{"paper_id":"f0008e32-f823-444b-8ded-299df56d85e3","body_text":"466\nCatamenial Pneumothorax (CP)\nLeonard Ranasinghe1*, Anne Liao2 and Michelle Nguyen2\n1College of Medicine, California Northstate University, USA\n2Medical Student, California Northstate University, USA\n*Corresponding author: Leonard Ranasinghe, College of Medicine, California Northstate University, 9700 West Taron Dr. Elk Grove, \nCA 95757, USA\nTo Cite This Article:  Leonard Ranasinghe. Catamenial Pneumothorax (CP). Am J Biomed Sci & Res. 2019 - 5(6). AJBSR.MS.ID.000969. DOI: \n10.34297/AJBSR.2019.05.000969.\nReceived: \n  October 17, 2019;  Published: \n   October 22, 2019\nCopy Right@Leonard Ranasinghe\nThis work is licensed under Creative Commons Attribution 4.0 License  AJBSR.MS.ID.000969\nAmerican Journal of\nBiomedical Science & Research\nwww.biomedgrid.com\n---------------------------------------------------------------------------------------------------------------------------------\nISSN: 2642-1747\n Review Article \nIntroduction\nCatamenial pneumothorax was first described by [1], as a \npneumothorax associated with diaphragmatic endometriosis \n[2]. was the first to coin the term catamenial pneumothorax. \nCatamenial describes a temporal relationship with the onset \nof menses, and CP usually presents 1 day to 72 hours within the \nonset of menses in an ovulating woman. CP is considered a very \nrare clinical condition. However [3], suggests that CP may be more \ncommon than previously suspected in their retrospective review, \nidentifying 8 CP patients out of 32 total pneumothorax female \npatients (25%) referred to their surgical center. According to \n[4], CP may have been missed before 1990 due to lack of proper \nvisualization of the diaphragm that video-assisted thoracoscopy \n(VATS) now allows today in pneumothorax patients. Although the \nexact etiology of CP is unknown, most proposed theories involve \nthe presence of ectopic endometrial tissue in the diaphragm or \nthorax cavity, known as thoracic endometriosis. CP is the most \ncommon presentation of thoracic endometriosis syndrome, over \nhemothorax, hemoptysis, and parenchymal nodules. In addition, \nCPs are predominantly right sided (>90%) as described in current \nliterature. CP should be considered in any woman of child-bearing \nage with recurrent pneumothoraces. Acute management of CP \nshould include strong clinical suspicion for a pneumothorax and \nappropriate placement of chest tube and decompression therapy \nfor the affected lung. Evaluation of a suspected CP includes video-  \n \nassisted thoracoscopy with a histological confirmation. Prevention \nof recurrences requires removal of ectopic endometrial tissue and \nrepair of diaphragmatic defects.\nProposed Theories of Etiology\nProstaglandin theory\nDuring menstruation, prostaglandins play a critical role in \ntriggering the contraction of uterine muscles to expel menstrual \nproducts. Prostaglandin F2 is a particularly potent vasoconstrictor \nof bronchioles and vascular structures. It is proposed to cause \nconstriction of the bronchioles especially during the expiratory \nphase, leading to lung collapse and pneumothorax [5]. The research \ndone by Rakhila et al (2015) further supports the prostaglandin \ntheory in the context of endometriosis. They found increased \nmRNA expression of prostaglandin E2 receptors, prostaglandin F2a \nreceptors, and prostaglandin transporter in ectopic endometrial \ntissue, increasing cell reactivity and uptake of prostaglandins \nduring menses [6]. This increases the potential for prostaglandins \nto affect the lungs, although warrants more research.\nCoelomic metaplasia\nThe pleura, peritoneum, and gonads develop from a common \nembryologic origin, the coelomic epithelium. Under the influence \nof estrogen, the pleura and peritoneum has been hypothesized to \nAbstract \nCatamenial pneumothorax (CP) presents as a recurrent respiratory emergency due to failure to identify and treat the underlying gynecological \ncondition. As a rare cause of pneumothorax, CP is unique in its temporal relationship with the onset of menses. Its nature of recurring during time \nof menstruation makes it less likely to be a separate spontaneous pneumothorax coinciding with menstruation. Several mechanisms have been \nproposed and although the exact pathophysiology of CP remains elusive, advances in surgical interventions have suggested diaphragmatic defects \nand thoracic endometriosis to play a fundamental role in the pathogenesis. In addition to technological advances, increased medical awareness \nand research have suggested that CP may be more common than previously thought. This review article will discuss the proposed mechanism of \npathophysiology, evaluation, and acute and long-term management.