{"paper_id":"5b6bf4f3-c6db-4eec-8a52-b49749f216dd","body_text":"Arbat et al. \nThe Egyptian Journal of Bronchology           (2024) 18:50  \nhttps://doi.org/10.1186/s43168-024-00298-7\nCASE REPORT Open Access\n© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nThe Egyptian Journal\nof Bronchology\nRecurrent catamenial hemoptysis: diagnostic \nchallenges and management strategies—a case \nreport\nAshok P . Arbat1*, Gauri Gadge1, Sweta R. Chourasia1, Parimal S. Deshpande1 and Swapnil I. Bakamwar1 \nAbstract \nCatamenial hemoptysis (CH) is a rare, known disease for which diagnosis is crucial and treatment is indefinite. In \nthis case report, CH was identified 2 years ago while taking medical history of the patient. It has disclosed hemop-\ntysis at night with breathlessness that was concurrent with her menses every month for the past 6 months. A series \nof radiological tests followed by a bronchoscopic examination during menses confirmed the diagnosis. A complex \nfluid-filled cystic lesion with few air foci in the right lower lobe superior segment with ground glass opacity was seen \nby a CT scan test. Subsequent bronchoscopy examination showed an active bleeding site at the right lower lobe \nsuperior segment. The bronchial wash tests were negative for microbial infections as well as for malignancies. Bron-\nchial artery embolization (BAE) was done and it ceased the hemoptysis. However, it recurred after 2 years of the BAE \nprocedure. The symptoms and amount of hemoptysis were milder; hence, repeated BAE was not required. Earlier, \nthe patient refused hormonal therapy (HT) owing to its side effects, but this time, she accepted HT. After 2 months \nof HT, hemoptysis gradually ceased. If complications arise in the future, then surgical treatment along with HT (combi-\nnation therapy) would be the course of treatment. The diagnosis of CH is challenging, and treatment procedures vary \nfrom patient to patient; hence, they are customised. Hormones regulate the CH recurrence even though the symp-\ntoms have ceased after treatment. Therefore, regular follow-up and close vigilance are crucial requirements.\nKeywords Catamenial hemoptysis, Bronchial artery embolization (BAE), Endometriosis, Menstruation, Case report\nBackground\nEndometriosis of the thorax or lung is a rare disease, and \nthe associated CH disorder is even rarer [1]. Because of \nCH in patients, it results in bleeding from the lung endo -\nmetrial site during menstruation. Endometrial tissue is \nthe source of bleeding which is implanted either in the \nlung parenchyma, pleura, or airways and is triggered by \nthe circulating sex hormones [2]. CH is a thoracic endo -\nmetriosis which is either pleural (83%) or pulmonary \n(17%). CH is reported in around 15% of reproductive-age \nwomen, which is further complicated by cases of infer -\ntility (32%), and chronic pelvic pain (48%). In 1% of \ncases, endometriosis could also be transformed into \nmalignancy  [3]. Pulmonary endometriosis (PE) could \nbe caused by multifactorial reasons; hence, its patho -\nphysiology is still not clear. Theories suggested are coe -\nlomic metaplasia, retrograde menstruation, stem cell, \nand microembolisation theory. Mostly, PE is considered \nto be caused by peritoneal implants or by invasion of the \nendometrium into the interstitium of the lung by lym -\nphatic or hematogenous metastasis during delivery or \nduring pelvic surgeries. All these theories failed to estab -\nlish a clear mechanism of PE [4]. PE is usually character -\nised by CH and it starts and stops with the menstruation \ncycle of the patient. Symptoms are variable and indefi -\nnite, too. Because of missing diagnoses and also because \n*Correspondence:\nAshok P . Arbat\nashok_arbat@yahoo.com\n1 Pulmonary Department, Ketki Research Institute of Medical Sciences, \n275, Central Bazar Road, Ramdaspeth, Nagpur, Maharashtra State, India\n\nPage 2 of 8Arbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \nof differences of opinion related to the selected line of \ntreatment, optimal