[Catamenial pneumothorax with persistent air leak]

Catamenial pneumothorax is a spontaneous recurrent pneumothorax that occurs in women of reproductive age and in temporal relationship with the menses. It usually occurs within 24 hours before or 72 hours after the start of the menstrual cycle; however, multiple variations have been described in terms of the temporal relationship. To date, it is considered a rare condition; this may be justified by the limited available knowledge on this disease leading to misdiagnosis. Often, making a diagnosis of catamenial pneumothorax is complicated; it mainly depends on the medical history; also, it may be a surgical or histopathological diagnosis. Management strategies for catamenial pneumothorax may include combinations of hormonal therapy, pleurodesis, lung parenchyma resection, and diaphragm resection/repair. The aim of reporting this atypical case of catamenial pneumothorax is to highlight the relevance of having the adequate knowledge on this entity so it does not go unnoticed despite its apparent low incidence.

Spontaneous recurrent menstrual pneumothorax: a case report

Introduction and importance

Endometriosis is most commonly found in the pelvic area, ~12% of people have it in other areas or organs, which is known as extrapelvic endometriosis. Thoracic endometriosis, which is also classified as extrapelvic endometriosis, manifests with four distinct forms: catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, or lung nodules. Catamenial pneumothorax is the most common clinical symptom of these; however, it is frequently neglected by clinicians and goes undiagnosed and untreated. As a result, it is critical to raise awareness of this medical condition among clinicians.

Case presentation

The authors present a case report of a 34-year-old woman of reproductive age who had recurrent episodes of spontaneous pneumothorax during menstruation and underwent treatment with thoracoscopic surgery as well as gynaecological hormonal drugs including oral progesterone and dienogest throughout this time. Based on her symptoms, a catamenial pneumothorax caused by thoracic endometriosis was suspected.

Clinical discussion

The clinical symptoms, pathogenesis, diagnosis, and treatment of Catamenial Pneumothorax are analyzed. Furthermore, the usage of gynaecological hormone medications in this condition has been discussed. The mechanisms of oral contraceptives and progestin-based medications are evaluated by comparing the patient's treatment process, highlighting their pros and cons.

Conclusions

Thoracoscopic surgery combined with postoperative gynaecological hormonal medications may be the most effective treatment for this issue. Several gynaecological hormonal medicines are available, each of which has its own set of pros and cons, and must be thoroughly evaluated as well as correctly tailored to the patient's specific circumstances to have a positive therapeutic outcome.

Catamenial Pneumothorax: A Rare Diagnosis Among Menstruating Women

Catamenial Pneumothorax is a rare condition often associated with endometriosis in menstruating women. Due to the rarity of this condition, its etiology is not well studied and, thus, effective treatment regimens have not been well established. We present a case of a 21-year-old female with no significant past medical history who developed recurrent episodes of spontaneous pneumothorax, chronologically associated with her menstrual cycle. This pattern is known as the sine qua non criteria and is one of the only established criteria in current literature for diagnosing catamenial pneumothorax. Our aim with this case report is to expand the current collection of published knowledge about this rare condition and to bring awareness so that those affected by catamenial pneumothorax can be diagnosed and treated more efficiently. Additional research on the pathophysiology of this disease needs to be done to aid in the development of effective treatment regimens.

Thoracic Endometriosis Syndrome (TES) in Martinique, a French West Indies Island

INTRODUCTION

Endometriosis is a female disease that affects 5-10% of women of childbearing age, with predominantly pelvic manifestations. It is currently declared as a public health priority in France. Thoracic endometriosis syndrome (TES) is the most common extra-pelvic manifestation.

OBJECTIVE

The objective of this study was to describe the epidemiological and clinical characteristics, and outcomes of patients with TES in Martinique.

PATIENTS AND METHODS

We performed a descriptive, retrospective study including all patients managed at the University Hospital of Martinique for TES between 1 January 2004 and 31 December 2020.

