Resumption of menstrual cycles after 14 years of amenorrhea in a woman infected with Mycobacterium africanum

Abstract

The most common site of tuberculosis is the lung. However, it can also affect the fallopian tubes or endometrium. We report a woman with a narrow and tubular uterine cavity due to Mycobacterium africanum. The endometrium was fibrotic leading to amenorrhea of over a decade. Despite treatment with multiple anti-tuberculosis medication and hysteroscopic adhesiolysis, menstrual cycles resumed only a few years later. It shows that the endometrium regenerates overtime.

Introduction

About one third of the world population is estimated to be infected with Mycobacterium tuberculosis [1]. However, its epidemiology varies around the world. If the rates in sub-Saharan Africa, India, and Southeast Asia is 100/100,000, the rates in the North America and Western Europe is less than 25 cases per 100,000 inhabitants [2]. With increasing travel and immigration of individuals from endemic countries, physicians in non-endemic countries might encounter patients with tuberculosis. The most common type is pulmonary tuberculosis. However, the bacteria might also spread to the genital area. In women, it can affect the fallopian tubes, ovaries or, endometrium.

We report resumption of menstrual cycles after 14 years of amenorrhea in a woman infected with Mycobacterium africanum.

Case presentation

A 30-year-old nulligravida, presented to our clinic in March 2009 with a history of amenorrhea for 12 years. She was originally from Ivory Coast. Following regular menses, her menstruation ceased to exist in 1997. Family history was unremarkable. Physical examination revealed multiple dark nodules on her legs. Biopsy of these nodules was done in another country. However, the results could not be obtained. Her BMI was 22.5 kg/m², serum FSH level was 6.9 IU/L, estradiol 182 pmol/L, PRL 8.1 μg/L, and TSH 1.6 mlU/L. Ultrasound; and MRI revealed intrauterine adhesions, and endometrial thickness was 1.7 mm. Progesterone challenge test with medroxy-progesterone acetate (MPA), and then with ethinyl estradiol, and MPA failed to induce her menses.

Hysteroscopic examination on October 2, 2009 revealed a narrow and tubular uterine cavity, the endometrium appeared fibrotic with poor vascularity (Fig. 1). Tubal ostia were not seen. Endometrial biopsy did not yield any endometrium, but endocervical curetting revealed numerous non-necrotizing epithelioid granulomas on histopathological examination (Fig. 2). The culture showed Mycobacterium africanum. Chest X-ray was normal. She was then treated with multiple anti-tuberculosis medication of isoniazide and rifampicin for 6 months. The skin lesions gradually disappeared 12 months later.

Fig. 1

Narrow and tubular uterine cavity, the endometrium appeared fibrotic

Fig. 2

Histopathology of endocervical curetting showing numerous non-necrotizing epithelioid granulomas with giant cells

Because menses did not resume, we performed another hysteroscopy in August 2010 where extensive and dense intrauterine adhesions were liberated (Fig.3). At the completion of the procedure, the right tubal ostium could be seen. A Foley catheter was inserted into the uterine cavity and the patient was treated with ethinyl estradiol, 6 mg daily for 21 days (day1–21) and MPA 10 mg daily for 5 days (day 17–21). Menses did not occur.

Fig. 3

Hysteroscopic adhesiolysis

Menstrual cycles returned in January 2012 with a 1 day bleeding every 2 months and, subsequently, became more regular and lasted 5–6 days within a year. This case report was exempted from review by The Research and Ethics Board of McGill University Health Center.

Discussion

Our case illustrates spontaneous resumption of menses over a decade after tuberculosis-related amenorrhea. It shows that normal endometrium regenerated overtime after proper treatment with antituberculosis drugs. In fact, lysis of intrauterine adhesions only did not lead to return of menses. Our patient was infected with Mycobacterium africanum. M. africanum is commonly found in West African countries, causing up to a quarter of cases of tuberculosis [3]. It is an infection of human only and is spread by an airborne route. It has a similar degree of infectivity to the regular M. tuberculosis organism. The treatment is similar to that of conventional tuberculosis [3].

Tuberculosis can affect the reproductive organs by direct spread from an intraabdominal focus or low genital tract infection, or by hematogenous spread from primary pulmonary lesion. The most common sites are the fallopian tube and the endometrium. The clinical manifestations of genital tuberculosis are infertility, abnormal uterine bleeding, and pelvic mass, or pelvic pain. The diagnosis is usually made by histopathology and culture of endometrial sampling, biopsy of lesions in the peritoneal cavity, or from peritoneal fluid.

Genital tuberculosis is an important cause of infertility in developing countries. In a report from India, it accounted for 7.5 % of 492 patients who underwent a hysterosalpingogram for evaluation of infertility [4, 5]. Unfortunately, the rate of successful conception after anti-tuberculosis treatment is relatively poor (19 % in one series) [6].

As shown on hysteroscopy examination, the endometrium appeared to be fibrotic suggesting extensive adhesions. Due to extensive damage to endometrial glands by the tuberculosis process, the endometrium may respond poorly to hormonal stimulation preventing or delaying endometrial regeneration. A high blood flow impedance of spiral artery might also impair regrowth of the endometrium [4].

Combined resistant endometrium and poor tubal condition in women with genital tuberculosis lead to infertility [5]. Pregnancy rate in women with genital tuberculosis is indeed low. In one study, the rates of conception and live birth were 19.2 and 7.2 %, respectively [6].

Our report suggests that regeneration of the endometrium and return of menses in women with tuberculosis-related amenorrhea even after proper treatment with antituberculosis drugs can take many years.