Low menstrual flow, need to be vigilant endometrial tuberculosis Xiaofang and Xiaoyan are outpatient clinic patients, both because of menstrual flow to the clinic, both of their menstrual flow used to be quite normal, but in the past six months the menstrual flow than before more than half of the reduction in color, black, and irregular bleeding in between periods, the clinic before the visit to see a number of physicians, Chinese and Western medicines have been used to treat the treatment, but the effect is not obvious. Both of them are in their 30s and have no children, so they are very anxious. Both patients have scanty menstruation, what exactly is the cause? We gave both patients a hysteroscopy, in which Xiaofang’s uterine wall can be seen multiple yellow nodular granulomatous cumbersome organisms (see Figure 1), pathology suggests that endometrial tuberculosis; and Xiaoyan’s uterine cavity is basically completely adherent, the normal form of the disappearance of the endometrial tissues can be seen only a little bit of the endometrial tissue (see Figure 2), the patient told us that she has had tuberculosis and has been through the anti-TB treatment for three years, and has not been able to get pregnant, the patient told us that she has had tuberculosis and after anti-TB treatment for three years, has not been able to get pregnant, we have been very anxious. Combined with her history, we diagnosed tuberculous adhesions of the uterus. Figure 1 Endometrial tuberculosis Figure 2 Tuberculous adhesions of the uterus Both of the two patients came to the clinic because of decreased menstrual flow, with very different hysteroscopic presentations, but both were diagnosed with endometrial tuberculosis. So what kind of disease is endometrial tuberculosis? Why does it cause changes in menstruation? How should the disease be treated formally? First of all, let’s understand what endometrial tuberculosis is. Endometrial tuberculosis is an inflammation of the uterine lining caused by Mycobacterium tuberculosis (called Mycobacterium antacidum because of the antacid staining of the smear), which is often followed by tuberculosis of the lungs, kidneys, gastrointestinal, bone or joints, etc., and it is often a part of systemic tuberculosis. The main source of endometrial tuberculosis pathogens is pulmonary or peritoneal tuberculosis. Mycobacterium tuberculosis from these sites reaches the reproductive organs through blood circulation, direct spread, or lymphatic transmission, and most often infects the fallopian tubes first, then spreads to cause endometrial tuberculosis. The incubation period of tuberculosis transmitted through the respiratory tract can be up to several years, so by the time endometrial tuberculosis is detected, the primary lesion may have disappeared. Endometrial tuberculosis accounts for 50-60% of female genital tuberculosis and occurs in women of childbearing age between 20-40 years old, with 80-90% of patients belonging to this age group, but it can also be seen in pre-pubescent girls and post-menopausal elderly women. Since the founding of the country, tuberculosis has been under control due to the great attention paid by our government to tuberculosis prevention and treatment and the development of anti-TB drugs. However, after the mid-1980s, due to HIV infection and the increase of drug-resistant strains of Mycobacterium tuberculosis, the disease has become prevalent again, with about 10 million new cases of tuberculosis each year and about 3 million deaths from tuberculosis. Mycobacterium tuberculosis causes a lack of specificity in the symptoms of the disease; for example, a patient with tuberculosis may not experience the typical symptoms of coughing up blood, but rather a prolonged cough. In addition, people are less vigilant about it, and the disease can develop, so it is not conducive to timely diagnosis and treatment. Endometrial tuberculosis is often spread from fallopian tube tuberculosis, mycobacterium tuberculosis attacks the endometrium in the early stage, the endometrium is congested and edematous, only a small number of granulomatous nodules, at this time, menstruation increases; with the development of the disease, caseous necrosis and superficial ulceration can occur, and then the endometrial layer is destroyed, and in severe cases, it can invade the myometrium, and menstruation is reduced or even amenorrhea with the damage to the endometrium. Although some of the tubercle bacilli are expelled with the periodic shedding of the endometrium, the proliferating functional endometrium can be re-infected and the disease can be prolonged. The formation of menstruation depends mainly on the endometrium, and changes in the endometrium from early to late stages lead to changes in the amount of menstruation from heavy to light. Therefore, in the early stage of endometrial tuberculosis, hysteroscopy reveals granulomatous growths in the uterine cavity (see Fig. 1), and in the late stage of endometrial tuberculosis, due to the complete destruction of the endometrium, hysteroscopy reveals scarring, or even complete adhesions (see Fig. 2). The box below shows the morphology of the tuberculosis foci presented under the microscope when the tissue was taken for pathologic examination under hysteroscopy. What are the clinical symptoms that may occur after Mycobacterium tuberculosis has invaded the endometrium? 