HYSTEROSCOPIC MARKERS HYSTEROSCOPIC MARKERS FOR ENDOMETRIAL FOR ENDOMETRIAL

TUBERCULOSISTUBERCULOSIS

Dr. PAAYAL CHOBE

Dr. Paayal ChobeDr. Paayal Chobe• MBBS (gold medalist), MD OBGYMBBS (gold medalist), MD OBGY

• Clinical fellowship in Gynae -Laparoscopy-Clinical fellowship in Gynae -Laparoscopy-Mumbai BEAMSMumbai BEAMS

• Diploma in Gynae Laparoscopy KIEL & Diploma in Gynae Laparoscopy KIEL & GIESSEN GERMANYGIESSEN GERMANY

• Presented poster in AICOG 2003 Presented poster in AICOG 2003 BANGALOREBANGALORE

• Presented paper use of Misoprostol prior to Presented paper use of Misoprostol prior to hysteroscopy AMOGS 2009-Aurangabadhysteroscopy AMOGS 2009-Aurangabad

• Faculty in state conference AMOGS 2009Faculty in state conference AMOGS 2009

GENITO URINARY GENITO URINARY TUBERCUOSISTUBERCUOSIS

Always secondary to Tuberculosis Always secondary to Tuberculosis elsewhere in the body usually in the elsewhere in the body usually in the

Lungs, Peritoneum, Lymph Glands Lungs, Peritoneum, Lymph Glands and Bone.and Bone.

11stst case was recorded by Morgagni on case was recorded by Morgagni on autopsy.autopsy.

INCIDENCE:INCIDENCE:

• Involvement of organs –NorriesInvolvement of organs –Norries

Site %Site %

Fallopian tubes 85-90Fallopian tubes 85-90

Endometrium 35-50Endometrium 35-50

Ovaries 5-6Ovaries 5-6

Cervix 3Cervix 3

Vagina & vulva 2Vagina & vulva 2

• Involvement of EndometriumInvolvement of Endometrium

• ExtensiveExtensive

• The Endometrium is replaced by hyalanized The Endometrium is replaced by hyalanized connective tissue thereby --------obliterating connective tissue thereby --------obliterating the cavity.the cavity.

• Patients present as Oligomenorrhoea to Patients present as Oligomenorrhoea to Amenorrhoea.Amenorrhoea.

HYSTEROSCOPY-HYSTEROSCOPY-

• Purely visual method of investigation.Purely visual method of investigation.• Gives better overall view of all the Gives better overall view of all the

pathological conditions and changes of pathological conditions and changes of thethe

endometrium.endometrium.• Better tissue perception as compared Better tissue perception as compared

to hysterosalphingography(HSG)to hysterosalphingography(HSG)• Should ideally be coupled with Should ideally be coupled with

laparoscopy laparoscopy

Pre-RequisitesPre-Requisites

• Proper counselingProper counseling• Detailed history taking and P/S P/V Detailed history taking and P/S P/V

examinationsexaminations• Pre-menstrualPre-menstrual• Role of Misoprostol prior to Role of Misoprostol prior to

hysteroscopyhysteroscopy• Paper presented at AMOGS 2009 study Paper presented at AMOGS 2009 study

conducted at Gauravi Centre For conducted at Gauravi Centre For Laparoscopy by Dr. Paayal ChobeLaparoscopy by Dr. Paayal Chobe

Diagnostic HysteroscopyDiagnostic Hysteroscopy

• Distension medium-normal salineDistension medium-normal saline

• Sites to look for markers-endocervixSites to look for markers-endocervix

• Uterine cavityUterine cavity

• EndometriumEndometrium

• Tubal ostiumTubal ostium

Hysteroscopic Pictures Hysteroscopic Pictures

Normal endometrial cavity on hysteroscopy

Normal ostium and Normal ostium and endometriumendometrium

Normal findings on Normal findings on hyteroscopyhyteroscopy

Hysteroscopy Markers Hysteroscopy Markers

• Usually os stenosed –so difficulty in Usually os stenosed –so difficulty in passing hysteroscope---misoprostol passing hysteroscope---misoprostol can be used priorcan be used prior

• Endocervical canal-narrowEndocervical canal-narrow• Endometrial cavity-Endometrial cavity-

obliterated,adhesions and distorted.obliterated,adhesions and distorted.• Endometrial lining-pale,patchyEndometrial lining-pale,patchy• Advanced cases tubal ostia not Advanced cases tubal ostia not

visualised. visualised.

Scanty EndometriumScanty Endometrium

Obliterated Endometrial Obliterated Endometrial CavityCavity

Fibrosed Endocervical canal & Fibrosed Endocervical canal & CavityCavity

Obliterated cavity Due to Obliterated cavity Due to adhesionsadhesions

Narrow endocervical canalNarrow endocervical canal

Confirmatory testConfirmatory test• Endometrial biopsy-Endometrial biopsy-• However negative endometrial biopsy is not an However negative endometrial biopsy is not an

indication for discontinuing AKT as HPE of indication for discontinuing AKT as HPE of endometrium does not necessarily reflect the endometrium does not necessarily reflect the state of fallopian tubesstate of fallopian tubes

Endometrial biopsy Endometrial biopsy

Other confirmatory testsOther confirmatory tests

• TB PCR-polmerase chain reactionTB PCR-polmerase chain reaction

• Senitivity 80-90% Senitivity 80-90%

Newer horizonsNewer horizons

• TB Interferon-gamma release assaysTB Interferon-gamma release assays

• Most recent available testMost recent available test

Summary-Summary-

• Endometrial tuberculosis-important Endometrial tuberculosis-important cause of infertilitycause of infertility

• Hysteroscopy better than HSG to Hysteroscopy better than HSG to diagnose diagnose

• Hysteroscopy should ideally be Hysteroscopy should ideally be coupled with laparoscopycoupled with laparoscopy

• Endometrial biopsy-confirmatory test Endometrial biopsy-confirmatory test