Endometrial tuberculosis mimicking gynecological malignancy in a postmenopausal woman

Abstract

Background

Female genital tuberculosis is a rare form of extrapulmonary tuberculosis that may mimic gynecologic malignancy, particularly when clinical and imaging findings are nonspecific. Diagnosis can be especially challenging in postmenopausal women.

Case Presentation

A 78-year-old postmenopausal woman presented with pelvic pain and was found to have marked endometrial cavity distention, hematometra, and a cervical lesion concerning for malignancy. Severe cervical stenosis prevented adequate endometrial sampling despite examination under anesthesia, attempted hysteroscopy, and dilation and curettage. Because malignancy could not be excluded, she underwent robotic-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Histopathologic examination demonstrated extensive necrotizing granulomatous inflammation involving the endometrium, myometrium, endocervix, and left adnexal soft tissue, without evidence of malignancy. Although acid-fast staining was negative, tissue mycobacterial culture grew Mycobacterium tuberculosis complex, and molecular testing confirmed M. tuberculosis complex DNA. Subsequent evaluation showed no evidence of active pulmonary tuberculosis, and antituberculosis therapy was initiated.

Conclusion

Female genital tuberculosis should be considered in the differential diagnosis of suspicious intrauterine or cervical lesions, even in postmenopausal women, particularly when cervical stenosis prevents adequate preoperative sampling and epidemiologic risk factors, including migration from a country with a higher tuberculosis burden, are present.

Highlights

• •Female genital tuberculosis can mimic gynecologic malignancy.
• •Genital tuberculosis can present unexpectedly after menopause.
• •Cervical stenosis can prevent adequate preoperative tissue sampling.
• •Molecular testing can confirm tuberculosis despite negative acid-fast stains.
• •Defintive surgery may be necessitated when malignancy cannot be excluded due to lack of preoperative pathologic diagnosis.

1. Introduction

Tuberculosis remains a major global public health problem, with more than 10 million new cases and over 1 million deaths reported annually (World Health Organization. Global Tuberculosis Report, 2025). Although most cases involve the lungs, extrapulmonary tuberculosis accounts for a substantial proportion of disease worldwide (Pai et al., 2016). Female genital tuberculosis is an uncommon form of extrapulmonary tuberculosis, representing approximately 5–10% of extrapulmonary cases in endemic areas (World Health Organization. Global Tuberculosis Report, 2025; Sharma, 2015); it is rare in the United States, accounting for fewer than 1% of all reported tuberculosis cases, and most commonly affects women of reproductive age (Hassoun et al., 2005; Tzelios et al., 2022).

Although best recognized as an important cause of infertility in women of reproductive age, female genital tuberculosis may also present in postmenopausal women, where the diagnosis is often unexpected (Sharma, 2015). Clinical manifestations are often nonspecific and include pelvic pain, abnormal uterine bleeding, pelvic masses, and constitutional symptoms (Tzelios et al., 2022). Imaging findings frequently overlap with those of gynecologic malignancies, making preoperative diagnosis challenging (Aggarwal et al., 2022). Endometrial biopsy remains the preferred initial diagnostic modality to classify intrauterine lesions (Palo et al., 2025), however, establishing a preoperative diagnosis may be challenging because the disease is typically paucibacillary, granulomatous inflammation may be patchy, and conventional microbiologic methods have limited sensitivity. Histopathologic evaluation demonstrating necrotizing granulomatous inflammation, supported by microbiologic or molecular confirmation, remains essential for diagnosis (Tjahyadi et al., 2022).

In this context, we report a rare case of female genital tuberculosis presenting as presumed endometrial malignancy in a postmenopausal woman, in whom severe cervical stenosis precluded adequate preoperative endometrial sampling and ultimately necessitated hysterectomy for definitive diagnosis. This case highlights the diagnostic challenges associated with female genital tuberculosis in postmenopausal women and emphasizes the importance of considering this rare entity in the differential diagnosis of endometrial or intrauterine lesions, even in patients without typical symptoms or multiple recognized risk factors for tuberculosis.