\n\n\nAm J Biomed Sci & Res                                                                                                                                                                           Copy@ Leonard Ranasinghe\nAmerican Journal of Biomedical Science & Research 467\ndifferentiate into endometrial cells, leading to lung damage and \npneumothorax [7]. This theory explains endometriosis in patients \nwho have had a hysterectomy or bilateral salpingectomy and in \nmen on high-dose estrogen therapy. However, this theory does not \nexplain why catamenial pneumothoraces are predominantly right \nsided or intrapulmonary pathologies.\nDiaphragmatic theory of air passage\nAccording to Carter et al (1990) [8], endometrial implants in \nthe pleura and diaphragm creates fenestrations and diaphragmatic \npores through cyclical necrosis with menses, allowing air to enter \nthe thorax. Bagan et al (2003)3 identified endometrial tissue \naround the diaphragmatic performations, which is further evidence \nof ectopic endometrial tissue to causing diaphragmatic holes. In \nstudies by [3,5], they found underlying diaphragmatic defects in \nevery CP patient, suggesting the fundamental role of the diaphragm \nin CP . The air that enters the thorax is hypothesized to originate \nfrom the fallopian tubes due to a lack of cervical mucus plug during \nmenstruation, then travels through the peritoneum and past the \ndiaphragm. However, this theory does not describe CP in patients \nthat lack fallopian tubes. In addition, air could enter the thorax with \nevery menstrual cycle, but CP is not observed with every menstrual \ncycle.\nRetrograde menstruation\nThis theory is based on the movement of endometrial tissue \ninto the peritoneum, up the right paracolic gutter, and through the \ndiaphragm preferentially on the right side due to the “piston” action \nof the liver against the diaphragm. The piston effect transmits \nperitoneal pressure through the diaphragm and allows passage of \nair and endometrial tissue into thoracic cavity [3]. This explains \nthe occurrence of right sided catamenial pneumothoraces but not \nleft sided. In addition, clockwise peritoneal circulation sweeps \nendometrial products from the pelvis up the right side of the \nperitoneal cavity. The falciform ligament halts migration to the left \nleading to predominantly right sided pneumothoraces. \nClinical Presentation\nDiagnosis of CP can be challenging but should be suspected \nin women in their fourth decade of life with recurrent right \nsided pleuritic chest pain in close temporal relation to onset \nof menstrual bleeding [9,10]. Chest pain the day preceding or \nwithin 72 hours of menstrual bleeding is typical of CP . Pain and \nassociated pneumothorax typically occurs on the right side [9,10]. \nCatamenial pneumothorax has late onset, generally in women 30 to \n40 years old. A history of pelvic endometriosis may or may not be \npresent, and diaphragmatic defects ranging from 1 to 10 mm are \nfrequently observed. A subset of CP , termed juvenile catamenial \npneumothorax (JCP) has been described in the literature [11]. \nThis is typically earlier in onset, from age 19 and below. JCP has \nthe usual features of close temporality with menses but does not \nappear to have preferential right sided laterality. A higher frequency \nof left sided PTX has been observed in this population, and as such \nhas been hypothesized to have a different etiology than usual CP . \nFurthermore, diaphragmatic defects observed in UCP are generally \nnot seen in JCP .\nEvaluation\nImaging by chest x ray and CT has limited use in diagnosis of CP \n[10]. Findings on CXR are typically consistent with pneumothorax, \ngenerally without mediastinal shift. Findings of pneumoperitoneum \nmay be present10. MRI may show hyperintensities representing \nendometrial deposits with T1 or T2 weighted images10. CT may \nalso be useful in imaging endometrial lesions [10]. However, as \npreviously discussed, endometrial deposits may not be present in \ncases of CP . Therefore, the gold standard in diagnosis of CP remains \nvideo-assisted thoracoscopy (VATS) [10] in combination with \nhistologic confirmation. Diaphragmatic defects and other lesions \nwithin the thoracic cavity may be easily visualized and repaired \nwith VATS.