1. Mycoplasma genitalium Infection in Women Manifests as Mild Cervicitis
Lisa E. Manhart1, Sara J. Nelson1, Emily B. Hancock1,
Jennifer K.H. Wroblewski 2, Patricia A. Totten2
Departments of Epidemiology1, and Medicine2
University of Washington, Seattle, WA

2. Mycoplasma genitalium
Pollack JD. Trends Microbiol 1997
Smallest known genome 580kb
One of the first fully sequenced (Fraser, Science 1995)
First bacterium to be chemically synthesized
(Gibson, Science 2008)
Strong association with urethritis in men
(Jensen, J Eur Acad Dermatol Venereol, 2004)
Associated with upper tract infection in women
Endometritis (Cohen, Lancet 2002)
Pelvic Inflammatory Disease (Simms, Sex Transm Infect 2003)
Tubal factor infertility (Clausen, Hum Rep 2001; Svenstrup, Fert Steril 2007)
Inconsistently associated with cervicitis

3. M. genitalium and cervicitis* * * *
*NS, p>0.05

4. METHODS
1038 women aged attending Public Health Seattle & King County STD clinic from
External genital and speculum exam
Cervical swabs
Urine
Self-obtained vaginal swabs
Mycoplasma genitalium testing
PCR assay targeting mgpB adhesin gene (Dutro et al, STD 2003)
TMA Research Only assay (Gen-Probe, Inc.)
M. genitalium infection defined as a positive test result by either test in any specimen type (Wroblewski et al, J Clin Micro 2006)
Chlamydia trachomatis / Neisseria gonorrhoeae
Cervical culture

5. Prevalence of M. genitalium, N. gonorrhoeae, and C. trachomatis

6. Sociodemographic Characteristics Associated with M. genitalium
MG-pos. MG-neg.
Characteristic N (%) N (%) p-value
n=116 n=897
Age (mean ± SD) (± 6.6) 26.9 (±7.3) <0.001
Black race 65 (56.5) 302 (34.4) <0.001
Single (93.9) 680 (77.5) <0.001
Income <$10,000/year 71 (65.1) 445 (52.4)
Current smoker 65 (58.6) 381 (44.0)
Age at sexual debut (±2.1) 15.8 (±2.4)
Oral contraceptive use 12 (10.3) 153 (17.1)
No association with number of sex partners (p=0.8) or time since last sexual encounter (p=0.9)

7. Easily Induced Cervical Bleeding
Clinical Findings
Easily Induced Cervical Bleeding
MG+
MG-
p=0.75
% with bleeding

8. Easily Induced Cervical Bleeding
Clinical Findings
Easily Induced Cervical Bleeding
MG+
MG-
p=0.75
% with bleeding
MG+
MG-
Cervical Mucopus
% with mucopus
p=0.95

9. Easily Induced Cervical Bleeding
Clinical Findings
Easily Induced Cervical Bleeding
MG+
MG-
p=0.75
% with bleeding
MG+
MG-
Cervical Mucopus
% with mucopus
p=0.95
p=0.15
Cervical PMN ≥30
MG+
MG-
% with PMN≥30

10. Easily Induced Cervical Bleeding Mucopurulent Cervicitis (MPC*)
Clinical Findings
Easily Induced Cervical Bleeding
MG+
MG-
p=0.75
% with bleeding
MG+
MG-
Cervical Mucopus
% with mucopus
p=0.95
p=0.15
Cervical PMN ≥30
MG+
MG-
% with PMN≥30
Mucopurulent Cervicitis (MPC*)
MG+
MG-
% with MPC
p=0.13
* MPC = ≥30 PMNs or cervical mucopus

11. Markers of Mild Cervicitis
Cervical PMN Count
Cloudy Cervical Discharge
p=0.006
p=0.32
% within PMN category
% with cloudy discharge
MG+
MG-

12. Multivariate model M. genitalium and Cervicitis
Outcome
AOR (95% CI)*
p-value
Mucopurulent Cervicitis**
1.6 ( )
0.12
Cloudy cervical discharge
2.0 ( )
0.006
* Odds ratios adjusted for CT, GC, and OCP use
** MPC defined as ≥30 PMNs or cervical mucopus

13. Age Effect on Association of M. genitalium and Cervicitis
OUTCOME
AOR (95% CI)* P
Mucopurulent Cervicitis**
Age <25
Age≥25
1.3 ( ) p=0.474
2.5 ( ) p=0.045
Cloudy cervical exudates
Age<25
1.8 ( ) p=0.065
2.4 ( ) p=0.032
* Odds ratios adjusted for CT, GC, and OCP use
** MPC defined as ≥30 PMNs or cervical mucopus

14. Strengths & Limitations
Large sample of women in an urban STD clinic with research emphasis resulted in careful assessment
M. genitalium infection assessed by two NAATs
Culture for N. gonorrhoeae and C. trachomatis less sensitive than NAAT
Multiple clinicians measuring cervicitis may have resulted in clinician-to-clinician variability
Cross-sectional analysis limits conclusions about causality

15. Summary Among all women:
M. genitalium marginally associated with MPC (OR 1.6, p=0.12)
M. genitalium strongly associated with cloudy cervical exudates (OR= 2.0, p=0.006)
Relationship with MPC was stronger among women ≥25
Similar to association between MPC and BV (Marrazzo JID 2006)
In contrast to association between MPC and CT (Marrazzo OBGYN 2002)
Age differences may partially
explain conflicting evidence
regarding relationship between
M. genitalium and MPC

16. Acknowledgements PHSKC STD Clinic Staff Yolanda Bantolino Sylvia Berry
Dwyn Dithmer-Schreck
M. Sylvan Lowens
Eduardo Munoz
Victory Murphy
Sally Pendras
Sue Szabo
Michael Verdon
Fred Koch
Barbara Krekeler
Totten Laboratory
Sabina Astete
Lisa Lowenstein
Interviewers
Anne Buffardi
Ethel Green
Tracy Peto
Lisa Ramachandra
Funding
NIH/NIAID U19 AI31448
NIH/NIAID R01 AI48634

18. RESULTS Clinical Findings by Age
Characteristic/Findings Overall <25 ≥25
N=1038 N=514 N=501
C. trachomatis (5.8) 37 (7.2) 23 (4.6)*
N. gonorrhoeae (2.2) 11 (2.1) 12 (2.4)
M. genitalium (11.5) 76 (15.2) 39 (7.9)**
Cervical friability 106 (10.2) 46 (8.9) 59 (11.8)
Cervical mucopus (3.5) 18 (3.5) 18 (3.6)
Cervical PMN ≥ (12.9) 51 (13.5) 46 (12.0)
MPC (9.6) 51 (9.9) 46 (9.2)
Cloudy cervical discharge 137 (13.2) 66 (12.8) 68 (13.6)
*p=0.08
** p<0.001

19. RESULTS Laboratory and Clinical Findings
MG-pos. MG-neg.
Characteristic N (%) N (%) p-value
n=116 n=897
C. trachomatis (6.0) 52 (5.8) 0.92
N. gonorrhoeae (3.5) 19 (2.1) 0.37
Cervical ectopy 14 (12.1) 92 (10.3) 0.55
Cervical friability 13 (11.2) 92 (10.3) 0.75
Cervical mucopus 4 (3.5) 32 (3.6) 0.95
Cervical PMN ≥ (17.8) 84 (12.3) 0.15
Abnormal cervical discharge 78 (67.2) 531 (59.2) 0.10