INTERNATIONAL JOURNAL OF LEPROSY^ Volume 49, Number 2Printed in the

Leprosy and Female Reproductive Organs'Subhash Chander Sharma, Bhushan Kumar, Kamla Dhall,

Surrinder Kaur, Sarla Malhotra, and Meera Aikat 2

Leprosy is a multi-system infection. Lep-rous granulomata have been demonstratedin internal organs like testis, liver, adrenals,lymph nodes, and bone marrow ( 1). Unlikethe male reproductive system and studiesof hormone levels ( 5" ) . "), the published lit-erature regarding the involvement of theuterus, fallopian tubes, and ovaries and theeffect of the disease on the normal phys-iological functions of the female reproduc-tive system is scanty ( r.7 .s.'"."). Leprosyhas not been found to affect female repro-ductive physiology ( 7 ." "), but gross men-strual abnormalities were reported by Kingand Marks ( 8). Prevention of menstrual dys-function with early institution of therapyhas been reported ("). The present studywas undertaken to study the involvementof female genital organs in leprosy and itseffect on menstruation, fertility, and men-opause.

MATERIALS AND METHODSThirty-five female leprosy patients of all

ages, irrespective of duration of the diseaseand treatment, were randomly selectedfrom the leprosy clinic of Nehru Hospital,attached to the Postgraduate Institute ofMedical Education and Research, Chandi-garh, India. Endometrial biopsies were tak-en in 26 patients during the premenstrualphase. Biopsies were taken in postmen-strual patients as and when they reported.Paraffin sections were stained with hema-

' Received for publication on 9 August 1979: ac-cepted for publication in revised form on 3 DecemberI980.

S. C. Sharma, M.D., Ex-Senior Resident in Der-matology; B. Kumar, M.D., Lecturer in Dermatology;K. Dhall, M.D., D.G.O., Assistant Professor of Ob-stetrics and Gynaecology; S. Kaur, M.D., M.A.M.S.,Associate Professor of Dermatology; S. Malhotra,M.D., Lecturer in Obstetrics and Gynaecology; NI.Aikat. M.B.B.S., D. Phil., M.A.M.S., Professor ofCytology, Postgraduate Institute of Medical Educationand Research, Chandigarh, India. Dr. Sharma's pres-ent address is Registrar in Dermatology, GlasgowRoyal Infirmary, 84 Castle Street, Glasgow G4 05F,United Kingdom.

toxylin and eosin for routine histology andby the Fite-Faraco method for demonstra-tion of acid-fast bacilli. Part of the endo-metrial tissue was cultured on LOwenstein-Jensen medium to rule out the presence ofM. tuberculosis. In two patients who hadinduced abortion at the fourth month ofgestation, the products of conception wereexamined for histopathology.

In six lepromatous (LL) patients havingbacillemia in peripheral blood smears asdemonstrated by the method of Saxena, etal. (u), menstrual blood was also examinedfor the presence of M. leprae by the samemethod.

RESULTSFifteen patients were of the LL type,

nine of the borderline lepromatous (BL)variety, two each of the mid-borderline(BB) and the borderline tuberculoid (BT)types, and seven belonged to the polar tub-erculoid (TT) group ('"). Slit smears werepositive in all LL and BL patients: the Bac-teriological Index (BI) ranged from 6+ to2+ and the Morphological Index (MI) from82% to 17%.* The duration of the diseasevaried from 9 months to 20 years with anaverage of 6 years. Twenty out of 35 pa-tients (57%) were in the reproductive agegroup (21-40 years), and nine had alreadyattained menopause.

Menstrual history. All patients had at-tained menarche between the ages of 12 and15 years, and the average age of menopausein the nine postmenopausal patients was 47years. Twenty-seven (77%) patients had orhad had regular periods with normal flow(this includes the nine postmenopausal wom-en). Two patients with primary sterility hadoligomenorrhea out of a total of four oli-

MI values recorded by other authors are frequentlylower. In our experience here and in the experienceof one of the authors (S.K.) elsewhere, extraordinarilyhigh MI values may he sometimes recorded in an oc-casional patient with untreated LL disease or duringa relapse.

177

178^ International Journal of Leprosy^ 1981

TABLE I. Menstrual cycle. TABLE 3. Onset or exacerbation of'symptoms of leprosy.

