ORIGINAL RESEARCH ARTICLE
Chronic Cervicitis: Presenting Features and Response
to Therapy
Shawn K. Mattson, MD, Julia P. Polk, MD, and Paul Nyirjesy, MD
Objectives: Chronic nongonococcal nonchlamydial cervicitis is a condi-
tion of unknown etiology. Data about treatment options are limited. Our
goal was to review a single center's experience in managing women with
chronic NGNCC.
Methods: We evaluated all encounters at a tertiary care center with ICD-9
code for cervicitis between April 2008 and March 2014. Cases were de-
fined by having two of the following 3 diagnostic criteria: mucopurulent
discharge noted by (1) patient or (2) practitioner, and (3) cervical bleeding
upon gentle probing. All women had negative nucleic acid amplification
testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomo-
nas vaginalis. Information regarding patient demographics, symptoms,
findings, treatment, and outcomes were analyzed. Cure was defined as res-
olution of patient-specific diagnostic criteria.
Results: Sixty-one women were identified. The mean age was 31 years;
73.7% were white, and 59% were nulliparous. The mean duration of symp-
toms was 25.2 months. Initially, all 61 patients received one of 3 antibiotic
treatments. The cure rate after initial antibiotic treatment was 65.6%. Nine-
teen patients required at least one further treatment. Additional treatments
included secondary antibiotics, hormonal treatments, vaginal hydrocortisone,
silver nitrate, cryotherapy, and loop excision electrosurgical procedure. Cure
rates were as follows: 57.9% with antibiotics, 50% with hormone treatment,
0% with hydrocortisone, 100% with silver nitrate, 0% with cryother-
apy, and 100% with loop electrosurgical excisional procedure. Of the
initial 61 women, 93.4% were eventually cured.
Conclusions: Nongonococcal nonchlamydial cervicitis is a condition
that can cause unremitting symptoms. Most patients will respond to antibi-
otics, although other treatments including surgery may be necessary.
Key Words: cervicitis, friability, mycoplasma genitalium,
chronic cervicitis
(J Low Genit Tract Dis 2016;20: e30–e33)
C ervicitis is a state of cervical inflammation that results in an
abnormal mucopurulent discharge and cervical friability.1
Chlamydia trachomatis and Neisseria gonorrhoeae are 2 common
sexually transmitted infections (STIs) known to cause clinical cer-
vicitis with or without symptoms.2 Collectively gonorrheal and
chlamydial diseases account for approximately 50% of the cases
of cervicitis; the etiology of the remaining cases is unknown.1–4
With at least 50% of cases of cervicitis not due to gonorrhea
or chlamydia, the suspected causes of these cases of nongonococ-
cal nonchlamydial cervicitis (NGNCC) remain unclear.2–6 Pro-
posed pathogens include Mycoplasma genitalium, Ureaplasma
urealyticum, U. parvum, Trichomonas vaginalis, and vaginal flora
associated with bacterial vaginosis (BV). In the case of the genital
Department of Obstetrics and Gynecology, Drexel University College of Med-
icine, Philadelphia, Pennsylvania
Reprint requests to: Shawn K. Mattson, MD, 817 N. 24th Street, Philadelphia,
PA. E-mail: shawn.mattson@drexelmed.edu
The authors have declared they have no conflicts of interest.
The results of this manuscript have been presented as a poster presentation at the
2015 Annual Meeting of the Infectious Diseases Society for Obstetrics and
Gynecology in Portland, Oregon.
IRB approval was obtained through the Drexel University College of Medicine
IRB (Protocol No. 1402002628).
© 2016, American Society for Colposcopy and Cervical Pathology
e30
Copyright © 2016 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
mycoplasmas, an absence of clinically available and validated
tests for these organisms, along with controversy regarding
their role and how best and whether to treat them, further com-
plicate clinical management.1,7–11 Similarly, the possible role
of viruses such as herpes simplex virus (HSV) and cytomegalo-
virus (CMV) in NGNCC is unclear.6
Given this multitude of unanswered questions surrounding
NGNCC, it is not surprising that there are no clear guidelines on
how to manage this condition. The 2015 CDC Sexually Trans-
mitted Diseases Treatment Guidelines recommend referral to a
gynecologic specialist in cases of persistent cervicitis, but there
is little guidance available to those specialists on how to man-
age these cases.12 Published information about management
options remains sparse. The Drexel Vaginitis Center, a tertiary
care program for women with chronic vulvovaginal symptoms,
is a center where women with NGNCC end up seeking care
when their first-line providers have been unable to help them.
