British Journal of Obstetrics and Gynaecology February 1977. Vol 84. pp 153-154
POSTMENOPAUSAL TUBERCULOSIS OF THE CERVIX CASE REPORT AND REVIEW BY
R. P. HUSEMEYER, Registrar Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London W12 OHS Summary A patient with tuberculosis of the cervix who presented with postmenopausal bleeding is reported and the related literature is reviewed.
dilatation of the cervix and endometrial curettage were not possible. A chest X-ray showed evidence of old primary tuberculous complexes. Intravenous pyelography revealed deformity of calyces in both upper poles and loss of renal substance compatible with a diagnosis of renal tuberculosis. Histological examination of punch biopsies of the cervix showed vascular inflammatory granulation tissue with epithelioid giant cell granulomata and early caseation. Cultures of the cervical biopsy material and a n early morning catheter urine specimen yielded Mycobacteriurn tuberculosis sensitive to streptomycin, para-aminosalicylic acid and isoniazid. Culture of sputum was negative. Treatment consisted of rifampicin 450 mg, isoniazid 300 mg, ethambutol 700 mg and pyridoxine 20 mg daily for nine months. At the completion of treatment there was a marked improvement in general health and the patients weight had increased by 8 . 0 kg. The ulceration of the cervix had healed, leaving it scarred and atrophic. Histology and culture of repeat cervical biopsies and cultures of urine were negative for tuberculosis.
TUBERCULOUS lesions of the cervix are rare in Britain, but are more common in developing countries (Koller, 1975). While they frequently simulate carcinoma (Finlaison, 1936; Coleman, 1969), few authors have reported cervical tuberculosis as a cause of postmenopausal bleeding. CASEREPORT An 8 1-year-old Caucasian woman presented with a sudden, brisk vaginal haemorrhage in June 1975. Prior t o that she had noticed intermittent slight vaginal bleeding for eight weeks and excessive vaginal discharge for many months. She had had five children and the menopause had occurred at the age of 50. Genital prolapse had developed at the age of 61 and reference to the records indicated that at this time there was a cystocoele with no other gynaecological abnormality and surgery was not undertaken. There was no past or family history of tuberculosis. The patient was frail and cachectic. Pelvic examination revealed a cystocoele and first degree uterine prolapse:. The cervix was almost completely replaced by an ulcerative lesion which appeared to have spread outwards from the region of the external 0s which was no longer recognizable. The margins of the ulcer were well defined with undermined edges. The base was friable and bled to touch. The uterus was not enlarged and the adnexae were normal. Because the cervical canal could not be located
DISCUSSION There are two reasons why cervical tuberculosis presenting with postmenopausal bleeding is rare. First, genital tuberculosis seldom presents in the postmenopausal period and second, lesions of the cervix are among 153
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the least common manifestations of genital tuberculosis. Jedberg (1950) reviewed 186 patients with confirmed genital tuberculosis of which 183 (98.4 per cent) were between the ages of 15 and 50 and the remaining three (1.6 per cent) were over 50 years of age, the oldest being 67. He concluded that “genital tuberculosis practically always occurs during fertile age”. Sutherland and Garrey (1951) reported 369 cases and only eight of them were postmenopausal, four of these presenting with vaginal bleeding. Francis (1 964) reviewed 135 cases of genital tuberculosis and found four women with postmenopausal bleeding. The menopause had, in all instances, occurred early and none of these patients was older than 46. Weibel et a1 (1926) reported a case of genital tuberculosis in a woman aged 90. The cervix is generally considered to be affected in about 3 per cent of cases of genital tuberculosis although thorough histological examination may reveal a higher incidence (Haines and Taylor, 1975). Stallworthy (1952) was surprised by the rarity of tuberculous lesions of the vulva, vagina and cervix in view of their exposure to infected discharge and he found no lower genital tract lesions in his series of 78 cases. Tuberculous involvement of the cervix occurred in five (1.36 per cent) of the 369 patients described by Sutherland and
Garrey (1951) and one of them was postmenopausal. The oldest reported case of tuberculosis of the cervix was that discovered at autopsy on a woman aged 87 (Rossle, 1911).
ACKNOWLEDGEMENTS I thank Mr Ian Cunningham, Consultant Obstetrician and Gynaecologist, Plymouth General Hospital, for permission to publish this case report, and Mr W. G. MacGregor, Reader, Institute of Obstetrics and Gynaecology, Hammersmith Hospital, for helpful advice. REFERENCES Coleman, D. V. (1969): Acta cytologica, 13, 104. Finlaison, F. H. (1936): Journal of Obstetrics and Gynaecology of the British Empire, 43,473. Francis, W. J. A. (1964): Journal of Obstetrics and Gynaecology of the British Commonwealth, 71, 418. Haines, M., and Taylor, C. W. (1975): Gynaecological Pathology, 2nd edition. Churchill Livingstone, London, p 35 I . Jedberg, H. (1950): Acta obstetricia et gynecologica Scandanavica, 31, supplement I . Koller, A. B. (1975): South African Medical Journal, 49, 1228.
Rossle (1 9 1 1) : Verhandelungender Deutschen Gesellschafi fur Gynakologie, 14, 441. Stallworthy, J. (1952): Journal of Obstetrics and Gynaecology of the British Empire, 59, 729. Sutherland, A. M., and Garrey, M. M. (1951): Glasgow Medical Journal, 32, 23 I . Weibel, W. in Halban, J., and Seitz, L. (1926): Biologie und Pathologie des Weibes, Volume 5, part I . Urban and Schwarzenberg, Berlin, p 324.
