Endometrial tuberculosis

　　Endometrial tuberculosis often spreads from tubal tuberculosis. Female genital tuberculosis first infects the fallopian tubes, then gradually spreads to the endometrium, ovaries, cervix, and other places. Due to the periodic shedding of the endometrium, the endometrial tuberculosis lesions are excreted accordingly, and the lesions are mostly localized in the endometrium. In the early stage, it presents as scattered millet-like nodules, and only a few severe cases may involve the muscular layer. The uterine body size is normal or slightly small, with no abnormalities in appearance.

　　After the tuberculosis bacteria infect the body, they generally do not cause immediate illness but rather go through a latent period. During this latent period, when the body's resistance is poor, the tuberculosis bacteria can invade the endometrium and eventually affect the basal layer of the endometrium.

　　Under the microscope, the endometrial cavity can see tuberculosis nodules, and in severe cases, caseous necrosis may occur. Typical tuberculosis nodules have 1-2 giant cells in the center, arranged in a horseshoe shape, surrounded by epithelioid cells, and there are a large number of lymphocytes and plasma cells infiltrating on the outer side. The characteristics of endometrial tuberculosis nodules are that the glands around the tuberculosis nodules are insensitive to ovarian hormones, showing persistent hyperplasia or insufficient secretion. Severe endometrial tuberculosis may appear caseous necrosis and present as superficial ulcers, causing most or all of the endometrium to be destroyed. Subsequently, scars may form, and the function of the endometrium is completely lost, leading to amenorrhea.

　　Endometrial tuberculosis can be complicated with diseases such as pelvic abscess, abnormal menstruation, and infertility. The specific complications are described as follows.

　　1. Pelvic abscess

　　As the condition progresses, the endometrium may transform into caseous tissue or form ulcers, which can lead to pelvic abscess. In severe cases, it can cause endometrial infection.

　　2. Abnormal menstruation

　　Due to the invasion of tuberculosis bacteria, the endometrium cannot be normally shed, causing menstrual abnormalities. Some patients may experience reduced menstrual volume, extended intervals, or even amenorrhea.

　　3. Infertility

　　Infertility can be divided into absolute infertility and relative infertility. Those who still cannot conceive after treatment are called absolute infertility; those who still have the possibility of conception after treatment are called relative infertility.

　　Endometrial tuberculosis belongs to relative infertility. Endometrial tuberculosis is one of the main causes of infertility. The primary focus of this disease is usually pulmonary tuberculosis, followed by peritoneal tuberculosis. The hematogenous dissemination first invades the fallopian tubes, then spreads to the endometrium, causing the fertilized egg to fail to implant normally in the endometrium. This leads to the occurrence of infertility.

　　Due to the severe destruction of the fallopian tube by the tuberculosis bacteria, the chance of normal pregnancy after sufficient anti-tuberculosis drug treatment is very rare.

　　Patients with endometrial tuberculosis mainly manifest as abnormal menstruation, infertility, lower abdominal pain, as well as systemic symptoms such as fatigue and night sweats, and the specific clinical manifestations are described as follows.

　　1. Abnormal Menstruation

　　Due to the influence of tuberculosis lesions, the endometrium may become congested or form ulcers in the early stage, leading to excessive menstrual bleeding; in the late stage, the endometrium is damaged, affecting the function of the endometrium, causing oligomenorrhea, or even amenorrhea.

　　2. Infertility

　　Due to the destruction of the endometrial tuberculosis lesions, the environment for the implantation and development of the fertilized egg is destroyed, or because the tuberculosis lesions of the fallopian tube cause the fallopian tube to be blocked, resulting in infertility. Therefore, many patients come to the hospital for examination due to infertility, and are finally diagnosed with endometrial tuberculosis.

　　3. Lower Abdominal Pain

　　Pain in the lower abdomen is often caused by pelvic tuberculosis, leading to pelvic congestion, adhesions, or the formation of abscesses, etc.

　　4. General Symptoms

　　Severe cases may present with systemic symptoms such as fatigue, night sweats, low fever, weight loss, and loss of appetite.

