Female Genital Tuberculosis
On this page
Direct answer
Female genital tuberculosis is infection of the upper genital tract by Mycobacterium tuberculosis, usually spreading from a pulmonary focus to the tubes and endometrium. In India it is a major cause of tubal factor infertility, and many women are asymptomatic or present with infertility, menstrual change or pelvic pain. Diagnosis rests on endometrial histology with culture or PCR, and treatment is the standard antitubercular regimen under the national programme.
What you must remember
- Sites of disease: the fallopian tubes are involved in most cases, the endometrium is commonly affected, and the ovaries and cervix are involved less often.
- Presentation: infertility is the commonest presentation, while menstrual irregularity and pelvic pain are common and systemic symptoms are often absent.
- Pathology: caseating granulomas, sometimes with acid-fast bacilli, appear in the endometrium, and tubal disease causes hydrosalpinx, adhesions and calcification.
- Endometrial diagnosis: endometrial biopsy sent for acid-fast bacilli culture, histology and PCR gives a specific diagnosis, with culture definitive but slow and PCR faster.
- Imaging: hysterosalpingography may show tubal occlusion, hydrosalpinx or a beaded tube, and hysteroscopy may show endometrial irregularity and synechiae.
- Treatment: the standard antitubercular regimen under the National Tuberculosis Elimination Programme, with surgery reserved for complications such as tubo-ovarian abscess.
A stepwise approach to infertility with tubal occlusion
A 29-year-old woman has four years of primary infertility, normal ovulation and bilateral tubal occlusion on hysterosalpingography. She has no obvious systemic illness, so genital tuberculosis is a possibility to be excluded before any assisted reproduction is planned. The steps below show how to reach a diagnosis and plan treatment.
- Take a focused history: Ask about contact with tuberculosis, night sweats, weight loss and previous pulmonary disease, recognising that systemic signs may be absent.
- Image the tubes: Hysterosalpingography or laparoscopy shows bilateral tubal occlusion, hydrosalpinx or peritubal adhesions that raise suspicion.
- Sample the endometrium: An endometrial biopsy is sent for histology, acid-fast staining, culture and PCR, with PCR providing the faster answer.
- Check for systemic disease: A chest X-ray, sputum examination and an interferon-gamma release assay or Mantoux test help identify latent or active tuberculosis elsewhere.
- Start antitubercular therapy: The standard regimen is started, with counselling about adherence and drug adverse effects.
- Plan contraception and fertility: Rifampicin lowers oral contraceptive efficacy, so an additional or non-hormonal method is used, and assisted reproduction is considered after treatment is complete.
Where the exam tries to catch you
Examiners test whether you can diagnose genital tuberculosis without relying on chest findings and sequence treatment before assisted reproduction.
- Trap: Start IVF straight away in a woman with tubal occlusion and suspected tuberculosis. Correct: Treat the infection and assess the endometrium first, because untreated endometrial disease can impair implantation.
- Trap: Rely on a normal chest X-ray to exclude genital tuberculosis. Correct: Genital tuberculosis can occur without pulmonary disease, so endometrial sampling is required.
- Trap: Assume a normal ultrasound excludes genital tuberculosis. Correct: Tubal and endometrial disease can be subtle, so the diagnosis depends on histology, culture or PCR.
- Trap: Forget that rifampicin reduces oral contraceptive effect. Correct: Rifampicin induces hepatic enzymes and lowers hormone levels, so an additional contraceptive method is advised during treatment.
Frequently asked questions
Which investigation confirms female genital tuberculosis?
An endometrial biopsy sent for acid-fast bacilli culture, histology and PCR confirms female genital tuberculosis. Culture is the reference standard but takes several weeks, whereas PCR gives a faster result, and granulomas on histology support the diagnosis.
Why does female genital tuberculosis cause infertility?
Female genital tuberculosis causes infertility through tubal occlusion and endometrial damage, which prevent fertilisation and implantation. Tubal disease with hydrosalpinx and adhesions is the commonest mechanism of infertility in this condition.
Is surgery needed for female genital tuberculosis?
Surgery is not needed in most women with female genital tuberculosis, because antitubercular therapy treats the infection. Surgery is reserved for complications such as tubo-ovarian abscess or diagnostic uncertainty that cannot be resolved by biopsy.
Can a woman on antitubercular therapy use hormonal contraception?
Rifampicin in antitubercular therapy reduces the effectiveness of oral contraceptives in women treated for genital tuberculosis. An additional or non-hormonal contraceptive method is advised throughout treatment, as per local guidance.
When is assisted reproduction considered in female genital tuberculosis?
Assisted reproduction such as IVF is considered in female genital tuberculosis after antitubercular therapy is complete and the endometrium has been assessed. Because tubal disease usually makes tubal surgery unsuitable, IVF is generally the route to pregnancy.