For women with PID of mild to moderate severity, parenteral and oral therapies appear to be effective. [ 36 ] [ 37 ]   It does not matter to their short- or long-term outcome whether antibiotics are administered to them as inpatients or outpatients. [ 38 ]  Typical regimens include  cefoxitin  or  cefotetan  plus  doxycycline , and  clindamycin  plus  gentamicin . An alternative parenteral regimen is  ampicillin / sulbactam  plus doxycycline.  Erythromycin -based medications can also be used. [ 39 ]  A single study suggests superiority of azithromycin over doxycycline. [ 34 ]  Another alternative is to use a parenteral regimen with  ceftriaxone  or cefoxitin plus doxycycline. [ 27 ]   Clinical experience guides decisions regarding transition from parenteral to oral therapy, which usually can be initiated within 24–48 hours of clinical improvement. [ 29 ]


Early diagnosis and immediate treatment are vital in reducing the chances of later complications from PID. Delaying treatment for even a few days could greatly increase the chances of further complications. Even when the PID infection is cured, effects of the infection may be permanent, or long lasting. This makes early identification essential.


A limitation of this is that diagnostic tests are not included in routine check-ups, and cannot be done using signs and symptoms alone; the required diagnostic tests are more invasive than that. [ 40 ]  Treatment resulting in cure is very important in the prevention of damage to the  reproductive system . Around 20 percent of women with PID develop infertility. [ 40 ]  Even women who do not experience intense symptoms or are asymptomatic can become infertile. [ 41 ]  This can be caused by the formation of scar tissue due to one or more episodes of PID, and can lead to tubal blockage. Both of these increase the risk of the inability to get pregnant, [ 27 ]  and 1% results in an ectopic pregnancy. [ 40 ]  Chronic pelvic/abdominal pain develops post PID 40% of the time. [ 40 ]  Certain occurrences such as a post pelvic operation, the period of time immediately after childbirth ( postpartum ),  miscarriage  or  abortion  increase the risk of acquiring another infection leading to PID. [ 27 ]


Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008. [ 10 ]  The number of cases of PID; however, is not clear. [ 8 ] This is largely due to diagnostic tests being invasive and not included in routine check-ups, despite PID being the most common reason for individuals to admit themselves under gynecological care. [ 40 ]  It is estimated to affect about 1.5 percent of young women yearly. [ 8 ]  In the United States PID is estimated to affect about one million people yearly. [ 12 ]  Rates are highest with teenagers and first time mothers. PID causes over 100,000 women to become  infertile  in the US each year. [ 27 ] [ 42 ]


Records show that...


Despite the indications of a general decrease in PID rates, there is an observed rise in the prevalence of gonorrhea and chlamydia. With that, in order to decrease the prevalence of PID, one should test for gonorrhea and chlamydia. [ 35 ]


Two nationally representative probability surveys referenced are the National Health and Nutrition Examination Survey (NHANES) and the National Survey of Family Growth (NSFG) surveyed women aged 18 to 44 from 2013 to 2014. [ 43 ]


The results:


A  sexually transmitted infection  ( STI ), also referred to as a  sexually transmitted disease  ( STD ) and the older term  venereal disease  ( VD ), is an  infection  that is  spread  by  sexual activity , especially  vaginal intercourse ,  anal sex ,  oral sex , or sometimes  manual sex . [ 1 ] [ 5 ] [ 6 ]  STIs often do not initially cause symptoms, [ 1 ]  which results in a risk of transmitting them on to others. [ 7 ] [ 8 ]  The term  sexually transmitted infection  is generally preferred over  sexually transmitted disease  or  venereal disease , as it includes cases with no  symptomatic disease . [ 9 ]  Symptoms and signs of STIs may include  vaginal discharge ,  penile discharge ,  ulcers on or around the genitals , and  pelvic pain . [ 1 ]  Some STIs can cause  infertility . [ 1 ]


Bacterial STIs include  chlamydia ,  gonorrhea , and  syphilis . [ 1 ]  Viral STIs include  genital warts ,  genital herpes , and  HIV/AIDS . [ 1 ]  Parasitic STIs include  trichomoniasis . [ 1 ]  Most STIs are treatable and curable; of the most common infections, syphilis, gonorrhea, chlamydia, and trichomoniasis are curable, while HIV/AIDS and genital herpes are not curable. [ 1 ]  Some  vaccinations  may decrease the risk of certain infections including  hepatitis B  and few types of  HPV . [ 2 ]   Safe sex  practices such as use of  condoms , having smaller number of sexual partners, and being in a relationship in which each person only has sex with the other also decreases STIs risk. [ 1 ] [ 2 ]   Comprehensive sex education  may also be useful. [ 10 ]


STI diagnostic tests are usually easily available in the  developed world , but they are often unavailable in the  developing world . [ 1 ]  There is often shame and  stigma  associated with STIs. [ 1 ]  In 2015, STIs other than HIV resulted in 108,000 deaths worldwide. [ 4 ]  Globally, in 2015, about 1.1 billion people had STIs other than HIV/AIDS. [ 3 ]  About 500 million have either syphilis, gonorrhea, chlamydia or trichomoniasis. [ 1 ]  At least an additional 530 million have genital herpes, and 290 million women have  human papillomavirus . [ 1 ]  Historical documentation of STIs in  antiquity  dates back to at least the  Ebers Papyrus  ( c.  1550 BCE ) and the  Hebrew Bible / Old Testament  (8th/7th C. BCE). [ 11 ]


Not all STIs are  symptomatic , and symptoms may not appear immediately after infection. In some instances a disease can be carried with no symptoms, which leaves a greater risk of passing the disease on to others. Depending on the disease, some untreated STIs can lead to  infertility ,  chronic pain  or death. [ 12 ]


The presence of an STI in  prepubescent  children may indicate  sexual abuse . [ 13 ]


A sexually transmitted infection present in a pregnant woman may be passed on to the infant before or after birth. [ 14 ]


Sexually transmitted infections include:


Twenty-seven different viruses have been identified in semen. Information on whether or not transmission occurs or whether the viruses cause disease is uncertain. Some of these microbes are known to be sexually transmitted. [ 76 ]


Many STIs are (more easily) transmitted through the  mucous membranes  of the  penis ,  vulva ,  rectum ,  urinary tract  and (less often—depending on type of infection) the  mouth ,  throat ,  respiratory tract  and  eyes . [ 77 ]  The visible membrane covering the  head of the penis  is a mucous membrane, though it produces no  mucus  (similar to the  lips  of the mouth). Mucous membranes differ from  skin  in that they allow certain pathogens into the body. The amount of contact with infective sources which causes infection varies with each pathogen but in all cases, a disease may result from even light contact from fluid carriers like venereal fluids onto a mucous membrane. [ citation needed ]


Some STIs such as HIV can be transmitted from mother to child either during pregnancy or breastfeeding. [ 78 ] [ 79 ]
Healthcare professionals suggest  safer sex , such as the use of  condoms , as a reliable way of decreasing the risk of contracting sexually transmitted infections during sexual activity, but safer sex cannot be considered to provide complete protection from an STI. The transfer of and exposure to bodily fluids, such as  blood transfusions  and other blood products, sharing injection  needles , needle-stick injuries (when medical staff are inadvertently jabbed or pricked with needles during medical procedures), sharing  tattoo  needles, and childbirth are other avenues of transmission. These different means put certain groups, such as medical workers, and  haemophiliacs  and drug users, particularly at risk. [ citation needed ]


It is possible to be an  asymptomatic  carrier of sexually transmitted infections. In particular, sexually transmitted infections in women often cause the serious condition of pelvic inflammatory disease. [ 80 ]


Testing  may be for a single infection, or consist of a number of tests for a range of STIs, including tests for  syphilis ,  trichomonas , gonorrhea,  chlamydia ,  herpes ,  hepatitis , and  HIV . No procedure tests for all infectious agents.


STI tests may be used for a number of reasons:


Early identification and treatment results in less chance to spread disease, and for some conditions may improve the outcomes of treatment. There is often a  window period  after initial infection during which an STI test will be negative. During this period, the infection may be transmissible. The duration of this period varies depending on the infection and the test. Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional. One report indicated that people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems. [ 81 ]


Until the 1990s, [ citation needed ]  STIs were commonly known as  venereal diseases , an antiquated  euphemism  derived from the Latin  venereus , being the adjectival form of  Venus , the  Roman goddess  of love. [ 82 ]  However, in the post-classical education era the euphemistic effect was entirely lost, and the common abbreviation "VD" held only negative connotations. Other former euphemisms for STIs include "blood diseases" and "social diseases". [ 83 ]  The present euphemism is in the use of the initials "STI" rather than in the words they represent. The  World Health Organization  (WHO) has recommended the more inclusive term  sexually transmitted infection  since 1999. [ 9 ]   Public health  officials originally introduced the term  sexually transmitted infection , which clinicians are increasingly using alongside the term  sexually transmitted disease  in order to distinguish it from the former. [ citation needed ]


Strategies for reducing STI risk include: vaccination,  mutual monogamy , reducing the number of sexual partners, and abstinence. [ 84 ]  Also potentially helpful is behavioral counseling for sexually active adolescents and for adults who are at increased risk. [ 85 ]  Such interactive counseling, which can be resource-intensive, is directed at a person's risk, the situations in which risk occurs, and the use of personalized goal-setting strategies. [ 86 ]


The most effective way to prevent sexual transmission of STIs is to avoid contact of body parts or fluids which can lead to transfer with an infected partner. Not all sexual activities involve contact:  cybersex ,  phone sex  or  masturbation  from a distance are methods of avoiding contact. Proper use of condoms reduces contact and risk. Although a condom is effective in limiting exposure, some disease transmission may occur even with a condom. [ 87 ]


Both partners can get tested for STIs before initiating sexual contact, or before resuming contact if a partner engaged in contact with someone else. Many infections are not detectable immediately after exposure, so enough time must be allowed between possible exposures and testing for the tests to be accurate. Certain STIs, particularly certain persistent viruses like HPV, may be impossible to detect. [ medical citation needed ]


Some treatment facilities use in-home test kits and have the person return the test for follow-up. Other facilities strongly encourage that those previously infected return to ensure that the infection has been eliminated. Novel strategies to foster re-testing have been the use of text messaging and email as reminders. These types of reminders are now used in addition to phone calls and letters. [ 88 ]  After obtaining a sexual history, a healthcare provider can encourage risk reduction by providing prevention  counseling . Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the person's culture, language, gender, sexual orientation, age, and developmental level. Prevention counseling for STIs is usually offered to all sexually active adolescents and to all adults who have received a diagnosis, have had an STI in the past year, or have  multiple sex partners . [ 86 ]


Vaccines are available that protect against some viral STIs, such as  hepatitis A ,  hepatitis B , and some types of  HPV . [ 89 ]  Vaccination before initiation of sexual contact is advised to assure maximal protection. The development of vaccines to protect against gonorrhea is ongoing. [ 90 ]