2. Case report

A 78-year-old Hispanic postmenopausal woman presented to the emergency department with a one-week history of progressively worsening lower back pain radiating to the left pelvic region. She denied recent trauma and reported only temporary relief with acetaminophen. Her medical history was significant for type 2 diabetes mellitus with diabetic nephropathy, hypertension, hyperlipidemia, rheumatoid arthritis, chronic kidney disease stage 2 and osteoarthritis. Her surgical history was notable for one cesarean delivery. She denied a family history of gynecologic malignancy, as well as tobacco, alcohol, or illicit drug use. She was born in Mexico and had been living in the United States for more than 40 years.

Computed tomography (CT) of the abdomen and pelvis demonstrated a distended endometrial cavity concerning for cervical outlet obstruction. Transvaginal ultrasonography demonstrated a 6.1 × 3.9 × 4.6 cm uterus containing a 1.2 × 0.4 × 0.9 cm echogenic lesion within the cervix, suspicious for a cervical mass or polyp. The upper endometrial cavity was markedly distended by a 4.9 × 3.1 × 3.4 cm avascular, homogeneously hypoechoic collection, favored to represent hematometra secondary to cervical obstruction. The ovaries were not visualized (See Fig. 1).

Fig. 1.

Preoperative transvaginal ultrasonographic findings. A. Longitudinal transvaginal ultrasound image demonstrating marked distention of the endometrial cavity consistent with hematometra. B. Sagittal and transverse views of the cervix demonstrating a 1.2-cm echogenic cervical lesion suspicious for a cervical mass or polyp.

Urine culture grew Escherichia coli. The patient was treated with antibiotics for a urinary tract infection before being discharged with outpatient gynecologic follow-up for further evaluation of the suspected cervical lesion.

3. Gynecologic oncology evaluation

Two weeks later, she was evaluated in the gynecologic oncology clinic. She reported only one prior Papanicolaou smear in her lifetime, which had been negative. On clinical examination, the cervix was severely stenotic and flush with the vagina, but no obvious cervical mass was seen or felt. Given the imaging findings, the patient underwent an examination under anesthesia with attempted hysteroscopy and dilation and curettage to obtain a tissue diagnosis. However, severe cervical stenosis prevented access to the endometrial cavity, and after suspected creation of a false passage, the procedure was aborted. Only a small amount of tissue recovered from the hysteroscopic drainage system was available for pathologic examination, demonstrating predominantly necrotic tissue with ghost cells and mucin, precluding a definitive diagnosis. Consequently, malignancy could not be excluded. Because of persistent concern for an underlying malignancy and the inability to obtain adequate endometrial tissue, definitive surgical management was recommended. Preoperative chest radiography showed no acute cardiopulmonary abnormalities. The patient subsequently underwent robotic-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Intraoperatively, bilateral tubo-ovarian adhesions were observed, but no other extra-uterine disease was noted. Intraoperative frozen section demonstrated diffuse necrosis involving the entire endometrial surface with granulomatous inflammation, without identified carcinoma.

3.1. Pathology

Gross examination of the resected uterus demonstrated extensive tan-yellow necrotic material diffusely involving the endometrial cavity (Fig. 2). Final histopathologic examination demonstrated necrotizing granulomatous endometritis involving the entire endometrial cavity (Fig. 3). Extensive endometrial surface necrosis was associated with underlying well-formed palisading granulomas containing Langhans giant cells. Granulomatous inflammation extended into the myometrium, endocervix, and left adnexal soft tissue. No malignancy was identified. Kinyoun and Fite stains for acid-fast bacilli, Gram stain, fungal smear, and fungal PCR were all negative. Tissue mycobacterial culture subsequently grew Mycobacterium tuberculosis complex, and polymerase chain reaction confirmed Mycobacterium tuberculosis complex DNA. Additionally, nucleic acid amplification testing (NAAT) detected Mycobacterium tuberculosis complex DNA, confirming the diagnosis of female genital tuberculosis.

Fig. 2.

Resected uterus demonstrating extensive tan-yellow necrotic material diffusely involving the endometrial cavity. A. Bivalved uterus. Necrotic nodules diffusely involve the endometrial surface. B. Serial cross-sections of the uterus showing exophytic configuration of the necrotic nodules with distinct borders.

Fig. 3.

