Catamenial hemoptysis and pneumothorax in a patient with cystic fibrosis

Gynecologic health care for females with cystic fibrosis

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Females with CF may have cyclic lung symptoms, yeast infections, and urinary incontinence.

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Contraception is safe, but comorbidities should be considered in method selection.

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Females with CF have reduced fertility, though the etiology is unknown.

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Females with CF underutilize basic preventive gynecologic services.

As females with cystic fibrosis (CF) increasingly reach their reproductive years, gynecologic issues have become an important area of clinical care and research. First, females with CF may have disease-specific gynecologic problems, including cyclic pulmonary symptoms, vaginal yeast infections, and urinary incontinence. Next, contraceptive methods are thought to be overall safe and effective, however further research is needed to confirm this and to understand the lower rates of uptake among females with CF compared to the general population. Further, females with CF have reduced fertility, although the etiology of this is unknown and under investigation. While assisted reproductive technologies may help achieve pregnancy, decision-making around parenthood remains complex. Finally, while patients and providers agree on the importance of sexual and reproductive health care, females with CF underutilize basic preventive services such as cervical cancer screening, and better approaches are needed to bridge the gap with gynecology. In this review, we discuss the current state of gynecologic care for females with CF, as well as clinical and research opportunities for improvement.

Catamenial haemoptysis in females with cystic fibrosis: a case series with review of management strategies

Catamenial haemoptysis, the expectoration of blood during menses, has not been extensively reported in the cystic fibrosis (CF) literature. We describe four cases (age range: 25-34 years) of catamenial haemoptysis across four CF centres in the United States. These cases may represent thoracic endometriosis versus hormonal fluctuations in airway inflammation or infection resulting in bronchial artery bleeding. We identify common and nuanced management strategies including use of pro-coagulants, hormone contraceptives, anti-inflammatories, bronchial artery embolization, and use of the newer cystic fibrosis transmembrane conductance regulator (CFTR) modulators.

Case report of pulmonary endometriosis and review of the literature

Pulmonary endometriosis is a rare form of thoracic endometriosis. We herein describe a 29-year-old woman with recurrent hemoptysis associated with her menstrual cycle. The patient had a 4-month history of catamenial hemoptysis without thoracic pain, respiratory embarrassment, cough, fever, night sweating, or loss of appetite. Chest computed tomography revealed exudation shadows in the right lower pulmonary lobe and small fiber lesions in the right middle lobe and left lung. Thoracoscopic wedge resection of the right lower pulmonary lobe was performed, and the pathological result was pulmonary endometriosis. No evidence of hemoptysis during menstruation was found following the operation.

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.

Pneumothorax in cystic fibrosis

Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.

Catamenial pneumothorax

Catamenial pneumothorax (CP) is the most common form of thoracic endometriosis syndrome, which also includes catamenial hemothorax, catamenial hemoptysis, catamenial hemopneumothorax and endometriosis lung nodules, as well as some exceptional presentations. Usually onset of lung collapse is less than 72 hours after menstruation. Most commonly occurs in women aged 30-40 years, but has been diagnosed in young girls as early as 10 years of age and post menopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis. Diagnosis can be hinted by high recurrence rates of lung collapse in a woman of reproductive age with endometriosis. Moreover; CA-125 is elevated. Video-assisted thoracoscopy or medical thoracoscopy is used for confirmation. In our current work we will present all aspects of CP from diagnosis to treatment.

Higher risk of hospitalization among females with cystic fibrosis

BACKGROUND

Persons with cystic fibrosis (CF) who tend to be hospitalized have poorer overall survival and quality of life. Whether differences exist in hospitalization rates between males and females with CF is unknown. The objective was to assess sex-specific differences in hospitalization rates after adjusting for clinically important factors within a universal health care system.

METHODS

A provincial-based longitudinal study using national CF registry data linked to health administrative databases examined differences in annual hospitalization rates estimated by Poisson regression using generalized estimating equations with adjustment for markers of CF disease severity.

RESULTS

Among those aged 7 to 19 years, the RR of respiratory-related annual hospitalizations among females vs. males was 1.38 (95% CI 1.11-1.73). Among those over 19 years, the corresponding RR was 1.30 (95% CI 1.06-1.59).

CONCLUSIONS

Females affected by CF are at a higher risk of respiratory-related hospitalization, which may extend beyond classic clinical measures of disease severity.

Cystic fibrosis and estrogens: a perfect storm

Irreversible destruction and widening of the airways due to acquired infections or genetic mutations as well as those of unknown cause are more severe in females. Differences between male and female anatomy, behavior, and hormonal state have been proposed to explain the increased incidence and severity in females with airway disease such as cystic fibrosis (CF); however, a mechanism to explain a sex-related difference has remained elusive. In this issue of the JCI, Coakley et al. report that elevations in the major estrogen hormone in humans--17beta-estradiol--reduce Ca2+-activated Cl- secretion by airway epithelial cells in culture, thereby disrupting ion and water balance (see the related article beginning on page 4025). They measure a similar diminution of nasal epithelial Ca2+-activated Cl- secretion in women with CF during the menstrual cycle phase at which 17beta-estradiol level is at its highest. These data suggest that for about one week of a four-week menstrual cycle, women with CF will have a reduced ability to efficiently clear airway secretions, the buildup of which is a hallmark of CF. The authors suggest that these data warrant the testing of antiestrogen therapy in females with CF and propose an alternative avenue for CF therapeutic development.

Pulmonary complications in adult patients with cystic fibrosis

Early diagnosis, treatments of acute exacerbations, and chronic therapies have all improved the lifespan of cystic fibrosis patients; however, the natural history remains one of worsening bronchiectasis and obstructive airways impairment. The progression of disease leads to eventual respiratory failure, but some will have other acute respiratory complications that require intervention. In this report, we review the most common life-threatening respiratory complications of cystic fibrosis, including pneumothorax, massive hemoptysis, and respiratory failure.