Condoms and  female condoms  only provide protection when used properly as a barrier, and only to and from the area that they cover. Uncovered areas are still susceptible to many STIs. [ citation needed ]


In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin; therefore, properly shielding the penis with a properly worn condom from the vagina or anus effectively stops HIV transmission. An infected fluid to broken skin borne direct transmission of HIV would not be considered "sexually transmitted", but can still theoretically occur during sexual contact. This can be avoided simply by not engaging in sexual contact when presenting open, bleeding wounds. [ citation needed ]


Other STIs, even viral infections, can be prevented with the use of latex, polyurethane or polyisoprene condoms as a barrier. Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms but are still too large to pass through latex or synthetic condoms. [ citation needed ]


Proper male condom usage entails: [ citation needed ]


In order to best protect oneself and the partner from STIs, the old condom and its contents are to be treated as infectious and properly disposed of. A new condom is used for each act of intercourse, as multiple usages increase the chance of breakage, defeating the effectiveness as a barrier. [ citation needed ]


In the case of female condoms, the device consists of two rings, one in each terminal portion. The larger ring should fit snugly over the cervix and the smaller ring remains outside the vagina, covering the vulva. This system provides some protection of the external genitalia. [ 91 ]


The  cap  was developed after the cervical  diaphragm . Both cover the cervix and the main difference between the diaphragm and the cap is that the latter must be used only once, using a new one in each sexual act. The diaphragm, however, can be used more than once. These two devices partially protect against STIs (they do not protect against HIV). [ 92 ]


Researchers had hoped that  nonoxynol-9 , a vaginal microbicide would help decrease STI risk.  Trials, however, have found it ineffective [ 93 ]  and it may put women at a higher risk of HIV infection. [ 94 ]  There is evidence that vaginal  dapivirine  probably reduces HIV in women who have sex with men, other types of vaginal microbicides have not demonstrated effectiveness for HIV or STIs. [ 95 ]


There is little evidence that school-based interventions such as sexual and reproductive health education programmes on contraceptive choices and condoms are effective on improving the sexual and reproductive health of adolescents. Incentive-based programmes may reduce adolescent pregnancy but more data is needed to confirm this. [ 96 ]


Specific age groups, persons who participate in risky sexual behavior, or those have certain health conditions may require screening. The CDC recommends that sexually active women under the age of 25 and those over 25 at risk should be screened for chlamydia and gonorrhea yearly. Appropriate times for screening are during regular pelvic examinations and preconception evaluations. [ 97 ]   Nucleic acid amplification tests  are the recommended method of diagnosis for gonorrhea and chlamydia. [ 98 ]  This can be done on either urine in both men and women, vaginal or cervical swabs in women, or urethral swabs in men. [ 98 ]  Screening can be performed:


In the case of rape, the person can be treated prophylacticly with antibiotics. [ 99 ]


An option for treating partners of patients ( index cases ) diagnosed with  chlamydia  or gonorrhea is  patient-delivered partner therapy , which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to their partner without the health care provider first examining the partner. [ 100 ] [ needs update ]  In term of preventing reinfection in sexually transmitted infection, treatment with both patient and the sexual partner of patient resulted in more successful than treatment of the patient without the sexual partner. There is no difference in reinfection prevention whether the sexual partner treated with medication without medical examination or after notification by patient. [ 101 ]


In 2008, it was estimated that 500 million people were infected with either syphilis, gonorrhea, chlamydia or trichomoniasis. [ 1 ]  At least an additional 530 million people have genital herpes and 290 million women have  human papillomavirus  (HPV). [ 1 ]  STIs other than HIV resulted in 142,000 deaths in 2013. [ 103 ]  In the United States there were 19 million new cases of sexually transmitted infections in 2010. [ 104 ]


In 2010, 19 million new cases of sexually transmitted infections occurred in women in the United States. [ 5 ]  A 2008  CDC  study found that 25–40% of U.S. teenage girls has a sexually transmitted infection. [ 105 ] [ 106 ]  Out of a population of almost 295,270,000 people [ 107 ]  there were 110 million new and existing cases of eight sexually transmitted infections. [ 108 ]


Over 400,000 sexually transmitted infections were reported in England in 2017, about the same as in 2016, but there were more than 20% increases in confirmed cases of gonorrhoea and syphilis. Since 2008 syphilis cases have risen by 148%, from 2,874 to 7,137, mostly among  men who have sex with men . The number of first cases of genital warts in 2017 among girls aged 15–17 years was just 441, 90% less than in 2009 – attributed to the national HPV immunisation programme. [ 109 ]


AIDS  is among the leading causes of death in present-day  Sub-Saharan Africa . [ 110 ]  HIV/AIDS is transmitted primarily via unprotected sexual intercourse. More than 1.1 million persons are living with  HIV/AIDS in the United States , [ 111 ]  and it disproportionately impacts  African Americans . [ 112 ]   Hepatitis B  is also considered a sexually transmitted infection because it can be spread through sexual contact. [ 113 ]  The highest rates are found in Asia and Africa and lower rates are in the Americas and Europe. [ 114 ]  Approximately two billion people worldwide have been infected with the hepatitis B virus. [ 115 ]


The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging  Naples  in the  Italian War of 1494–98 . [ 116 ]  The disease may have originated from the  Columbian Exchange . [ 117 ] [ 118 ]  From Naples, the disease swept across  Europe , killing more than five million people. [ 119 ]  As  Jared Diamond  describes it, "[W]hen syphilis was first definitely recorded in Europe in 1495, its  pustules  often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months," rendering it far more  fatal  than it is today. Diamond concludes, "[B]y 1546, the disease had evolved into the disease with the symptoms so well known to us today." [ 120 ] [ better source needed ]  Gonorrhea is recorded at least up to 700 years ago and associated with a district in Paris formerly known as "Le Clapiers". This is where the prostitutes were to be found at that time. [ 90 ]


Prior to the invention of modern medicines, sexually transmitted infections were generally incurable, and treatment was limited to treating the symptoms of the infection. The first voluntary hospital for STIs was founded in 1746 at  London Lock Hospital . [ 121 ]  Treatment was not always voluntary: in the second half of the 19th century, the  Contagious Diseases Acts  were used to arrest suspected prostitutes. In 1924, a number of states concluded the  Brussels Agreement , whereby states agreed to provide free or low-cost medical treatment at ports for merchant seamen with STIs. A proponent of these approaches was  Nora Wattie , OBE, Venereal Diseases Officer in Glasgow from 1929, encouraged  contact tracing  and volunteering for treatment, rather than the prevailing more judgemental view and published her own research on improving sex education and maternity care. [ 122 ]


The first effective treatment for a sexually transmitted infection was  salvarsan , a treatment for syphilis. With the discovery of  antibiotics , a large number of sexually transmitted infections became easily curable, and this, combined with effective public health campaigns against STIs, led to a public perception during the 1960s and 1970s that they have ceased to be a serious medical threat. [ citation needed ]


During this period, the importance of contact tracing in treating STIs was recognized. By tracing the sexual partners of infected individuals, testing them for infection, treating the infected and tracing their contacts, in turn, STI clinics could effectively suppress infections in the general population. [ citation needed ]


In the 1980s, first genital herpes and then  AIDS  emerged into the public consciousness as sexually transmitted infections that could not be cured by modern medicine. AIDS, in particular, has a long asymptomatic period—during which time  HIV  (the human immunodeficiency virus, which causes AIDS) can replicate and the disease can be transmitted to others—followed by a symptomatic period, which leads rapidly to death unless treated. HIV/AIDS entered the United States from Haiti in about 1969. [ 123 ]  Recognition that AIDS threatened a global  pandemic  led to public information campaigns and the development of treatments that allow AIDS to be managed by suppressing the replication of HIV for as long as possible. Contact tracing continues to be an important measure, even when diseases are incurable, as it helps to contain infection.


Multiple sex partners  (MSP) is the measure and incidence of engaging in  sexual activities  with two or more people within a specific time period. Sexual activity with MSP can happen simultaneously or serially. MSP includes sexual activity between people of a different  gender  or the same gender.


The term  polyamorous  is a behavior and not a measure describing multiple sexual relationships at the same time. [ 1 ]


Young people having MSP in the last year is an indicator used by the  Centers for Disease Control and Prevention  (CDC) in evaluating  risky sexual behavior  in  adolescents  and a tool in the monitoring of changes in HIV/AIDS infection rates and deaths worldwide. [ 2 ]


Epidemiologists and clinicians who quantify risks associated with MSP do so to identify those who have had sexual intercourse with more than one partner in the past 12 months. For the purposes of the  World Health Organization  (WHO)'s effort to eliminate  HIV  infection, quantifying measures progress in reducing the percentage of those with  AIDS . The World Health Organization (WHO) has described their rationale by assuming that the spread of HIV in most locales depends upon the number of  MSP. Those who have MSP possess a higher risk of HIV transmission than individuals that do not have multiple sex partners. [ 3 ]


WHO uses indicators, such as MSP, age, mortality, morbidity, geographical location and signs and  symptoms  of disease. This is done so that change can be measured and so that the effect of indicators can be assessed. [ 3 ]


Following the initial quantification of the number of MSP, the respondent is again surveyed three and then five years later. In addition to the survey, respondents' sexual histories are obtained. Analysis assists those conducting the study to verify and help define the term MSP. [ 3 ]


For the indicator MSP, WHO has defined a summary of what it measures, rationale for the indicator, numerator, denominator and calculation, recommended measurement tools,  measurement, frequency, and the strengths and weaknesses of the indicator. [ 3 ]


WHO's definition of MSP has some strengths and weaknesses The quantification is an indicator and a picture of the levels of higher-risk sex in a locale. If those surveyed changed their activity to one sexual partner, the change will be quantified by changes in the indicator. This disadvantage is that though a respondent may reduce the number of MSP in a 12-month period, the indicator will not reflect this change in sexual activity. Even so, decreasing the number of MSP may not indicate a change. Potentially this definition and quantification may have a significant impact on the pandemic of HIV and used as a measure of program success. WHO recommends that additional indicators that quantify MSP more precisely to capture the reduction in multiple sexual partners in general. [ 3 ] [ 4 ]  According to the CDC's Youth Risk Behavior Surveillance System, having multiple sex partners has been quantified to mean that   those greater than or equal to age 25 had four or more sexual partners in one year. [ 5 ]


Epidemiologists in Tanzania used the indicator MSP in their study of AIDS incidence among 15-19-year-olds by documenting the respondent as being sexually active and having MSP in the last 12 months. [ 6 ]


A complete medical history includes an assessment of the number sexual partners with which a person has had within a certain time period. [ 7 ]


A social history (abbreviated "SocHx") that part of a medical exam addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically important. [ 8 ]  MSP is only the description of the behavior described in clinical terms.  Promiscuity  can mean that a moral judgement is made because some parts of societies promote sexual activity to occur only within exclusive, single-partner, committed relationships. [ 9 ]  is often the way researchers define a society's promiscuity levels at any given time.  MSP increases the risk of many diseases and other conditions.


