- Email: [email protected]
Short course chemotherapy for endometrial tuberculosis in infertile women
75
Znt. J. Gynecol. Obstet., 1990,32: 75-76 International Federation of Gynecology and Obstetrics
Short course chemotherapy infertile women
for endometrial
tuberculosis
in
U.N. Jindal”, S.K. Jindalb and G.I. Dhall” Departments of aObstetrics and Gynaecology and Tulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012 (India) (Received March lst, 1989) (Revised and accepted April 12th 1989)
Abstract A daily regimen of rifampicin (450 mg) and isoniazid (300 mg) was tried for 9 months in 14 women with histologically diagnosed endometrial tuberculosis (TB). Follow-up endometrial biopsies were negative for tubercular disease in all patients. Three (21.4%) of the 14 women conceived between 3 and 12 months after starting treatment. Keywords: Endometrial tuberculosis; course chemotherapy; Infertility.
what cavalier, in that strict treatment protocols often are lacking [6]. For example, in one report from the United States, four cases of gynecological TB were included, but the authors did not discuss specific medical issues as they related to the disease [l]. Unlike pulmonary, lymph node and pleural TB, gynecological TB presents unique difficulties in diagnosis and interpretation of the therapeutic response. Materials and methods
Short
Introduction Although tuberculosis of the genital tract is an uncommon disease in developed countries, it remains an important problem in India [4,9]. Short course chemotherapy (SCC) regimens have been extensively evaluated in the treatment of pulmonary tuberculosis (TB). To date, however, no such large-scale evaluation is available for patients who demonstrate extra-pulmonary TB [7], despite existence of a few reports on SCC in some forms of extrapulmonary TB (e.g., pleural and lymph node). Prospective controlled studies on genitourinary and gynecological manifestations are sparse [1,5,9]. In general, treatment of extra-pulmonary TB is some0020-7292/90/$03 50
0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
The case material was selected out of 627 couples seen in the infertility clinic during a 2year period. Endometrial biopsy was performed in all these women as a routine part of the workup for infertility. Endometrial TB was diagnosed from the biopsy material on the basis of finding discrete, tubercular granulomas consisting of caseation, epithelioid cells, lymphocytes, and giant cells and/or the growth of Mycobacterium tuberculosis from the specimen for this report. A total of 24 patients (3.8%) had evidence of active endometrial disease; only 14 could comply with the follow-up schedule and were studied. An additional 40 patients had evidence of old healed genital or pulmonary TB; these women were not included in the study. The study group of 14 women was started on a daily regimen of rifampicin (RIF), 10 Clinical and Clinical Research
76
Jindal et al.
mg/kg body weight, and isoniazid (INH), 300 mg for 9 months after demonstration of normal hepatic and renal function. Endometrial biopsy was repeated every 3 months as a part of the follow-up protocol. Hysterosalpingography (HSG) was performed after completion of treatment. A further follow-up examination was performed 3-6 months following the 9 months of continuous treatment. Results The mean age of the patients was 25.6 years (range 20-33 years), and the duration of their infertility ranged from 36 to 144 months (average 56 months). All had regular menstrual periods, but eight complained of scanty flow. Nine patients had primary and five secondary infertility. None had palpable pelvic masses. All patients responded favorably to the treatment. Repeat endometrial biopsy was negative for active tubercular disease after 3 months in all patients and remained negative subsequently. There were no relapses at the 6th month after completion of treatment. Three women (21.4%) conceived after 3-12 months of starting the treatment. HSG showed extensive irreparable tubal damage in six patients. Discussion In a report on a retrospective survey on the management of extra-pulmonary TB in 180 patients were Wales, data from presented. Nineteen had gynecological TB, of whom nine received INH and RIF for 9-12 months [6]. It was noted that although short course therapy was commonly given, no clear-cut policy existed for its administration. Limited data on efficacy of SCC in genitourinary tuberculosis are available; however, experience with gynecological TB is scant at best [ 1,3,8]. Two reasons support the concept that SCC would be equally effective in extrapulmonary TB. First, extra-pulmonary sites contain fewer tubercle bacilli than the
Int J Gynecol Obstet 32
