November 1992, Volume 42, Issue 11

Original Article

A CUNICOPATHOLOGICAL STUDY OF ENDOMETRIAL TUBERCULOSIS IN INFERTILITY

Parveen Haider  ( Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi. )
Sadiqua N. Jafarey  ( Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi. )

INTRODUCTION

Tuberculosis endometritis is found in 50-90% of women with genital tuberculosis1-4. The fallopian tubes are the initial site of involvement and are invariably affected in almost all cases3,4. Infection first commences in the mucosa and then spreads through the tubal wail to the peritoneal surface5,6. The endometrium gets involved by seeding from the tubes5-9. However, in rare instances, reinfection from its basal layer or myometrium may occur8,10. Endometrial tuberculosis may take one of the three forms8. It may be a part ofwidespreadpelvic involvement, the advanced type1, be a part of the gross infection involving the uterine wall but confined to the uterus, or may occur as few small isolated lesions confined to the endometrium8. The characteristic histopathological lesion may be proliferative, exudative or mixed. In the absence of typical granulomas, certain minor lesions can be sugges­tive of a tubercular aetiology and these include focal lymphocytic aggregates, cystic dilatation and distortion of glands, active destruction of epithelium and the presence of inflammatory exudate in the glandular lumen2,11-13. There may be an occasional plasma cell infiltration and this has been found to be associated with acute flare ups following curettage11.

PATIENTS, METHODS AND RESULTS

On the basis of clinical presentation, the patients were divided into 2 groups. Group I included 12 women who presented with infertility alone while group II included 11 cases who had other associated symptoms. Menstrual disturbances were present in all group II cases, with amenorrhoea being the commonest com­plaint (9).
Histopathology of endometrium
Various bistopathological lesions seen were as follows:
1. Proliferative lesions: Solid epitheloid granulomas without caseation were seen in 18(78%) cases.
2. Exudative lesions: Extensive tuberculous granula­tion tissue with frank caseation were seen in 2 (8.6%) cases.
3. Minor lesions were seen in one and no lesion in 2 cases.
Phasing of uninvolved endometrium
The intervening endometrium showed prolifera. tive phase in 14(60.8%) and secretory in 5(21.7%) cases.
The endometrium was hyperplastic in 2 (8.6%) cases while no phase could be detected in 2(8.6%) other cases on account of extensive caseating exudative lesions.
clinicopathological correlation:
When clinical syrnptomatology was correlated with the histopathological picture it was observed that:
(a) all cases with infertility who had no menstrual disturbances had proliferative lesions,
(b) patients with infertility and amenorrhoea had exudative lesions with frank caseation and
(c) cases with infertility and menorrhagia had hyper­plastic intervening endometrium. Though most biopsies were timed for a pre-menstrual phase, a high incidence of proliferative endometrium (60.8%) was found.

COMMENTS

Infertility is the commonest mode of presentation of genital tuberculosis and in the present study, 89% patients presented with this complaint. We observed that the clinical symptomatology correlated very well with the pathology reflected in the endometrium. The classical tuberculousgranulomais essentially similar to that found in other organs. The granulomas are generally young, immature and non-caseating found mostly in the superfi­cial parts of the endometrium either focal or diffuse and in the second half of the menstrual cycle2,4,11,14. This characteristic proliferative lesion was seen in all cases of infertility without any associated symptoms and may be attributed to the lack of time for the development of caseation due to the interruptions of menstrual cycle2,11,13. ­However, where infertility was associated with other symptoms, the classical picture changed. Two cases with long standing amenorrhoea, one of them being primary investigated at the age of 18 years had exudative lesions. It can be assumed that lack of periodic shedding favours the development of extensive tuber­culous granulation tissue and frank caseation2,11,13. Endometrial tuberculosis does not always give a characteristic pattern and sometimes minor lesions may be demonstrated2,11,13. A variety of endometrial patterns are found in association with tuberculous lesions such as prolifera­tive, secretory polypoidal and hyperplastic2,11,13. The last mentioned picture is infrequently met with, except in cases where irregular bleeding is the predominant complaint11. This pattern was observed in two of our cases who presented with infertility and menorrhagia. Although all biopsies were taken in the second half of the menstrual cycle, we observed a high incidence of proliferative endometrium (60.8%). This is consistent with the earlier reports2,12,13. The likely explanation is the possibility of an altered ovarian function presumably due to defective ovarian steroidogenesis or the result of end organ failure2,12,13.

ACKNOWLEDGEMENT

Our deepest gratitude to Dr. Qainar Jamal of Basic Medical Sciences Institute, Karachi for her help with the histopathology results.

REFERENCES

1. Bobrow, L.M. and Batts, J.A. Pelvic tuberculosis. Am.J.Obstet.Gynecol., 1952;64:1242­-50.
2. Malik, G.B., Maheshwari, B. and Lal, N.Tuberculosis endometritis, A clinicopathologi­cal study of 1000 cases. Br.J. Obstet.Gynaecol., 193;90:84-86.
3. Lee, J., Warner, L and Khaleghian, N.R. Sonographic features of tuberculous endometritis. J.Clin.Ultrasound, 1983;11:331-33.
4. Sutherland, A.M. Tuberculosis of the female genital tract. Tubercle., 1985;66:79-83.
5. Whitfield, C.R. Pelvic infection, in Dewhurst\\\'s textbook of obstetrics and gynaecology for postgraduates. 4th ed. Oxford, Blackwell, 1986, pp.604-6.
6. Tindall, V.R. Genital tuberculosis, in Jeffcoate’s principles of gynaecology. 5th ed. London, Butterwortha, 1987, pp.301-8.
7. Knaus, H.H. Surgical treatment of genital and peritoneal tuberculosis in the female. Am.J.Obstet.Gynecol., 1962;83:73-79.
8. Schaefer, G., Marcus., R.S and Kramer, E.E. Postmenopausal endometrial tuberculosis. Am.J.Obstet.Gynaecol., 1972112681-87.
9. Khilnani, P.H., Pandit, A.A. and Krishna, U.R Cytology as an aid in the diagnosis of genital tuberculosis.J. Posigrad. Med., 1988;34:100-2.
10. Barns, T., Smith, I-LG.M. and Snaith, L.M. Isoniazid in the treatment of female genital tuberculosis. Lancet, 1953;1:817-20.
11. Govan, A.D.T. Tuberculous endometritis.J.Pathol., Bact., 1962;83:363-72.
12. Tripathy, S.N. and Tripathy, S.N. Endometrial tuberculosis, 3. Indian Med.Assoc., 1987;85:136-40.
13. D\\\'Costa, G.F. and Nagle, S.B. Thberculous endometritis. A histopathological study. 3. Postgrad., Med., 1988;34:7-11.
14. Tripathy, S.N. and Tripathy, S.N. Genital manifestations of pulmonary tuberculosis. Int.J. Gynaecol., Obstet., 1981;19:319-26.

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