Histopathologic features. A. Low power magnification shows granulomatous inflammation in the endometrium and myometrium with extensive endometrial necrosis. B. Mid power magnification shows palisading granulomatous inflammation at the endomyometrial junction and well-formed granulomas in the myometrium. C. High power magnification shows well-formed granulomas with Langhans giant cells rimmed by lymphocytes. This granuloma is located deep within the myometrium.

3.2. Post-operative treatment

Following the diagnosis, the patient was referred to a dedicated tuberculosis clinic, and the case was reported to the appropriate public health authorities. Subsequent tuberculosis evaluation demonstrated a positive T-SPOT.TB assay. As the patient had no pulmonary symptoms and chest imaging showed no evidence of pulmonary tuberculosis, active pulmonary involvement was considered unlikely. Standard antituberculosis therapy has been initiated consisting of isoniazid (300 mg daily), rifampin (600 mg daily), pyrazinamide (1500 mg daily), ethambutol (1200 mg daily), and pyridoxine (50 mg daily). At her postoperative follow-up, she was recovering well, with well-healed abdominal incisions and no pelvic pain, vaginal bleeding, or bowel or bladder dysfunction.

4. Discussion

Our patient presented with cervical stenosis resulting in hematometra and imaging findings highly suspicious for cervical or endometrial malignancy. Tissue sampling for differential diagnosis and treatment planning is generally recommended before definitive surgical management. However, in the absence of a visible cervical lesion and severe cervical stenosis, adequate sampling could not be obtained despite attempted cervical dilation and hysteroscopic evaluation. Consequently, hysterectomy became necessary to establish the diagnosis. Final histopathology unexpectedly demonstrated necrotizing granulomatous endometritis caused by Mycobacterium tuberculosis complex, highlighting an uncommon but important diagnostic challenge in postmenopausal women. Although female genital tuberculosis has previously been reported to mimic gynecologic malignancy (Viegas de Carvalho et al., 2025; Micha et al., 2007), most reports emphasize the radiologic or clinical resemblance. Additionally, our case demonstrates how severe cervical stenosis may prevent adequate endometrial sampling, thereby complicating the diagnostic workup and leading to definitive surgery before the correct diagnosis can be established. Antituberculosis therapy is the primary treatment for female genital tuberculosis, while surgery is generally reserved for diagnostic uncertainty or complications such as a persistent tubo-ovarian abscess (Sharma, 2015; Tzelios et al., 2022). In our case, hysterectomy was performed to establish a diagnosis and to exclude malignancy. This case therefore represents an uncommon presentation of a rare disease in a low-incidence setting and highlights the difficulty of distinguishing genital tuberculosis from malignancy when tissue acquisition is limited. Tal et al. demonstrated that targeted screening in a United States academic fertility center identified genital tuberculosis among selected high-risk patients, underscoring that the disease remains clinically relevant even outside endemic regions (Tal et al., 2020). In our case, the diagnosis was particularly unexpected because the patient was postmenopausal and presented with findings concerning for malignancy rather than infertility. Although she had lived in the United States for more than four decades, she was born in Mexico, a country with a substantially higher tuberculosis burden than the United States (World Health Organization. Global Tuberculosis Report, 2025). This epidemiologic risk factor only became apparent in retrospective review and highlights the importance of obtaining a detailed migration and country-of-origin history when evaluating patients with atypical gynecologic presentations. M. tuberculosis infection may remain latent for decades before progressing to active disease. Therefore, reactivation following remote exposure is biologically plausible in this patient; however, the timing of infection and duration of latency cannot be established with certainty (Pai et al., 2016).

4.1. Differential diagnosis of female genital tuberculosis

The differential diagnosis of female genital tuberculosis encompasses both infectious and noninfectious inflammatory conditions, including chronic endometritis, pyometra, and less commonly, systemic granulomatous disorders such as sarcoidosis (Tzelios et al., 2022; Aggarwal et al., 2022). In women of reproductive age, the disease is also frequently mistaken for chronic pelvic inflammatory disease since both conditions may present with elevated erythrocyte sedimentation rate, a nonspecific biomarker of inflammation (Grace et al., 2017).

The histopathologic differential diagnosis of granulomatous endometritis is broad and includes infectious etiologies, such as tuberculosis and fungal infections, as well as noninfectious conditions including sarcoidosis, foreign-body reactions, and xanthogranulomatous inflammation (Shah et al., 2017). In our case, extensive necrosis with limited viable tissue represented a significant diagnostic challenge, because both malignancy and infectious granulomatous diseases remained plausible preoperative considerations given the clinical scenario. In such situations, failure to obtain adequate endometrial tissue may necessitate definitive surgical management to establish a diagnosis.