The goal of this study was to review this center’s experience
in evaluating and treating women with NGNCC.
METHODS
Participants were selected from the Drexel Vaginitis Center, a
tertiary care center with approximately 500 new and 4300 return
patient encounters annually. Patients are typically referred to the
center with persistent or recurrent symptoms. Each new patient
undergoes a standardized history and examination, which includes
testing for vaginal pH, amines, saline, 10% KOH microscopy, as
well as any indicated additional testing.
A retrospective chart review was performed on all electronic
medical records from the Drexel Vaginitis Center between April 1,
2008, and March 1, 2014, with the ICD-9 code (616.0) for cervi-
citis. Charts were further analyzed, and only those that met criteria
for a clinical diagnosis of cervicitis were included. Any patient
who had an abnormal Pap smear was disqualified. The clinical
diagnosis of cervicitis was defined as at least 2 of the following
3 criteria: (1) a friable cervix, (2) symptoms of discharge as
described by the patient, or (3) evidence of mucopurulent dis-
charge on speculum exam as noted by the provider. The diag-
nosis, as well as any subsequent evaluation of cure, was made
by one of 3 providers: a gynecologist and one of 2 nurse prac-
titioners. Each patient had nucleic acid amplification tests
(NAAT) for N. gonorrhoeae, C. trachomatis, or T. vaginalis. A pos-
itive test for any of these 3 organisms at the time of cervicitis di-
agnosis excluded them from the study. Bacterial cultures were
obtained in a minority of patients where group A streptococcal
(GAS) infection was suspected. Once they became commercially
available, NAATs for M. genitalium, Mycoplasma hominis, and
U. urealyticum were also sent for each patient. All data were
analyzed with descriptive statistics. Institutional review board
approval was obtained from Drexel University College of
Medicine’s office of research to perform this study (IRB pro-
tocol no. 1402002628).
Additional data was collected on eligible patients, including
demographic information, gynecologic and obstetric history, and
social history. Clinical information regarding examination find-
ings, symptoms, treatments, and responses was recorded for all
subjects. Each patient received one of 3 initial treatment regimens:
Journal of Lower Genital Tract Disease • Volume 20, Number 3, July 2016
Journal of Lower Genital Tract Disease • Volume 20, Number 3, July 2016 Chronic Cervicitis

In general, patient management was individualized. There

TABLE 1. Demographics of Women With Cervicitis (n = 61) were no formal regimens. Additional treatments were given until
either a cure was reached or the patient was lost to follow-up. In
Age (mean, standard deviation) 31 yo, 8.55 yrs
cases where a patient’s symptoms were intractable to all the afore-
Marital status mentioned treatments, more invasive tactics such as cryotherapy
Single/separated 41 (67.2%) and loop electrosurgical excisional procedure (LEEP) were con-
Married 20 (32.8%) sidered. These treatments were used in the hopes that local cauter-
Partners in last year ization, freezing, or removal of the abnormal areas would lead to
changes and healing in the cervical epithelium that would de-
0 3 (4.9%)
crease patient symptoms and clinical findings.
1 33 (54.1%)
>1 18 (29.5%)
Unknown 7 (11.5%)
Race RESULTS
White 37 (60.7%) Of the estimated 3000+ new patients seen during the study
Asian 6 (9.8%) period, 71 women were identified as having cervicitis (based on
African American 5 (8.2%) ICD-9 codes and clinical criteria). Six of these women were ex-
Hispanic 1 (1.6%) cluded for having an active STI—including Neisseria
gonorrhoeae (n = 1), Chlamydia trachomatis (n = 4), or Tricho-
Not recorded 12 (19.7%)
monas vaginalis (n = 4). Therefore, 65 women met the study in-
Nulliparous 36 (59.0%) clusion criteria for NGNCC. Of those 65, an additional
Smoker 5 (8.2%) 4 patients were excluded because of incomplete charts or loss to
History of LEEP/cold knife cone 4 (6.6%) follow-up. The final analysis was of 61 patients. Demographic in-
History of abnormal Pap 23 (37.7%) formation for the 61 patients is presented in Table 1. Most patients
History of recurrent BV 19 (31.1%) were white and single and had either zero or one sexual partner in
History of recurrent yeast 39 (63.9%) the past year.
History of STI 27 (44.3%) Table 2 summarizes the clinical picture of the patient popula-
GC (% overall, % of STI) 1 (1.6%, 3.7%) tion. Although discharge was the most common complaint
CT (% overall, % of STI) 5 (8.2%, 18.5%) (n = 55, 90.2%), many women also had additional vulvovaginal
symptoms such as irritation, itching, burning, or dyspareunia.