　　Endometrial tuberculosis is mostly secondary infection, with primary lesions mainly caused by pulmonary tuberculosis. Therefore, actively preventing and treating pulmonary tuberculosis is of great significance for preventing genital tuberculosis.

　　Section 1: Vaccination Prevention

　　Like pulmonary tuberculosis, in addition to strengthening anti-tuberculosis publicity and education, attention should be paid to the health care of children and adolescents. Prevent the infection of Mycobacterium tuberculosis, and seek medical attention as soon as possible after不幸感染Mycobacterium tuberculosis to avoid the spread of infection.

　　1. Vaccination Age:Newborns weighing more than 2200g can be vaccinated with BCG 24 hours after birth, and a booster dose can be administered if necessary within 3 months. Infants after 3 months and adolescent girls until puberty should be vaccinated with BCG if the tuberculin test is negative.

　　2. Contraindications:Pregnancy should be avoided during the active stage of tuberculosis. After the disease is stable for 5 years or more after treatment, pregnancy can be considered.

　　3. Precautions:Patients with genital tuberculosis may have Mycobacterium tuberculosis in their vaginal discharge and menstrual blood, and isolation should be strengthened to avoid transmission.

　　Section 2: Enhancing Body Resistance and Immunity

　　Pay attention to the combination of work and rest. Strengthen nutrition, eat more fresh fruits and vegetables rich in vitamins, and more poultry, fish, meat, and eggs rich in protein. Participate in sports activities appropriately to enhance physical fitness.

　　The examination of endometrial tuberculosis includes blood tests, pathological tissue examination, X-ray examination, laparoscopy, and hysteroscopy, among others. The specific examination methods are described as follows.

　　Section 1: Blood:Unless there is a mixed infection, the white blood cell count is generally not high, and the number of lymphocytes may increase.

　　Section 2: Polymerase Chain Reaction Detection:Quantitative determination of Mycobacterium tuberculosis by specific fluorescent polymerase chain reaction (PCR) in blood or tissues can make a rapid diagnosis of the disease. PCR detection of Mycobacterium tuberculosis DNA in different tissue sites is a relatively rapid and sensitive method, but the results should be considered in terms of the course of the disease.

　　Three, Serum CA125 level measurement:The serum CA125 level in advanced abdominal tuberculosis patients is significantly elevated.

　　Four, Tuberculin Test:A positive tuberculin test indicates a previous tuberculosis infection, which has little diagnostic significance. If it is strongly positive, it suggests the existence of active lesions in the body, but does not indicate the site of the lesions. A negative result also cannot exclude tuberculosis.

　　Five, Tuberculosis Bacillus Culture and Animal Inoculation

　　Cultures of menstrual blood, scraped endometrium, cervical secretions, uterine cavity secretions, puncture fluid from pelvic masses, or pelvic encapsulated effusions, etc., should be examined for positive results after 2 months; or these substances are inoculated under the abdominal wall subcutaneously of guinea pigs, and after 6-8 weeks, the specimens are dissected. If tuberculosis bacteria are found in the lymph nodes around the inoculation site, it can be diagnosed. If the result is positive, further drug sensitivity tests can be performed to guide clinical treatment.

　　Blood culture (collecting 6-8ml of menstrual blood on the first day of menstruation) can avoid the spread of tuberculosis caused by curettage, but the positive rate is lower than that of endometrial bacteriological examination. It is generally recommended to perform histological examination, bacterial culture, and animal inoculation simultaneously to improve the positive diagnostic rate.