pulmonary sites; second, both INH and RIF penetrate extra-pulmonary sites in high concentrations [2]. The present study utilizes stringent criteria of diagnosis of endometrial TB and the response to treatment. The results were gratifying in that the disease was cured in the first 3 months of therapy and no relapse was evident on subsequent follow-up. Three of 14 women whose infertility was attributable to genital TB conceived after treatment. In spite of this, conception is not an essential criterion of successful treatment, in view of a high incidence of irreparable tubal damage at the time of diagnosis. We believe the g-month regimen of INH and RIF is effective and can be recommended for endometrial TB. References Dutt AK, Moers D, Stead WW: Short course chemotherapy for extrapulmonary tuberculosis - nine years experience. Ann Intern Med 104: 7,1986. Fox W: Whither short course chemotherapy. Br J Dis Chest 73: 331, 1981. Gow JG: Genitourinary tuberculosis: a seven year review. Br J Urol51: 239,1979. Jindal UN, Dhaliwal LK, Dhall GI: Female genital tuberculosis and infertility. XV Eastern Regional Int Union Against Tuberc Meeting, Lahore, p. 302, December 1987. Malik SK, Behera D, Gilhotra R: Tubercular pleural effusion and lymphadenitis treated with rifampicin containing regimen. Chest 92: 904, 1987. Monie RDH, Hunter AM, Rocchiccioli KMS: Management of extrapulmonary tuberculosis in South and West Wales (1976-78). Br Med J 285: 415, 1982. National Consensus Conference on Tuberculosis: Standard therapy for tuberculosis 1985. Chest (Suppl) 87: 117s, 1985. Skutil S, Varga J, Obsitnik M, Moro I: Six month chemotherapy of urogenital tuberculosis. Bull Int Union Tuberc 57: 46,1982. Sutherland AM: Tuberculosis of the female genital tract. Tubercle 66: 79, 1985. Address for reprints: S.K. Jindal Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research Chandigarh - 160 012 India
Znt. J. Gynecol. Obstet., 1990,32: 75-76 International Federation of Gynecology and Obstetrics
Short course chemotherapy infertile women
for endometrial
tuberculosis
in
U.N. Jindal”, S.K. Jindalb and G.I. Dhall” Departments of aObstetrics and Gynaecology and Tulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012 (India) (Received March lst, 1989) (Revised and accepted April 12th 1989)
Abstract A daily regimen of rifampicin (450 mg) and isoniazid (300 mg) was tried for 9 months in 14 women with histologically diagnosed endometrial tuberculosis (TB). Follow-up endometrial biopsies were negative for tubercular disease in all patients. Three (21.4%) of the 14 women conceived between 3 and 12 months after starting treatment. Keywords: Endometrial tuberculosis; course chemotherapy; Infertility.
what cavalier, in that strict treatment protocols often are lacking [6]. For example, in one report from the United States, four cases of gynecological TB were included, but the authors did not discuss specific medical issues as they related to the disease [l]. Unlike pulmonary, lymph node and pleural TB, gynecological TB presents unique difficulties in diagnosis and interpretation of the therapeutic response. Materials and methods
Short
Introduction Although tuberculosis of the genital tract is an uncommon disease in developed countries, it remains an important problem in India [4,9]. Short course chemotherapy (SCC) regimens have been extensively evaluated in the treatment of pulmonary tuberculosis (TB). To date, however, no such large-scale evaluation is available for patients who demonstrate extra-pulmonary TB [7], despite existence of a few reports on SCC in some forms of extrapulmonary TB (e.g., pleural and lymph node). Prospective controlled studies on genitourinary and gynecological manifestations are sparse [1,5,9]. In general, treatment of extra-pulmonary TB is some0020-7292/90/$03 50
0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
The case material was selected out of 627 couples seen in the infertility clinic during a 2year period. Endometrial biopsy was performed in all these women as a routine part of the workup for infertility. Endometrial TB was diagnosed from the biopsy material on the basis of finding discrete, tubercular granulomas consisting of caseation, epithelioid cells, lymphocytes, and giant cells and/or the growth of Mycobacterium tuberculosis from the specimen for this report. A total of 24 patients (3.8%) had evidence of active endometrial disease; only 14 could comply with the follow-up schedule and were studied. An additional 40 patients had evidence of old healed genital or pulmonary TB; these women were not included in the study. The study group of 14 women was started on a daily regimen of rifampicin (RIF), 10 Clinical and Clinical Research
76
Jindal et al.
