Has the Time Come to Systematically Test for Mycoplasma genitalium?

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Mycoplasma genitalium has gained attention in the general scientific community as the smallest known free-living organism and the first to be chemically synthesized.1 Clinically, M. genitalium was first identified among 2 men with nongonococcal urethritis (NGU),2 has been consistently associated with NGU in men,3 and is clearly sexually transmitted between heterosexual partners.4 Nevertheless, the majority of epidemiologic investigations have focused on men, and less evidence exists linking M. genitalium infection in women to reproductive tract disease. In this issue of the journal, Gaydos et al present data linking M. genitalium to cervicitis among a predominantly young, African American group of women attending a sexually transmitted diseases clinic,5 adding further supporting evidence to the hypothesis that M. genitalium is also pathogenic in women.Gaydos et al sought to determine the prevalence of various organisms among women attending an inner city STD clinic and assess their relationship with cervicitis using rigorous laboratory assessments employing multiple nucleic acid amplification tests with different targets. Despite testing for Neisseria gonorrhoeae, Chlaymdia trachomatis, and Trichomonas vaginalis, after adjusting for other reproductive tract pathogens only M. genitalium was significantly associated with cervicitis. Although it was somewhat surprising that cervicitis was not associated with either N. gonorrhoeae or C. trachomatis, this may be partially due to a broad definition of cervicitis (cervical discharge or easily induced cervical bleeding or clinician-noted diagnosis of cervicitis).Despite the clear association between M. genitalium and cervicitis observed in this study, not all studies have been consistent. In fact, 5 of the now 13 (38%) published studies presenting data on cervicitis failed to observe a significant association with M. genitalium,6–10 and at least 2 other analyses in 2 separate populations have also failed to report strong associations (Manhart, unpublished data). Thus, while the study conducted by Gaydos et al adds to the evidence supporting an association between M. genitalium and cervicitis,11–17 the published data on this are far from consistent. Many of these studies used different definitions of cervicitis, which almost certainly contributes to the differences in results. Furthermore, virtually all of these studies assessed prevalent cervicitis and prevalent M. genitalium infection at the same point in time. This makes it impossible to draw conclusions about either temporal sequence and/or causality. Longitudinal studies that evaluate both the acquisition of M. genitalium and the development of cervicitis will be essential to definitively determine to what extent this emerging sexually transmitted organism is causally associated with cervicitis.Although cervicitis was the focus of the Gaydos investigation, the more important concern with cervical pathogens is whether they are able to ascend from the cervix into the upper reproductive tract and cause serious sequelae such as pelvic inflammatory disease, ectopic pregnancy, and infertility. The limited number of studies conducted on upper reproductive tract infection are mostly consistent and suggest that M. genitalium can result in pelvic inflammatory disease18 and infertility.19 While further studies are necessary to confirm these observations, this suggests that, irrespective of its role in cervicitis, infection with M. genitalium is something clinicians should pay attention to.The prevalence of M. genitalium in Gaydos’ population was remarkably high (19.2%) and higher in fact than C. trachomatis (11.1%), N. gonorrhoeae (4.6%), or T. vaginalis (15.3%). In other STD clinic populations, prevalence of M. genitalium in women has ranged between 4% to 6%10–14; prevalences as high as that observed by Gaydos et al have previously only been reported in African populations,15 or adolescents.8 If M.

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