　　Six, Pathological and histological examination

　　If there are millet-like nodules or caseous material in the pelvic cavity, it is generally necessary to perform diagnostic curettage. For infertility and suspicious patients, endometrial pathological tissue examination should also be performed. The curettage should be performed within 12 hours after the onset of menstruation, as the lesions are more prominent at this time. Attention should be paid to scraping the endometrium of both uterine horns, as endometrial tuberculosis often originates from the fallopian tubes, causing the lesions to appear first in the lateral angles of the uterine cavity. The scraped tissue should be sent for pathological examination in its entirety, and it is best to make a systematic and continuous section of the specimen to avoid missed diagnosis. If typical tuberculosis nodules are found in the sections, it can be diagnosed. In cases with inflammatory granulomas in the endometrium, endometrial tuberculosis should be highly suspected. The presence of giant cell system (macrophages have a strong phagocytic and killing effect on tuberculosis bacilli) without tuberculous lesions cannot deny the existence of tuberculosis. Suspected patients need to be re-examined every 2-3 months, and if three negative endometrial examinations are found, it can be considered that there is no endometrial tuberculosis. Because curettage surgery has the risk of tuberculosis spread, prophylactic anti-tuberculosis treatment should be used before and after surgery. Other lesions such as cervix, vagina, and vulva also need to be examined by pathological tissue examination for an accurate diagnosis.

　　Seven, X-ray examination

　　1. Chest X-ray imaging:If necessary, X-ray examinations of the gastrointestinal and urinary systems can also be performed to detect the primary lesion, but many patients when diagnosed with genitourinary tuberculosis, their primary lesion often has healed and left no trace. Therefore, a negative X-ray film cannot exclude pelvic tuberculosis.

　　2. Abdominal X-ray imaging:If isolated calcification foci are shown, it suggests a previous pelvic lymph node tuberculosis.

　　3. Iodine oil contrast hysterosalpingography:Iodine oil contrast hysterosalpingography has certain value in the diagnosis of genitourinary tuberculosis, with its imaging characteristics being:

　　(1) Uterine cavity: Morphologies vary, and there may be different degrees of narrowing or deformation. Even in individuals without a history of uterine scraping or abortion, the edges may appear saw-toothed.

　　(2) The fallopian tube lumen has multiple narrowings, presenting as a typical beaded or slender rigid appearance.

　　(3) When the contrast medium enters the uterine wall: stroma, parametrial lymphatic vessels, or blood vessels, consider the possibility of endometrial tuberculosis.

　　(4) Obstruction between the ampulla and isthmus of the fallopian tube, with the injection defect of iodine oil into the stroma of the fallopian tube.

　　(5) Corresponding to the site of fallopian tube, ovary, and pelvic lymph nodes: there are numerous scattered millet-like translucent spot shadows, resembling calcified foci.

　　Uterine tube iodine oil contrast may introduce tuberculosis bacilli or caseous substances into the pelvic and abdominal cavity, even causing disease spread and endangering life, therefore, it should be strictly controlled in indications. It is not suitable to perform contrast examination when there is pus in the fallopian tube or other diseases. Anti-tuberculosis drugs should be administered before and after the examination to prevent the disease from worsening. The appropriate time for contrast examination is within 2 to 3 days after the menstrual period.

　　8. Laparoscopy

　　Laparoscopy is more valuable in diagnosing early pelvic tuberculosis in women than other methods. Laparoscopy can be performed on patients with negative pathological and bacteriological examinations of the endometrium. Under the laparoscope, observe the presence of millet-like nodules on the serosal surface of the uterus and fallopian tubes, whether there are membranous adhesions around the fallopian tubes, and whether there are masses in the fallopian tubes and ovaries, etc. At the same time, take suspicious lesion tissue for biopsy and collect cul-de-sac fluid for tuberculosis culture, etc.

　　9. Hysteroscopy

　　Hysteroscopy can directly find the focus of endometrial tuberculosis and can take a tissue sample for pathological examination under direct vision, but it may cause tuberculosis to spread. Moreover, severe adhesions and deformation of the uterine cavity due to tuberculosis destruction may interfere with the observation effect and be difficult to differentiate from traumatic uterine cavity adhesions, so it is not suitable as the first choice. If hysteroscopy is necessary for diagnosis, active tuberculosis should be excluded before the examination, and anti-tuberculosis treatment should be carried out. Under hysteroscopy, the endometrium may appear congested and red due to inflammatory reaction, and the focus is yellowish or grayish. Mild lesions show uneven endometrium with white millet-like nodules on the surface; severe lesions result in endometrial destruction by tuberculosis, leading to uterine cavity adhesions, irregular shape, and the cavity may be filled with disordered, brittle polypoid protuberances. Scar tissue is hard, and even calcified foci may form, making it difficult to dilate and separate.