RESULTS

During the study period, we identified 479 cases of pneumothorax, of which 212 were women (44%). Sixty-three patients (30% of all female pneumothorax) were catamenial pneumothorax (CP) including 49 pneumothoraxes alone (78% of catamenial pneumothorax) and 14 hemopneumothorax (22% of catamenial pneumothorax). There were 71 cases of TES, including 49 pneumothoraxes (69%), 14 hemopneumothoraxes (20%) and 8 hemothorax (11%). The annual incidence of TES was 1.1 cases/100,000 inhabitants. The prevalence of TES was 1.2/1000 women aged from 15 to 45 years and the annual incidence of TES for this group was 6.9/100,000. The annual incidence of CP was 1 case/100,000 inhabitants. The average age at diagnosis was 36 ± 6 years. Eight patients (11%) had no prior diagnosis of pelvic endometriosis (PE). The mean age at pelvic endometriosis diagnosis was 29 ± 6 years. The mean time from symptom onset to diagnosis was 24 ± 50 weeks, and 53 ± 123 days from diagnosis to surgery. Thirty-two patients (47%) had prior abdominopelvic surgery. Seventeen patients (24%) presented other extra-pelvic localizations. When it came to management, 69/71 patients (97%) underwent surgery. Diaphragmatic nodules or perforations were found in 68/69 patients (98.5%). Histological confirmation was obtained in 55/65 patients who underwent resection (84.6%). Forty-four patients (62%) experienced recurrence. The mean time from the initial treatment to recurrence was 20 ± 33 months. The recurrence rate was 16/19 (84.2%) in patients who received medical therapy only, 11/17 (64.7%) in patients treated by surgery alone, and 17/31 (51.8%) in patients treated with surgery and medical therapy (p = 0.03).

CONCLUSIONS

We observed a very high incidence of TES in Martinique. The factors associated with this high incidence in this specific geographical area remain to be elucidated. The frequency of recurrence was lower in patients who received both hormone therapy and surgery.

A Rare Case of Catamenial Pneumothorax and a Review of the Current Literature

A 34-year-old female smoker, with a history of pelvic endometriosis, presented with initial symptoms of shortness of breath and a choking sensation. She was found to have a right pneumothorax on chest x-ray. Over the next eight months, she ultimately underwent three tube thoracostomies, two video-assisted thoracoscopic surgeries (VATS), wedge resection, and repeated pleurodesis due to pneumothorax recurrence. She was seen multiple times post-surgically with the focus of treatment being smoking cessation rather than contraceptive therapy, despite an early follow-up visit noting that the initial symptoms coincided with her menstruation. The purpose of this article is to bring attention to this rarely diagnosed condition. With added awareness and understanding of the underlying causes and available treatments, medical providers could likely spare many women from similar experiences and dramatically improve the quality of their lives.

Video‐assisted surgical diagnosis and pleural adhesion management in catamenial pneumothorax: A case and literature review

Catamenial pneumothorax is a rare primary spontaneous pneumothorax associated with the menstrual phase and is the most common manifestation of thoracic endometriosis syndrome. We report a case of a 32‐year‐old woman with a history of endometriosis who presented to the emergency ward with a chief complaint of dyspnea and right‐sided chest pain, and a chest X‐ray showed a right pneumothorax. Initial management was by placing a chest tube to expand the right lung. The patient underwent a video‐assisted thoracoscopy and talc pleurodesis, during which we found multiple perforations in the tendinous part of the diaphragm. A partial resection of the tendinous part of the diaphragm was done. Our review indicated that primary spontaneous pneumothorax in women should be suspected as catamenial pneumothorax due to thoracic endometriosis. The gold standard procedure for diagnosis and treatment is surgery. Hormonal therapy is an effective choice to prevent and reduce post‐operative recurrence.

Catamenial pneumothorax: Not only VATS diagnosis

Background

Catamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP.

Materials and methods

In this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy.

Results

Eight women (median age 36 years, range: 21-45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis.

Conclusions

In the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued.

[Mystery of endometriosis - catamenial pneumothorax]

The review is devoted to clinical picture, main theories of pathogenesis, traditional and innovative methods of diagnosis and surgical treatment of catamenial pneumothorax. Currently, clinicians prefer magnetic resonance imaging and thoracoscopy for diagnosis of this disease. Various researchers are actively searching for laboratory diagnostic methods that can confirm endometrioid nature of pneumothorax. Treatment and prevention of catamenial pneumothorax are a controversial issue depending both clinical picture and preferences of the attending physician. Currently, the majority of authors believe that hormonal therapy combined with diaphragm resection ensures optimal anti-relapse effect in patients with thoracic endometriosis.