POSTMENOPAUSAL TUBERCULOSIS OF THE CERVIX CASE REPORT AND REVIEW BY
R. P. HUSEMEYER, Registrar Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London W12 OHS Summary A patient with tuberculosis of the cervix who presented with postmenopausal bleeding is reported and the related literature is reviewed.
dilatation of the cervix and endometrial curettage were not possible. A chest X-ray showed evidence of old primary tuberculous complexes. Intravenous pyelography revealed deformity of calyces in both upper poles and loss of renal substance compatible with a diagnosis of renal tuberculosis. Histological examination of punch biopsies of the cervix showed vascular inflammatory granulation tissue with epithelioid giant cell granulomata and early caseation. Cultures of the cervical biopsy material and a n early morning catheter urine specimen yielded Mycobacteriurn tuberculosis sensitive to streptomycin, para-aminosalicylic acid and isoniazid. Culture of sputum was negative. Treatment consisted of rifampicin 450 mg, isoniazid 300 mg, ethambutol 700 mg and pyridoxine 20 mg daily for nine months. At the completion of treatment there was a marked improvement in general health and the patients weight had increased by 8 . 0 kg. The ulceration of the cervix had healed, leaving it scarred and atrophic. Histology and culture of repeat cervical biopsies and cultures of urine were negative for tuberculosis.
TUBERCULOUS lesions of the cervix are rare in Britain, but are more common in developing countries (Koller, 1975). While they frequently simulate carcinoma (Finlaison, 1936; Coleman, 1969), few authors have reported cervical tuberculosis as a cause of postmenopausal bleeding. CASEREPORT An 8 1-year-old Caucasian woman presented with a sudden, brisk vaginal haemorrhage in June 1975. Prior t o that she had noticed intermittent slight vaginal bleeding for eight weeks and excessive vaginal discharge for many months. She had had five children and the menopause had occurred at the age of 50. Genital prolapse had developed at the age of 61 and reference to the records indicated that at this time there was a cystocoele with no other gynaecological abnormality and surgery was not undertaken. There was no past or family history of tuberculosis. The patient was frail and cachectic. Pelvic examination revealed a cystocoele and first degree uterine prolapse:. The cervix was almost completely replaced by an ulcerative lesion which appeared to have spread outwards from the region of the external 0s which was no longer recognizable. The margins of the ulcer were well defined with undermined edges. The base was friable and bled to touch. The uterus was not enlarged and the adnexae were normal. Because the cervical canal could not be located
DISCUSSION There are two reasons why cervical tuberculosis presenting with postmenopausal bleeding is rare. First, genital tuberculosis seldom presents in the postmenopausal period and second, lesions of the cervix are among 153
154
HUSEMEYER
the least common manifestations of genital tuberculosis. Jedberg (1950) reviewed 186 patients with confirmed genital tuberculosis of which 183 (98.4 per cent) were between the ages of 15 and 50 and the remaining three (1.6 per cent) were over 50 years of age, the oldest being 67. He concluded that “genital tuberculosis practically always occurs during fertile age”. Sutherland and Garrey (1951) reported 369 cases and only eight of them were postmenopausal, four of these presenting with vaginal bleeding. Francis (1 964) reviewed 135 cases of genital tuberculosis and found four women with postmenopausal bleeding. The menopause had, in all instances, occurred early and none of these patients was older than 46. Weibel et a1 (1926) reported a case of genital tuberculosis in a woman aged 90. The cervix is generally considered to be affected in about 3 per cent of cases of genital tuberculosis although thorough histological examination may reveal a higher incidence (Haines and Taylor, 1975). Stallworthy (1952) was surprised by the rarity of tuberculous lesions of the vulva, vagina and cervix in view of their exposure to infected discharge and he found no lower genital tract lesions in his series of 78 cases. Tuberculous involvement of the cervix occurred in five (1.36 per cent) of the 369 patients described by Sutherland and
Garrey (1951) and one of them was postmenopausal. The oldest reported case of tuberculosis of the cervix was that discovered at autopsy on a woman aged 87 (Rossle, 1911).
ACKNOWLEDGEMENTS I thank Mr Ian Cunningham, Consultant Obstetrician and Gynaecologist, Plymouth General Hospital, for permission to publish this case report, and Mr W. G. MacGregor, Reader, Institute of Obstetrics and Gynaecology, Hammersmith Hospital, for helpful advice. REFERENCES Coleman, D. V. (1969): Acta cytologica, 13, 104. Finlaison, F. H. (1936): Journal of Obstetrics and Gynaecology of the British Empire, 43,473. Francis, W. J. A. (1964): Journal of Obstetrics and Gynaecology of the British Commonwealth, 71, 418. Haines, M., and Taylor, C. W. (1975): Gynaecological Pathology, 2nd edition. Churchill Livingstone, London, p 35 I . Jedberg, H. (1950): Acta obstetricia et gynecologica Scandanavica, 31, supplement I . Koller, A. B. (1975): South African Medical Journal, 49, 1228.
Rossle (1 9 1 1) : Verhandelungender Deutschen Gesellschafi fur Gynakologie, 14, 441. Stallworthy, J. (1952): Journal of Obstetrics and Gynaecology of the British Empire, 59, 729. Sutherland, A. M., and Garrey, M. M. (1951): Glasgow Medical Journal, 32, 23 I . Weibel, W. in Halban, J., and Seitz, L. (1926): Biologie und Pathologie des Weibes, Volume 5, part I . Urban and Schwarzenberg, Berlin, p 324.