　　Patients with endometrial tuberculosis should consume more foods rich in protein, vitamins, and dietary fiber; avoid sour, astringent, and spicy foods. The specific dietary precautions and dietary therapy are described as follows.

　　First, dietary therapy for endometrial tuberculosis

　　1. Almond Coix Seed Egg Soup

　　Almond 30 grams, Coix seed 60 grams, fresh eggs 3, fish-odor grass 50 grams, red dates and honey as needed. Coix seed, almond (mashed), and red dates (with seeds removed) are cleaned and placed in a pot, 1000 milliliters of water is added, and the mixture is brought to a boil with strong fire, then simmered over low heat for 1 hour; fish-odor grass is placed in another pot and cooked for 30 minutes, the juice is then poured into eggs and honey, mixed with the Coix seed, almond, and red date soup, stirred well and set aside. It can be eaten with meals, 1 to 3 times a day, each time 150 to 200 milliliters. It can clear lung heat and nourish lung yin. It is suitable for lung abscess caused by lung dryness (symptoms include coughing up pus and blood, persistent cough, chest pain, irritability, thirst, dry throat, night sweats, and weight loss, etc.). It is commonly used in the dietary therapy for patients with tuberculosis, lung abscess, emphysema, bronchiectasis, and chronic bronchitis who have dryness and heat with abundant phlegm and lung fluid damage.

　　2, Lily White-berry Beef Soup

　　60 grams of lily, 60 grams of white-berry, 15 red dates, 400 grams of beef, 5 slices of ginger, and a little salt. Wash the beef with boiling water and cut it into thin slices; remove the shell of the white-berry, soak it in hot water to remove the outer film, and then wash it clean; wash the lily, red dates (with the seeds removed), and ginger (5 slices) clean, put them in a pot, add 500 milliliters of water, bring it to a boil with high heat first, then add the lily, red dates, white-berry, and ginger slices, cook the lily with medium heat until it is cooked, add the beef, continue to cook until the beef is tender, and add salt to taste. It can be eaten with meals, 1 to 3 times a day, 150 to 200 milliliters each time. It can nourish the blood and yin, moisten the lungs and invigorate the Qi, relieve asthma and astringe essence. It is often used in the dietetic therapy for pulmonary tuberculosis with spleen and lung Qi deficiency, cough with sputum, insufficient middle Qi, hoarse voice, frequent urination at night, irregular menstruation, and excessive leukorrhea.

　　3, Sheep Lung Persimmon Frost Almond Soup

　　1 sheep lung (about 500 grams), 30 grams of persimmon frost, 30 grams of almond, 30 grams of ghee, and 60 grams of honey. First, peel the almond and grind it into fine powder, mix it with persimmon frost and ghee in a bowl, add honey and mix well, then add a little water while mixing, and wait until the above four herbs are evenly mixed into a thick juice for use; wash the sheep lung clean with water, squeeze out the blood, and then pour the thick medicine juice into the sheep lung, add 600 milliliters of water, and steam it until it is cooked. It can be eaten with meals, 1 to 3 times a day, 150 to 200 milliliters each time. It can nourish yin and moisten dryness, clear heat and relieve cough, and invigorate the Qi and nourish the blood. It is suitable for patients with long-term illness, yin deficiency and internal dryness, lung heat caused by consumption of lung Qi, dry lips, and emaciation, and other conditions. It is often used in the dietetic therapy for pulmonary tuberculosis, emphysema, bronchitis, bronchial asthma, and heart disease of pulmonary origin.

