Catamenial pneumothorax revisited: Clinical approach and systematic review of the literature
Open accessAbstract
Background Catamenial pneumothorax is a rare entity of spontaneous, recurring pneumothorax in women. It has been associated with thoracic endometriosis, yet varying clinical courses and the lack of consistent intraoperative findings have led to conflicting etiologic theories.Methods We discuss etiology, clinical course, and surgical treatment of 3 women with catamenial pneumothorax. In addition, the world literature since the first description is reviewed.Results Three women (31, 32, and 39 years old) had recurrent, menses-associated, right-sided spontaneous pneumothoraces. They had undergone video-assisted thoracoscopic surgery previously, with various unsuccessful procedures. Finally, with video-assisted thoracoscopic surgery multiple small perforations in the tendinous part of the right diaphragm with adjacent endometrial implants were detected. After plication of the involved area, 2 patients have been free of recurrence for 22 and 13 months, respectively. Laparoscopic evaluation in 1 woman with a further recurrence revealed asymptomatic pelvic endometriosis. This patient has been free of recurrence since initiation of luteinizing hormone-releasing hormone analog therapy for 17 months. In a review of 229 cases of catamenial pneumothorax in the literature, adequate information was given for 195 patients (85.2%). One hundred fifty-four (79%) were treated surgically, with detailed findings reported for 140 (91%). Thoracic endometriosis was diagnosed in 73 patients (52.1%), and 54 (38.8%) showed diaphragmatic lesions. Pleurodesis, with or without diaphragmatic repair or wedge resection, was performed in 81.7% of the cases.Conclusions Catamenial pneumothorax may be suspected in ovulating women with spontaneous pneumothorax, even in the absence of symptoms associated with pelvic endometriosis. During video-assisted thoracoscopic surgery, inspection of the diaphragmatic surface is paramount. Plication of the involved area alone can be successful. In complicated cases, hormonal suppression therapy is a helpful adjunct.
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Among patients diagnosed with TES, 50%-84% have concomitant pelvic endometriosis.
“Among patients diagnosed with TES, 50%–84% have concomitant pelvic endometriosis.12”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
Endometriosis is nine times more likely to occur on the right hemidiaphragm than on the left.
“This theory is supported by the observation that endometriosis is nine times more likely to occur on the right hemidiaphragm than on the left.8,12,17”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
In the largest review of patients with catamenial pneumothorax, 52.1% were diagnosed with thoracic endometriosis based on VATS findings.
“In the largest review of patients with catamenial pneumothorax, 52.1% were diagnosed with thoracic endometriosis based on VATS findings.12”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
VATS is the gold standard diagnosis and treatment for TES, most notably for catamenial pneumothorax.
“VATS is the gold standard diagnosis and treatment for TES, most notably for catamenial pneumothorax.12,16,45,51,53”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
Catamenial pneumothorax is the most common manifestation of diaphragmatic endometriosis in cases reported in the literature.
“Catamenial pneumothorax is the most common manifestation of diaphragmatic endometriosis in cases reported in the literature [44]”
Women with thoracic endometriosis present at an older mean age (35 y) than patients with only pelvic endometriosis (25-30 y).
“When compared with a mean age at presentation of 25 to 30 y in patients with only pelvic endometriosis, the age at presentation of patients with thoracic endometriosis is increased to a mean of 35 y.8,12”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
In 23.1% of explored TES cases, blebs and bullae were the only lesions identified; in 8.5%, pathologic findings were absent.
“This explanation is of particular importance in 23.1% of explored cases of TES in which blebs and bullae were the only lesions identified and 8.5% of cases in which pathologic findings were absent.12,31”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
The right hemithorax is involved in up to 92% of cases, the left in 5%, and bilateral involvement in 3%.
“The right hemithorax is involved in up to 92% of cases, with 5% of cases involving the left hemithorax and 3% experiencing bilateral involvement.12”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
The most commonly reported intraoperative findings in catamenial pneumothorax include diaphragmatic lesions (38.8%), endometriosis of the visceral pleura (29.6%), discrete lesions such as bullae, blebs, or scarring (23.1%), and no findings (8.5%).
