A 55-year-old postmenopausal woman, gravida 5 para 5, menopausal for 3 years presented with irregular vaginal bleeding for the past one month associated with passage of clots. There was no pain at abdomen, foul smelling discharge, fever, loss of weight, loss of appetite, or prior postcoital bleeding. The patient was otherwise well and had no significant medical history. She had no personal or family history of gynecological or other malignancy. She was not smoking or had alcohol and substance abuse. She has never used oral contraceptives or HRT. General physical and systemic examination detected no abnormality. On per speculum examination vagina was healthy and there was some bleeding from the cervix. Uterus was anteverted, 8-10 weeks in size and bilateral fornices free. Pap smear could not be performed because of vaginal bleeding. A Pap smear performed in another clinic four months ago was normal.
Transvaginal pelvic ultrasound was performed and showed an anteverted uterus with a grossly abnormal endometrial echo pattern. The endometrium was heterogenous and had an irregular surface (Figure 1). After the history and physical examination, endometrial biopsy was performed with profuse, curettings obtained. Blood loss was not excessive and the patient was discharged home the same day. Histopathology of the curettings showed epithelioid cell granulomas with Langhans giant cells (Figure 2).
The patient's hepatitis and HIV status were negative. All hematological and biochemical investigations were normal. PCR was performed on the formalin-fixed paraffin-embedded tissue for diagnosis of tuberculosis. PCR was positive for  Mycobacterium tuberculosis in the endometrium. Other tests for tuberculosis, namely, Mantoux was positive at 32mm and ESR was 77mm. A chest X-ray showed mild cardiomegaly but no evidence of pulmonary tuberculosis. The patient received antituberculosis treatment (4 drugs: isoniazid, rifampicin, ethambutol, and pyrazinamide) for six months and it has been learned that her bleeding ended in the fourth week of her treatment. At subsequent follow-up visits, patient is doing well and has been disease-free for 10 months.