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The lung function starts with the first moment of life and ceases with death.

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In an intermediate period in females life journey, hormonal changes start with the menarche and ends by the menopause.

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It seems that the lungs are affected by such biological feminine events.

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It had been observed through centuries by many women that some respiratory symptoms and even distinct clinical morbidities associate with their cycles.

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Emerging understanding of the role of sex hormones in respiratory health and disease represents a major advance in personalized treatment planning for menses associated respiratory aliments.

Early menses lead to asthma, poor lung function Women who start menstruating early are at a high risk of developing asthma and poor lung function.

The study suggests that women with early menarche have lower lung function and more asthma risk in adulthood reaffirming the role of hormonal and metabolic factors in women's respiratory health.

American Journal of Respiratory and Critical Care Medicine, August 2010

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Respiratory symptoms during menstruation

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Catamenial lung disorders

Women with asthma experience cyclic changes in airflow as well as gas transfer and membrane diffusing capacity supportive of a hormonal effect on lung function.

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SOB – TIC – Chest pain

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Exacerbation / deterioration of already present lung diseases

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Pulmonary endometriosis

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Endometrial tissue is located in the pleura, lungs bronchi and or the diaphragm Endometrial cells at these sites are affected by the hormonal changes of the menstrual cycle with concomitant active bleeding The clinical presentations include : Catamenial pneumothorax 80% Catamenial haemothorax Catamenial haemoptysis Lung nodules 14% 5% rare Thoracic endometrial syndrome was first described by Barnes J in 1953 in J Obst. Gyncolog. Br. Emp : Endometriosis of the pleura and ovaries 60(6) : 823-24

Between 2:10 % of females at reproductive age world wide have Endometriosis In USA between 5.5:6 Million females suffer from Endometriosis

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Baron Carl von Rokitansky 1804 – 1878

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Austerian physician, pathologist, humanist, philosopher and liberal politician

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1 st to describe systemic Endometriosis

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Open communication between the atmosphere and peritoneal cavity during menstruation can allow air to migrate from the abdomen via diaphragmatic fenestrations into the pleura. (cure achieved by tubal and fenestration obliteration)

2. Endometrial implants over the diaphragm induce the defects

3. PGF2

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excessively released during menstruation causes bronchiolar and alveolar constriction and rupture PGF2

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4. Lymphatic & or haematogenous embolization endometrial tissue from the uterine vessels Women with bronchopulmonary endometriosis tend to have a history of uterine manipulation or trauma (e.g., hysteroscopy, dilation and curettage). This supports the lymphovascular embolization theory, whereas those with pleural disease most often have a history of pelvic endometriosis.

of

Concerning the etiology of CPT, it is hypothesized that transgression or erosion of the diaphragm as an anatomic boundary by endometriotic tissue represents the central pathophysiologic mechanism of CPT . This can be stimulated through a heat-stable factor from the peritoneal fluid, together with an increased proteolytic capacity.

Endometriotic cells can demonstrate a higher maneuverability with an enhanced potential for local invasiveness

Catamenial Pneumothorax

Lillington and associates coined the term catamenial pneumothorax. They proposed a model in which the expansion of intraparenchymal subpleural endometriotic tissue during menses would cause a check valve airway obstruction, eventually leading to alveolar rupture.

Lillington GA, Mitchell SP, Wood GA. Catamenial pneumothorax. JAMA. Mar 6 1972;219(10):1328-1332.

Clinical picture of catamenial pneumothorax

Patients with CP present with symptoms of spontaneous pneumothorax that are usually nonspecific such as : 1. Pleurisy, 2. Cough, 3. Shortness of breath 4. Peri-scapular or radiating neck pain due to diaphragmatic irritation. In most cases, symptoms are mild to moderate while severe presentations are rare

Alifano M, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac Surg. Feb 2006;81(2):761-769.

Catamenial Pneumothorax Endoscopy

In the largest review of CP cases, more than 50% (52.1%) of patients with CP assessed with VATS were diagnosed as having thoracic endometriosis. Diaphragmatic abnormalities (fenestrations or endometriosis, alone or combined) are the most commonly described lesions (38.8%), followed by endometriosis of the visceral pleura (29.6%). In the remainder of cases, discrete lesions, such as bullae, blebs, and scarring (23.1%), or no findings (8.5%) are noted.