The CDC in the past has quantified  MSP for adolescents with the following descriptions: [ citation needed ]


Some clinicians define MSP by also taking into account concurrent sexual relationships. [ 11 ]


The likelihood of developing substance abuse or dependence increases linearly with the number of sex partners, an effect more pronounced for women. People who have a higher number of sex partners do not have higher rates of anxiety or depression. [ 12 ] [ 13 ]  A Durex Global Sex Survey found that men in New Zealand had claimed an average of 44 sex partners over their lifetime. [ 14 ]


MSP increases the risk of developing bacterial vaginosis. [ 15 ]  MSP can result in pregnant women with a greater risk of contracting HIV. [ 16 ]  HIV is strongly associated with having MSP. [ 17 ]  Having multiple sex partners is associated with higher incidences of STIs. [ 18 ]


Prevention of disease strategies include intensive counseling of those who have met the definition of multiple sex partners. [ 8 ]


In Jamaica, one of the primary contributing associations to the AIDS/HIV epidemic is the risky behavior of having multiple sex partners. A 2004 Behavioral Surveillance Survey demonstrated that 89 percent of males and 78 percent of females aged 15 to 24 had sex with a nonmarital or noncohabitating partner in the preceding 12 months. Fifty-six percent of males and 16 percent of females had multiple sex partners in the preceding 12 months. [ 19 ]


In Sub-Saharan Africa, travel and wealth is a risk factor in engaging in sexual activities with multiple sex partners. [ 20 ]


Risky sexual behavior  is the description of the activity that will increase the probability that a person engaging in  sexual activity  with another person infected with a  sexually transmitted infection  will be  infected , [ 1 ] [ 2 ] [ 3 ]  become  unintentionally pregnant , or make a partner pregnant. It can mean two similar things: the behavior itself, and the description of the partner's behavior. [ 1 ]


The behavior could be unprotected  vaginal ,  oral ,  anal , or  non-penetrative manual intercourse . The partner could be a  non-exclusive sexual partner ,  HIV-positive , and/or an  intravenous drug user . [ 1 ] [ 2 ] [ 4 ]


Risky sexual behaviors can include: [ 5 ]


Risky sexual behavior includes  unprotected intercourse ,  multiple sexual partners , and  illicit drug use . [ 1 ] [ 2 ] [ 10 ]  The use of  alcoholic drinks  and  illicit drugs  greatly increases the risk of  gonorrhea ,  chlamydia ,  trichomoniasis ,  hepatitis B , and  HIV/AIDS . [ 2 ]  Trauma from penile-anal sex has been identified as a risky sexual behavior. [ 11 ]


Risky sexual behaviors can lead to serious consequences both for person and their partner(s). This sometimes includes  cervical cancer ,  ectopic pregnancy , and  infertility . [ 4 ]  An association exists between those with a higher incidence of  body modifications  (such as  body piercings  and  tattoos ) and risky sexual behaviors. [ 11 ]


According to the National Youth Behavior Risk Survey, 19% of all sexually active adolescents in the US consumed  alcohol  or used other drugs before their last sexual intercourse. [ 12 ]  In contrast, adolescents who reported no substance use were found to be the least likely to engage in sexual risk-taking. [ 13 ]


Most Canadian and American adolescents aged 15 to 19 years describe having had sexual intercourse at least one time. In the same population, 23.9% and 45.5% of young, adolescent females describe having sex with two or more sexual partners during the previous year. Of the males in the same population, 32.1% of Canadian males had two or more partners and 50.8% of American males also describe a similar experience. [ 4 ]


Alcohol is the most commonly used substance among youth aged 18–25 years. 10% of young adults had an alcohol use disorder in 2018, which is greater than the prevalence among all other age cohorts. [ 14 ]  Research indicates that alcohol can lead to risky sexual behavior including lack of condom use, sexual intercourse with a non-primary partner, as well as lower likelihood of using contraception in general. [ 15 ]


Among older age cohorts, a similar positive trend can be observed in risky sexual behavior when combined with alcohol use. For instance, research on older men who have sex with men (MSM) showed that the likelihood of engaging in risky sexual activities increased with the use of alcohol and other drugs. [ 16 ]


There are several factors linked to risky sexual behaviors. These include inconsistent condom use, alcohol use, polysubstance abuse, depression, lack of social support, recent incarceration, residing with a partner, and exposure to  intimate partner violence  and  childhood sexual abuse . Further research is needed to establish the exact causal relationship between these factors and risky sexual behaviors. [ 17 ] [ 18 ]  Sexual health risk reduction can include motivational exercises, assertiveness skills, educational and behavioral interventions. Counseling has been developed and implemented for people with severe mental illness, may improve participants' knowledge, attitudes, beliefs, behaviors or practices (including assertiveness skills) and could lead to a reduction in risky sexual behavior. [ 10 ]


There are several studies on the management of risky sexual behavior among youth, with most focusing on the prevention of  sexually transmitted infections  (STIs) such as  HIV . [ 19 ] [ 20 ] [ 21 ]  A  meta-analysis  evaluating prevention interventions among adolescents offers support for these programs in contributing to successful outcomes such as decreased incident STIs, increased  condom use , and decreased or delayed  penetrative sex . [ 20 ]  The findings showed that most interventions were administered in a group format and involved  psychoeducation  on HIV/AIDS, active interpersonal skills-training with some additionally focusing on self-management skills-training and condom information/ demonstrations. Some evidence suggests that family interventions may be beneficial in preventing long-term risky sexual behavior in early adulthood. [ 22 ]


Acute  prostatitis  is a serious  bacterial   infection  of the  prostate  gland. This infection is a  medical emergency . It should be distinguished from other forms of prostatitis such as  chronic bacterial prostatitis  and  chronic pelvic pain syndrome (CPPS) .


Men with acute prostatitis often have chills, fever, pain in the lower back,  perineum , or genital area, urinary frequency and  urgency often at night ,  burning or painful urination , body aches, and a demonstrable infection of the urinary tract, as evidenced by  white blood cells  and bacteria in the  urine . Acute prostatitis may be a complication of  prostate biopsy . [ 2 ]  Often, the prostate gland is very tender to  palpation through the rectum . [ 3 ]


Acute prostatitis is relatively easy to diagnose due to its symptoms that suggest infection. The organism may be found in blood or urine, and sometimes in both. [ 2 ]  Common bacteria are  Escherichia coli ,  Klebsiella ,  Proteus ,  Pseudomonas ,  Enterobacter ,  Enterococcus ,  Serratia ,  and  Staphylococcus aureus .  This can be a medical emergency in some patients and hospitalization with intravenous antibiotics may be required. A  complete blood count  reveals increased white blood cells.  Sepsis  from prostatitis is very rare, but may occur in  immunocompromised  patients; high  fever  and malaise generally prompt  blood cultures , which are often positive in sepsis. A  prostate massage  should never be done in a patient with suspected acute prostatitis, since it may induce sepsis. Since bacteria causing the prostatitis is easily recoverable from the urine, prostate massage is not required to make the diagnosis. Rectal palpation usually reveals an enlarged, exquisitely tender, swollen prostate gland, which is firm, warm, and, occasionally, irregular to the touch.  C-reactive protein  is elevated in most cases. [ 4 ]


Antibiotics  are the first line of treatment in acute prostatitis. Antibiotics usually resolve acute prostatitis infections in a very short time, however a minimum of two to four weeks of therapy is recommended to eradicate the offending organism completely. [ 5 ]  Appropriate  antibiotics  should be used, based on the microbe causing the infection. Some antibiotics have very poor penetration of the prostatic capsule, others, such as  ciprofloxacin ,  trimethoprim/sulfamethoxazole , and  tetracyclines  such as  doxycycline  penetrate prostatic tissue well. In acute prostatitis, penetration of the prostate is not as important as for category II because the intense inflammation disrupts the prostate-blood barrier. It is more important to choose a bactericidal antibiotic (kills bacteria, e.g., a  fluoroquinolone  antibiotic) rather than a bacteriostatic antibiotic (slows bacterial growth, e.g. tetracycline) for acute potentially life-threatening infections. [ 6 ]


Severely ill patients may need hospitalization, while nontoxic patients can be treated at home with  bed rest , analgesics, stool softeners, and hydration. Men with acute prostatitis complicated by  urinary retention  are best managed with a  suprapubic catheter  or  intermittent catheterization . Lack of clinical response to antibiotics should raise the suspicion of an  abscess  and prompt an imaging study such as a  transrectal ultrasound  (TRUS). [ 7 ]


Adult T-cell leukemia/lymphoma  ( ATL  or  ATLL ) is a rare  cancer  of the immune system's  T-cells [ 1 ] [ 2 ] [ 3 ]  caused by human T cell leukemia/lymphotropic virus type 1 ( HTLV-1 ). [ 4 ]  All ATL cells contain integrated HTLV-1 provirus further supporting that causal role of the virus in the cause of the neoplasm. [ 4 ]  A small amount of HTLV-1 individuals progress to develop ATL with a long latency period between infection and ATL development. ATL is categorized into 4 subtypes: acute, smoldering, lymphoma-type, chronic. Acute and Lymphoma-type are known to particularly be aggressive with poorer prognosis. [ 5 ]


Globally, the retrovirus HTLV-1 is estimated to infect 20 million people per year with the incidence of ATL approximately 0.05 per 100,000 per year with endemic regions such as regions of Japan, as high as 27 per 100,000 per year. [ 6 ]  However, cases have increased in non-endemic regions with highest incidence of HTLV-1 in southern/northern islands of Japan, Caribbean, Central and South America, intertropical Africa, Romania, northern Iran. ATL normally occurs around the age of 62 years but median age at diagnosis does depend on prevalence of the HTLV-1 infection in the geographic location. [ 7 ]


Current treatment regiments for ATL are based on clinical subtype and response to initial therapy. Some therapy modalities for treatment may not available in all countries therefore strategies differ across the world. All patients are referred to clinical trials if available. Beyond clinical trials, treatments are centered on multiagent chemotherapy, zidovudine plus interferon a (AZT/IFN), and allogenic hematopoietic stem cell transplantation (alloHSCT). [ 6 ]