mg/kg body weight, and isoniazid (INH), 300 mg for 9 months after demonstration of normal hepatic and renal function. Endometrial biopsy was repeated every 3 months as a part of the follow-up protocol. Hysterosalpingography (HSG) was performed after completion of treatment. A further follow-up examination was performed 3-6 months following the 9 months of continuous treatment. Results The mean age of the patients was 25.6 years (range 20-33 years), and the duration of their infertility ranged from 36 to 144 months (average 56 months). All had regular menstrual periods, but eight complained of scanty flow. Nine patients had primary and five secondary infertility. None had palpable pelvic masses. All patients responded favorably to the treatment. Repeat endometrial biopsy was negative for active tubercular disease after 3 months in all patients and remained negative subsequently. There were no relapses at the 6th month after completion of treatment. Three women (21.4%) conceived after 3-12 months of starting the treatment. HSG showed extensive irreparable tubal damage in six patients. Discussion In a report on a retrospective survey on the management of extra-pulmonary TB in 180 patients were Wales, data from presented. Nineteen had gynecological TB, of whom nine received INH and RIF for 9-12 months [6]. It was noted that although short course therapy was commonly given, no clear-cut policy existed for its administration. Limited data on efficacy of SCC in genitourinary tuberculosis are available; however, experience with gynecological TB is scant at best [ 1,3,8]. Two reasons support the concept that SCC would be equally effective in extrapulmonary TB. First, extra-pulmonary sites contain fewer tubercle bacilli than the
Int J Gynecol Obstet 32
pulmonary sites; second, both INH and RIF penetrate extra-pulmonary sites in high concentrations [2]. The present study utilizes stringent criteria of diagnosis of endometrial TB and the response to treatment. The results were gratifying in that the disease was cured in the first 3 months of therapy and no relapse was evident on subsequent follow-up. Three of 14 women whose infertility was attributable to genital TB conceived after treatment. In spite of this, conception is not an essential criterion of successful treatment, in view of a high incidence of irreparable tubal damage at the time of diagnosis. We believe the g-month regimen of INH and RIF is effective and can be recommended for endometrial TB. References Dutt AK, Moers D, Stead WW: Short course chemotherapy for extrapulmonary tuberculosis - nine years experience. Ann Intern Med 104: 7,1986. Fox W: Whither short course chemotherapy. Br J Dis Chest 73: 331, 1981. Gow JG: Genitourinary tuberculosis: a seven year review. Br J Urol51: 239,1979. Jindal UN, Dhaliwal LK, Dhall GI: Female genital tuberculosis and infertility. XV Eastern Regional Int Union Against Tuberc Meeting, Lahore, p. 302, December 1987. Malik SK, Behera D, Gilhotra R: Tubercular pleural effusion and lymphadenitis treated with rifampicin containing regimen. Chest 92: 904, 1987. Monie RDH, Hunter AM, Rocchiccioli KMS: Management of extrapulmonary tuberculosis in South and West Wales (1976-78). Br Med J 285: 415, 1982. National Consensus Conference on Tuberculosis: Standard therapy for tuberculosis 1985. Chest (Suppl) 87: 117s, 1985. Skutil S, Varga J, Obsitnik M, Moro I: Six month chemotherapy of urogenital tuberculosis. Bull Int Union Tuberc 57: 46,1982. Sutherland AM: Tuberculosis of the female genital tract. Tubercle 66: 79, 1985. Address for reprints: S.K. Jindal Department of Pulmonary Medicine Postgraduate Institute of Medical Education and Research Chandigarh - 160 012 India