HSV (% overall, % of STI) 4 (6.6%, 14.8%)
As can be expected in a population of women with persistent
HPV (% overall, % of STI) 21 (34.4%, 77.8%) NGNCC, more than 50% of patients had symptoms of more than
Trichomonas (% overall, % of STI) 5 (8.2%, 18.5%) a year's duration. In an effort to mitigate these frustrating symp-
toms from as many angles as possible, careful counseling regard-
ing skin care and hygiene habits was offered to patients when it
was deemed clinically appropriate.
azithromycin 500 mg 2 pills together, followed by once daily In certain instances and given the clinical suspicion, aerobic
for 14 days, doxycycline 100 mg twice daily for 14 days, or bacterial cultures were performed to look for potential pathogens
moxifloxacin 400 mg daily for 14 days. These therapies were such as group A Streptococcus (GAS). None of the 9 cultures per-
designed to target the presumed bacterial causes of NGNCC. formed were positive for either GAS or Staphylococcus aureus.
Patients then returned for a follow-up appointment 4 to
6 weeks after initiation of treatment. At this time, the physical
examination was repeated, and symptoms were assessed for
TABLE 2. Initial Presentation for Women With Cervicitis (n = 61)
improvement. A clinical cure was defined by resolution of cervi-
cal friability and/or discharge (whichever findings were present
Symptoms
upon diagnosis). Symptomatic cure was defined as a reduction
in subjective symptoms by 50% or more. Clinical cure did Abnormal discharge 55 (90.2%)
not always correlate with a symptomatic cure. For the purposes Irritation 39 (63.9%)
of this study, when it is not explicitly stated, “cure” refers to a Itching 35 (57.4%)
clinical cure. Patients who were not cured at their last follow-up Odor 27 (44.3%)
visit and were then lost to follow-up were categorized as being Burning 26 (42.6%)
not cured. Dyspareunia 24 (39.3%)
Patients who were not cured by the initial therapeutic ap- Intermenstrual vaginal bleeding 21 (34.4%)
proach were treated with one of 11 possible secondary treatments. Vaginal bleeding with coitus 16 (26.2%)
The secondary tier therapies that were pursued included hormonal
Urinary 7 (11.5%)
treatments (depot medroxyprogesterone 150 mg every 3 months 
Symptom duration
2 doses, estradiol cream 1g vaginally twice a week for a minimum
of a month), additional antibiotics (clindamycin cream nightly Average, standard deviation 25.2 mo (30.2 mo)
for 14 days, doxycycline, azithromycin, or moxifloxacin as ≤1 mo 10 (16.4%)
previously described), silver nitrate applied to the cervix, and >1–3 mo 7 (11.5%)
vaginal hydrocortisone (10% cream, 3 g nightly for a minimum >3–12 mo 12 (19.7%)
of 2 weeks). If further treatment was required, the approach was >12 mo 32 (52.5%)
generally to use a different class of antibiotics or depot medroxy- Physical findings
progesterone if no contraindication existed. If, at any point, an Discharge 46 (75.4%)
area of isolated cervical friability was found, then in-office silver Friability 43 (70.5%)
nitrate was added to the regimen.

© 2016, American Society for Colposcopy and Cervical Pathology e31

Copyright © 2016 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Mattson et al. Journal of Lower Genital Tract Disease • Volume 20, Number 3, July 2016
All the cultures were reported as growing "normal vaginal flora.”
Two (22.8%) of the 9 cultures grew group B streptococci.
Thirty women had testing through commercial laborato-
ries by NAAT for genital mycoplasmas. No patient tested pos-
itive for M. genitalium. In most cases, no testing was available
for individual Ureaplasma spp, and results were reported as either
positive or negative for Ureaplasma spp. Five women (16.7%)
were positive for M. hominis, and eight (26.7%) were positive
for Ureaplasma spp. Of those, 3 (10%) were positive for both
M. hominis and Ureaplasma spp.
As part of the routine workup, all women were tested for bac-
terial vaginosis (BV) using Amsel's criteria. Of the 61 patients,
two were positive for BV. Both women were treated, and both
had resolution of their symptoms. One woman was treated with
doxycycline and clindesse 2% cream, and she reported resolution
of her symptoms (although she was not objectively evaluated as
she missed her follow-up appointment). The second woman was
treated with the standard 7-day course of metronidazole 500 mg
twice daily, and at her follow-up visit 3 weeks later, there was no
longer evidence of BV.