ATL is usually a highly aggressive  non-Hodgkin's lymphoma  with no characteristic  histologic  appearance except for a diffuse pattern and a mature T-cell  phenotype . [ 8 ]  Circulating  lymphocytes  with an irregular nuclear contour (leukemic cells) are frequently seen. Several lines of evidence suggest that  HTLV-1  causes ATL. This evidence includes the frequent isolation of HTLV-1 from patients with this disease and the detection of HTLV-1 proviral  genome  in ATL leukemic cells. ATL is frequently accompanied by visceral involvement,  hypercalcemia ,  skin lesions , and lytic bone lesions. Bone invasion and  osteolysis , features of bone metastases, commonly occur in the setting of advanced solid tumors, such as breast, prostate, and lung cancers, but are less common in hematologic malignancies. However, patients with HTLV-1–induced ATL and  multiple myeloma  are predisposed to the development of tumor-induced osteolysis and hypercalcemia. One of the striking features of ATL and  multiple myeloma  induced bone disease is that the bone lesions are predominantly osteolytic with little associated osteoblastic activity. In patients with ATL, elevated serum levels of IL-1, TGFβ, PTHrP, macrophage inflammatory protein (MIP-1α), and receptor activator of nuclear factor-κB ligand (RANKL) have been associated with hypercalcemia. Immunodeficient mice that received implants with leukemic cells from patients with ATL or with HTLV-1–infected lymphocytes developed hypercalcemia and elevated serum levels of PTHrP. [ 9 ]  Most patients die within one year of diagnosis. [ 10 ]


Infection with HTLV-1, like infection with other  retroviruses , probably occurs for life and can be inferred when  antibody  against HTLV-1 is detected in the  serum . [ 11 ]


Transmission of  HTLV-1  is believed to occur from mother to child; by sexual contact; and through exposure to contaminated blood, either through  blood transfusion  or sharing of contaminated needles. [ 12 ]


Diagnosis is made based on the combination of clinical features, characteristic morphologic and immunophenotypic changes of malignant cells. As clinical features and prognosis can be diverse, the disease is subtype-classified into four categories according to the Shimoyama classification: acute, lymphoma, chronic, smoldering. [ 13 ]  Normally, identification of at least 5 percent of tumor cells in peripheral blood and confirmation of human T-lymphotropic virus type-1 are sufficient for diagnosis of acute, chronic, and smoldering types. For the lymphoma type, histopathologic examination by biopsy of lymph nodes may be needed. [ 14 ]


The immunophenotype of ATLL includes positive markers such as CD2, CD3, CD4, CD5, and CD25, with negative markers for CD7, CD8, and cytotoxic markers. Additionally, there is partial positivity for CD30, CCR4, and FOXP3. [ 15 ]


Treatment options that have been tried include  zidovudine  and the  CHOP  regimen. [ 11 ]   Pralatrexate  has also been investigated. [ 16 ]  Recently, it has been reported that the traditional glucocorticoid-based chemotherapy toward ATL are largely mediated by thioredoxin binding protein-2 (TBP-2/TXNIP/VDUP1), suggesting the potential use of a TBP-2 inducer as a novel therapeutic target. [ 17 ] [ 18 ]


In 2021,  mogamulizumab  was approved for relapsed/refractor treatment of ATL in Japan. [ 19 ]


At a medical conference in December 2013, researchers reported anywhere from 21 to 50% of ATL patients have disease expressing CD30. [ 20 ]  Although not FDA approved, treatment with CD30-targeting  brentuximab vedotin  in CD 30+ cases may be beneficial and supported by current NCCN guidelines. [ 21 ]


HTLV-1 infection in the  United States  appears to be rare. Although little  serologic  data exist, the prevalence of infection is thought to be highest among African-Americans living in the Southeast. A prevalence rate of 30% has been found among African-American intravenous drug users in  New Jersey , and a rate of 49% has been found in a similar group in  New Orleans . It is possible that the prevalence of infection is increasing in this risk group. Studies of HTLV-1 antibody indicate that the virus is endemic in southern  Japan , in the  Caribbean ,  South America , and in  Africa . [ 7 ]


ATL is relatively uncommon among those infected with  HTLV-1 . The overall incidence of ATL is estimated at 1 per 1,500 adult HTLV-1 carriers per year. Those cases that have been reported have occurred mostly among persons from the Caribbean or African Americans from the Southeast United States (National Institutes of Health, unpublished data). There appears to be a long latent period between  HTLV-1  infection and the start of ATL. [ 5 ]


Novel approaches to the treatment of PTCL in the relapsed or refractory setting are under investigation.  Pralatrexate  is one compound currently under investigations for the treatment of PTCL. [ 16 ]


aggressive:   Sézary disease


British Social Hygiene Council  ( BSHC , until 1925 the  National Council for Combating Venereal Diseases ,  NCCVD ) was a British organization dedicated to eradicating  venereal diseases  and educating the public about them. [ 1 ] [ 2 ] [ 3 ] [ 4 ]  It was founded in 1914. [ 5 ] [ 6 ]


This article about a UK medical organisation, hospital, or association is a  stub . You can help Wikipedia by  expanding it .


The  Brussels Agreement  (formally the  International Agreement respecting Facilities to be given to Merchant Seamen for the Treatment of Venereal Diseases ) is a 1924  multilateral treaty  whereby states agreed to provide free or low-cost medical facilities in  ports  where  merchant seamen  could be treated for  sexually transmitted diseases . [ citation needed ]


The Brussels Agreement was concluded in  Brussels ,  Belgium  on 1924. The treaty entered into force on 1925. The Agreement was widely ratified and its effects were studied by a 1958  World Health Organization  (WHO) study group. [ 1 ]  The WHO determined that the Agreement had been successful at improving the health of merchant seamen. The treaty remains in force for 70 states. It was most recently ratified by  Papua New Guinea , in 1977.


Belgium  is the official depositary for the treaty. [ citation needed ]


A  canine transmissible venereal tumor  ( CTVT ), also known as a  transmissible venereal tumor  ( TVT ),  canine transmissible venereal sarcoma  ( CTVS ),  sticker tumor  and  infectious sarcoma , is a  histiocytic   tumor  of  the external genitalia of the dog  and other canines, and is transmitted from animal to animal during  mating . It is one of only three known  transmissible cancers  in  mammals ; the others are  devil facial tumor disease , a cancer which occurs in  Tasmanian devils , and  contagious reticulum cell sarcoma  of the  Syrian hamster .


The tumor cells are themselves the infectious agents, and the tumors that form are not genetically related to the host dog. [ 1 ]  Although the genome of a CTVT is derived from an individual  canid  (specifically from a population of  Native American dogs  with coyote contribution), [ 2 ] [ 3 ]  it is now essentially living as a unicellular, asexually reproducing (but  sexually transmitted )  pathogen . [ 4 ]  Sequence analysis of the genome suggests it diverged from canids over 6,000 years ago; possibly much earlier. [ 4 ]  Estimates from 2015 date its time of origin to about 11,000 years ago. [ 5 ]  However, the  most recent common ancestor  of  extant  tumors is more recent: it probably originated 200 to 2,500 years ago. [ 1 ] [ 6 ]


Canine TVTs were initially described by Russian  veterinarian  M.A. Novinsky (1841–1914) in 1876, when he demonstrated that the tumor could be transplanted from one dog to another by infecting them with tumor cells. [ 7 ]


In male  dogs , the tumor affects the  penis  and  foreskin . In female dogs, it affects the  vulva . Rarely, the mouth or nose are affected. [ 8 ]  The tumor often has a  cauliflower -like appearance. Signs of genital TVT include a discharge from the prepuce and in some cases  urinary retention  caused by blockage of the  urethra . [ 9 ]  Signs of a nasal TVT include nasal  fistulae ,  nosebleeds  and other nasal discharge, facial  swelling , and enlargement of the submandibular  lymph nodes . [ 10 ]


Canine transmissible venereal tumors are  histiocytic   tumors  that may be transmitted among dogs through  coitus , licking, biting and sniffing tumor affected areas. The concept that the tumor is naturally transmissible as an  allograft  came from three important observations. First, CTVTs can only be experimentally induced by transplanting living tumor cells, and not by killed cells or cell filtrates. Second, the tumor  karyotype  is  aneuploid  but has characteristic marker  chromosomes  in all tumors collected in different geographic regions. Third, a  long interspersed nuclear element  (LINE-1) insertion near the  c-myc  gene has been found in all tumors examined so far and can be used as a diagnostic marker to confirm that a tumor is a CTVT. [ 6 ] [ 11 ]


Canine transmissible venereal tumors are most commonly seen in sexually active dogs in  tropical ,  subtropical  and temperate climates where there are large populations of stray dogs, but little is known about the details of transmission. [ 12 ]  The disease is spread when dogs mate, and can even be transmitted to  other canine species , such as  foxes  and coyotes. [ 13 ]  Spontaneous regression of the tumor can occur, probably due to a response from the  immune system . [ 14 ]  CTVT undergoes a predictable cycle: an initial growth phase of four to six months (P phase), a stable phase, and a regression phase (R phase), [ 15 ]  although not all CTVTs will regress. The tumor does not often  metastasize  (occurring in about less than 5 percent of cases), [ 16 ]  except in puppies and  immunocompromised  dogs. Metastasis occurs to regional  lymph nodes , [ citation needed ]  but can also be seen in the  skin ,  brain ,  eye ,  liver ,  spleen ,  testicle , rectum and  muscle . [ 17 ]  A  biopsy  is necessary for diagnosis.


The success of this single cell lineage, believed to be the longest continually propagated cell lineage in the world, can be attributed to the tumor's mode of transmission in a specific host system. Although direct contact is generally not a highly efficient mode of transfer, CTVTs take advantage of the  popular sire effect  of domestic dogs. A single male can produce dozens of litters over his lifetime, allowing the tumor to affect many more females than it could if a monogamous species were the host. Understanding the epidemiology of CTVTs could provide insights for populations that may experience CTVT exposure and information about disease prevalence. [ citation needed ]


The CTVT cells have fewer  chromosomes  than normal dog cells. Dog cells normally have 78 chromosomes, while the cancer cells contain 57–64 chromosomes [ 7 ]  that are very different in appearance from normal dog chromosomes. All dog chromosomes except  X  and  Y  are  acrocentric , having a  centromere  very near to the end of the chromosome, while many of the CTVT chromosomes are metacentric or submetacentric, having a centromere nearer to the middle. [ 9 ]


All tumor cells of this type of cancer share extremely similar genetic code, often if not always unrelated to the  DNA  of their host. [ 6 ]  In addition to the aforementioned c-myc insertion, a few other potential  driver mutations  have been identified. [ 18 ]


The tumor, when treated with the  chemotherapy  drug  vincristine , regresses as the host  immune system  is activated.  CCL5  may play an important role in the immune response. [ 19 ]


Surgery may be difficult due to the location of these tumors. Surgery alone often leads to recurrence.  Chemotherapy  is very effective for TVTs. The  prognosis  for complete  remission  with chemotherapy is excellent. [ 20 ]  The most common chemotherapy agents used are  vincristine ,  vinblastine , and  doxorubicin . [ 14 ]   Use of  autohaemotherapy in treatment of TVTs also showed promising results in many cases. [ 21 ]   Radiotherapy  may be required if chemotherapy does not work. [ 17 ]


