Abstract
Introduction Catamenial pneumothorax is a rare condition characterized by menstruation-associated pneumothorax, and is typically linked with intrathoracic endometriosis. It is often a recurrent condition necessitating coordinated surgical and medical management. We present a case of serial catamenial pneumothoraces which highlights the need for maintaining a high clinical suspicion of this pathology and further research on optimal treatment. Case Description A 42-year-old woman presented with dyspnea one day after undergoing a cosmetic surgery under general anesthesia. Imaging demonstrated a right-sided pneumothorax for which she underwent pigtail chest tube placement with subsequent resolution (Figure 1). Over the following year, she experienced three additional right-sided pneumothoraces. During that period, she was told she may have endometriosis given her history of dysmenorrhea, and noted her pneumothoraces always occurred during menstruation. She underwent multiple video-assisted thoracoscopic surgery (VATS) with mechanical and chemical pleurodeses, partial pleurectomy, and wedge resection of the lung. No endometrial lesions were visualized intraoperatively , however pathology from the wedge resection showed endometrial glands. Despite initiation of leuprolide for prevention, she recently developed a recurrent pneumothorax with tension physiology, requiring repeat VATS with total pleurectomy and redo-pleurodesis. She has since remained on leuprolide without recurrence. Discussion The essential criterion for diagnosis of catamenial pneumothorax is the temporal relationship with menses, typically occurring within 72 hours before or after menstruation. It is often right-sided with associated intrathoracic endometriosis. VATS is the primary method of diagnosis and treatment, though there is no clear consensus on the optimal method of pleurodesis or extent of bleb resection and diaphragmatic intervention. Our patient met the sine qua non criteria as her pneumothoraces occurred during menstruation. Intrathoracic endometrial implants were not confirmed until her fourth VATS, highlighting the need for high clinical suspicion for catamenial pneumothorax and consideration of earlier therapy for endometriosis in young, female patients with recurrent pneumothoraces. She also had recurrent diaphragmatic defects which were repaired with each thoracoscopy. This suggests intrathoracic endometriosis may be associated with damage to the diaphragm, though the exact pathophysiology of this process remains unclear. Whether closure of diaphragmatic defects can prevent recurrent catamenial pneumothorax is a source of ongoing research. Despite repeated surgical intervention and hormonal suppressive therapy, our patient continued to have recurrent pneumothoraces. In refractory cases such as this, surgically-induced menopause with hysterectomy and bilateral salpingo-oophorectomy has been used with mixed success, emphasizing the need for further study in this population. This abstract is funded by: None