1, increased vaginal discharge, endometrial tuberculosis due to the endometrium of all the endometrium into caseous granulation tissue, there can be a plasma foul-smelling vaginal discharge, such as the combination of cervical infection, there can be pus or pus and blood discharge, and there can be contact bleeding; 2, changes in menstruation, the early stage of the disease, there can be a decrease in menstrual flow, to the late stage due to the endometrium of the destruction of the atrophic, there can be a reduction in menstruation; 3, abdominal pain, endometrial tuberculosis patients, 25% of the patients with endometrial tuberculosis are in the same condition. Endometrial tuberculosis patients, 25%-50% of the patients, with varying degrees of lower abdominal pain, manifested as long-term lower abdominal pain, aggravated before menstruation; 4, serious patients often have emaciation, low-grade fever, night sweats, fatigue and other systemic manifestations, and there is a history of infertility and menstrual abnormalities; 5, gynecological examination: the patient’s uterus is often found to be poorly developed, uterus is small or deformity. If there is a combination of pelvic tuberculosis, you can feel the pelvic mass or pressure pain and other positive signs. Diagnosis of endometrial tuberculosis can be done through the following tests: X-ray film, found in the chest, abdomen, such as foci; can be found through the hysterosalpingography tubes were bead-like changes; hysteroscopy can be directly found endometrial tuberculosis foci, and biopsy can be taken under the direct vision of the pathology of the examination, the endometrium can be seen in the early stage of the disease is high and low, the surface of the small nodules can be attached; late lesions are the uterine cavity Adhesions, irregular shape, scar tissue hard, and even the formation of stone-like calcified foci; laparoscopy is also a method of diagnosis. Many patients in the clinic often ask whether this disease is serious or not. In fact, Mycobacterium tuberculosis infection is not terrible, which is due to the development of anti-tuberculosis drugs. But it caused by endometrial tuberculosis on the patient has a great impact, often leading to adhesions in the uterine cavity, the formation of scar tissue, so that the original fertile “soil” has become barren, resulting in impediments to embryo implantation; endometrial tuberculosis is another feature of endometrial tuberculosis, tuberculosis nodules around the glands insensitive to the response of ovarian hormones, manifested as persistent hyperplasia or secretion. Insufficient. Fertility is seriously affected by the abnormal ovarian function, and infertility occurs in the vast majority of patients. Whether patients with endometrial tuberculosis can restore fertility depends on whether the treatment is timely and thorough, due to the irreversibility of the lesion, the lesion is mild, the active treatment may restore fertility, but due to the destruction of the fallopian tube and the endometrium by tuberculosis bacteria, the chances of obtaining a normal pregnancy are small, endometrial tuberculosis has a long latent period and often has no conscious symptoms, and when it is detected the primary lesion has already been cured, but it is too late. The damage to the uterine cavity caused by tuberculosis is generally irreversible, even if the tuberculosis is cured, the chances of natural conception are also very small, so it is very important to prevent this disease, in childhood should be inoculated with BCG vaccine according to the plan, tuberculosis should be avoided during pregnancy, when there is a patient with tuberculosis in the family, we should pay attention to the isolation and treatment of tuberculosis, tuberculosis, should be treated in time to prevent the spread of the genitals. The treatment of endometrial tuberculosis is relatively complicated, requiring regular and sufficient courses of anti-TB medication. Patients with tuberculous uterine adhesions are often combined with tubal tuberculosis, which is very difficult to treat, and require hysteroscopic electrosurgery to separate the adhesions and modern assisted reproduction techniques to obtain a pregnancy, and the specific treatment plan will be decided by the doctor according to the condition of the lesions and the patient’s fertility requirements.