\nManagement & Complications\nFor acute management of pneumothorax, appropriate treatment \nwith placement of a chest tube or decompression to reinflate the lung \nmay be indicated [12]. Historically, axillary thoracotomy was the \nmainstay for treatment of CP [13]. However, axillary thoracotomy \npresented several difficulties, particularly in that visualization \nof the diaphragm was virtually impossible. VATS provides an \neffective means of visualizing the diaphragm and thoracic cavity, \nand allows good access to repair any perforations or other defects \nobserved13. The literature describes several different methods of \nrepair, including removal of defects by stapler, simple suturing of \ndefects, and plication [5,13,14]. A retrospective study by Bagan et al \nadvocates for the use of the application of glue in combination with \npolyglactin mesh to the diaphragm to treat perforations which may \nnot be visualized, and promote fibrotic adhesion of the diaphragm \nwith the lung to prevent recurrence4. Repair of defects is typically \nfollowed by pleurectomy or pleurodesis by mechanical or chemical \nmeans (Talc powder) to promote fibrosis and adhesion between \nlung and diaphragmatic surfaces3. Surgical intervention is followed \nwith medical treatment to prevent recurrence [15]. \nMedical treatment for CP aims to suppress ovulation [10], and \noptions for treatment are similar to those used in management of \nendometriosis. These include gonadotropin releasing hormone \n(GnRH) analogs, danazol, oral contraceptive agents, and progestin \ndrugs. Pregnancy, and consequent anovulation, has also been \nobserved to suppress episodes of CP [9]. Use of GnRH analogs \nis typically limited to 6 to 12 months due to side effects14 of \nhypoestrogenism, particularly decreased trabecular bone density, \nvaginal dryness, and hot flashes. Bone density is typically restored \nafter 2 years of GnRH analog cessation. Recurrence of CP has been \nobserved in some cases with delayed initiation of medical treatment \nfollowing surgical intervention [14], but there is some evidence in \n\nAm J Biomed Sci & Res                                                                                                                                                                             Copy@ Leonard Ranasinghe\nAmerican Journal of Biomedical Science & Research 468\nthe literature that appropriate surgical treatment alone may be \neffective in prevention of recurrence [16]. \nAcknowledgements\nWe would like to thank Dr. Leonard Ranasinghe for his \nassistance and mentorship.\nReferences\n1. Maurer ER, Schaal JA, Mendez FL (1958) Chronic recurring spontaneous \npneumothorax due to endometriosis of the diaphragm. Journal of the \nAmerican Medical Association 168(15): 2013-2014.\n2. Lillington GA, Mitchell SP , Wood GA (1972) Catamenial pneumothorax \nJama 219(10): 1328-1332.\n3. Alifano M, Roth T , Broet SC, Schussler O, Magdeleinat P , et al. (2003) \nCatamenial pneumothorax: a prospective study. Chest 124(3): 1004-\n1008.\n4. Bagan P , Barthes FLP , Assouad J, Souilamas R, Riquet M (2003) \nCatamenial pneumothorax: retrospective study of surgical treatment. \nThe Annals of thoracic surgery 75(2): 378-381.\n5. Leong AC, Coonar AS, Lang Lazdunski L (2006) Catamenial pneumothorax: \nsurgical repair of the diaphragm and hormone treatment. The Annals of \nThe Royal College of Surgeons of England 88(6): 547-549.\n6. Rakhila H, Bourcier N, Akoum A, Pouliot, M. (2015). Abnormal expression \nof prostaglandins E2 and F2α receptors and transporters in patients \nwith endometriosis. BioMed research international 2015: 808146.\n7. Matsuura K, Ohtake H, Katabuchi H, Okamura H (1999) Coelomic \nmetaplasia theory of endometriosis: evidence from in vivo studies and \nan in vitro experimental model. Gynecologic and obstetric investigation \n47(Suppl 1): 18-22.\n8. Carter EJ, Ettensohn DB (1990) Catamenial pneumothorax. Chest 98(3): \n713-717.\n9. Rossi NP , Goplerud CP (1974) Recurrent catamenial pneumothorax. \nArchives of Surgery 109(2): 173-176.\n10. Narula N, Ngu S, Avula A, Mansour W, Chalhoub M (2018) Left-sided \nCatamenial Pneumothorax: A Rare Clinical Entity. Cureus 10(5): e2567.\n11. Inoue T , Chida M, Inaba H, Tamura M, Kobayashi S, et al. (2015) Juvenile \ncatamenial pneumothorax: institutional report and review. Journal of \ncardiothoracic surgery 10(1): 83.\n12. Arunthari V, Sevin BU, Krishna M, Johnson MM (2008) Catamenial \npneumothorax with umbilical and diaphragmatic endometriosis: a case \nreport and review of the literature. Southern medical journal 101(10): \n1043-1045.\n13. Hazelrigg SR (2003) Secondary spontaneous pneumothorax: catamenial \npneumothorax. Chest 124(3): 781-782.\n14. Attaran S, Bille A, Karenovics W, Lang Lazdunski L (2013) \nVideothoracoscopic repair of diaphragm and pleurectomy/abrasion \nin patients with catamenial pneumothorax: a 9-year experience. Chest \n143(4): 1066-1069.\n15. Black MC, Joubert K, Seese L, Ocak I, Frazier A, et al. (2019) Innovative \nand Contemporary Interventions of Diaphragmatic Disorders. Journal of \nthoracic imaging 34(4): 236-247.\n16. Subotic D, Mikovic Z, Atanasijadis N, Savic M, Moskovljevic D (2016) \nHormonal therapy after the operation for catamenial pneumothorax–is \nit always necessary? Journal of cardiothoracic surgery 11(1): 66.","source_license":"CC0","license_restricted":false}