Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), continues to pose a major global health threat, despite significant advances in its diagnosis and treatment. According to the World Health Organization (WHO) Global TB Report 2023, an estimated 10.6 million people developed TB globally in 2022, with 1.3 million deaths among HIV-negative individuals and nearly 187,000 among HIV-positive patients. India accounted for over a quarter of global TB cases, underscoring the country’s substantial disease burden [1].

While pulmonary tuberculosis (PTB) remains the most common form, extrapulmonary tuberculosis (EPTB)—involving organs other than the lungs—constitutes a considerable proportion of TB morbidity. Among various forms of EPTB, female genital tuberculosis (FGTB) is particularly underrecognized and underreported. It affects approximately 9–27% of infertile women in high TB burden countries such as India, with many cases going undiagnosed due to its latent, asymptomatic progression and low bacillary load [2,3].

The pathophysiology of FGTB typically involves hematogenous dissemination from a primary focus, most commonly the lungs. The fallopian tubes are the first and most frequently affected site (90–100%), followed by the endometrium (50–60%), ovaries (20–30%), cervix (5–15%), and vagina/vulva (1–2%) [4,5]. The disease often manifests during a woman’s reproductive years and presents with non-specific symptoms such as infertility, menstrual disturbances, pelvic pain, and constitutional features, or may remain entirely asymptomatic.

Diagnosis of FGTB poses a significant clinical challenge due to its nonspecific symptomatology and paucibacillary nature. Conventional methods such as histopathology and culture on Lowenstein–Jensen (LJ) medium, though specific, suffer from low sensitivity and long turnaround time. Newer techniques like polymerase chain reaction (PCR) and Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) have shown greater promise due to their rapid detection capability and improved sensitivity, even in paucibacillary specimens [6,7]. CBNAAT, in particular, can detect MTB and rifampicin resistance within two hours and is recommended by WHO as the initial diagnostic tool for suspected EPTB cases [8].

Despite these advances, FGTB remains a major yet silent contributor to infertility and reproductive health compromise in women. In India, where infertility is often stigmatized, women with undiagnosed genital TB face not only physiological consequences but also severe psychosocial distress. The intersection of infectious disease and reproductive medicine demands integrated diagnostic approaches and increased clinical awareness.

Against this background, the present study was undertaken to investigate the incidence of genital tract involvement in women with extragenital TB, to compare the diagnostic accuracy of HPE and CBNAAT, and to evaluate the sociodemographic factors associated with disease presentation. This research contributes to the growing body of evidence advocating for early screening of FGTB in EPTB patients, especially in high-burden, low-resource settings.

Study Design and Duration

This prospective observational study was carried out over a period of 24 months, from September 2022 to August 2024. The research was conducted at the Department of Obstetrics and Gynaecology, Government Maternity Hospital, and the Department of Pulmonology, Government Chest and TB Hospital, both located in Hanamkonda, Telangana, India.

Ethical Clearance

Ethical approval for this study was obtained from the Institutional Ethics Committee (IEC) of Kakatiya Medical College, Warangal. The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent. The ethical clearance number is KMC/IEC/2022/OBG/042, dated 28/08/2022.

Sample Size Calculation

The sample size was calculated based on a hypothesized prevalence of genital tract involvement among extragenital TB patients. According to previous studies, the prevalence ranges from 10–20% in high-burden settings. Taking a prevalence of 15%, with a 95% confidence level and 7% absolute precision, the minimum sample size required was estimated using the formula: n = Z² × p(1−p)/d² = (1.96)² × 0.15(1−0.15) / (0.07)² = 3.8416 × 0.1275 / 0.0049 ≈ 100. Hence, a total of 100 subjects were included to ensure statistical adequacy and account for potential dropouts.

Study Population

A total of 100 women aged between 20 and 45 years, with a history of or ongoing treatment for extragenital tuberculosis, were recruited from the participating institutions. Detailed clinical evaluation, treatment history, and consent were documented before sample collection.