4.2. Role of molecular diagnostic assays

Diagnostic testing for tuberculosis includes tests that identify TB infection and tests that confirm active disease at a specific anatomical site. Interferon-gamma release assays, including T-SPOT.TB, and the tuberculin skin test identify TB infection but cannot distinguish latent infection from active disease or establish genital involvement (Tzelios et al., 2022). Tissue-based evaluation includes histopathologic examination, acid-fast staining, mycobacterial culture, and nucleic acid amplification testing (Tzelios et al., 2022; Tjahyadi et al., 2022). Mycobacterial culture permits microbiologic confirmation and drug-susceptibility testing but may require several weeks, whereas molecular testing may provide earlier confirmation (Pai et al., 2016). The limited sensitivity of acid-fast staining is particularly relevant in endometrial tuberculosis. In a study evaluating molecular and bacteriological methods in formalin-fixed paraffin-embedded specimens, Ziehl-Neelsen staining demonstrated substantially lower sensitivity than GeneXpert MTB/RIF and real-time PCR, and molecular methods identified additional cases missed by conventional staining (Baye et al., 2024). A recent systematic review and meta-analysis demonstrated substantially higher sensitivity for PCR-based testing compared to Ziehl-Neelsen staining or mycobacterial culture, supporting the integration of molecular diagnostics into the investigation of suspected genital tuberculosis (Palo et al., 2025). When granulomatous inflammation raises concern for tuberculosis, prompt communication between the pathologist and treating clinician is important so that fresh, unfixed tissue can be submitted for mycobacterial culture and, when available, molecular testing.

4.3. Infection control and public health considerations

According to guidance from the Centers for Disease Control and Prevention (CDC), isolated extrapulmonary tuberculosis without a draining lesion or pulmonary or laryngeal involvement generally requires standard rather than airborne precautions; no special surgical draping, instrumentation, or sterilization is required beyond routine reprocessing. If infectious pulmonary or laryngeal tuberculosis is suspected, airborne precautions, including appropriate respiratory protection, should be implemented (Centers for Disease Control and Prevention, 2025). Close-contact testing is not typically required for isolated genital tuberculosis; however, confirmed cases should be reported to public health authorities because tuberculosis is nationally notifiable in the United States, and the relevant authorities determine whether contact investigation is indicated (Centers for Disease Control and Prevention, 2024).

5. Conclusion

Female genital tuberculosis should remain in the differential diagnosis of endometrial or intrauterine lesions in postmenopausal women, particularly in patients who have migrated from countries with a higher incidence of tuberculosis, or those with atypical presentations. Cervical stenosis may further constitute an additional barrier to adequate endometrial sampling. This case highlights how female genital tuberculosis can closely mimic endometrial or cervical malignancy and ultimately necessitate definitive surgery when an adequate tissue diagnosis cannot be obtained preoperatively. Recognition of relevant epidemiologic factors, including migration history, may raise clinical suspicion and prompt earlier targeted diagnostic testing.

Studies in human

This study was performed in compliance with relevant laws, regulatory frameworks and guidelines where the research took place.

Ethics committee approval was not required under relevant laws and institutional guidelines. Ethics committee approval was not required for this single-patient case report in accordance with institutional guidelines. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Case reports

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CRediT authorship contribution statement

Kamilla L. Dávid: Writing – review & editing, Writing – original draft, Visualization, Project administration, Methodology, Investigation, Formal analysis, Conceptualization. Eva Orrego: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptualization. Andres Macari-Jorge: Writing – review & editing, Visualization, Resources. Diletta Fumagalli: Writing – review & editing, Project administration. Rebecca Yorke: Writing – review & editing, Visualization, Resources. Mary R. Schwartz: Writing – review & editing, Visualization, Supervision, Resources, Methodology, Funding acquisition. Aparna A. Kamat: Writing – review & editing, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Conceptualization.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Informed consent and patient details

Written informed consent to take part in the study and to publish the article has been obtained from all participants or their legal representatives. The privacy rights of participants have been observed.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.