management of CH is challenging \n[5]. Hormonal therapy, conservative treatment, and sur -\ngical removal of the lesion are the three main treatment \nplans for CH. Here, we describe a case of CH in a young, \nunmarried female patient who was treated with bronchial \nartery embolisation (BAE), but the disease recured after \n2  years of treatment. It is to be noted that she had not \ntaken any adjuvant pharmacological treatment during the \npost-treatment period till the recurrence of the disease, \nand during this time interval, she was asymptomatic too. \nHere, in this case report, we are focusing on identifica -\ntion, diagnosis, and treatment strategies for CH custom -\nised in accordance with the patient’s requirements.\nCase presentation\nTwo years ago, a 19-year-old unmarried female of Asian \nethnicity consulted our hospital’s out-patient department \n(OPD) for complaints of hemoptysis with breathlessness \ncontinuously for 8 days with cough and white expectora -\ntion in the last 7  days. The total amount of hemoptysis \nwas approximately 150–180  ml. A mild cold on and off  \nin the morning was observed. She also complained of \nabdominal pain for the last 3 days. While taking history, \nit was revealed that she had suffered from this complex -\nity for the past 6 months. Hemoptysis specifically starts \nat night along with breathlessness and cough, which \nceases spontaneously or after taking medications. Cystic \nairway disease, or cystoid adenoma, was suspected (pro -\nvisional diagnosis) owing to her symptoms. CH was also \nsuspected, as she later mentioned that these conditions \noccur, especially 2 days before or at the time of menstrua-\ntion. She denied a history of pelvic endometriosis, uter -\nine diseases, bleeding diathesis, or smoking. There was \nno family history of CH. She was therefore admitted dur -\ning menstruation for further treatment and management. \nAt the time of admission, she was afebrile with a temper -\nature of 97 °F; blood pressure was 120 mmHg/70 mmHg; \npulse rate was 58/min; SPO2 was 98%; respiratory rate \nwas 18/min; and the abdomen was soft. She was con -\nscious and oriented. The general condition was moderate, \nand cardiovascular symptoms (CVS) S1 and S2 were nor -\nmal. She was investigated hematologically, clinically, and \nradiologically. Her blood investigation result was normal, \nwith haemoglobin (HB) = 13.5, platelets = 341,000, and a \nnegative HIV/HBSAG test result.\nThe chest X-ray showed a thin-walled (with a wall \nthickness of 2.8 mm) cavitatory lesion of size 3.4 × 3.5 cm \nseen in the right lower zone, with radiopacity noted in \nthe lower part of the cavity (Fig.  1). A plain and contrast-\nenhanced multidetector computed tomography (MDCT) \nchest with pulmonary angiography by a 128-slice MDCT \nscanner was done (Fig.  2). There was no evidence of a \npulmonary embolism. A well-defined cavitary lesion \n(38 × 32 × 24 mm) was showing air-fluid level with high-\ndensity content in the superior segment of the right \nlower lobe, with increased peripheral vascularity showing \nsupply through the branch of the right bronchial artery. \nMultiple ill-defined areas of ground glass opacities were \nnoted diffusely and randomly in the right lower lobe, pre-\ndominantly surrounding the cavitatory lesion, suggesting \nthe possibility of intracavitary haemorrhage with associ -\nated adjacent consolidation and alveolar haemorrhages. \nWell-defined adjacent lung parenchyma showed multiple \ncysts measuring approximately 6.5 × 5 cm, and emphyse -\nmatous changes in the right lower lobe superior segment \nmay represent congenital cystic adenomatoid malforma -\ntion (CPAM). A visualised abdominal section showed \nmultiple ill-defined concretions in the bilateral renal pel -\nvicalyceal system. Her erythrocyte sedimentation rate \n(ESR) was 10  mm, echo was normal, ejection fraction \n(EF) was 64%, left ventricular systolic (LV sys) function \nwas good, and tricuspid valve regurgitation was trivial. \nHer coagulation profile result showed prothrombin time \n(Pt) -14.5, control (MNPT) -14, and INR-1.04. Bronchos -\ncopy (Olympus ® BF-P240 Flexible Bronchoscope) was \nperformed during menstruation. Bronchoscopy was done \nwhen her menses were ongoing under local anaesthesia \n(lignocaine 4%) to identify and locate the bleeding site \nof CH. The bronchoscope was entered through the nasal \nFig. 1 Chest X-ray of the patient showed thin-walled (thickness \n2.8 mm) cavitatory lesion (3.4 × 3.5 cm) right lower zone \nwith radio-opacity lower part of the cavity\n\nPage 3 of 8\nArbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \n \npassage. Pharynx, vocal cord, trachea, and carina were \nnormal. However, active bleeding was seen (Fig.  3, video) \nat the right superior segment (B6a segment). The bleed -\ning lesion of CH was thus identified. Bronchoscopy went \nuneventful; hence, no intervention was required. Bron -\ncho alveolar lavage (BAL) was collected and subjected \nto acid-fast bacillus (AFB), fungal, and gram staining. \nBAL was also tested for tuberculosis and malignancy. In \nall three staining results, tuberculosis plus malignancy \ntests were negative. AFB, bacterial, and fungal cultures of \nBAL were also done, which were also found to be nega -\ntive. Cystic airway disease, or cystoid adenoma, was thus \nruled out, and diagnosis of CH was confirmed. Counsel -\nling for the patient and her relatives was done.\nHormonal therapy was not acceptable to the patient; \nhence, bronchial artery embolisation (BAE) was chosen \nas a treatment regime (Fig.  4). After BAE, hemoptysis \nstopped, and her health was stable. She was discharged \nwith prescribed drugs, that is, antacids, antifibrinolytics, \nhaemostatic agent, and antibiotics. There was no episode \nof CH till 2 years post-procedure.\nRecently, hemoptysis recured after a gap of 2  years. \nThe severity of hemoptysis was milder as compared to \nprevious episodes before BAE. The amount of bleeding \nwas reduced to one-fourth (20–40  ml) of that in earlier \ntimes. A gynaecologist at our hospital was consulted for \nexamining the abdominal and pelvic regions to check \nfor concurrent pelvic endometriosis, which could be \ndeveloped or was already developed. Her sonography \nreport showed a normal uterus and endometrium. Both \nthe ovaries and abdomen were normal too. Cyproter -\none (2  mg) + ethinyl estradiol (0.035  mg) combination \npill along with tranexamic acid (500 mg) tablet was pre -\nscribed for controlling hemoptysis episodes. After taking \nmedicine for 2  months, catamenial hemoptysis gradu -\nally ceased.  Side effects related to HT were reported by \nher which included swelling and pain in both legs with \nelevated ESR (52) and CRP (11.83) level which subsided \nwith medications.\nDiscussion\nHemoptysis is a dreadful and distressing symptom that \nis associated with several respiratory ailments. It is com -\nmonly found in the cases of tuberculosis (TB), pneu -\nmonia, bronchitis, lung cancer, bronchiectasis due to \ncystic fibrosis, COPD, etc. Hemoptysis also occurs due \nto pulmonary endometriosis (PE). PE can result in cata -\nmenial pneumothorax (73%), catamenial hemothorax \nFig. 2 Plain and contrast-enhanced MDCT chest with pulmonary angiography with 128-slice MDCT scanner showed well-defined cavitary lesion \nshowing air-fluid level with high-density content in the superior segment of right lower lobe with increased peripheral vascularity showing supply \nthrough the branch of right bronchial artery. Multiple ill-defined areas of ground glass opacities are noted diffusely and randomly in right lower \nlobe predominately surrounding the cavitatory lesion\nFig. 3 Active bleeding is seen through bronchoscopy in the right \nlower lobe superior segment (B6a) of the patient’s lung\n\nPage 4 of 8Arbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \n(14%), catamenial hemoptysis (7%), and pulmonary \nnodules (6%) [6]. CH is a rare form of lung disease that \nis difficult to diagnose (refer to Table  1 for diagnostic \napproaches applied to CH by various medical fraterni -\nties). It is usually suspected when no other underlying \ncause of recurrent hemoptysis is noted. In order to dif -\nferentiate CH from other forms of hemoptysis, a clini -\ncal correlation concurrent with the menstrual cycle is \nneeded. The diagnosis of such cases could be done by \nCT scans synchronised with the menstrual cycle during \nhemoptysis, which in turn helps in detecting the lesion \nand also ruling out any other reason for hemoptysis [7]. \nAs reported by Kim et al. [5], the ground glass opacities \npredominantly appear on thorax CT during CH. Other \nfindings that could be included are nodular lesions, well-\ndefined opacities, bullous formations, and thin-walled \ncavities [6]. In our patient, the chest CT scan images have \nshown complex fluid-filled cystic lesions with few air foci \nin the superior segment of the right lower lobe and mul -\ntiple other small cystic areas with ground glass opacity \nin the right lower lobe. Our observation correlates with \nthe other reported findings, which confirm that usually \nlung lesions are confined to the lower lobes of the right \nlung [5]. There are possibilities of misdiagnosis when \nCT and chest X-Ray manifestations are not done during \nmenstruations and due to non-specificity of image find -\nings. The bronchoscopy examination utilised in this case \nwas fruitful, as the causative lesion was identified during \nhemoptysis, and BAL was efficiently collected too to test \nand discard other causes of hemoptysis. At times, there \nis a limitation in the utility of bronchoscopy for CH. It \nshows normal findings mainly when the location of the \nlesion is not known, when it is not performed during \nmenstruation and hemoptysis, or when the lesion is situ -\nated in the distal parenchyma [8]. Chest X-Ray, CT scan, \nand bronchoscopy were utilised efficiently during menses \nto conform CH diagnosis.\nThere are no specific guidelines for the treatment of \nCH. The summarisation of treatment regimens for CH \nis represented in Table  2. Treatment modalities that are \ntested and prescribed include hormonal therapy, medi -\ncal conservative management, and surgical treatment \n[12]. Rarely used treatment strategies include bilateral \noophorectomies, clomiphene citrate therapy, elexacaftor/\ntezacaftor/ivacaftor therapy, photodynamic therapy \n(PDT), indocyanine green-assisted targeting for minimal \ninvasive surgery, hysterectomy, bilateral salpingoopho -\nrectomy, and, in rare cases, lung transplantation. Hor -\nmonal therapy includes gonadotropin-releasing hormone \nagonists, progestational drugs, oral contraceptives, and \ndanazol, which work by suppressing the endometrium. \nThese drugs are effective yet come with heavy side effects \n[17]. High cost of the drug further adds financial burden \nto the patients. Moreover, its effect ends when the dose is \ndiscontinued and leads to a recurrence of the symptoms \n[5]. It is also not advisable for patients who are planning \nFig. 4 Bronchial artery embolisation (BAE) procedure done in the catamenial hemoptysis patient. A Active lesion was seen before BAE. Bronchial \nartery angiogram showing blush from the lesion. B Right bronchial artery cannulated for embolisation. C Right pulmonary artery angiogram to look \nfor feeding vessel (if any). D. Post embolisation image. BAE was successfully performed\n\nPage 5 of 8\nArbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \n \nTable 1 Tabular representation of diagnostic procedures for catamenial hemoptysis and related observational content and associated limitations\nSr. no Diagnostic tools Observe for Limitations Remarks Reference\n1 Clinical characteristics - Hemoptysis during menstruation\n- Woman of reproductive age\n- Presence of endobronchial ectopic \nor intrathoracic endometrial tissue\n- Other causes of hemoptysis should be \nruled out\n- Check for pelvic endometriosis\n- History of gynaecological or obstet-\nric procedures like any pelvic surgery \nor abortion procedure\n- Test for increased cancer antigen (CA \n125)\n- Heightened