Menstrualcycle

No. of cases % of total

Onset/exacerbation at No. of cases % of total

liumenorrhea^

27"^

77.2Oligomenorrhea^4 '

^11.4

Menorrhagia^

4^

11.4

Includes nine postmenopausal cases who had hadeumenorrhea before menopause.

'' Includes two patients with primary sterility.

Menarche^

2.8During pregnancy^

3^

8.6Puerperium^

9^

25.8Menopause^ 1

^2.8

No correlation^ 21

^60.0

gomenorrheics, and four patients had ex-cessive flow with irregular cycles (Table I).

Obstetrical history. Twenty-five patients(68.5%) were multiparous, and five had onechild each. Of the remaining six, one wasunmarried, three were recently married,and two had primary sterility for the last 12to 15 years. A gynecological checkup of oneof the sterile patients revealed an infantileuterus while in the other no cause could beascertained (Table 2).

Correlation of onset/exacerbation of thedisease with obstetrical and gynecologicalevents. In 21 patients (60%), there was nocorrelation between the first appearance ofsymptoms and any gynecological or ob-stetrical event. In nine patients (25.8%),there was a definite relationship with puer-perium, in one each with menarche andmenopause, and three (8.6%) had a rela-tionship with pregnancy (Table 3).

Endometrial tissue. Endometrial tissuewas available for study in only 17 out of the26 patients (48.6%) in whom the biopsy wasattempted. In all nine postmenopausalwomen, either no tissue could he obtainedor it was not sufficient to be commentedupon. In 13, the specimen obtained was inthe secretory phase and in four in the pro-liferative phase. None of the biopsy speci-mens revealed leprous granulomata or the

TABLE 2. Fertility status.

LL BL BB BT lrr Total

1^

53^—^—^4

9^

4^

I^5^203^

I1

presence of M. leprae. Six weeks' incuba-tion of the endometrial tissue on LOwen-stein-Jensen medium did not grow tuberclebacilli. Endometrial washings from themenopausal women revealed no M. lepraeon smear nor grew tubercle bacilli. Prod-ucts of conception in the two multiparouspatients did not reveal M. leprae or leprousgranulomata. Menstrual blood examined insix cases with bacillemia failed to show M.leprae.

DISCUSSION

The widely prevalent belief that duringpregnancy and puerperium lesions of lep-rosy either appear for the first time or thedisease tends to show greater activity hasbeen confirmed by many observers(1.7.8. 13. 11) In the present study there wasa significant correlation in 14 out of 35 pa-tients (40%) in the first appearance or ex-acerbation of symptoms of leprosy withmenarche, pregnancy, puerperium, or men-opause. This can perhaps be attributed toa further fall in the immunity of the patientson account of the added stress of pregnancyand confinement. A high incidence of ste-rility (56%) and of irregular and scantymenses (35%) have been reported by Fle-ger, et al. ("). On the other hand, in thepresent study sterility or menstrual distur-bances were not found more often than hasbeen previously reported ( 7 13) in the pop-ulation at large.

Leprosy bacilli seem to cross the placen-tal barrier and have been demonstrated inthe placenta, in cord blood ( 11), and in theproducts of conception ( 2). On the otherhand, histopathological studies on abortedproducts of conception from two of our pa-tients did not reveal any granulomata orleprosy bacilli. The study reiterates thefindings of previous authors ( 7 . 13) in record-

No. ofchildren

2-33-10NoneUnmarried

49, 2^,Sliarma, et al.: Female Reproductive Organs^179

f

ing normal menarche, menstrual cycles,and fertility in patients with leprosy.

SUMMARYThirty-five adult female patients with ba-

cillary positive leprosy were studied to de-termine its effect on menarche, menstrualcycle, fertility, and menopause. Endome-trial biopsies studied in 26 patients showedno evidence of leprosy bacilli granuloma ortubercle bacilli on culture. Menstrual bloodexamined in six patients with hacillemia didnot reveal leprosy bacilli. Products of con-ception examined from two patients werenegative for granulomata or leprosy bacilli.Leprosy was found to have no direct effecton menarche, menstruation, fertility, andmenopause.