Cervical cancer  is a  cancer  arising from the  cervix  or in any layer of the wall of the cervix. [ 2 ]  It is due to the abnormal growth of  cells  that have the ability to invade or spread to other parts of the body. [ 12 ]  Early on, typically no symptoms are seen. [ 2 ]  Later symptoms may include abnormal  vaginal bleeding ,  pelvic pain  or  pain during sexual intercourse . [ 2 ]  While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer. [ 13 ]


Virtually all cervical cancer cases (99%) are linked to genital  human papillomavirus infection  (HPV); [ 14 ] [ 5 ] [ 6 ]  most  who have had HPV infections, however, do not develop cervical cancer. [ 3 ] [ 15 ]  HPV 16 and 18 strains are responsible for approximately 70% of cervical cancer cases globally and nearly 50% of high grade cervical pre-cancers. [ 16 ] [ 17 ]  Minor risk factors include  smoking , a  weak immune system ,  birth control pills , starting sex at a young age, and having many sexual partners. [ 2 ] [ 4 ]   Genetic factors  also contribute to cervical cancer risk. [ 18 ]  Cervical cancer typically develops from  precancerous changes  called  cervical intraepithelial neoplasia  over 10 to 20 years. [ 3 ]  About 90% of cervical cancer cases are  squamous cell carcinomas , 10% are  adenocarcinoma , and a small number are other types. [ 4 ]  Diagnosis is typically by  cervical screening  followed by a  biopsy . [ 2 ]   Medical imaging  is then done to determine whether or not the cancer has spread. [ 2 ]


HPV vaccination  is the most cost-effective public health measure against cervical cancer. [ 14 ]  There are six licensed HPV vaccines. [ 16 ]  They protect against two to seven high-risk strains of this family of  viruses  and may prevent up to 90% of cervical cancers. [ 9 ] [ 19 ] [ 20 ]  By the end of 2023, 143 countries (74% of WHO member states) provided the HPV vaccine in their national immunization schedule for girls. [ 21 ]  As of 2022, 47 countries (24% of WHO member states) also did it for boys. [ 22 ] : 654   As a risk of cancer still exists, guidelines recommend continuing regular  Pap tests . [ 9 ]  Other methods of prevention include having few or no sexual partners and the use of  condoms . [ 8 ]  Cervical cancer screening using the Pap test or  acetic acid  can identify precancerous changes, which when treated, can prevent the development of cancer. [ 23 ]  Treatment may consist of some combination of  surgery ,  chemotherapy , and  radiation therapy . [ 2 ]   Five-year survival rates  in the United States are 68%. [ 24 ]  Outcomes, however, depend very much on how early the cancer is detected. [ 4 ]


Worldwide, cervical cancer is both the fourth-most common type of cancer and the fourth-most common cause of death from cancer in women, with over 660,000 new cases and around 350,000 deaths in 2022. [ 3 ] [ 25 ]  This is about 8% of the total cases and total deaths from cancer. [ 26 ]  88% (2020 figure) of cervical cancers and 90% of deaths occur in low- and middle-income countries and 2% (2020 figure) in high-income countries. [ 22 ] : 650  [ 27 ] [ 3 ] [ 28 ]  Of the 20 hardest hit countries by cervical cancer, 19 are in Africa. [ 29 ]  In low-income countries, it is one of the most common causes of cancer death with an incidence rate of 47.3 per 100,000 women. [ 30 ] [ 23 ]  In  developed countries , the widespread use of cervical screening programs has dramatically reduced rates of cervical cancer. [ 31 ]  Expected scenarios for the reduction of mortality due to cervical cancer worldwide (and specially in low-income countries) have been reviewed, given assumptions with respect to the achievement of recommended prevention targets using triple-intervention strategies defined by WHO. [ 32 ]  In medical research, the most famous  immortalized cell line , known as  HeLa , was developed from cervical cancer cells of a woman named  Henrietta Lacks . [ 33 ]


17 November is the Cervical Cancer Elimination Day of Action. [ 34 ]  The date marks the day in 2020 when WHO launched the Global strategy to accelerate the elimination of cervical cancer as a public health problem, with a resolution passed by 194 countries. [ 34 ]  To eliminate cervical cancer, all countries must reach and maintain an incidence rate of below 4 per 100 000 women. [ 35 ] [ 36 ]


The early stages of cervical cancer may be completely  free of symptoms . [ 5 ] [ 31 ]   Vaginal bleeding , contact bleeding (one most common form being bleeding after sexual intercourse), or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. [ 37 ]  In advanced disease,  metastases  may be present in the  abdomen ,  lungs , or elsewhere. [ 38 ]


Symptoms of advanced cervical cancer may include  loss of appetite , weight loss, fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy vaginal bleeding, bone fractures, and (rarely) leakage of urine or faeces from the vagina. [ 39 ]  Bleeding after douching or after a pelvic exam is a common symptom of cervical cancer. [ 40 ]


Infection with some types of HPV is the greatest risk factor for cervical cancer, followed by smoking. [ 41 ]   HIV  infection is also a risk factor. [ 41 ]  Not all of the causes of cervical cancer are known, however, and several other contributing factors have been implicated. [ 42 ] [ 43 ]


Infection with HPV  is generally believed to be required for cervical cancer to occur. [ 44 ]  HPV types 16 and 18 are the cause of 75% of cervical cancer cases globally, while 31 and 45 are the causes of another 10%. [ 45 ]


Women who have multiple sexual partners, or have partners who have multiple sexual partners, regardless of sex are at higher risk of cervical cancer. [ 46 ] [ 47 ]


Over 200 types of HPV known, [ 48 ]  12 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59), [ 48 ]  three as probable high-risk (26, 53, and 66), and 12 as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108). [ 49 ]


Genital warts , which are a form of  benign tumor  of  epithelial  cells, are also caused by various strains of HPV. However, these serotypes are usually not related to cervical cancer. Having multiple strains at the same time is common, including those that can cause cervical cancer along with those that cause warts.


Cigarette smoking , both active and passive, increases the risk of cervical cancer. Among HPV-infected women, current and former smokers have roughly two to three times the incidence of invasive cancer. Passive smoking is also associated with increased risk, but to a lesser extent. [ 50 ]


Smoking has also been linked to the development of cervical cancer. [ 51 ] [ 52 ] [ 41 ]  Smoking can increase the risk in women a few different ways, which can be by direct and indirect methods of inducing cervical cancer. [ 51 ] [ 41 ] [ 53 ]  A direct way of contracting this cancer is a smoker has a higher chance of  cervical intraepithelial neoplasia  (CIN3) occurring, which has the potential of forming cervical cancer. [ 51 ]  When CIN3 lesions lead to cancer, most of them have the assistance of the HPV virus, but that is not always the case, which is why it can be considered a direct link to cervical cancer. [ 53 ]  Heavy smoking and long-term smoking seem to have more of a risk of getting the CIN3 lesions than lighter smoking or not smoking at all. [ 54 ]  Although smoking has been linked to cervical cancer, it aids in the development of HPV, which is the leading cause of this type of cancer. [ 41 ]  Also, not only does it aid in the development of HPV, but also if the woman is already HPV-positive, she is at an even greater likelihood of contracting cervical cancer. [ 54 ]


Long-term use of  oral contraceptives  is associated with increased risk of cervical cancer in women who have had  HPV . Women who have used oral contraceptives for 5 to 9 years have about three times the incidence of invasive cancer, and those who used them for 10 years or longer have about four times the risk. [ 50 ] [ 55 ]


Having many pregnancies is associated with an increased risk of cervical cancer. Among HPV-infected women, those who have had seven or more full-term pregnancies have around four times the risk of cancer compared with women with no pregnancies, and two to three times the risk of women who have had one or two full-term pregnancies. [ 50 ]


The  Pap test  can be used as a  screening test , but produces a  false negative  in up to 50% of cases of cervical cancer. [ 56 ] [ 57 ]  Other concerns is the cost of doing Pap tests, which make them unaffordable in many areas of the world. [ 58 ]


Confirmation of the diagnosis of cervical cancer or precancer requires a biopsy of the cervix. This is often done through  colposcopy , a magnified visual inspection of the cervix aided by using a dilute  acetic acid  (e.g.  vinegar ) solution to highlight abnormal cells on the surface of the cervix, [ 5 ]  with visual contrast provided by staining the normal tissues a mahogany brown with Lugol's iodine. [ 59 ]  Medical devices used for biopsy of the cervix include  punch forceps . Colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. Further diagnostic and treatment procedures are  loop electrical excision procedure  and  cervical conization , in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe  cervical intraepithelial neoplasia . [ 60 ] [ 61 ]


Often before the biopsy, the doctor asks for medical imaging to rule out other causes of woman's symptoms. Imaging modalities such as  ultrasound , CT scan, and MRI have been used to look for alternating disease, spread of the tumor, and effect on adjacent structures. Typically, they appear as heterogeneous mass on the cervix. [ 62 ]


Interventions such as playing music during the procedure and viewing the procedure on a monitor can reduce the anxiety associated with the examination. [ 63 ]


Cervical intraepithelial neoplasia  (CIN) means the development of abnormal cells on the surface of the cervix. It is caused by an HPV infection but in most cases it is resolved by the immune system. However a small percentage of people might develop a more serious CIN which, if left untreated, can develop into cervical cancer. [ 64 ] [ 65 ]  CIN is often diagnosed during routine Pap smear examination or colposcopy. [ 65 ]


The naming and  histologic  classification of cervical carcinoma precursor lesions has changed many times over the 20th century. The  World Health Organization  classification system was descriptive of the lesions, naming them mild, moderate, or severe  dysplasia  or  carcinoma  in situ  (CIS). [ 66 ] [ 67 ]  The term cervical intraepithelial neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardize treatment. [ 67 ]  For premalignant dysplastic changes, cervical intraepithelial neoplasia grading  (CIN 1–3) is used. It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS as CIN3. [ 68 ]  More recently, CIN2 and CIN3 have been combined into CIN2/3.  These results are what a pathologist might report from a biopsy. [ citation needed ]


These should not be confused with the  Bethesda system  terms for Pap test ( cytopathology ) results.  Among the Bethesda results:  Low-grade squamous intraepithelial lesion  (LSIL) and  high-grade squamous intraepithelial lesion  (HSIL). An LSIL Pap may correspond to CIN1, and HSIL may correspond to CIN2 and CIN3, [ 67 ]  but they are results of different tests, and the Pap test results need not match the histologic findings. [ medical citation needed ]


Histologic  subtypes of invasive cervical carcinoma include: [ 69 ] [ 70 ]