suspicion is required for CH \ndiagnosis\n- Non-specific physical examination\n- Unremarkable auscultation\n- History of gynaecological or obstetric \nprocedures like induced abortion could \nlead to CH\n- Smokers have more chances for CH\nKim CJ et al. [5]\nJang HI et al. [9]\nKim JH et al. [10]\n2 Chest CT scan - Ground glass opacities\n- Consolidation\n- Nodule\n- Ill- or well-defined opacities\n- Thin-walled cavities\n- Bullous formations\n- The size of the active lesion \neither reduces or disappears \nbetween menses\n-Located mostly in right lung field\n- If done on non-menses day, then lesion \nsite and other specifications would be \nnon- or less-visible\n- Non-specific imaging and laboratory \nfindings\n- Chest CT should be performed \nduring the first 2 days of menstrua-\ntion to discover pulmonary haemor-\nrhage, and with volumetric acquisition \ntechnique and thin (1–2 mm) sections, \nbecause the lesions can be very small\n- Comparison of serial CT scans helps \nin detection and determination of CH-\ncausing factor\n- To avoid excessive radiation expo-\nsure in young women, CT should be \nperformed using a low-tube current \nadjusted to the patient’s body size, \nwithout intravenous contrast administra-\ntion, and limited to the region of interest \non follow-up\nSuwatanapongched T et al. [11]\nShin SP et al. [12]\nKim CJ et al. [5]\nKim JH et al. [10]\n3 Bronchoscopic examination - Help in localisation of bleeding lung \nsegment or lobe\n- Beneficial if lesion is present in mucosa \nof large bronchi\n- Beneficial if bleeding site is superficial\n– Beneficial if done during menstruation\n- Bronchial wash could be used for ruling \nout microbial infection and malignancies\n- Distal parenchymal lesion could not be \ndetected\n- Non-experienced examiner/clinician \ncould not recognise the suspicious \nmucosal lesion\nShin SP et al. [12]\nAzizad-Pinto P et al. [13]\n4 Invasive tools (VATS) - Direct visualisation of the diaphrag-\nmatic section and lung\n- Shows larger masses\n- Shows violet and brown endometrial \ndeposits\n- Higher diagnostic accuracy\n- Can show perforation on the surface \nof the diaphragm\n- Invasive resection could lead to com-\nplications\n- Selection of ‘fit-for-surgery’ patients \nshould be done carefully\n- Localisation of lesion is important \nfor the success of the surgery\nKim JH et al. [10]\nNezhat C et al. [14]\nCassina PC et al. [15]\n5 MRI - Less radiation exposure than CT\n- Can differentiate parenchymal \nfrom pleural implants\n- Limited to the study of diaphrag-\nmatic localizations of endometriosis \nand related hernias\n- MR imaging typically demonstrates \na hyperintense lesion on fat-sup-\npressed T1- and T2-weighted images \nat the pleura or diaphragm, signifying \nhaemorrhage coinciding with menses\n- MR imaging lacks spatial resolution\nCassina PC et al. [15]\nAzizad-Pinto P et al. [13]\nMarchiori E et al. [16]\n\nPage 6 of 8Arbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \nTable 2 Tabulation of treatment procedures for catamenial hemoptysis and associated advantages and disadvantages\nSr. No Treatment type Methodology Advantage Disadvantage References\n1 Medical treatments Hormonal suppression of endometrium - Complete remission of endome-\ntriomas and effusions can be achieved \nwith 6 months of therapy,\n- Less invasive\n- Can preserve fertility\n- Hemoptysis in CH recurs in 50% \n(approx.) patients\n- Menopausal symptoms may develop\n- Symptoms recur when medication \nis stopped\n-Could not be used for young females \nseeking pregnancy\n- Costly drugs\n- Associated side effects like osteoporo-\nsis, depression, and hot flashes\n- The optimal dosage and duration \nof hormonal treatment remains unde-\ntermined\nKim CJ et al. [5], Jang HI et al. [9]\nKim JH et al. [10]\nShin SP et al. [12]\n2 Surgery Video-assisted VATS -Safer\n- Reduces postoperative analgesic \nrequirements\n-Shortened hospital-stay\n- Surgical treatment is considered when: \n(a) a single TE lesion is identified; (b) \nthe patient wishes to become preg-\nnant; (c) the patient