world, e.g., Mycobacterium tuberculosis, Schistosoma haematobium, Epstein–Barr virus, amoebiasis, and cytomegalovirus, but are uncommon in the United States. However, when taking a history it is important to determine if there has been recent travel outside the United States, especially to parts of the world where these diseases are prevalent. The patient's past travel experience or her sexual partner's travel experience are important when evaluating the patient with vaginitis and cervicitis. The patient's travel experience can be significant when administering empirical antimicrobial treatment, especially when treating suspected gonococcal cervicitis. N. gonorrhoeae acquired from Asia tends to be resistant to the antibiotics commonly administered in the United States to treat gonococcal infection. Therefore, all patients being evaluated for vaginitis should be evaluated for the coexistence of cervicitis.
To understand vaginitis and cervicitis one must understand what has been defined as a healthy vaginal microflora. The assumption is that Lactobacillus is a key factor in maintaining a healthy vaginal ecosystem; however, there are likely other important factors that are at play that maintain the vaginal ecosystem in a healthy state. Although there is still a significant void in our knowledge of all components of the vaginal ecosystem needed to maintain it in a healthy state, we do know that Lactobacillus does apparently have a significant role in maintaining dominance and suppresses the pathogenic bacteria. A healthy vaginal ecosystem is defined as an ecosystem that exhibits no symptoms (odorless; no itching, burning, or discomfort), discharge is white to slate gray, and microscopically the squamous epithelial cells are well estrogenized and there are ≤5 white blood cells seen microscopically at 40× magnification per field. The bacteria observed at 40× magnification are mostly large bacilli, and other bacterial morphotypes are rarely observed.
An understanding of the dynamics of endogenous vaginal microflora and its interaction with the vaginal ecosystem is emerging. The available data enable us to begin to understand the role of Lactobacillus in maintaining a healthy vaginal flora and possibly preventing infection of the lower as well as the upper genital tract. Lower genital infection or alterations of the endogenous vaginal microflora result in vaginitis.
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