Though squamous cell carcinoma is the cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades. [ 5 ]  Endocervical adenocarcinoma represents 20–25% of the histological types of cervical carcinoma. Gastric-type mucinous adenocarcinoma of the cervix is a rare type of cancer with aggressive behavior. This type of malignancy is not related to high-risk human papillomavirus (HPV). [ 76 ]
Noncarcinoma malignancies which can rarely occur in the cervix include  melanoma  and  lymphoma .  The  International Federation of Gynecology and Obstetrics  (FIGO) stage does not incorporate  lymph node  involvement in contrast to the  TNM  staging for most other cancers. For cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage, but is not to replace the original clinical stage. [ citation needed ]


Cervical cancer is staged by the FIGO system, which is based on clinical examination rather than surgical findings. Prior to the 2018 revisions to FIGO staging, the system allowed only these diagnostic tests to be used in determining the stage: palpation, inspection,  colposcopy , endocervical  curettage ,  hysteroscopy ,  cystoscopy ,  proctoscopy , intravenous  urography , and  X-ray  examination of the lungs and skeleton, and cervical  conization . However, the system allows use of any imaging or pathological methods for staging. [ 77 ]


Checking cervical cells with the  Papanicolaou test  (Pap test) for cervical pre-cancer has dramatically reduced the number of cases of, and mortality from, cervical cancer. [ 31 ]  Liquid-based cytology may reduce the number of inadequate samples. [ 78 ] [ 79 ] [ 80 ]  Pap test screening every three to five years with appropriate follow-up can reduce cervical cancer incidence up to 80%. [ 81 ]


Pap test screening can reveal abnormal cells on the surface of the cervix called  cervical intraepithelial neoplasia  (CIN) that in a small percentage can develop into cervical cancer. These  precancerous changes  can be confirmed with further examination known as  colposcopy .


Personal invitations encouraging women to get screened are effective at increasing the likelihood they will do so. Educational materials also help increase the likelihood women will go for screening, but they are not as effective as invitations. [ 82 ]


According to the 2010 European guidelines, the age at which to start screening ranges between 20 and 30 years of age, but preferentially not before age 25 or 30 years, and depends on burden of the disease in the population and the available resources. [ 81 ]


In the United States, screening is recommended to begin at age 21, regardless of age at which a woman began having sex or other risk factors. [ 83 ]  Pap tests should be done every three years between the ages of 21 and 65. [ 83 ]  In women over the age of 65, screening may be discontinued if no abnormal screening results were seen within the previous 10 years and no history of CIN2 or higher exists. [ 83 ] [ 84 ] [ 85 ]  HPV vaccination status does not change screening rates. [ 84 ]


A number of recommended options exist for screening those 30 to 65. [ 86 ]  This includes cervical cytology every 3 years, HPV testing every 5 years, or HPV testing together with cytology every 5 years. [ 86 ] [ 84 ]  Screening is not beneficial before age 25, as the rate of disease is low. Screening is not beneficial in women older than 60 years if they have a history of negative results. [ 50 ]  The American Society of Clinical Oncology guideline has recommend for different levels of resource availability. [ 87 ]


Pap tests have not been as effective in developing countries. [ 88 ]  This is in part because many of these countries have an impoverished health care infrastructure, too few trained and skilled professionals to obtain and interpret Pap tests, uninformed women who get lost to follow-up, and a lengthy turn-around time to get results. [ 88 ]  Visual inspection with acetic acid and HPV DNA testing have been tried, though with mixed success. [ 88 ]


There are six licensed HPV vaccines: three bivalent (protect against two types of HPV), two quadrivalent (against four), and  one nonavalent vaccine  (against nine) [ 16 ]  Three HPV vaccines ( Gardasil, Gardasil 9 , and  Cervarix ) reduce the risk of cancerous or precancerous changes of the cervix and  perineum  by about 93% and 62%, respectively. [ 89 ]  All have excellent safety profiles and are highly efficacious, or have met immunobridging standards. [ 22 ] : 668   The vaccines are between 92% and 100% effective against HPV 16 and 18 up to at least 8 years. [ 50 ]


HPV vaccines are typically given to age 9 to 26, as the vaccine is most effective if given before infection occurs. The primary target group in most of the countries recommending HPV vaccination is young  adolescent  girls, aged 9-14. [ 16 ]  As of 2022, 125 countries include HPV vaccines in their routine vaccinations for girls, and 47 countries recommend them for boys, as well, [ 22 ] : 654   including Japan. [ 90 ]


The duration of effectiveness and whether a  booster  will be needed is unknown. The high cost of this vaccine has been a cause for concern. Several countries have considered (or are considering) programs to fund HPV vaccination. The  American Society of Clinical Oncology  guideline has recommendations for different levels of resource availability. [ 87 ]


Barrier protection or  spermicidal gel  use during sexual intercourse decreases, but does not eliminate risk of transmitting the infection. [ 50 ]   Condoms  may protect against genital warts. [ 91 ]   They also provide protection against other sexually transmitted infections, such as  HIV  and  Chlamydia , which are associated with greater risks of developing cervical cancer. [ medical citation needed ]


Vitamin A  is associated with a lower risk [ 92 ]  as are  vitamin B12 ,  vitamin C ,  vitamin E , and  beta-Carotene . [ 93 ]


The treatment of cervical cancer varies worldwide, largely due to access to surgeons skilled in radical pelvic surgery and the emergence of fertility-sparing therapy in developed nations. Less advanced stages of cervical cancer typically have treatment options that allow fertility to be maintained if the patient desires. [ 94 ]


Because cervical cancers are radiosensitive, radiation may be used in all stages where surgical options do not exist. Surgical intervention may have better outcomes than radiological approaches. [ 95 ]  In addition, chemotherapy can be used to treat cervical cancer and is more effective than radiation alone. [ 96 ]  Chemoradiotherapy may increase overall survival and reduce the risk of disease recurrence compared to radiotherapy alone. [ 97 ]


Precancerous cells ( cervical intraepithelial neoplasia ) that would lead to cancer and early-stage cervical cancer (IA1) can be treated effectively by various surgical techniques. Surgical treatment methods include excision, where a  cone-shaped portion  of the cervix is removed, and ablation which removes only the parts with abnormal tissues. While these effectively reduce the risk of cancer developing or spreading, they cause an increased risk of  premature birth  in future pregnancies. Surgical techniques that remove more cervical tissue come with less risk of the cancer recurring but a higher chance of giving birth prematurely. Due to this risk, taking into account the age, childbearing plans of the woman, the size and location of the cancer cells are crucial for choosing the right procedure. [ 60 ] [ 61 ]  There is low-certainty evidence that peri-operative care approaches, such as 'fast-track surgery' or 'enhanced recovery programmes' may lower surgical stress and improve recovery after gynaecological cancer surgery. [ 98 ]


Microinvasive cancer (stage IA) may also be treated by  hysterectomy  (removal of the whole uterus, including part of the  vagina ). [ 99 ]  For stage IA2, the  lymph nodes  are removed as well. Alternatives include local surgical procedures such as a  loop electrical excision procedure   or  cone biopsy . [ 100 ] [ 101 ]  A systematic review concluded that more evidence is needed to inform decisions about different surgical techniques for women with cervical cancer at stage IA2. [ 102 ]


If a cone biopsy does not produce clear margins [ 103 ]  (findings on biopsy showing that the tumor is surrounded by cancer free tissue, suggesting all of the tumor is removed), one more possible treatment option for women who want to preserve their fertility is a  trachelectomy . [ 104 ]  This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care, [ 105 ]  as few doctors are skilled in this procedure. Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown. If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the woman is under general anaesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the woman consented. Due to the possible risk of cancer spreading to the lymph nodes in stage 1B cancers and some stage 1A cancers, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation. [ citation needed ]


A radical trachelectomy can be performed abdominally [ 106 ]  or vaginally [ 107 ]  and opinions are conflicting as to which is better. [ 108 ]  A radical abdominal trachelectomy with lymphadenectomy usually only requires a two- to three-day hospital stay, and most women recover very quickly (about six weeks). Complications are uncommon, although women who can conceive after surgery are susceptible to preterm labour and possible late miscarriage. [ 109 ]  A wait of at least one year is generally recommended before attempting to become pregnant after surgery. [ 110 ]  Recurrence in the residual cervix is rare if the trachelectomy has cleared the cancer. [ 105 ]  Yet, women are recommended to practice vigilant prevention and follow-up care, including Pap screenings/ colposcopy , with biopsies of the remaining lower uterine segment as needed (every 3–4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through  safe sex  practices until one is actively trying to conceive. [ citation needed ]


Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or  radiation therapy . Radiation therapy is given as external beam radiotherapy to the pelvis and  brachytherapy  (internal radiation). Women treated with surgery who have high-risk features found on pathologic examination are given radiation therapy with or without chemotherapy to reduce the risk of relapse. [ citation needed ]   A Cochrane review has found moderate-certainty evidence that radiation decreases the risk of disease progression in people with stage IB cervical cancer, when compared to no further treatment. [ 111 ]  However, little evidence was found on its effects on overall survival. [ 111 ]


Larger early-stage tumors (IB2 and IIA more than 4 cm) may be treated with radiation therapy and  cisplatin -based chemotherapy, hysterectomy (which then usually requires  adjuvant  radiation therapy), or cisplatin chemotherapy followed by hysterectomy. When cisplatin is present, it is thought to be the most active single agent in periodic diseases. [ 112 ]  Such addition of platinum-based chemotherapy to chemoradiation seems not only to improve survival but also reduces risk of recurrence in women with early stage cervical cancer (IA2–IIA). [ 113 ]  A Cochrane review found a lack of evidence on the benefits and harms of primary hysterectomy compared to primary chemoradiotherapy for cervical cancer in stage IB2. [ 114 ]


Advanced-stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy. On 15 June 2006, the US  Food and Drug Administration  approved the use of a combination of two chemotherapy drugs,  hycamtin  and cisplatin, for women with late-stage (IVB) cervical cancer treatment. [ 115 ]  Combination treatment has significant risk of  neutropenia ,  anemia , and  thrombocytopenia  side effects. [ 116 ]


There is insufficient evidence whether anticancer drugs after standard care help women with locally advanced cervical cancer to live longer. [ 117 ]


For surgery to be curative, the entire cancer must be removed with no cancer found at the margins of the removed tissue on examination under a microscope. [ 118 ]  This procedure is known as exenteration. [ 118 ]


No evidence is available to suggest that any form of follow-up approach is better or worse in terms of prolonging survival, improving quality of life or guiding the management of problems that can arise because of the treatment and that in the case of radiotherapy treatment worsen with time. [ 119 ]  A 2019 review found no controlled trials regarding the efficacy and safety of interventions for vaginal bleeding in women with advanced cervical cancer. [ 120 ]


Immunotherapy with immune checkpoint inhibitors, such as  pembrolizumab  (Keytruda), has also been approved by the U.S. Food and Drug Administration (FDA) for certain patients with recurrent or metastatic cervical cancer, demonstrating promising results in ongoing clinical trials.  [ 121 ]   [ 122 ]  In October 2021, the FDA expanded this approval to include pembrolizumab in combination with chemotherapy, with or without  bevacizumab , for people with persistent, recurrent, or metastatic cervical cancer, underscoring the potential of immunotherapeutic approaches in this setting.  [ 123 ]  Additional immunotherapy agents, including other PD-1 and PD-L1 inhibitors, are under investigation and have similarly shown encouraging outcomes in clinical studies.