　　4, White-berry Silver Ear Soup

　　30 grams of white-berry, 50 grams of silver ear, 30 grams of almond, 300 grams of water chestnut, 30 grams of water chestnut powder, and an appropriate amount of rock sugar. First, wet the water chestnut powder and rock sugar with water, peel and wash the water chestnut, and cut it into small pieces; soak the silver ear, almond, and white-berry in water for 2 hours, wash them clean, put them in a pot, add 500 milliliters of water, bring it to a boil with high heat first, then simmer it with low heat for 4 hours, and then add the water chestnut pieces, wet rock sugar, and water chestnut powder in order. It can be eaten with meals, 1 to 3 times a day, 150 to 200 milliliters each time. It can clear the lungs, moisten the dryness, and relieve cough. It is suitable for patients with pulmonary tuberculosis (with symptoms such as shortness of breath, less phlegm, blood in sputum, shortness of breath, weakness, or accompanied by low fever).

　　5, Bird's Nest Rock Sugar Soup

　　6 grams of bird's nest, 12 grams of rock sugar. First, put the bird's nest in a炖盅, add warm water to soak and soften it, then use tweezers to pick out the bird feathers, wash it clean with clear water, drain the water, tear it into thin strips, and place it in a bowl; dissolve the rock sugar with about 200 milliliters of boiling water, filter out the impurities, and bring it to a boil with the bird's nest in the pot. It can be eaten with meals, 1 to 3 times a day, 150 to 200 milliliters each time. It can nourish the lungs, moisten the dryness, resolve phlegm, and relieve cough. It is suitable for yin deficiency and lung dryness, dry mouth and nose, emaciated cough, cough with blood streaks, and other conditions. It is often used in the dietetic therapy for pulmonary tuberculosis, bronchiectasis, and lung abscess.

　　6. Sheep marrow and raw earth porridge:The composition is 50 grams each of sheep spinal cord and honey, 10 grams of raw earth, 15 grams of cooked sheep fat oil, 25 grams of yellow wine, a little ginger thread, and a little table salt. The preparation method is to put the sheep spinal cord and raw earth in a pot, boil the soup until cooked, remove the medicinal residue, and then add cooked sheep fat oil, table salt, ginger thread, yellow wine, and honey, and heat until boiling. Indications are to nourish yin and clear heat, and relieve cough and phlegm. It is suitable for symptoms such as low fever, cough, and sputum in tuberculosis. The dosage is to eat in one meal or in several meals.

　　7. Silver ear pigeon egg porridge:The composition is 2 grams of silver ear, 20 grams of rock sugar, and 1 pigeon egg. The preparation method is to soak the silver ear in water for 20 minutes, knead it, add 400 grams of water, boil with high heat, and then add rock sugar, simmer with low heat until soft; then crack the pigeon egg, steam for 3 minutes with low heat, and then add it to the cooked silver ear porridge, and boil it. Indications are to nourish yin and moisten the lungs, benefit the stomach and generate fluid. It is suitable for dry cough in tuberculosis. The dosage is to drink the soup and eat the silver ear and pigeon egg.

　　8. Carrot honey soup:The composition is 1000 grams of carrots, 100 grams of honey, and 3 grams of alum. The preparation method is to clean and slice the carrots, add 350 grams of water, boil for 20 minutes, remove the residue, add honey and alum, stir well, and then boil for a moment. Indications are to relieve phlegm and cough. It is suitable for symptoms such as white sputum cough and tuberculosis hemoptysis. The dosage is to take 3 times a day, 50 grams each time.

　　9. Turtle soup for nourishing yin:The composition is 250 grams of turtle meat, 9 grams each of bai bu, di gu pi, and zhi mu, 24 grams of raw earth, and an appropriate amount of table salt. The preparation method is to blanch the turtle in boiling water, cut off the head and claws; peel off the hard shell, remove the internal organs, clean it, and cut it into 1 cm square pieces, and put it with the cleaned bai bu, di gu pi, zhi mu, and raw earth into a pot, add an appropriate amount of water, boil with high heat, and then simmer with low heat for 2 hours, add table salt for seasoning, and it is ready. Indications are to nourish yin and clear heat, and anti-aging. It is suitable for yin deficiency and tuberculosis with symptoms such as evening fever, night sweats, and hot palms and soles. The dosage is to eat with meals, one dose per day.