The first-line treatment for all women with NGNCC was a
course of antibiotics. The most commonly prescribed were
azithromycin, doxycycline, and moxifloxacin. With an initial
course of one of these antibiotics, 30 (49.2%) of 61 women
were cured; 25 (65.8%) of 38 with azithromycin, 11 (78.6%)
of 14 with doxycycline, and 4 (44.4%) of 9 with moxifloxacin.
Nineteen patients (31.1%) required at least one further treat-
ment, and 8 (57.9%) of them received treatment with a second
antibiotic regimen. Eight patients received antibiotics as second-
line therapy. Of these 8 patients, 3 (37.5%) achieved cure, 1 with
azithromycin (100%), 2 with moxifloxacin (40%), and none
with doxycycline.
After antibiotic therapy, alternate second-line therapy includ-
ing depot medroxyprogesterone, vaginal hydrocortisone cream or
silver nitrate was given to 11 patients. Five (45.5%) received depot
medroxyprogesterone; 3 (60%) of those 5 were cured. Three women
(27.2%) received hydrocortisone cream, and 3 also received silver
nitrate for isolated areas of cervical friability. All of the 3 women
who received hydrocortisone cream necessitated further treat-
ment. The 3 women who received silver nitrate were cured.
Ten (16.4%) of the original 61 women required 3 or more
treatments, and of those ten 9 achieved a cure. Novel third- and
fourth-line treatments included clindamycin cream (2/3 cured),
cryotherapy (0/1 cured), estradiol cream (1/1 cured), and as a last
resort, anLEEP procedure (2/2 cured).
The last element of our investigation included an analysis
of therapeutic outcomes specifically for patients who tested
positive for genital mycoplasma. We looked explicitly at whether
there was an association between a positive test for genital myco-
plasmas or for Ureaplasma spp. alone and cure from a single
antibiotic regimen. The analysis was performed using a chi-
square model. We found that the presence of a positive test
for any genital mycoplasma (P = 0.273) or for Ureaplasma
spp. alone (P = 0.454) was not associated with cure from one
of the first-line antibiotic regimens. These patients were not
routinely sampled for a test of cure.
Overall, of the 61 patients with at least one follow-up visit,
57 (93.4%) were cured, and 4 (6.6%) were not cured. Forty
(70.2%) were cured with a single treatment, 9 (15.8%) were
cured with 2 treatments, and 8 (14.0%) were cured with 3 or
more treatments.
DISCUSSION
To our knowledge, there are no good estimates of how
commonly NGNCC occurs. Despite approximately 500 new
e32
Copyright © 2016 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
annual patient encounters at the Drexel Vaginitis Center, only
65 cases were encountered over a 6-year period. In other pop-
ulations, NGNCC may be similarly uncommon. For example,
in a randomized control multicenter trial by Taylor and col-
leagues evaluating antibiotic treatment of NGNCC in patients
attending STI and family planning clinics, there were insuffi-
cient cases to complete enrollment.3 Nevertheless, for this
presumably small percentage of women who have this condi-
tion and the gynecologists who take care of them, the trouble-
some symptoms and lack of reliable treatment regimens is
particularly frustrating.
As discussed earlier, the cause of NGNCC is unknown. My-
coplasma genitalium, a urogenital pathogen known to cause STIs
in men and women, has been recently associated with cervicitis in
women with high-risk sexual behavior.8–10,13 Multiple studies
have shown a statistically significant 2- to 3-fold greater risk of
cervicitis when Mycoplasma genitalium is detected using poly-
merase chain reaction.5,9–11 Despite these data, there is insuffi-
cient evidence to support a causal link between clinical disease
(including symptomatic cervicitis and pelvic inflammatory dis-
ease) and the presence of M. genitalium.3,7,14 There is a lack of
consensus regarding the true prevalence of M. genitalium, further
propagated by the current lack of FDA-approved validated diag-
nostic test and lack of standardized treatment guidelines.5–8,12,15
In our study, there were no patients who tested positive for
M. genitalium. Over a quarter of these patients were positive for
Ureaplasma spp. Ureaplasmas are commonly isolated bacteria
of the female genital tract. There are 2 predominant species that
are recognized: Ureaplasma urealyticum and U. parvum. Their
overall prevalence rate among sexually active women is high
(12%–64%); however, the literature to date has failed to show
a linkage between carriage of either species and cervicitis.7 Our
study was unable to address the pathogenic role of Ureaplasma
spp. in causing cervicitis, as we did not routinely perform tests
of cure. We found no clear correlation between positive NAAT
for Ureaplasma and clinical response to appropriate antibiotic
therapy. It should be emphasized that our results could be due
to referral bias to our clinic or the fact that we were using com-
mercially available NAATs to test for genital mycoplasmas in-
stead of validated diagnostic tests. Nevertheless, this limitation
reflects the real-life challenges that other clinicians treating
women with NGNCC face.