Another immune checkpoint inhibitor,  cemiplimab-rwlc  (Libtayo), received FDA approval in September 2022 for patients with recurrent or metastatic cervical cancer that has progressed on or after chemotherapy, further highlighting the expanding role of immunotherapeutic strategies in advanced disease.  [ 124 ]


Tisotumab vedotin  (Tivdak) was approved for medical use in the United States in September 2021. [ 125 ] [ 126 ]


Prognosis depends on the stage of the cancer. For intraepithelial cervical neoplasmas the prognosis is good. [ 127 ]   With treatment, the five-year  relative survival rate  for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) five-year survival rate is about 66%. These statistics may be improved when applied to women newly diagnosed, bearing in mind that these outcomes may be partly based on the state of treatment five years ago when the women studied were first diagnosed. [ 128 ]


With treatment, 80–90% of women with stage I cancer and 60–75% of those with stage II cancer are alive 5 years after diagnosis. Survival rates decrease to 58% for women with stage III cancer and 17% or fewer of those with stage IV cancer five years after diagnosis. [ 128 ]  Recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. About 35% of women with invasive cervical cancer have persistent or recurrent disease after treatment. [ 129 ]


There is an ethnic disparity in five-year survival in the United States. Average survival rates of the dominate squamous cell carcinoma are 72% for  Hispanic  and  Asian-Pacific  women, 68% for  White women  and 61% for  Black women . [ 130 ]


Regular screening has meant that precancerous changes and early-stage cervical cancers have been detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the UK by preventing cervical cancer. [ 131 ]
About 1,000 women per year die of cervical cancer in the UK.  All of the  Nordic countries  have cervical cancer-screening programs in place. [ 132 ]  The Pap test was integrated into clinical practice in the Nordic countries in the 1960s. [ 132 ]


In Africa outcomes are often worse as diagnosis is frequently at a latter stage of disease. [ 133 ]  In a scoping review of publicly-available cervical cancer prevention and control plans from African countries, plans tended to emphasize survivorship rather than early HPV diagnosis and prevention. [ 134 ]


Chemotherapy works by attacking cells that rapidly divide. This kills cancer cells, but can also impact normal cells leading to adverse side effects. Common chemotherapy side effects include; hair loss, mouth sores, loss of appetite, diarrhea, nausea and vomiting, premature menopause, infertility, and damage to the blood-forming cells within bone marrow. Most acute side effects are temporary, dissipating when treatment ceases, but some can be long-lasting or permanent. Long-term chemotherapy side effects include changes in the menstrual cycle, neuropathy, and  nephrotoxicity . [ 135 ]


Radiation therapy (RT) adverse effects; for a complete side effect list see


Curative cervical radiation therapy may affect unintended tissues located within the delivery pathway(s) or adjacent to the target lesion, each tissue with a  unique sensitivity and response to radiation injury . Common acute RT effects involve the gastrointestinal system, e.g., diarrhea and constipation; urinary tract, e.g., frequent urination; and may cause  cervicitis . Common late RT complications include: infertility or  premature ovarian failure ;  vaginal stenosis ; lower motor neuron syndrome;  telangiectasias , and subsequent hemorrhage; and  progressive myelopathy , which may result in irreversible neurologic deficits ranging from minor sensory symptoms to complete  paraplegia . [ 136 ]  Radiotherapy late effects (with occurrence rates) include  osteonecrosis  (8-20%),  bladder ulceration  (<3%),  vaginal stenosis  (>2.5%) [ 137 ]  and chronic  pelvic radiation disease  (1-10%), e.g.,  irreversible lumbosacral plexopathy . [ 138 ]


Pelvic radiation also induces secondary malignancies such as  leukemia ,  lymphoma ,  bladder cancer , pelvic malignancy,  colorectal cancer , bone and  soft-tissue sarcoma  with occurrence rates between 0.2-1.0% per year for each. [ 136 ]


Worldwide, cervical cancer is both the fourth-most common type of cancer and the fourth-most common cause of death from cancer in women, with over 660,000 new cases and around 350,000 deaths in 2022. [ 3 ] [ 25 ]  It is the second-most common cause of female-specific cancer after  breast cancer , accounting for around 8% of both total cancer cases and total cancer deaths in women. [ 26 ]  88% (2020 figure) of cervical cancers and 90% of deaths occur in  low- and middle-income countries (LMICs)  and 2% (2020 figure) in  high-income countries (HICs) . [ 22 ] : 650  [ 27 ] [ 140 ]  It is the most frequently detected cancer during pregnancy, with an occurrence of 1.5 to 12 for every 100,000 pregnancies. [ 141 ]


The large majority of cervical cancer cases in 2020 (88%) occurred in LMICs, where they account for 17% of all cancers in women, compared with only 2% in high-income countries (HICs). In sub-Saharan Africa, the region with the highest rates of young women living with HIV (WLWH), approximately 20% of cervical cancer cases occur in WLWH. HPV infection is more likely to persist and to progress to cancer in WLWH. Mortality rates vary 50-fold between countries, ranging from <2 per 100 000 women in some HICs to >40 per 100 000 in some countries of sub-Saharan Africa. [ 22 ] : 650


Of the 20 hardest hit countries by cervical cancer, 19 are in  Africa . [ 29 ]


Australia  is on target to eliminate cervical cancer. [ 35 ]  It anticipates to achieve this in the next 10 years. [ 35 ]


In 2022, it is estimated that 942 new cases of cervical cancer will be diagnosed in Australia. In 2022, it is estimated that a female has a 1 in 180 (or 0.56%) risk of being diagnosed with cervical cancer by the age of 85. [ 142 ]


In 2020, there were 165 women aged 25–74 who died from cervical cancer, which is a mortality rate of 2 deaths per 100,000 women in the population. Over the 5 years 2016–2020, there were 62 Aboriginal and Torres Strait Islander women aged 25–74 who died from cervical cancer, which is a mortality rate of 7 deaths per 100,000 Indigenous women in the population. Over the 5 years 2016–2020, the age-standardised mortality rate among Aboriginal and Torres Strait Islander women was 3.8 times the rate of non-Indigenous Australians. [ 143 ]


The number of women diagnosed with cervical cancer has dropped on average by 4.5% each year since organised screening began in 1991 (1991–2005). [ 144 ]  Regular twice-yearly Pap tests can reduce the incidence of cervical cancer up to 90% in Australia, and save 1,200 Australian women from dying from the disease each year. [ 145 ]   It is predicted that because of the success of the primary HPV testing programme there will be fewer than four new cases per 100 000 women annually by 2028. [ 146 ]


An estimated 1,450 Canadians will be diagnosed with cervical cancer in 2022. An estimated 380 will die from it. [ 147 ]


In India, the number of people with cervical cancer is rising, but overall the age-adjusted rates are decreasing. [ 148 ] [ 149 ]  Usage of condoms in the female population has improved the survival of women with cancers of the cervix. [ 150 ]


As of 2022, the World Health Organization announced that "each year in the WHO European Region more than 66 000 women are newly diagnosed with cervical cancer and more than 30 000 die from this preventable disease." [ 151 ]


Cervical cancer is the 12th-most common cancer in women in the UK (around 3,100 women were diagnosed with the disease in 2011), and accounts for 1% of cancer deaths (around 920 died in 2012). [ 152 ]  With a 42% reduction from 1988 to 1997, the NHS-implemented screening programme has been highly successful, screening the highest-risk age group (25–49 years) every 3 years, and those ages 50–64 every 5 years. [ citation needed ]


An estimated 13,170 new cervical cancers and 4,250 cervical cancer deaths will occur in the United States in 2019. [ 153 ]  The median age at diagnosis is 50. The rates of new cases in the United States was 7.3 per 100,000 women, based on rates from 2012 to 2016. Cervical cancer deaths decreased by approximately 74% in the last 50 years, largely due to widespread Pap test screening. [ 154 ]  The annual direct medical cost of cervical cancer prevention and treatment prior to introduction of the HPV vaccine was estimated at $6 billion. [ 154 ]


The Nigerian Institute of Medical Research (NIMR) reports that 28 Nigerian women lose their lives daily due to this disease. This alarming statistic underscores the pressing need for better awareness, prevention, and treatment efforts across the country. Numerous Nigerian women lack access to these preventive measures. In many regions of the country, screening tests such as Pap tests and HPV tests are not easily accessible or affordable [ 155 ] [ 156 ]


Epidemiologists  working in the early 20th century noted that cervical cancer behaved like a sexually transmitted disease. In summary:


These historical observations suggested that cervical cancer could be caused by a sexually transmitted agent. Initial research in the 1940s and 1950s attributed cervical cancer to  smegma . [ 163 ]  During the 1960s and 1970s it was suspected that infection with  herpes simplex virus  (HSV) was the cause of the disease. In summary, HSV was seen as a likely cause because it is known to survive in the female reproductive tract, to be transmitted sexually in a way compatible with known risk factors, such as promiscuity and low socioeconomic status. [ 164 ]  Herpes viruses were also implicated in other malignant diseases, including  Burkitt's lymphoma ,  Nasopharyngeal carcinoma ,  Marek's disease  and the Lucké renal adenocarcinoma. HSV was recovered from cervical tumour cells. [ citation needed ]


A description of  human papillomavirus  (HPV) by  electron microscopy  was given in 1949, and HPV-DNA was identified in 1963. [ 165 ]  It was not until the 1980s that HPV was identified in cervical cancer tissue. [ 166 ]   It has since been demonstrated that HPV is implicated in virtually all cervical cancers. [ 167 ]  Specific viral subtypes implicated are HPV 16, 18, 31, 45 and others.