“The most commonly reported intraoperative findings included diaphragmatic lesions (38.8%); endometriosis of the visceral pleura (29.6%); discrete lesions such as bullae, blebs, or scarring (23.1%); and no findings (8.5%).12”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
GnRH analogs are highly effective in suppressing the hypothalamic-pituitary-ovarian axis and the growth of endometrial-like cells, but can be associated with menopausal-like symptoms and osteoporosis.
“Typically, gonadotropin-releasing hormone (GnRH) analogs are used first-line, as they are highly effective in suppressing the hypothalamic-pituitary-ovarian axis and the growth of endometrial-like cells, but they can be associated with the development of menopausal-like symptoms and osteoporosis.8,12,48,52,53”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [12]
Several studies have suggested that combined surgical and postoperative hormonal therapy reduces recurrence.
“Several studies have suggested the utility of combined surgical and postoperative hormonal therapy to reduce recurrence.”
From Extra-pelvic endometriosis: a review. (2020) · cites this paper as [75]
CP has occurred overwhelmingly at the right side, which is over 90% of CP cases.
“CP has occurred overwhelmingly at the right side, which is over 90% of CP cases.”
From Extra-pelvic endometriosis: a review. (2020) · cites this paper as [75]
50%-84% of patients with CP have concomitant pelvic endometriosis.
“50%‐84% of patients with CP have concomitant pelvic endometriosis.”
From Extra-pelvic endometriosis: a review. (2020) · cites this paper as [75]
It can take multiple exacerbations to receive a correct diagnosis of thoracic endometriosis syndrome.
“It can take multiple exacerbations to receive a correct diagnosis [ 10 , 27 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [27]
Video-assisted thoracoscopy is the surgery of choice in patients with catamenial pneumothorax, as it is diagnostic and therapeutic.
“Video-assisted thoracoscopy is the surgery of choice in patients with catamenial pneumothorax, as it is diagnostic and therapeutic [ 14 , 27 , 58 , 66 , 67 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [27]
Scheduling surgery within the first few days of menses allows increased diagnostic yield.
“The patient should have surgery scheduled within the first few days of menses to allow increased diagnostic yield [ 27 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [27]
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- Authors
- Korom, S., Canyurt, H., Missbach, A., Schneiter, D., Kurrer, M. O., Haller, U., Keller, P. J., Furrer, M., & Weder, W.
- Affiliations
- University Hospital Zurich (CH)
- Kantonsspital Graubünden (CH)
- Corresponding author
- Weder, Walter
- Venue
- The Journal of Thoracic and Cardiovascular Surgery
- Publisher
- Elsevier BV
- Published
- 2004-10
- Volume
- 128
- Issue
- 4
- Pages
- 502-508
- ISSN
- 0022-5223 (ISSN-L)
- OpenAlex
- W2041118863
- Cited by
- 239
- References
- 111
- Citations by year
- 2026: 10 · 2025: 13 · 2024: 6 · 2023: 14 · 2022: 10 · 2021: 16 · 2020: 10 · 2019: 21 · 2018: 12 · 2017: 10 · 2016: 9 · 2015: 9 · 2014: 8 · 2013: 13 · 2012: 6
- FWCI
- 1.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Thoracic and Cardiovascular Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Pleural and Pulmonary Diseases
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Pneumothorax, Barotrauma, Emphysema
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Keywords
- catamenial pneumothorax, spontaneous pneumothorax, thoracic endometriosis, diaphragmatic endometriosis, video-assisted thoracoscopic surgery, pleurodesis, diaphragmatic plication, luteinizing hormone-releasing hormone analogue, pelvic endometriosis, recurrent pneumothorax
- MeSH terms
- Adult, Endometriosis, Female, Humans, Menstruation, Pneumothorax, Pleurodesis, Thoracic Surgery, Video-Assisted
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