Catamenial Pneumothorax in the Setting of a Recent Stroke

Catamenial pneumothorax is a unique condition associated with thoracic endometriosis. It often presents in females of reproductive age as a recurrent pneumothorax aligned with the menstrual cycle. We present a case of a young female diagnosed with catamenial pneumothorax within one year of experiencing a stroke. The clinical presentation related to the stroke allowed for a unique diagnostic process and management considerations. The patient was successfully treated with progesterone-based contraception in the setting of an estrogen contraindication.

Catamenial Pneumothorax as the First Expression of Thoracic Endometriosis Syndrome and Pelvic Endometriosis

Objective: The menstrual-related catamenial pneumothorax (CP) can be the first expression of thoracic endometriosis syndrome (TES), which is the presence of endometriotic lesions in the lungs and pleura, and pelvic endometriosis (PE). This study aims to analyze our experience with this specific correlation describing our multidisciplinary approach to CP. Methods: Hospital records of 32 women, operated for CP at our Department from January 2001 to December 2021 were reviewed. Surgical treatment consisted of videothoracoscopy and laparoscopy when indicated. Results: TES and PE were diagnosed in 13 (40.6%) and 12 (37.5%) women, respectively. The association of TES and PE was present in 11 cases (34%). Fifteen patients (46.9%) underwent laparoscopy, of which 11 concurrently with videothoracoscopy. Most of the patients affected had stage III–IV endometriosis (40.6%). All patients received hormonal therapy after surgery. Five patients with PE conceived spontaneously resulting in six live births. The mean follow-up was 117 ± 71 months (range 8–244). Pneumothorax recurrence occurred in six patients (18.8%). At present, all women are asymptomatic, with no sign of pneumothorax recurrence. Conclusions: CP might be the first expression of TES and/or PE. A multidisciplinary approach is advocated for optimal management of the disease.

[Catamenial pneumothorax]

Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of ectopic endometrial tissue in the chest cavity. The typical clinical manifestation is a spontaneous pneumothorax, which usually presents with chest pain, dyspnea, and/or cough. The diagnosis requires a high level of clinical suspicion and a complete gynecological history. Imaging studies can help with the diagnosis, although the gold standard is video-assisted thoracoscopic surgery (VATS). Surgical treatment in combination with at least 6 months of hormonal medical treatment has been shown to improve the prognosis and reduce the recurrence of this entity. We present the case of a 40-year-old patient with a history of pelvic endometriosis and multiple episodes of pneumothorax, who consulted at our institution for a new episode of spontaneous pneumothorax. A VATS was performed where nodules in the parietal pleura and diaphragmatic orifices were identified. In the postoperative period, she continued with hormonal treatment. At 6 months of follow-up, she reported improvement in pain and did not present new episodes of pneumothorax.

Multi-Loculated Catamenial Pneumothorax: A Rare Complication of Thoracic Endometriosis

The presence of endometrial tissue outside the uterine cavity is known as endometriosis. Catamenial pneumothorax (CP) is a recurrent spontaneous pneumothorax that occurs in women of childbearing age. Thoracic endometriosis is a rare clinical entity, and CP is the most common presentation. Imaging diagnosis is based on computed tomography (CT) scans and magnetic resonance imaging (MRI), detecting blood products in endometrial deposits. We report a case of right CP in a 37-year-old woman with chest pain and dyspnea 48 hours after the onset of menstruation. The pneumothorax was drained, continuous hormonal therapy was started, and she underwent video-assisted thoracoscopic surgery (VATS), which revealed multiple diaphragmatic fenestrations and a solitary nodular thickening in the diaphragmatic pleura (endometrial deposit). After pleurodesis, multiple CP recurred, and later underwent a total hysterectomy. CP is the most common form of thoracic endometriosis and should be suspected in women of childbearing age.

The management of women with thoracic endometriosis: a national survey of British gynaecological endoscopists

OBJECTIVES

This study evaluates current national opinions on screening, diagnosis, and management of thoracic endometriosis.

BACKGROUND

Thoracic endometriosis is a rare but serious condition with four main clinical presentations: pneumothorax, haemoptysis, haemothorax, and pulmonary nodules. There are no specialist centres in the United Kingdom despite growing patient desire for recognition, investigation, and treatment.