In work that was initiated in the mid-1980s, the HPV vaccine was developed, in parallel, by researchers at  Georgetown University  Medical Center, the  University of Rochester , the  University of Queensland  in Australia, and the U.S.  National Cancer Institute . [ 168 ]  In 2006, the US  Food and Drug Administration  (FDA) approved the first preventive HPV vaccine, marketed by  Merck & Co.  under the trade name Gardasil. [ citation needed ]


17 November is the Cervical Cancer Elimination Day of Action. [ 34 ]  The date marks the day in 2020 when WHO launched the Global strategy to accelerate the elimination of cervical cancer as a public health problem, with a resolution passed by 194 countries. [ 34 ]  In November 2020, the  World Health Organization  (WHO), under backing from the  World Health Assembly , set out a strategy to eliminate cervical cancer by 2050. The strategy involves vaccinating 90% of girls by the age of 15, screening 70% of women by the age of 35 and again by the age of 45, and treating 90% of women identified with cervical disease. [ 169 ]  To eliminate cervical cancer, all countries must reach and maintain an incidence rate of below 4 per 100 000 women. [ 35 ] [ 36 ]


In Australia, Aboriginal women are more than five times more likely to die from cervical cancer than non-Aboriginal women, suggesting that Aboriginal women are less likely to have regular Pap tests. [ 170 ]  There are several factors that may limit indigenous women from engaging in regular cervical screening practices, including sensitivity in discussing the topic in Aboriginal communities, embarrassment, anxiety and fear about the procedure. [ 171 ]  Difficulty in accessing screening services (for example, transport difficulties) and a lack of female GPs, trained Pap test providers and trained female Aboriginal Health Workers are also issues. [ 171 ]


The  Australian Cervical Cancer Foundation  (ACCF), founded in 2008, promotes 'women's health by eliminating cervical cancer and enabling treatment for women with cervical cancer and related health issues, in Australia and in developing countries.' [ 172 ]   Ian Frazer , one of the developers of the Gardasil cervical cancer vaccine, is the scientific advisor to ACCF. [ 173 ]   Janette Howard , the wife of the then-Prime Minister of Australia,  John Howard , was diagnosed with cervical cancer in 1996, and first spoke publicly about the disease in 2006. [ 174 ]


A 2007 survey of American women found 40% had heard of HPV infection and less than half of those knew it causes cervical cancer. [ 175 ]  Over a longitudinal study from 1975 to 2000, it was found that people of lower socioeconomic census brackets had higher rates of late-stage cancer diagnosis and higher morbidity rates. After controlling for stage, there still existed differences in survival rates. [ 176 ]  Women in the US experience  stigma  around HPV infection, vaccination and cervical cancer. This is predominantly driven by fear of social judgment and rejection, self-blame, and shame, with notable negative influences from gender and social norms, as both  human papillomavirus  infection and cervical cancer were stigmatized due to the perception that they arise from reckless behavior such as having multiple sexual partners or neglecting screening. [ 177 ]


Transgender men and gender-diverse people who have a cervix (even if partially intact) or have a prior history of cervical cancer or precancerous conditions, and are age 21 or older who has ever had sex with anyone need to get screened for cervical cancer. [ 178 ] [ 179 ]  Transmasculine people are just as likely as cisgender women to have cervical cancer, but are less likely to undergo cervical screening, because of dysphoria, gender disaffirmation or disempowerment of the individual by healthcare providers, [ 180 ]  or being misinformed of HPV and cervical cancer risks [ 181 ]   as well as many healthcare providers perceiving transmasculine individuals to be at low risk of cervical cancer. [ 182 ]


Transgender women who have not had bottom surgery have no risk of cervical cancer, as they do not have a cervix. Trans women who have had bottom surgery to create a vagina (vaginoplasty) and possibly a cervix, are at a very small risk to develop cancer in the tissues of their neo-vagina or neo-cervix as these tissues are made up of different cells than a cervix in a cisgender woman [ 183 ] [ 184 ]  Cervical cancer screening is not necessary in trans women who have undergone vaginoplasty because they do not have a cervix. [ 185 ]


Intersex  people with a cervix are also able to have cervical cancer. [ 186 ]


Cervicitis  is  inflammation  of the  uterine cervix . [ 1 ]  Cervicitis in women has many features in common with  urethritis  in men and many cases are caused by  sexually transmitted infections . Non-infectious causes of cervicitis can include  intrauterine devices ,  contraceptive diaphragms , and  allergic  reactions to  spermicides  or  latex   condoms . [ 2 ]
Cervicitis affects over half of all women during their adult life. [ 1 ]


Cervicitis may ascend and cause endometritis and  pelvic inflammatory disease  (PID). Cervicitis may be acute or chronic. [ 3 ]


Cervicitis may have no symptoms. [ 1 ]  If symptoms do manifest, they may include:


Cervicitis can be caused by any of a number of infections, of which the most common are  chlamydia  and  gonorrhea , with chlamydia accounting for approximately 40% of cases. [ 4 ]  Other causes include  Trichomonas vaginalis ,  herpes simplex virus , and  Mycoplasma genitalium . [ 3 ]


While sexually transmitted infections (STIs) are the most common cause of cervicitis, there are other potential causes as well. This includes vaginitis caused by bacterial vaginosis or  Trichomonas vaginalis . This also includes a device inserted into the pelvic area (i.e. a cervical cap,  IUD , pessary, etc.); an allergy to spermicides or latex in condoms; or, exposure to a chemical, for example while douching. [ 3 ] [ 4 ]  Inflammation can also be idiopathic, where no specific cause is found. [ 4 ]  While IUDs do not cause cervicitis, active cervicitis is a contraindication to placing an IUD. If a person with an IUD develops cervicitis, it usually does not need to be removed, if the person wants to continue using it. [ 5 ]


There are also certain behaviors that can place individuals at a higher risk for contracting cervicitis. High-risk sexual behavior, a history of STIs, many sexual partners, sex at an early age, and sexual partners who engage in high-risk sexual behavior or have had an STI can increase the likelihood of contracting cervicitis. [ 6 ]


To diagnose cervicitis, a clinician will perform a  pelvic exam . This exam includes a  speculum  exam with visual inspection of the cervix for abnormal discharge, which is usually purulent or bleeding from the cervix with little provocation. [ 4 ]  Swabs can be used to collect a sample of this discharge for inspection under a microscope and/or lab testing for  gonorrhea ,  chlamydia , and  Trichomonas vaginalis . A bimanual exam in which the clinician palpates the cervix to see if there is any associated pain should be done to assess for  pelvic inflammatory disease . [ 3 ]


The risk of contracting cervicitis from STIs can be reduced by using condoms during every sexual encounter. Condoms are effective against the spread of STIs like chlamydia and gonorrhea that cause cervicitis. Also, being in a long-term monogamous relationship with an uninfected partner can lower the risk of an STI. [ 8 ]


Ensuring that foreign objects like tampons are properly placed in the vagina and following instructions how long to leave it inside, how often to change it, and/or how often to clean it can reduce the risk of cervicitis. [ 1 ]  In addition, avoiding potential irritants like douches and deodorant tampons can prevent cervicitis. [ 1 ]


Non-infectious causes of cervicitis are primarily treated by eliminating or limiting exposure to the irritant.  Antibiotics , usually azithromycin or doxycycline, or antiviral medications are used to treat infectious causes. Women at increased risk of sexually transmitted infections (i.e., less than 25 years of age and a new sexual partner, a sexual partner with other partners, or a sexual partner with a known sexually transmitted infection), should be treated presumptively for chlamydia and possibly gonorrhea, particularly if follow-up care cannot be ensured or diagnostic testing is not possible. For lower risk women, deferring treatment until test results are available is an option. [ 4 ]


To reduce the risk of reinfection, women should abstain from sexual intercourse for seven days after treatment is started. Also, sexual partners (within the last sixty days) of anyone with infectious cervicitis should be referred for evaluation or treated through expedited partner therapy (EPT). EPT is the process by which a clinician treats the sexual partner of a patient diagnosed with a  sexually transmitted infection  without first meeting or examining the partner. Sexual partners should also avoid sexual intercourse until they and their partners are adequately treated. [ 4 ]


Untreated cervicitis is also associated with an increased susceptibility to  HIV  infection. Women with infectious cervicitis should be tested for other sexually transmitted infections, including HIV and syphilis. [ 4 ]


Cervicitis should be followed up. Women with a specific diagnosis of chlamydia, gonorrhea, or trichomonas should see a clinician in three months after treatment for repeat testing because they are at higher risk of getting reinfected, regardless of whether their sex partners were treated. [ 4 ]  Treatment in pregnant women is the same as those who are not pregnant. [ 4 ]


Chlamydia , or more specifically a  chlamydia infection , is a  sexually transmitted infection  caused by the bacterium  Chlamydia trachomatis . [ 3 ]  Most people who are infected have no symptoms. [ 1 ]  When symptoms do appear, they may occur only several weeks after infection; [ 1 ]  the  incubation period  between exposure and being able to infect others is thought to be on the order of two to six weeks. [ 7 ]   Symptoms in women may include  vaginal discharge  or  burning with urination . [ 1 ]  Symptoms in men may include discharge from the penis, burning with urination, or  pain and swelling of one or both testicles . [ 1 ]  The infection can spread to the upper genital tract in women, causing  pelvic inflammatory disease , which may result in future  infertility  or  ectopic pregnancy . [ 2 ]


Chlamydia infections can occur in other areas besides the genitals, including the anus, eyes, throat, and lymph nodes. Repeated chlamydia infections of the eyes that go without treatment can result in  trachoma , a common cause of blindness in the  developing world . [ 8 ]


Chlamydia can be spread during  vaginal ,  anal ,  oral , or  manual sex  and can be passed from an infected mother to her baby during childbirth. [ 1 ] [ 9 ]  The eye infections may also be spread by personal contact, flies, and contaminated towels in areas with poor sanitation. [ 8 ]  Infection by the bacterium  Chlamydia trachomatis  only occurs in humans. [ 10 ]  Diagnosis is often by  screening , which is recommended yearly in sexually active women under the age of 25, others at higher risk, and at the first  prenatal visit . [ 1 ] [ 2 ]  Testing can be done on the urine or a swab of the cervix, vagina, or  urethra . [ 2 ]  Rectal or mouth swabs are required to diagnose infections in those areas. [ 2 ]


Prevention is by  not having sex , the use of  condoms , or having sex with only one other person, who is not infected. [ 1 ]  Chlamydia can be cured by  antibiotics , with typically either  azithromycin  or  doxycycline  being used. [ 2 ]   Erythromycin  or azithromycin is recommended in babies and during pregnancy. [ 2 ]  Sexual partners should also be treated, and infected people should be advised not to have sex for seven days and until symptom free. [ 2 ]   Gonorrhea ,  syphilis , and  HIV  should be tested for in those who have been infected. [ 2 ]  Following treatment, people should be tested again after three months. [ 2 ]


Chlamydia is one of the most common sexually transmitted infections, affecting about 4.2% of women and 2.7% of men worldwide. [ 4 ] [ 5 ]  In 2015, about 61 million new cases occurred globally. [ 11 ]  In the United States, about 1.4 million cases were reported in 2014. [ 3 ]  Infections are most common among those between the ages of 15 and 25 and are more common in women than men. [ 2 ] [ 3 ]  In 2015, infections resulted in about 200 deaths. [ 6 ]  The word  chlamydia  is from the  Greek   χλαμύδα , meaning 'cloak'. [ 12 ] [ 13 ]