cannot tolerate \nthe side effects of hormonal therapy; (d) \nmedication fails; or (e) symptoms recur \nafter hormonal cessation\n- Could not be performed in unfit \npatients\n-Could not be done for extensive lesions\n- Invasive, hence complication could \narise\n- Would be failed if exact location \nof lesion is missed\nKim JH et al. [10]\nNezhat C et al. [14]\nCassina PC et al. [15]\n3 Alternative treatment choice Bronchial artery embolisation - Opted for large amount of hemoptysis\n- Minimal invasive\nPossible rare complications are spinal \ncord injury, esophageal ulceration, stroke, \nbronchial infarction, and transient chest \npain\n- Chances of recurrence\nShin SP et al. [12]\n\nPage 7 of 8\nArbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \n \na pregnancy. Surgical treatment could be applied in cases \nwhere medical treatment either failed or stopped due to \nassociated complications. For example, video-assisted \nthoracoscopic surgery (VATS), lobectomy, wedge resec -\ntion, open surgery, and endoscopic laser treatment are \nsuch surgical techniques [18]. There are few reports \nabout conservative management techniques as a treat -\nment modality, mostly among women of reproductive \nage [19]. In general, the BAE procedure is mostly used \nto cure hemoptysis caused by lung cancer, TB, bronchi -\nectasis, aspergillosis, or chest trauma for large volume \nof hemoptysis [12]. Only a few side effects are associated \nwith BAE; otherwise, it is a lifesaving, minimally inva -\nsive procedure that provides long-term relief and a better \nlife ahead. It is also considered a better option than con -\nservative management techniques [20]. Moreover, as the \npatient was reluctant for HT and surgical removal of the \nlesion, BAE was decided as a treatment regime. CH is a \nrare disease, and only a few have tried BAE as a treatment \noption [12]. Usually, follow-up of 3 to 5 months post-pro-\ncedure was observed in other studies, and if there were \nnegative hemoptysis episodes during menstruation, then \nit was considered a successful procedure. In our case, the \npatient did not complain of hemoptysis subsequently for \n2  years post-procedure; however, it recurred with the \nsame symptoms but with milder intensity. Hence, follow-\nup should be done over a longer period of time rather \nthan only for the shorter term.\nHormone therapy is necessary for treatment even \nwhen surgical removal of the CH lesion is adopted \nbecause CH is a hormone-stimulated disorder and \ntherefore could be triggered repeatedly. Since our \npatient was young, she was reluctant to undergo hor -\nmonal therapy out of fear of associated side effects that \nmight erupt, like menopausal symptoms, and could \naffect her reproductivity. HT could be used as a preven -\ntive measure for CH patients if the patient is not plan -\nning a pregnancy and if HT suits the patient without \ncomplications. Hence, BAE was opted for, but without \nhormonal therapy. That is why it might be the rea -\nson for CH recurrence after 2  years. As reported by \nChannabasavaiah AD et  al., up to 50% of CH patients \ncomplained of recurrent hemoptysis when only medi -\ncal therapy was given [21]. Recently, clinicians have \nbeen stressing combined surgical and medical treat -\nment strategies as there were better and more effective \noutcomes. Combining hormonal therapy with surgi -\ncal treatment (removing endometrial tissue to inhibit \nestrogen stimulation) ensures the complete therapeutic \nremedy for CH [13, 22– 24]. For the next phase of CH \ntreatment, BAE could not be performed as the amount \nof hemoptysis was less. Surgical treatment was deferred \nas symptoms were milder and the patient was young \ntoo. Hence, HT was preferred. The patient had reported \nsubsided CH in the first menstruation episode that \ngradually stopped in the second-month cycle. Patient’s \nperspective for CH treatment at our centre states that \nthe patient was satisfied with the BAE as it ceased hem -\noptysis for 2 years and when it re-erupted the volume \nof hemoptysis, coughing and degree of breathless -\nness was significantly lowered than pre-BAE episodes. \nThus, mental and physical disturbances caused by CH \nsubsided simultaneously. Depending on the hormonal \ntreatment and its long-term effect, surgical removal of \nthe lesion combined with hormonal therapy might be \nplanned for a complete recovery from CH.