METHODS

We distributed a multiple-choice email survey to senior members of the British Society for Gynaecological Endoscopy. Descriptive statistics were used to present the results. Results: We received 67 responses from experienced clinicians having provided over 800 combined years of endometriosis patient care. The majority of respondents managed over 100 endometriosis patients annually, for more than five years. Over one third had never managed a patient with symptomatic thoracic endometriosis; just 9% had managed more than 30 cases over the course of their career. Screening varied by modality with only 4% of clinicians always taking a history of respiratory symptoms while 69% would always screen for diaphragmatic endometriosis during laparoscopy. The management of symptomatic thoracic endometriosis varied widely with the commonest treatment being surgery followed by hormonal therapies. Regarding management, 71% of respondents felt the team should comprise of four or more different specialists, and 56% believed care should be centralised either regionally or nationally.

CONCLUSIONS

Thoracic endometriosis is poorly screened for amongst clinicians with varied management lacking a common diagnostic or therapeutic pathway in the United Kingdom. Specialists expressed a preference for women to be managed in a large multidisciplinary team setting at a regional or national level.

Cyclical Hemoptysis and Pelvic Pain in a Young Female: A Sign of Thoracic Endometriosis Syndrome

Distant autoimplantation of endometrial implants presents with signs and symptoms specific to the affected site. The constellation of cyclical hemoptysis, pleuritic chest pain, dyspnea, or cough in the right gynaecologic setting should raise concern for thoracic endometriosis syndrome (TES). Although extra-pelvic implications of endometriosis are well known, TES is exceedingly rare. We present an unusual case of aggressive TES that re-emerged after a period of latency despite suppressive therapy, making the case for future studies to establish surveillance schedules and advanced therapies. As these implants become sizable, they require a combination of medical and surgical therapies often with psychological support. This case illustrates the importance of prompt diagnosis and a multidisciplinary approach to TES.

Extra-pelvic endometriosis: A review

Background

Extra‐pelvic endometriosis is a rare type of endometriosis, which occurs in a distant site from gynecological organs. The diagnosis of extra‐pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis. The main objective of this review was to characterize abdominal wall endometriosis (AWE) and thoracic endometriosis (TE).

Methods

The authors performed a literature search to provide an overview of AWE and TE, which are the major types of extra‐pelvic endometriosis.

Main findings

Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin. Surgical treatment appeared to be effective for AWE. Case reports indicated that the diagnosis and treatment of catamenial pneumothorax or endometriosis‐related pneumothorax (CP/ERP) are challenging, and a combination of surgery and postoperative hormonal therapy is essential. Further, catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.

Conclusion

Evidence‐based approaches to diagnosis and treatment of extra‐pelvic endometriosis remain immature given the low prevalence and limited quality of research available in the literature. To gain a better understanding of extra‐pelvic endometriosis, it would be advisable to develop a registry involving a multidisciplinary collaboration with gynecologists, general surgeons, and thoracic surgeons.

Catamenial pneumothorax in Ghana: case report and literature review

Catamenial pneumothorax is a rare condition that is often misdiagnosed. It is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Etiology is unknown but could be linked to endometriosis. Pleural ablation via thoracoscopy and hormonal therapy are mainstay treatment options to avoid recurrence. We present a case of a young adult female who experienced gradual painless abdominal distention that resolved spontaneously after each menses twelve years post menarche. She was first seen at a peripheral facility where laparotomy undertaken was negative for suspected ectopic pregnancy. However, a bleeding omental mass was noticed and a biopsy taken. Histopathology reported it as an endometriotic tissue. The patient subsequently had recurrent cyclical chest pains and breathlessness leading to the diagnosis of catamenial pneumothorax. She had chemical pleurodesis done with sterile talc after chest tube drainage and has been well over two years now.

Circulating Endometrial Cells in Women With Spontaneous Pneumothorax

BACKGROUND

The occurrence of catamenial pneumothorax (CP) is rare, and the awareness of this diagnosis among physicians is insufficient. CP is highly correlated with pelvic endometriosis and remains the most common form of thoracic endometriosis syndrome. Circulating endometrial cells (CECs) have been previously detected in patients with pelvic endometriosis. Could CECs bring new insights into pneumothorax management?

