Chest
Volume 124, Issue 3, September 2003, Pages 1004-1008
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Clinical Investigations
MISCELLANEOUS
Catamenial Pneumothorax: A Prospective Study

https://doi.org/10.1378/chest.124.3.1004Get rights and content

Objectives:

To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms.

Design:

A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded.

Setting:

A university hospital.

Methods:

At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used.

Results:

In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found.

Conclusions:

Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

Section snippets

Patients and Methods

All women of reproductive age who had been referred to our center over an 18-month period (ie, July 2000 to December 2001) for surgical treatment of an SP were included in the study. Patients presenting with pneumothorax secondary to a known underlying lung disease were excluded. Indications for referral to our center were as follows: recurrent pneumothorax; persistent (ie, > 5 days) air leak and/or pneumothorax despite adequate chest drainage; and failure of previous surgery.

In the study

Results

In 8 of the 32 women (25%), the catamenial character of pneumothorax was recognized on the basis of clinical history. Their mean age was 32.5 years (age range, 19 to 45 years). Two women had a history of secondary infertility (defined as a failure to conceive following 1 year of unprotected sexual intercourse after having had a child), whereas in no case was pelvic endometriosis known preoperatively (Table 1). In all eight women, the pneumothorax was recurrent (range, 1 to 4 previous episodes)

Discussion

CP involves women of reproductive age and occurs within 72 h from the onset of menstruation. The right side is involved in the great majority of cases (95%), in a recurrent manner.1,6 Several hypotheses about its pathogenesis have been raised including the following: (1) spontaneous rupture of blebs; (2) alveolar rupture caused by prostaglandin-induced bronchiolar constriction; (3) sloughing of endometrial implants of visceral pleura with subsequent air leak; and (4) in the absence of the

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