What is the treatment for Catamenial Pneumothorax (collapsed lung occurring in conjunction with menstruation)?

Treatment of Catamenial Pneumothorax

Catamenial pneumothorax requires a combined approach of video-assisted thoracoscopic surgery (VATS) with diaphragmatic repair and pleurectomy/pleural abrasion, followed by mandatory postoperative hormonal therapy to achieve ovarian suppression. 1, 2

Recognition and Diagnosis

Suspect catamenial pneumothorax in any woman presenting with chest pain, dyspnea, and sometimes hemoptysis occurring within 72 hours before or after menstruation. 1 The condition is significantly underdiagnosed—among women undergoing routine surgical treatment for recurrent pneumothorax, catamenial pneumothorax has been diagnosed in as many as 25%. 1

Key diagnostic features:

• Typically right-sided pneumothorax (85-95% of cases) 3, 4
• Recurrent episodes coinciding with menstrual cycle 1
• Often occurs in women with history of pelvic endometriosis (30-51% of cases) 3
• Peak incidence in fourth decade, often multiparous women 5

Surgical Management

Primary Surgical Approach

VATS is the definitive surgical treatment and should include three components: 1, 2

1. Diaphragmatic inspection and repair: Thoracoscopy typically reveals fenestrations (defects) and small endometrial deposits on the diaphragmatic surface. 1 When diaphragmatic pores or fenestrations are identified, cover the diaphragm with polytetrafluoroethylene (PTFE) mesh after suturing the defects. 4

2. Lung parenchyma resection: Perform atypical resection of abnormal-appearing lung segments (hemorrhagic, emphysematous, or blebs) using stapler equipment. 3

3. Pleurodesis: Execute either pleurectomy or pleural abrasion to obliterate the pleural space and prevent recurrence. 4 The British Thoracic Society notes no significant difference in outcomes between bullectomy and surgical pleurodesis for pneumothorax recurrence, complications, or mortality. 1

Technical Considerations

A totally videothoracoscopic approach with diaphragmatic mesh coverage and pleurectomy/pleural abrasion has demonstrated excellent results with minimal recurrence when combined with hormonal therapy. 4 In a 9-year surgical series, this approach showed only one recurrence among 12 patients (which occurred before initiating hormonal therapy), with median follow-up of 45.8 months. 4

Postoperative Hormonal Therapy

Hormonal therapy is essential postoperatively and should not be optional. 1, 2 Medical therapy aims to achieve ovarian rest and suppress cyclical endometrial proliferation. 2

Hormonal options include:

• GnRH analogues (gonadotropin-releasing hormone analogs) for 6-12 months postoperatively 3, 4
• Danazol 5
• Hormonal contraceptives or progestagens 5

The combination of efficient pleurodesis (preferably thoracoscopic talc application performed during menstruation) with medication appears most effective, though no controlled studies have been performed. 5

Critical Management Pitfalls

Avoid these common errors:

• Delayed diagnosis: The average patient experiences multiple recurrences before correct diagnosis—one case series reported 18 recurrent pneumothoraces before diagnosis. 6 Always consider catamenial pneumothorax in women with recurrent pneumothoraces. 1, 2

• Incomplete surgical treatment: Failure to address diaphragmatic fenestrations leads to recurrence. 3 One patient who had a tiny diaphragmatic hole left unrepaired and received no postoperative hormonal therapy experienced recurrence at 6.5 months. 3

• Omitting postoperative hormonal therapy: Surgery alone has high recurrence rates. 7, 3 Early diagnosis and postoperative hormonal therapy are just as important as surgical intervention for successful outcomes. 7

Multidisciplinary Coordination

Management requires coordination between respiratory physicians, thoracic surgeons, and gynecologists. 1, 6 The respiratory physician should manage initial pneumothorax treatment and coordinate surgical referral, while gynecologists guide hormonal therapy selection and monitor for pelvic endometriosis. 6

Pathophysiology Context

The most accepted theory explains catamenial pneumothorax as aspiration of air from the abdomen and genital tract via diaphragmatic fenestrations. 1, 2 However, the presence of endometriosis deposits on visceral pleural surfaces suggests erosion of visceral pleura may be an alternative mechanism. 1 This dual pathophysiology explains why comprehensive surgical treatment addressing both diaphragmatic defects and pleural surfaces is necessary. 4