{"paper_id":"a1ea3f24-6a2c-476d-a85b-28595700f243","body_text":"Abstract\nBackground\nCatamenial pneumothorax (CP) is the most common manifestation of thoracic endometriosis syndrome (TES). Recurrence remains a major challenge after surgical intervention, and evidence on long-term hormonal management is limited. This study evaluates whether dienogest (DNG) can serve as effective long-term maintenance therapy following gonadotropin-releasing hormone agonist (GnRH-a) induction in patients with recurrent CP.\nMethods\nThis retrospective case series included four women aged 36–49 years with recurrent pneumothorax temporally associated with menstruation. We summarized clinical manifestations, thoracic surgical findings and pathological results (when available), gynecological evaluations, treatment regimens, recurrence outcomes, and adverse events. A literature review was conducted to identify previous reports on hormonal management of TES/CP. During long-term DNG treatment, periodic assessments included liver and renal function, coagulation profiles, breast ultrasonography, endometrial thickness, bone mineral density, and estradiol levels.\nResults\nAll four patients showed a clear temporal association between pneumothorax and menstruation. One had histologically confirmed diaphragmatic endometriosis; the other three had only lung collapse with repeatedly negative thoracic imaging. After GnRH-a induction, all received individualized DNG maintenance (2–4 mg/day), initiated at 4 mg/day in severe or frequently recurrent cases or after low-dose failure and tapered to 2–3 mg/day once remission was achieved. After effective maintenance, no recurrence occurred during follow-up. Safety monitoring was unremarkable in three patients; one developed elevated liver enzymes after 21 months and normalized after switching back to GnRH-a. Literature review showed limited evidence on long-term DNG maintenance after GnRH-a induction, with no prior reports of individualized dose adjustment.\nConclusions\nIn this small case series, a structured regimen of GnRH-a induction followed by individualized DNG maintenance (2–4 mg/day; 4 mg/day initially or after escalation in severe/refractory cases, then tapered to 2–3 mg/day) appeared effective in preventing recurrent CP/TES, with no recurrence after effective maintenance was established. Long-term DNG was generally well tolerated, but safety conclusions are limited by the small sample size and one case of transient liver enzyme elevation; regular hepatic monitoring is required.\nSimilar content being viewed by others\nAbbreviations\n- ALT:\n-\nAlanine aminotransferase\n- BMD:\n-\nBone mineral density\n- CP:\n-\nCatamenial pneumothorax\n- CT:\n-\nComputed tomography\n- DIE:\n-\nDeep infiltrating endometriosis\n- DNG:\n-\nDienogest\n- GnRH-a:\n-\nGonadotropin-releasing hormone agonist\n- MRI:\n-\nMagnetic resonance imaging\n- TES:\n-\nThoracic endometriosis syndrome\n- VATS:\n-\nVideo-assisted thoracoscopic surgery\nAbbreviations\n- ALT:\n-\nAlanine aminotransferase\n- BMD:\n-\nBone mineral density\n- CP:\n-\nCatamenial pneumothorax\n- CT:\n-\nComputed tomography\n- DIE:\n-\nDeep infiltrating endometriosis\n- DNG:\n-\nDienogest\n- GnRH-a:\n-\nGonadotropin-releasing hormone agonist\n- MRI:\n-\nMagnetic resonance imaging\n- TES:\n-\nThoracic endometriosis syndrome\n- VATS:\n-\nVideo-assisted thoracoscopic surgery\nAcknowledgements\nThe authors would like to thank the medical and nursing staff of the Department of Thoracic Surgery at the general hospital for their support and contributions to the clinical management of the patients included in this study.\nFunding\nThis study was supported by the National Natural Science Foundation of China (81871144 to LXS). The funding body had no role in the study design, data collection, analysis, interpretation, or manuscript writing.\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nEthics approval and consent to participate\nThis retrospective study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of the Obstetrics and Gynecology Hospital of Fudan University (IRB Approval No.: 2023 − 112). Written informed consent was obtained from all four patients.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare no competing interests.\nAdditional information\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary Information\nRights and permissions\nOpen Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.\nAbout this article\nCite this article\nCao, Y., Shen, M., Guo, SW. et al. Stepwise hormonal therapy for recurrent catamenial pneumothorax: GnRH agonist induction followed by individualized dienogest maintenance — a case series and literature review. BMC Women's Health (2026). https://doi.org/10.1186/s12905-026-05072-z\nReceived:\nAccepted:\nPublished:\nDOI: https://doi.org/10.1186/s12905-026-05072-z","source_license":"CC0","license_restricted":false}