METHODS

This study aims to describe the occurrence and molecular characteristics of CECs in women with spontaneous pneumothorax (SP) (N = 20) with high suspicion of its catamenial character. CECs were enriched from peripheral blood by size-based separation (MetaCell). In addition to cytomorphology, gene expression profiling of captured cells was performed for 24 endometriosis-associated genes.

RESULTS

CECs were present in all 20 patients with SP. Enriched CECs exhibited four character features: epithelial, stem cell-like, stroma-like, and glandular. However, not all of them were present in every sampling. Gene expression profiling revealed two distinct phenotypes of CECs in SP and/or CP: one of them refers to the diaphragm openings syndrome and the other to endometrial tissue pleural implantations. Comparisons of the gene expression profiles of CECs in pneumothorax (CECs-SP group) with CECs in pelvic endometriosis (CECs-non-SP group) have revealed significantly higher expression of HER2 in the CECs-SP group compared with the CECs-non-SP group.

CONCLUSIONS

This proof-of-concept study demonstrates successful isolation and characterization of CECs in patients with SP. Identification of CECs in SP could alert endometriosis involvement and help early referral to gynecologic consultation for further examination and treatment.

[Pneumothorax catamenial: results of 18 cases operas]

L'objectif de notre étude était de proposer une approche thérapeutique du pneumothorax cataménial à partir des résultats de nos 18 cas opérés. Il s'agit d'une étude rétrospective de Janvier 1994 à Décembre 2016 qui a concerné 18 patientes âgées en moyenne de 32,2 ans opérées d'un pneumothorax cataménial droit (16 cas) et bilatéral (2 cas). Les patientes ont été réparties en 3 groupes en fonction de l'évolution dans le temps de notre attitude chirurgicale: le groupe 1 (G1) de janvier 1994 à juin 2006, le groupe 2 (G2) de juillet 2006 à février 2008 et le groupe 3(G3) de mars 2008 à décembre 2016, ces groupes contenaient respectivement 5, 2 et 11 patientes. Ces patientes toutes nullipares avaient une dysménorrhée depuis la puberté associée dans 11 cas à des douleurs thoraciques cataméniales. La radiographie standard du thorax a été systématique et complétée dans 8 cas par un scanner thoracique qui a objectivé en plus du pneumothorax, des bulles apicales (5 cas). L'exploration par mini thoracotomie postéro-latérale (16 cas) et par vidéothoracoscopie (2 cas de G3) a retrouvé des fenestrations diaphragmatiques (18 cas) et des bulles (5 cas). La biopsie des lésions et la résection des bulles a été systématique. Vis-à-vis des fenestrations diaphragmatiques, la chirurgie a consisté dans le groupe 1 en une résection-suture avec abrasion pleurale, dans le groupe 2 une couverture par un patch de Gore-tex avec abrasion pleurale et dans le groupe 3 une couverture par un patch avec talcage pleural. Une hormonothérapie (triptoreline) de 6 mois a été prescrite à chaque patiente en postopératoire pour suspendre les menstrues. Le résultat de la chirurgie a été apprécié sur la base de la survenue ou non d'une récidive du pneumothorax à la reprise des menstrues. La mortalité a été nulle. Le séjour hospitalier post opératoire moyen était de 9,32 jours. Les examens anatomopathologiques ont confirmé l'endométriose thoracique dans 9 cas. Après un suivi moyen de 5,3 ans, le résultat était bon chez 12 patientes (3/5 de G1, 1/2 de G2 et 8/11 de G3), 3 patientes de G3 ont continué de présenter des épisodes de dyspnée minime au début de quelques menstrues sans récidive radiologique, 3 patientes (2 de G1 et 1 de G2) ont récidivé et ont fait l'objet de reprise chirurgicale. En cas de pneumothorax cataménial avec fenestrations diaphragmatiques, nous proposons une phrénoplastie de recouvrement au patch associée à un talcage pleural et une hormonothérapie complémentaire concomitante de 6 mois.