Inclusion Criteria

Women eligible for participation in the study were those aged between 20 and 45 years who had a confirmed diagnosis of extrapulmonary tuberculosis based on clinical, radiological, or microbiological evidence. Participants were either currently undergoing anti-tubercular therapy (ATT) or had previously completed a full course of treatment. Only those who expressed willingness to participate and provided written informed consent were enrolled in the study.

Exclusion Criteria

Women were excluded from the study if they were below 20 or above 45 years of age, had a previously diagnosed case of genital tuberculosis, or presented with significant comorbid conditions such as diabetes mellitus, hypertension, coronary artery disease, epilepsy, asthma, cerebrovascular accident, HIV infection, or recent COVID-19. Pregnant women and those unwilling to provide informed consent were also excluded from participation.

Sample Collection and Laboratory Investigations

Endometrial tissue was collected through dilation and curettage (D&C), ideally performed during the late secretory phase or on Day 1 of menstruation. The specimen was divided into two parts. One part was fixed in 10% buffered formalin and sent for histopathological examination. Slides were stained with Hematoxylin and Eosin (H&E), and the presence of epithelioid granulomas, caseous necrosis, and Langhans-type giant cells was considered diagnostic of TB. The second portion of the tissue was suspended in 0.9% normal saline and subjected to CBNAAT (GeneXpert MTB/RIF) in the Department of Microbiology, MGM Hospital, Warangal. This assay simultaneously detects the presence of Mycobacterium tuberculosis complex DNA and rifampicin resistance.

Data Collection

Data were collected using a structured case proforma, covering sociodemographic details, BMI, housing type, overcrowding, education level, history of TB (family, childhood, or contact), BCG vaccination status, and ATT status. All findings and laboratory reports were systematically documented.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 24.0. Categorical variables were presented as frequencies and percentages, while continuous variables were summarized using means and standard deviations. The Chi-square test or Fisher’s exact test was applied for evaluating associations between categorical variables. A p-value of <0.05 was considered statistically significant for all tests.

Age Distribution of Subjects

The study revealed a distinct age-wise distribution among participants. The highest proportion (53%) were in the 26–30 years age group, followed by 24% in the 20–25 years group, indicating that younger reproductive-aged women are more frequently affected. Subjects in the 31–35 age group accounted for 19%, while older age groups (36–40 and 41–45 years) contributed minimally, with 3% and 1% respectively. Statistical analysis using Pearson’s correlation showed a moderate negative correlation between age category and PCR positivity (R = -0.48, p = 0.000), suggesting that younger age groups had a higher likelihood of testing positive for genital TB via PCR. This trend highlights the reproductive age as a critical window for tuberculosis-related complications (Figure 1).

Figure 1: Age Distribution of the Subjects

BMI Distribution of Subjects

The analysis of body mass index (BMI) showed that 45% of participants had a normal BMI (18.5–24.9 kg/m²), while 32% were categorized as overweight (25.0–29.9 kg/m²). A notable 18% were underweight (<18.5 kg/m²), and 5% were classified as obese (>30 kg/m²). The presence of undernutrition and overweight among women with tuberculosis reflects both ends of the nutritional spectrum associated with disease susceptibility and chronic infection. A mild inverse correlation was observed between BMI category and PCR positivity (R = -0.57, p = 0.000), implying slightly higher PCR positivity in underweight individuals, though the association was not statistically significant (Figure 2).

Figure 2: Age Distribution of the Subjects

Education Level of Subjects

Educational attainment was predominantly at the school level (58%), followed by 31% illiterate subjects and only 11% with college-level education. This indicates that limited education may influence health-seeking behavior, awareness of tuberculosis symptoms, and adherence to treatment protocols, potentially increasing the risk of extrapulmonary involvement such as genital TB (Figure 3).

Figure 3: Education Level of Subjects

Socioeconomic Status of Subjects

Socioeconomic profiling revealed that 36% of participants belonged to the lower-middle class, 23% to the lower class, and 18% to the upper-middle class. A smaller percentage came from upper-lower (14%) and upper-class (9%) backgrounds. The data highlight that TB predominantly affects individuals from socioeconomically disadvantaged environments, where factors such as poor living conditions, limited access to healthcare, and malnutrition may contribute to disease progression and delayed diagnosis (Figure 4).

Figure 4: Socioeconomic Status of Subjects

Laboratory Test Results

The laboratory profile of participants reflected prominent markers of systemic inflammation and immune activation, commonly associated with chronic infectious diseases like tuberculosis. Abnormalities in total leukocyte count were observed in 93% of subjects, suggesting a widespread immune response to ongoing infection. A persistently elevated leukocyte count is indicative of a pro-inflammatory state and is often seen in patients with active or disseminated tuberculosis.

Lymphocyte counts were found to be abnormal in 79% of cases, which may represent either lymphopenia due to immunosuppression or a reactive lymphocytosis, depending on the phase and severity of infection. Since lymphocytes play a crucial role in mediating cellular immunity against Mycobacterium tuberculosis, any deviation from normal levels reflects immune dysregulation and the host’s attempt to contain the infection.

Furthermore, an elevated erythrocyte sedimentation rate (ESR) was noted in 75% of the participants. ESR is a nonspecific yet reliable marker of chronic inflammation, and its elevation supports the presence of an ongoing disease process with granulomatous activity, which is characteristic of extrapulmonary and genital TB. Persistent elevation of ESR in such cases can also be useful in monitoring treatment response.

Interestingly, only 15% of the participants had abnormal hemoglobin

Diagnostic Test Evaluation

To assess the diagnostic accuracy for detecting genital tract involvement in women with extragenital tuberculosis, two modalities were compared: histopathological examination (HPE) and polymerase chain reaction (PCR). HPE, which involves microscopic examination of tissue sections, demonstrated a very high specificity of 100% and a positive predictive value (PPV) of 100%, indicating that when granulomatous inflammation consistent with TB is seen, the diagnosis is definitive. However, HPE had poor sensitivity (8.2%), suggesting that it fails to detect a majority of true TB cases due to the paucibacillary nature of female genital TB. On the other hand, PCR showed a markedly higher sensitivity of 44.3%, with a specificity of 80.4%. The PPV and NPV of PCR were 60% and 68.5%, respectively (Table 1). These results underline the importance of incorporating molecular techniques like PCR in routine diagnostic workflows, particularly when histological evidence is inconclusive. PCR’s ability to detect even minute quantities of MTB DNA enhances its value as a frontline diagnostic tool in reproductive-age women with suspected genital TB (Table 1).

Table 1: Diagnostic Evaluation of the Subjects-Sensitivity, Specificity, PPV, NPV

This prospective observational study evaluated the prevalence and diagnostic features of genital tract involvement among women with extragenital TB. The findings highlight the reproductive-age group, particularly those between 26 and 30 years, as the most affected demographic. This observation aligns with previous research by Weerakiet et al. (1999), who reported that over 50% of genital TB cases occurred in women aged 26–30 years [9]. The vulnerability of this age group is attributed to increased pelvic organ vascularity and hormonal activity, which may facilitate hematogenous seeding of Mycobacterium tuberculosis.

In terms of BMI, most women in the present study fell into the normal (45%) and overweight (32%) categories. This is consistent with findings by Malhotra et al. (2010), who noted that nutritional status may influence host immune response but is not always a determinant of disease presence [3].

A notable proportion of participants (58%) were school-level literates, with 31% being illiterate. Education level has previously been shown to correlate with delayed health-seeking behaviour and poor awareness regarding TB transmission and fertility implications. Similar patterns were observed in a study by Sharma et al. (2015), where lower educational status was significantly associated with delayed diagnosis of female genital TB [2].

Socioeconomically, the lower-middle class (36%) represented the majority, emphasizing the well-documented link between TB and poverty. Low-income environments are often associated with overcrowding, poor nutrition, and limited access to healthcare—all factors contributing to TB transmission and progression [10].

Laboratory findings in this study showed significant abnormalities in inflammatory markers, with elevated total leukocyte counts (93%) and ESR (75%). These results reinforce the findings by Raut et al. (2001), who documented similar patterns in women with pelvic TB and proposed routine inflammatory markers as valuable screening tools [11].
The diagnostic evaluation revealed that PCR had higher sensitivity (44.3%) compared to histopathology (8.2%), while HPE retained a specificity of 100%. These results are consistent with a study by Moussa et al. (2000), which reported the superiority of PCR in detecting Mycobacterium tuberculosis DNA in endometrial samples, particularly in paucibacillary specimens [6]. Although histopathology remains the gold standard owing to its high specificity, its diagnostic utility diminishes in cases lacking visible granulomas, particularly during the early proliferative phase or endometrial shedding stages of the menstrual cycle

Furthermore, the presence of genital TB in 12% of extragenital TB cases underscores the need for routine gynecological evaluation in women presenting with EPTB. Previous studies by Varma (1991) and Namavar Jahromi et al. (2001) also reported similar prevalence rates and highlighted the silent nature of the disease, often detected only during infertility workups [12,13].

Despite technological advancements, a significant number of genital TB cases continue to be missed due to the lack of clinical suspicion, limited availability of molecular diagnostics in peripheral centres, and the asymptomatic nature of the disease in its early stages [14-17]. This highlights the importance of including CBNAAT or PCR in diagnostic algorithms, particularly in endemic regions, as recommended by the WHO

Limitations

This study, while informative, has several limitations. Firstly, it was conducted at a single-center tertiary care institution, which may limit the generalizability of the findings to broader populations. Secondly, the relatively small sample size may not capture the full spectrum of demographic and clinical variations in extragenital tuberculosis. Thirdly, the study did not assess follow-up outcomes such as fertility restoration or treatment success rates, which are essential for understanding long-term implications. Additionally, the diagnostic methods were limited to histopathology and PCR; more advanced molecular techniques such as GeneXpert Ultra or culture-based assays were not utilized due to resource constraints.

Recommendations

• Routine screening for genital tuberculosis should be considered in all women of reproductive age presenting with extrapulmonary TB, particularly those with infertility or menstrual irregularities.
• Molecular diagnostics like PCR or CBNAAT should be made more accessible at primary and secondary healthcare centers for early and accurate diagnosis of genital TB.
• Further multi-centric studies with larger sample sizes and follow-up of reproductive outcomes are recommended to validate findings and guide management protocols.
• Clinician awareness regarding the silent progression of female genital TB should be enhanced through targeted training and public health initiatives.

This study highlights that genital tract involvement is a significant, yet frequently overlooked, manifestation among women with extragenital tuberculosis. A prevalence of 12% was observed, with the majority of patients falling in the reproductive age group and coming from socioeconomically disadvantaged backgrounds. PCR demonstrated superior sensitivity compared to histopathology, making it a valuable diagnostic tool for early detection in paucibacillary conditions. Integration of molecular techniques into routine screening, especially in TB-endemic regions, is essential for timely intervention, prevention of long-term reproductive morbidity, and achieving national TB elimination targets.

Conflict of Interest

The authors declare that there is no conflict of interest related to this study.]

Funding Sources

No external funding was received for the conduct of this research. All resources and laboratory investigations were supported by the respective departments of the Government Maternity Hospital and Government Chest and TB Hospital, Hanamkonda.

Acknowledgements

The authors express their sincere gratitude to Dr. Sarladevi Madam, Professor and Head of the Department of Obstetrics and Gynaecology, Government Maternity Hospital, Hanamkonda, for her invaluable guidance, continuous support, and encouragement throughout the course of this study. We also thank all the patients who participated and the technical staff for their cooperation during data and sample collection.

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