RESUMENSe estudiaron 35 mujeres adultes con lepra y con

baciloscopia positiva, pant determiner el efecto de IainfecciOn en Ia menarca, ciclo menstrual, fertilidad y

menopausia. Las biopsias endometriales estudiadas en26 pacientes no mostraron evidencias de granulomashacilares leprosos, ni de bacilos de Ia tuberculosis por

cultivo. El examen de Ia sangre menstrual en 6 pa-

cientes con bacilemia no revehi Ia presencia de bacilosde la lepra. El examen de los productos de Ia concep-

cirin de dos pacientes tampoco revel6 Ia presencia de

granulomas o bacilos de Ia lepra. No se encontai que

Ia lepra tuviera un efecto directo sobre la menarca,

menstruation, fertilidad y menopausia.

RESUME

Trente-cinq malades adultes de sexe feminin, pre-

sentant une lepre bacteriologiquernent positive, ontête etudies afin de determiner l'effet de la lepre sur Ia

menarque, le cycle menstruel, Ia fertilite, et la meno-pause. Des biopsies de l'endometre ont ete etudiees

chez 26 malades. Ces biopsies n'ont revele aucun

signe de granulOmes bacillaires lepreux ou de bacilles

tuberculeux a la culture. Le sang menstruel examinechez 6 malades presentant une bacillemie n'a pas re-vele de bacilles de Ia lepre. Les produits de la con-

ception examines chez 2 malades etaient negatifs en

ce qui concerne les granulOmes ou les bacilles de lalepre. On en conch' que la lepre n'a aucun effet directstir Ia menarque, Ia menstruation, la fertilite, ou hi

menopause.

REFERENCESI. BERNARD, J. C. and VAZQUEZ, C. A. J. Visceral

lesions in lepromatous leprosy. Int. J. Lepr. 45(1973) 94-101.

2. BoGum!, T. G., SHUBIN, A. S. and GRISHUKINA,

J. V. Electron microscopy of human placenta

cells in health and in lepra. Astrakhan 5/10 (1968)531-535.

3. BoDuso, T. G. The question of the menstrual

function in women with lepromatous leprosy be-

fore pubescence. Sci. Works Lepr. Res. Inst. 9/14(1976) 116-118.

4. COCIIRANE, R. G. and DAvEY, T. F., EDS. Lep-rosy in Theory and Practice. 2nd ed. Bristol: John

Wright and Sons Ltd., 1964.

5. DASS, J., MURUGESAN, K., LAUMAS, K. R., DEO,

M. (3., KANDDAR1, K. C. and 13DuLANI, L. K.

Androgenic status of lepromatous leprosy patientswith gynecomastia. Int. J. Lepr. 44 (1976) 469-

474.6. FLEGER, J., BERIC, B. and PRICA, S. The impor-

tance of leprosy in gynaecology and midwifery.Trop. Dis. Bull. 60 (1963) 446-447.

7. Hmums, U., SURVEY, R. and CHAKRAVARTI, D.

Leprosy in gynecology and obstetrics. Int. J.Lepr. 40 (1972) 399-402.

8. KING, J. A. and MARKS, R. A. Pregnancy andleprosy. Am. J. Ohstet. Gynecol. 76 (1958) 438-442.

9. MoRLEY, J. E., DISTILLER, L. A., SAGEL, J.,KOK, S. H., KAY, G., CARR, P. and KATZ, M.

Hormonal changes associated with testicular atro-phy and gynaecomastia in patients with leprosy.Clin. Endocrinol. 6 (1977) 299-303.

10. RIDLEY, D. S. and JOPLING, W. H. Classificationof leprosy according to immunity. A five-groupsystem. Int. J. Lepr. 34 (1966) 255-271.

II. SAMUEL, E., KUMAR, B., KAUR, S., KANNAN,

K., DASH, R. J., Ros -rocn, G. K. and DATIA, D.N. Serum testosterone, estradio1-17B and pitu-

itary gonadotropins in leprosy. J. Steroid Bio-

chem. 9 (1978) 851.

12. SAXENA, H., AJWANI, K. D., PRADHAN, S.,

CHANDRA, J. and KUMAR, A. A preliminary

study of hacteremia in leprosy. Lepr. India 47(1975) 79-84.

13. SHARMA, S. C., DHALL, K., KUMAR, 13. and

KAUR, S. Leprosy and female genital organs (Apreliminary report). Bull. P.G.I. 12 (1978) 198-201.

14. SURVEY, R. B., HARDAS, U. D. and CHAKRAVAR-

TI, D. Leprosy complicating pregnancy and puer-perium. Lepr. India 46 (1974) 234-237.