Korom S, Canyurt H, Missbach A, et al. Catamenial pneumothorax revisited: clinical approach and systematic review of the literature. J Thorac Cardiovasc Surg. Oct 2004;128(4):502-508.

Catamenial Pneumothorax Endoscopy

Diaphragmatic fenestrations range from a few millimeters to 2 cm. Endometrial deposits in both the diaphragm and pleura have a similar appearance and range from a few millimeters to 1 cm. Their color ranges from violet to brown, depending on the day of menstrual cycle.

Performance of a combined VATS and laparoscopy procedure in a single session is another diagnostic approach.

Alifano M, Venissac N, Mouroux J. Recurrent pneumothorax associated with thoracic endometriosis. Surg Endosc. Jul 2000;14(7):680.

Catamenial haemothorax

CHT is an uncommon manifestation of TES accounting for approximately 14% of cases. As with CP, CHt is almost always unilateral and right sided, although left-sided hemothorax has been reported. Again, symptoms are nonspecific and include pleuritic pain, shortness of breath, and cough. The presence of bloody effusion is variable. Computed tomography (CT) of the chest may show multiloculated effusions, nodular lesions of the pleura, or bulky pleural masses.

Catamenial haemoptysis and lung nodules

CH and lung nodules are both clinical entities of bronchopulmonary TES and are very rare manifestations. Hemoptysis is a quite variable manifestation, with neither massive hemoptysis nor deaths being described so far. An association with menses may not always be appreciated, and diagnostic delays of up to 4 years from the onset of symptoms have been reported. CH and lung nodules are interrelated entities. Thus, patients who present with CH frequently have associated lung nodules on imaging studies and vice versa.

CP, CHt, CH, and lung nodules represent the main clinical entities in TES. However, they are not the only manifestations of TES, other manifestations include catamenial phrenic nerve irritation causing a catamenial pain-only syndrome, namely cyclic shoulder, neck, epigastric, or right upper quadrant pain

Imaging in Thoracic Endometriosis

Imaging in Thoracic Endometriosis

X ray chest and preferably CT scan can identify menstrual associated pulmonary and bronchial infiltrates and confirm both their amelioration by the end of the cycle and their recurrence with each following cycle. Thus performing imaging studies and bronchoscopy during menses assist in the diagnosis of pleural and bronchopulmonary disease. i.e

Repeated imaging studies or bronchoscopy during midcycle typically documents the disappearance of the previously reported findings, thus strengthening the clinical suspicion.

Hope-Gill B, Prathibha BV. Catamenial haemoptysis and clomiphene citrate therapy. Thorax. Jan 2003;58(1):89-90.

Treatment of Catamenial Pneumothorax

VATS is the gold standard modality for both the definitive diagnosis and surgical treatment of CP.

Alifano M, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac Surg. Feb 2006;81(2):761-769.

Tissue diagnosis of respiratory endometriosis can be achieved by: 1. FOB forceps biopsy 2. TBNA 3. US/CT guided lung biopsy 4. Surgical lung biopsy

Medical Treatment

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Danazol 2.

Contraceptive pills 3.

GnRH analogues Recurrent rate at 1 y : 50 – 60 %

Medical Treatment often serves as a diagnostic tool with the +ve response paving the way for more effective surgical treatment

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Thoacentesis and chest tube 2.

VATS +/- laparoscopy : with complete inspection of the pleura and both diaphragmatic surfaces for fenestrations and nodules 3.

Small, few mms, endometrial nodules can be fulgurated by diathermy or CO2 laser 4.

Large nodules should be excised from the pleura and the lungs even if combined with necessary parenchymal resection : segmentectomy or lobectomy

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Large diaphragmatic fenestrations can be sutured +/- mesh coverage 6.

Pleurodesis in combination with any of the previous procedures adds to the efficiency of management 7.

Based on the recurrence rate estimates of pervious modalities combined surgical and subsequent hormonal treatment is recommended

TES is a challenging clinical entity. A high index of clinical suspicion is of paramount importance as both diagnosis and treatment may often be delayed for years.

Endometriosis has variable and often subtle clinical and macroscopic features that include Catamenial pneumothorax Catamenial haemothorax Catamenial haemoptysis Lung nodules

A multidisciplinary approach by thoracic and gynecologic surgical teams carries the highest chance of making an accurate diagnosis and providing the appropriate treatment strategies.