Left-sided Catamenial Pneumothorax: A Rare Clinical Entity

Catamenial pneumothorax (CP) is an extremely rare pulmonary pathology seen in women of reproductive age, typically occurring within 72 hours from the onset of menstrual bleeding. Multiple theories have been proposed to explain the etiopathogenesis of CP; however, the exact underlying mechanism remains elusive. More than 90% of reported cases in the literature describe a right-sided presentation of pneumothorax. In this case report, we describe a rare left-sided presentation of CP and discuss the current literature on underlying etiopathogenesis, diagnostics, and available therapeutic modalities for managing this rare clinical entity.

Refractory thoracic endometriosis syndrome with bilateral hemothorax

Thoracic endometriosis syndrome (TES) is a rare disorder presenting with catamenial pneumothorax, hemothorax, hemoptysis or pulmonary nodules. Bilateral involvement is uncommon, and only a very few cases have been reported in the literature. We report a case of bilateral catamenial hemothorax in a patient with recurrent thoracic endometriosis. Despite multiple surgical interventions, the patient continued to develop hemopneumothorax coinciding with menses. Remission was finally achieved with the addition of gonadotropin-releasing hormone agonist, highlighting the effectiveness of postoperative adjuvant hormone therapy and supporting a combined surgical and medical approach in the treatment of TES in patients who desire future fertility.

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.

Catamenial pneumothorax - a review of the literature

Catamenial pneumothorax should be defined as recurrent accumulation of air in the pleural cavity in reproductive-age women without concomitant respiratory diseases. The sine qua non criterion is the occurrence of the pneumothorax in the period of 72 hours before or after the menses. Additional criteria include characteristic pleural lesions, right-sided occurrence, and coexistence of endometriosis. There are no radiological or pathological conditions allowing an exact confirmation of catamenial pneumothorax. In the case of catamenial pneumothorax, treatment failure most commonly consists in disease recurrence. It may occur even as late as several years after the initial treatment. The recurrence rate in patients undergoing surgery ranges from 8% to 40%. Finding and resecting the visible pleural lesions is of key importance during surgical treatment. Reconstruction of the diaphragm must be performed in every patient in whom diaphragmatic perforations are found. Hormonal therapy seems to be effective in sustaining the effects of surgical treatment.

Left-Sided Catamenial Pneumothorax with Thoracic Endometriosis and Bullae in the Alveolar Wall

Catamenial pneumothorax (CP) is generally caused by intraperitoneal air leaking from the uterus into the thoracic cavity via a defect in the endometrial tissue of the diaphragm and is usually detected in the right thorax. We report a case of left-sided CP caused by endometriosis in the visceral pleura and with no abnormal findings in the diaphragm. A 33-year-old female patient presented at the end of a course of low-dose contraceptive pills for pelvic endometriosis, with spontaneous pneumothorax in the left chest. Chest CT revealed a bulla in the left upper lung lobe. The patient underwent partial resection of the lung. Immunohistochemistry confirmed the presence of endometrial stromal tissue in the visceral pleura and confirmed this as the cause of pneumothorax since there were no observable abnormalities in the diaphragm. This case suggests that immunohistochemical examination of patients with spontaneous pneumothorax can detect alternative endometrial lesions.

Two Young Women with Left-sided Pneumothorax Due to Thoracic Endometriosis

Pneumothorax associated with thoracic endometriosis (TE) generally occurs in women around 30 years old and it usually affects the right pleural cavity. We herein report two cases of TE associated with left-sided pneumothorax in young women. The prevalence of TE in younger patients may be underestimated if these cases are treated as spontaneous pneumothorax. Pneumothorax occurring in younger patients has not been reported to show laterality. TE-related or catamenial pneumothorax in young women must therefore represent a different clinical entity from the condition seen in older patients.

Surgical treatment of catamenial pneumothorax: Report of three cases

Catamenial pneumothorax (CP) is a rare entity of spontaneous, recurring pneumothorax in females. Although it has been known to be associated with thoracic endometriosis, varying clinical course and the lack of consistent intraoperative findings have led to conflicting etiological theories. We herein discuss the etiology, clinical course, and surgical treatment of three patients with CP. Three females (aged 40 years, 28 years, and 34 years) had recurrent right-sided spontaneous pneumothoraces that coincided with their menses. They had undergone video-assisted thoracoscopic surgery (VATS) previously. Blueberry spots in the right diaphragm were detected in all three cases. Two patients had recurrence, postoperatively. The other patient, who received luteinizing hormone-releasing hormone analog therapy for an abdominal endometriosis in the perioperative period and postoperative chemical pleurodesis to prevent recurrence, has been free of recurrence for 15 months, postoperatively. However, pelvic endometriosis was detected in this patient only. Therefore, CP should be suspected in ovulating females with spontaneous pneumothorax, even in the absence of any symptoms associated with pelvic endometriosis. In addition, while performing VATS, careful inspection of the diaphragmatic surface is important. In complicated cases, hormonal suppression therapy and chemical pleurodesis might also be helpful adjunct modalities.