　　10. Chicken liver, oyster, and oyster shell soup:The composition is 1-2 chicken livers, 15-24 grams of fresh oysters, 12-15 grams of oyster shell. The preparation method is to clean and cut the chicken liver, crush the fresh oysters and oyster shell; first decoct the oysters and oyster shell for 60 minutes, then add the chicken liver, wait until the chicken liver is cooked, and then drink the soup. Indications are to nourish the liver and kidney, and resolve phlegm and phlegm. It is suitable for chronic cough with fever, malnutrition, tuberculosis, lymphatic tuberculosis, etc. The dosage is one dose per day.

　　Two, endometrial tuberculosis should be eaten.

　　5. You can eat more milk, eggs, lean meat, fish, tofu, etc., to supplement the consumption of protein metabolism.

　　4. Provide a large amount of vitamins A, D, C, and B-complex to enhance the body's resistance.

　　3. Pay attention to the amount of dietary fiber provided, maintain smooth bowel movements. Eat more fresh vegetables, fruits, and coarse grains.

　　Three, avoid eating for endometrial tuberculosis.

　　1. Products with sour and astringent properties are prone to cause blood stasis and qi stagnation, and should be avoided. Spicy and warm herbs are beneficial for promoting circulation, can be consumed, but should not be eaten excessively, as excessive spiciness and stimulation can also worsen pain.

　　2. Avoid eating spicy and irritating foods.

　　3. Eat less or not eat spinach. If it is unavoidable, you can blanch the spinach in hot water first, so that part of the oxalic acid dissolves in the water, and then remove it for eating. In this way, the body can reduce the intake of some oxalic acid.

　　4. Avoid eating greasy, smoked, and fried foods; avoid smoking, drinking, rooster, lamb, and other warm-acting pathogenic substances.

　　The treatment of endometrial tuberculosis includes antituberculosis treatment and surgical treatment, and the specific methods are described as follows.

　　First, Antituberculosis Treatment

　　Currently, short-course combined drug treatment is used for antituberculosis treatment, which shortens the duration of medication, reduces the dose, and alleviates the toxic and side effects of drugs, making it easier for patients to accept. When taking medication, attention must be paid to the fact that toxic and side effects may occur in some patients, such as nerve damage, liver and kidney dysfunction (including jaundice), and appropriate treatment should be given according to the specific conditions of the patient.

　　Second, Surgical Treatment

　　1. Indications for Surgery

　　(1) After drug treatment, the symptoms of tubal ovarian abscess have subsided, but the mass has not disappeared, and the patient feels recurrent symptoms.

　　(2) Drug treatment is ineffective, and a tuberculous abscess has formed.

　　(3) There is a large amount of encapsulated effusion.

　　(4) The endometrium is extensively destroyed, and antituberculosis drug treatment is ineffective.

　　(5) For patients with tuberculous peritonitis complicated with ascites, combined surgical and drug treatment is beneficial to the cure of peritoneal tuberculosis.

　　2. Surgical Method If the patient requests to retain the uterus, the uterus can be retained according to the condition that the endometrial tuberculosis lesion has healed. For those with large masses in the fallopian tubes and ovaries that cannot be separated, hysterectomy with removal of the adnexa can be performed.

　　3. Scope of Surgery The scope of surgery should be determined according to age and the extent of the lesion. Since most patients are women of childbearing age, when surgical treatment is necessary, the preservation of the patient's ovarian function should also be considered.

　　4. Special Cases The adhesions caused by pelvic tuberculosis are numerous, extremely extensive and dense, making it difficult to separate surgically. If it is done forcibly, it can cause unnecessary damage. The surgeon should stop the operation immediately when encountering the above situation, and a second operation may be necessary 3 to 6 months after the operation for tuberculosis.