Despite not knowing the cause of NGNCC, most patients can
be adequately treated with resolution of symptoms and signs. Our
results indicate that antibiotics are an appropriate initial treatment
option. Few other studies have shown improved or resolved
symptoms with antibiotics; however, the ideal regimen has
not been defined and previous results are mixed.15,16 For instance,
Taylor et al randomized women with “idiopathic mucopurulent
cervicitis” (NGNCC) to receive either placebo or cefixime and
azithromycin, and found at the 2-month follow-up that 33%
of those in the placebo arm were cured versus 19% in the treat-
ment arm.3 Additionally, Paavonen et al showed high rates
of persistent or recurrent cervicitis in a cohort of patients with
NGNCC 3 months after treatment with either doxycycline (23%)
or amoxicillin (33%).16 The Centers for Disease Control and
Prevention (CDC)12 recommend empirical antibiotic therapy
of cervicitis only in women at high risk of STI and suggest cov-
erage for C. trachomatis and N. gonorrhoeae. Furthermore,
they report that prolonged or repeated antibiotics has unknown
benefit at this time. Our results suggest that antibiotics can be
effective in women with NGNCC, even when they are not at
high risk for STI. Although antibiotics may be an appropriate
initial strategy in the treatment of cervicitis, given the lack of
response of many patients, it is reasonable to wonder whether
in some cases the cause of chronic cervicitis may be related
© 2016, American Society for Colposcopy and Cervical Pathology
Journal of Lower Genital Tract Disease • Volume 20, Number 3, July 2016
to other factors—such as the inflammation or association with
a cervical ectropion.
For second-line treatments, there is no standard indicated
therapy; however, additional antibiotics may be helpful. The
CDC, although it offers some guidance for first-line treatment
of cervicitis, does not address additional therapies. Our results
indicate that a second course of treatment with a different anti-
biotic may also be useful in women with NGNCC.
The use of nonantibiotic therapies is poorly described in
the literature. Topical estrogen, although well tolerated, proved
unhelpful in our study. For anecdotal reasons, we used depot
medroxyprogesterone, which proved successful in some cases.
Similarly, the simple application of silver nitrate to areas of
bleeding on the cervix also showed promise in refractory patients.
Finally, our results with cryotherapy and LEEP, described else-
where, indicate that surgical therapy may be a viable option for
the truly refractory patient. The thought was that some disruption
in the cervical epithelium might generate changes in the cervical
epithelium that might help promote healing and decrease patient
symptoms. Although these modalities are used in clinical practice
when other options have failed, to our knowledge, this is the first
published report of their effectiveness in women with NGNCC.
As a descriptive study of a unique patient population, our
results are hampered with clear limitations. First of all, our
numbers are small. In accordance with CDC guidelines, the di-
agnosis of NGNCC was purely clinical. CDC guidelines state
that cervicitis is characterized by 2 major diagnostic criteria:
“purulent or mucopurulent endocervical exudate” and “sustained
endocervical bleeding easily induced by passage of cotton
swab”.16 Similarly, definitions of cure and failure were a func-
tion of patient symptoms and physical examination, all of
which could be influenced by the knowledge that all patients re-
ceived active treatment. Apart from routine testing for gonorrhea,
chlamydia, trichomoniasis, and bacterial vaginosis, testing for
other potential pathogens was limited by test availability and qual-
ity. As a clinical center focusing on patient care, treatments were
individualized, and there were no control groups.
CONCLUSIONS
Nongonococcal nonchlamydial cervicitis is an uncommon
reason for referral to a tertiary-care vaginitis center. Although
our results do not shed any light on potential causes for cervi-
citis, we found that a majority (59%) of patients could be cured
with 1 or 2 courses of antibiotics. For those patients refractory
to antibiotic therapy, topical silver nitrate, depot medroxypro-
gesterone, cryotherapy, or even LEEP are possible thera-
peutic options. These treatment strategies would be an
interesting subject for a prospective study or controlled trial.
However, given the relatively small number of cases we en-
countered, we anticipate that future efforts at performing
© 2016, American Society for Colposcopy and Cervical Pathology
Copyright © 2016 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Chronic Cervicitis
randomized controlled multicenter studies may be difficult
to complete successfully.17
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