Female Genital Tuberculosis: All you need to know about this less known form of TB

Genital TB often goes undetected and diagnosis remains a challenge despite being the third most common site for TB infection, after the lungs and lymph nodes

Tuberculosis (TB) is a persistent and age-old health challenge, capable of affecting various organs and tissues within the body, excluding only hair and nails. However, beyond its commonly known impact on the lungs or kidneys, there exists a silent and often overlooked form of TB that profoundly affects women’s reproductive health. 

Female Genital Tuberculosis (FGTB) targets critical areas such as the fallopian tubes, uterine lining, ovaries, cervix, and vagina/vulva.

A public health challenge

TB poses a significant global public health challenge, affecting approximately 10 million individuals worldwide annually. About 2.5 million new infections were reported in India in 2021. It can be pulmonary or extrapulmonary TB. FGTB is a type of extrapulmonary TB (EPTB) which is responsible for 9 percent of all cases of EPTB. 

According to Dr JB Sharma, Obstetrician and Gynecologist at All India Institute of Medical Sciences in New Delhi, FGTB is a major cause of morbidity in females

“It leads to infertility, dyspareunia, menstrual dysfunction, chronic pelvic inflammatory disease, and chronic pelvic pain,” Sharma told HealthLEADS.

A study published in the Indian Journal of Tuberculosis reveals that 25 percent of women suffering from pulmonary TB in the country also have silent genital TB. The primary causative agent of FGTB is Mycobacterium tuberculosis (occasionally Mycobacterium bovis and/or atypical mycobacteria). Hence, this type of TB usually occurs secondary to primary pulmonary TB. It typically develops as a result of  the TB of the lungs or other organs and spreads by lymphatic, hematogenous, or direct dissemination from abdominal TB. Around 90 percent of women with FGTB experience fallopian tube damage.

Chronic illness with milder symptoms

Dr Sharma explains that women with FGTB may either show no symptoms or experience symptoms similar to other gynecological conditions such as ovarian cysts, ectopic pregnancy, or even genital cancer, particularly in the early stages. Often, infertility is the only presenting symptom.

He cited a case where a postmenopausal woman presented with a complaint of discharge per vaginum, but the diagnosis turned out to be massive uterovaginal prolapse with a cervical lesion, mimicking cervical cancer. Later, FGTB was diagnosed in this case. 

“In a case like this, it appeared to be cervical cancer to the doctors and later realisation actually highlights that mostly clinical features of FGTB are non-specific, and it maybe a reason for late diagnosis,” Dr Sharma says. “I believe that a high index of suspicion is needed for its early detection. For example patients with chronic pelvic pain, pelvic inflammatory disease not responding to routine antibiotic therapy and unexplained infertility should raise suspicion for FGTB.”

Genital TB diagnosis

Genital TB often goes undetected and diagnosis remains a challenge despite being the third most common site for TB infection, after the lungs and lymph nodes. 

Doctors use various tests and processes to diagnose FGTB: Clinical suspicion based on medical history (including a family history of TB, past history of TB or antituberculous treatment), presence of comorbid medical conditions, menstrual disorder, complete physical examination, use of imaging procedures, surgical and histopathology findings, and tests like polymerase chain reaction (PCR) or Gene expert to detect the presence of the genetic material of TB bacteria’s DNA body fluids.

Doctors also use a hysterosalpingogram (HSG) to diagnose tubal blockage associated with FGTB. The procedure involves introducing a radio-opaque dye through the cervix into the uterus, and successive X-rays are taken to track the passage of the dye into the uterus and fallopian tubes. HSG may reveal obstruction of the tubes or constriction of the uterine cavity due to adhesions. Tubal blockage can occur at various points along the course of the fallopian tube, and in some cases, the damaged tubes may develop blockage at the distal end, leading to distension with tubal secretions and fluid, known as hydrosalpinx.

Preventive measures 

Early detection and prompt treatment play a crucial role in curbing the spread of FGTB. Dr Sharma recommends starting the anti-tubercular medical therapy (AKT) treatment once the diagnosis is confirmed and completing the full course of treatment without interruption. For those diagnosed with infectious TB, it’s essential to test close contacts as part of the case-finding and contact-tracing process.

Dr Sharma emphasizes the significance of maintaining a robust immune system, which acts as a defense against 60 percent of FGTB cases. He suggests increased testing, prompt vaccinations, good hygiene, proper waste disposal, good ventilation with exposure to natural light, and seeking medical attention for anyone exposed to TB or exhibiting symptoms like pelvic pain or irregular menstrual cycles.

Treatment for FGTB typically involves a multi-drug anti-tubercular therapy in consultation with a TB specialist. The first-line treatment comprises a four-drug regimen for six months, involving daily doses of rifampicin, isoniazid, pyrazinamide, and ethambutol for the initial two months, followed by daily isoniazid, rifampicin, and ethambutol for the subsequent four months. In cases where first-line treatment fails, such as in patients with HIV co-infection or multidrug-resistant TB, a second-line treatment is adopted.

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