Journal of Mid-life Health Journal of Mid-life Health
Home | About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions | Online submission | Subscribe | Advertise Users Online: 708  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size 




 
 Table of Contents 
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 213-215  

An uncommon cause of postmenopausal bleeding


1 Department of Obstetrics and Gynecology, Government Medical College and Hospital, Chandigarh, India
2 Department of Pathology, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication26-Dec-2019

Correspondence Address:
Dr. Geetika Garg
Department of Obstetrics and Gynecology, Government Medical College and Hospital, Chandigarh - 160 030
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmh.JMH_17_18

Rights and Permissions
   Abstract 

A 65-year-old multiparous female was evaluated for postmenopausal bleeding. Imaging was strongly suggestive of malignancy. However, hysteroscopic-guided endometrial biopsy revealed tuberculous endometritis. The patient responded to antitubercular therapy and recovered completely. Genital tuberculosis is typically considered a disease of young women presenting with infertility. However, tuberculous endometritis should be considered in a patient of postmenopausal bleeding, particularly in developing countries. It is a rare, but curable cause of postmenopausal bleeding.

Keywords: Endometrial carcinoma, postmenopausal bleeding, tuberculous endometritis


How to cite this article:
Garg G, Singh A, Goel B, Bhagat R. An uncommon cause of postmenopausal bleeding. J Mid-life Health 2019;10:213-5

How to cite this URL:
Garg G, Singh A, Goel B, Bhagat R. An uncommon cause of postmenopausal bleeding. J Mid-life Health [serial online] 2019 [cited 2020 Jan 24];10:213-5. Available from: http://www.jmidlifehealth.org/text.asp?2019/10/4/213/274008


   Introduction Top


Postmenopausal bleeding represents one of the most common reasons for referral to gynecological services, largely due to the suspicion of an underlying malignancy. Although, in most instances, the bleeding comes from a benign source, endometrial carcinoma is present in approximately 10% of women referred with postmenopausal bleeding. We present a case of postmenopausal bleeding in which imaging was suggestive of malignancy, but histology revealed a rare but curable etiology.


   Case Report Top


A 65-year-old multiparous female presented to the outpatient department with complaints of intermittent bleeding and foul-smelling discharge per vaginum for the past 1 year. She had no pain abdomen, fever, loss of weight, or prior postcoital bleeding. She had no personal or family history of gynecological or other malignancy. Endometrial sampling done 2 months ago in another clinic revealed endometrial abscess on histopathological examination. However, she did not respond to the antibiotic treatment and was referred to our institute. General physical and systemic examination was unremarkable. Per speculum examination showed healthy vagina and cervix. On per vaginum examination, uterus was small, atrophic with no palpable adnexal mass. Transvaginal pelvic ultrasound revealed variegated echo pattern of endometrial cavity with ill-defined hypoechoic focus in the upper part of endometrial cavity. Magnetic resonance imaging of pelvis revealed T2 hyperintense, irregular marginated lesion measuring 20 mm × 13 mm involving the mid-body of endometrium with extension into/compression of junction zone, suggestive of malignancy. Cervix and bilateral ovaries were normal. The patient underwent hysteroscopy-guided endometrial biopsy. On hysteroscopy, uterine cavity appeared shaggy with presence of a small necrotic polypoidal growth. Curetting was obtained from the surface of uterine growth. Histology of the curetting showed epithelioid cell granulomas with Langhan's giant cells, consistent with tuberculous endometritis [Figure 1]. However, Ziehl–Neelsen staining for acid-fast bacilli was negative [Figure 2]. The patient received multidrug antitubercular therapy for 6 months. After the completion of therapy, no tissue could be obtained on repeat endometrial biopsy. At subsequent follow-up visits, the patient is doing well and is asymptomatic for 9 months.
Figure 1: Low-power photomicrograph showing epithelioid cell granulomas (red arrow), Langhan's type of giant cells (green arrow) and foci of calcification (asterisk) (H and E, ×100)

Click here to view
Figure 2: Low-power photomicrograph showing negative Ziehl–Neelsen staining for acid-fast bacilli (ZN, ×400)