A case of multisystem endometriosis

Catamenial pneumothorax is a rare complication secondary to pleural endometriosis. We present a case of a 37-year-old-female with a history of recurrent pneumothoraces with an associated temporal relationship to the onset of her menses. In addition to her recurrent pneumothoraces, on further evaluation, she was found to have multiple nodular masses within the omentum. A thoracoscopic biopsy was subsequently performed, which showed endometrial implants within the pleural space and within the omental cavity. The radiological features and pathogenesis of this rare disease are reviewed and discussed with reference to relevant literature.

Immunohistochemical analysis of thoracic endometriosis

Thoracic endometriosis is a rare disease responsible for catamenial pneumothorax. The immunohistochemical features of thoracic endometriosis are not well understood. An immunohistochemical examination of 84 diaphragmatic specimens of catamenial pneumothorax using antibodies against estrogen receptor (ER), progesterone receptor (PgR), CD10 and smooth muscle actin (SMA) was conducted. The endometrial tissue was small, and focally located around the chasm of the tendon on the side of the thoracic cavity. Endometrial stroma were detected in 84/84 (100%) of the specimens, endometrial glands were detected in 21/84 (25%) and smooth muscle was detected in 1/84 (1.2%). The endometrial stroma exhibited positive staining for ER in 74/84 (88.1%) of the specimens, PgR in 84/84 (100%), CD10 in 74/84 (88.1%) and SMA in 46/84 (54.8%). Because thoracic endometriosis is small in size, and only 25% of the resected tissue specimens were accompanied with the endometrial gland, an immunohistochemical analysis can be useful for their detection. The fact that over half of the thoracic endometrial stroma showed positive staining for SMA, and the existence of thoracic endometriosis accompanied by smooth muscle, indicated that some part of the thoracic endometriosis may have the ability to differentiate into smooth muscle, although further studies are needed to confirm this hypothesis.

Catamenial pneumothorax associated with multiple diaphragmatic perforations and pneumoperitoneum in a reproductive woman

Catamenial pneumothorax (CP) is considered to be an extremely rare entity, characterized by recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses, usually in the right-side thorax cavity in women of reproductive age.The etiology remains obscure. We report a rare case of CP complicated with multiple diaphragmatic perforations as the only thoracoscopy finding, and also with right-side isolated pneumoperitoneum confirmed by a chest X-ray. This case strongly supports the hypothesis that CP may be caused by the air through the perforations of the diaphragm.

Catamenial pneumothorax: surgical repair of the diaphragm and hormone treatment

Catamenial pneumothorax is defined as spontaneous pneumothoraces occurring within 72 h before or after onset of menstruation. It is rare but clinical index of suspicion should be high in ovulating women with spontaneous pneumothoraces. The mechanism is unclear but is thought to involve pre-existing or acquired diaphragmatic defects and endometrial implants. Traditional therapy involving hormonal treatment or surgical pleurodesis alone is associated with high rates of recurrence. A series of four patients with catamenial pneumothorax managed at our institution is presented to highlight the condition to various surgical specialties to whom it may present, and to emphasise the importance of both surgical and hormonal interventions in preventing recurrence. Each patient underwent video-assisted thoracoscopic inspection of the diaphragm, mechanical pleurodesis and, most importantly, repair of diaphragmatic defects with an artificial mesh. Surgical treatment was strictly followed by a course of gonadotrophin-releasing hormone analogue therapy in three patients, with no recurrence to date (longest follow-up 45 months). The fourth patient suffered a postoperative recurrence when hormonal treatment was delayed for 6 weeks, stressing the importance of hormonal treatment in conjunction with surgery.