\nIn conclusion, in young female patients, episodes of \nhemoptysis should be closely monitored, especially \nduring the menstrual cycle, as it could be a case of CH. \nRadiological techniques used for diagnosis play a cru -\ncial role in the identification of CH when conducted \nduring menstruation. Similarly, bronchoscopy helps \nin locating the bleeding site and in collection of BAL \nto check for any microbial infection and malignancies \nthat rule out other causes of hemoptysis. This case \nsuggests that, in the long term, CH can recur after \nBAE. Regular, long-term follow-up and vigilance for \nrelated symptoms are necessary to be tracked. Failed \nearly medical intervention often directs patients to opt \nfor surgical removal of the active lesion responsible \nfor CH through pulmonary surgical procedures com -\nbined with medical therapy for an effective outcome. \nHowever, hormonal therapy alone could be beneficial \ntoo. The selection of treatment procedures should be \ndone according to the clinical symptoms and patients’ \nnecessity to maintain fertility.\nAbbreviations\nCH  Catamenial hemoptysis\nCT  Chest tomography\nBAE  Bronchial artery embolisation\nHT  Hormonal therapy\nOPD  Out-patient department\nCVS  Cardiovascular symptoms\nHB  Haemoglobin\nHIV  Human immunodeficiency virus\nHBsAg  Hepatitis B surface antigen\nMDCT  Multidetector computed tomography\nCPAM  Congenital cystic adenomatoid malformation\nESR  Erythrocyte sedimentation rate\nEF  Ejection fraction\nLV sys  Left ventricular systolic\nPt  Prothrombin time\nMNPT  Mean normal prothrombin type\nINR  International normalised ratio\nAFB  Acid-fast bacillus\nCRP  C-reactive protein\nTB  Tuberculosis\nCOPD  Chronic obstructive pulmonary disease\nPE  Pulmonary endometriosis\nPDT  Photodynamic therapy\nVATS  Video-assisted thoracoscopic surgery\nBAL  Bronchoalveolar lavage\n\nPage 8 of 8Arbat et al. The Egyptian Journal of Bronchology           (2024) 18:50 \nSupplementary Information\nThe online version contains supplementary material available at https:// doi. \norg/ 10. 1186/ s43168- 024- 00298-7.\nAdditional file 1. Video of the procedure.\nAcknowledgements\nWe are thankful to Mr. Hemant Balapure for assisting in bronchoscopy and \nfor taking a video of the procedure. We acknowledge Dr. Sandeep Chude \n(radiologist) for providing the bronchial artery embolization (BAE) procedure \nimages.\nAuthors’ contributions\nSC wrote the initial draft of the manuscript, editing and literature search. AA, \nGG, SB, and PD managed the diagnosis and treatment. GG, editing, reviewing, \nand methodology; AA, review, editing, supervision, and final approval of the \nmanuscript; SB and PD, visualisation investigation, and reviewing. All authors \napprove the final version of the manuscript.\nFunding\nThis study received no external funding.\nAvailability of data and material\nData and material are available on request from the corresponding author.\nDeclarations\nEthics approval and consent to participate\nThis study is ethically approved and due course of consent was taken by our \nhospital’s ethics committee.\nConsent for publication\nConsent for publication has been taken from the patient and will be made \navailable on demand.\nCompeting interests\nThe authors declare that they have no competing interests.\nReceived: 21 May 2024   Accepted: 22 June 2024\nReferences\n 1. Giudice LC, Kalo LC (2004) Endometriosis. Lancet 364:1789–1799\n 2. Augoulea A, Lambrinoudaki I, Christodoulakos G (2008) Thoracic endo-\nmetriosis syndrome. Respiration 75:113–119\n 3. 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Chest 124:1004–1008\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}