Click here to view



   Discussion Top


Genitourinary tuberculosis is a common form of extrapulmonary tuberculosis, accounting for 9% of all cases.[1] The female genital organs affected by Mycobacterium tuberculosis (in descending order of frequency) are  Fallopian tube More Detailss (95%–100%), uterine endometrium (50%–60%), ovaries (20%–30%), cervix (5%–15%), uterine myometrium (2.5%), and vagina/vulva (1%).[2] It usually occurs secondary to tuberculosis at other sites (primarily the lungs). The spread occurs through hematogenous or lymphatic routes.[3] It can occur in any age group, but women in the reproductive age group (15–45 years) are the most affected.[4] In most cases, the disease is asymptomatic or present with minimal symptoms, among which infertility is the most common. Other reported symptoms include menstrual irregularities, pelvic pain, and abnormal vaginal discharge. Tuberculous endometritis in postmenopausal females is very rare, as atrophic endometrium offers a poor milieu for the growth of Mycobacterium.[5] Postmenopausal bleeding is the presenting manifestation in 1%–1.6% of Indian patients with genital tuberculosis.[6] In postmenopausal women, tuberculous endometritis presents with symptoms resembling endometrial malignancy, such as postmenopausal bleeding, persistent leukorrhea, and pyometra.[7] The diagnosis of genital tuberculosis requires a high index of suspicion, thorough clinical assessment, and the use of appropriate investigations. Baseline investigations such as chest radiograph, Mantoux test, and erythrocyte sedimentation rate are nonspecific. In a study of 72 patients of genital tuberculosis, 43% had no abnormality on pelvic examination, while 23.6% presented with adnexal mass and myoma-like lesions each, 4.2% had adnexal tenderness, and 1.4% each had irregular uterus or uterine prolapse or cervical polyp.[8] They also reported normal chest radiograph in 81% of patients.[8] Mantoux test has a sensitivity and specificity of 55% and 80%, respectively.[9] The imaging modalities that are useful in the diagnosis of genital tuberculosis include hysterosalpingography (HSG) and ultrasonography (USG). HSG evaluates the internal structure of the female genital tract and tubal patency, whereas USG allows simultaneous evaluation of ovarian, uterine, and extrapelvic involvement.[10] Histopathological evidence in the biopsy of premenstrual endometrial tissue or demonstration of tubercle bacilli in culture of menstrual blood or endometrial curetting only can provide a definite diagnosis of tubercular endometritis. Being a paucibacillary disease, demonstration of M. tuberculosis is not possible in all cases. The typical lesions on histopathology are epithelioid cell granulomas with or without Langhan's giant cells. Caseation necrosis is rare and develops late in the course of the disease.[8] Treatment of genital tuberculosis consists of 6 months of antitubercular therapy. Majority of the patients respond to medical management. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is required in case of persistence of pelvic mass or recurrence of pain or bleeding after 9 months of treatment. To reduce the risk of perioperative complications, surgery should be performed at least 6 weeks after initiation of antitubercular therapy.[11] In the index case, the characteristic histopathology and the response to antitubercular therapy confirmed the diagnosis of tubercular endometritis. Culture of the endometrial tissue was not done as grossly the endometrium appeared neoplastic.


   Conclusion Top


Tuberculous endometritis is a rare, but curable cause of postmenopausal bleeding. It is imperative to consider this possibility in a patient of postmenopausal bleeding, particularly in developing countries, to facilitate early diagnosis and treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Golden MP, Vikram HR. Extrapulmonary tuberculosis: An overview. Am Fam Physician 2005;72:1761-8.  Back to cited text no. 1
    
2.
Das P, Ahuja A, Gupta SD. Incidence, etiopathogenesis and pathological aspects of genitourinary tuberculosis in India: A journey revisited. Indian J Urol 2008;24:356-61.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Aliyu MH, Aliyu SH, Salihu HM. Female genital tuberculosis: A global review. Int J Fertil Womens Med 2004;49:123-36.  Back to cited text no. 3
    
4.
Qureshi RN, Samad S, Hamid R, Lakha SF. Female genital tuberculosis revisited. J Pak Med Assoc 2001;51:16-8.  Back to cited text no. 4
    
5.
Maestre MA, Manzano CD, López RM. Postmenopausal endometrial tuberculosis. Int J Gynaecol Obstet 2004;86:405-6.  Back to cited text no. 5
    
6.
Samal S, Gupta U, Agarwal P. Menstrual disorders in genital tuberculosis. J Indian Med Assoc 2000;98:126-7, 129.  Back to cited text no. 6
    
7.
Singh N, Sumana G, Mittal S. Genital tuberculosis: A leading cause for infertility in women seeking assisted conception in North India. Arch Gynecol Obstet 2008;278:325-7.  Back to cited text no. 7
    
8.
Saracoglu OF, Mungan T, Tanzer F. Pelvic tuberculosis. Int J Gynaecol Obstet 1992;37:115-20.  Back to cited text no. 8
    
9.
Raut VS, Mahashur AA, Sheth SS. The Mantoux test in the diagnosis of genital tuberculosis in women. Int J Gynaecol Obstet 2001;72:165-9.  Back to cited text no. 9
    
10.
Shah HU, Sannananja B, Baheti AD, Udare AS, Badhe PV. Hysterosalpingography and ultrasonography findings of female genital tuberculosis. Diagn Interv Radiol 2015;21:10-5.  Back to cited text no. 10
    
11.
Sutherland AM. Surgical treatment of tuberculosis of the female genital tract. Br J Obstet Gynaecol 1980;87:610-2.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

Top
  
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed115    
    Printed2    
    Emailed0    
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal