The silent synechiae: female genital tuberculosis masquerading as resistant polycystic ovarian syndrome-induced amenorrhoea

Abstract

Female genital tuberculosis (FGTB) is a significant cause of menstrual disturbances and infertility in tuberculosis-endemic regions. However, its diagnosis is frequently delayed due to its paucibacillary nature and nonspecific presentation. We report the case of a 28-year-old woman with a known history of polycystic ovarian syndrome (PCOS). She presented with secondary amenorrhoea of six months’ duration following the discontinuation of oral contraceptive pills (OCPs). While amenorrhoea is common in PCOS due to anovulation, this patient failed to exhibit withdrawal bleeding after a therapeutic challenge with progesterone and a subsequent course of OCPs. Pelvic ultrasonography provided false reassurance, showing polycystic ovarian morphology with normal endometrial thickness. A diagnostic hysteroscopy was performed to rule out outflow tract obstruction. It revealed filmy fundal synechiae and pale, unhealthy endometrium. Histopathology confirmed caseating epithelioid-cell granulomas with Langhans giant cells, and TB PCR detected Mycobacterium tuberculosis DNA. The patient was treated with a standard six-month anti-tubercular therapy (ATT) regimen under the national tuberculosis elimination programme (NTEP), resulting in the resumption of regular menstrual cycles. This case underscores the necessity of investigating structural causes, such as FGTB, in women with PCOS who present with atypical amenorrhoea refractory to hormonal withdrawal.