• The lung function starts with the first moment of life and ceases with death.

• In an intermediate period in females life journey, hormonal changes start with the menarche and ends by the menopause.

• It seems that the lungs are affected by such biological feminine events.

• It had been observed through centuries by many women that some respiratory symptoms and even distinct clinical morbidities associate with their cycles.

• Emerging understanding of the role of sex hormones in respiratory health and disease represents a major advance in personalized treatment planning for menses associated respiratory aliments.

The Menstrual Cycle & The Lung

Menarche and the lung

Women who start menstruating early are at a high risk of developing asthma and poor lung function.

The study suggests that women with early menarche have lower lung function and more asthma risk in adulthood reaffirming the role of hormonal and metabolic factors in women's respiratory health.

Early menses lead to asthma, poor lung function

American Journal of Respiratory and Critical Care Medicine, August 2010

Menstruation and the Lungs • Respiratory symptoms during

menstruation

• Catamenial lung disorders

Ferenc Macsali et al, Menstrual Cycle and Respiratory

Symptoms in a GeneralNordic–Baltic Population

Am J Respir Crit Care Med Vol 187, Iss. 4, pp 366–373, Feb 15, 2013

Effects of the menstrual cycle on lung function variables in women with asthma. Farha S, Asosingh K,

Laskowski D, Hammel J, Dweik RA, Wiedemann HP, Erzurum SC. Am J Respir Crit Care Med. 2009

Aug 15;180(4):304-10

Women with asthma experience cyclic changes in airflow as well as

gas transfer and membrane diffusing capacity supportive of a hormonal effect on lung function.

Catamenial lung disorders

• SOB – TIC – Chest pain

• Exacerbation / deterioration of already present lung diseases

• Pulmonary endometriosis

• Endometrial tissue is located in the pleura, lungs bronchi and or the diaphragm

• Endometrial cells at these sites are affected by the hormonal changes of the menstrual cycle with concomitant active bleeding

• The clinical presentations include :Catamenial pneumothorax 80%Catamenial haemothorax 14%Catamenial haemoptysis 5%Lung nodules rare

Thoracic endometrial syndrome was first described by Barnes J in 1953 in J Obst. Gyncolog. Br. Emp : Endometriosis of the pleura and ovaries 60(6) : 823-24

Pulmonary Endometriosis

Between 2:10 % of females at reproductive age world wide have Endometriosis

In USA between 5.5:6 Million females suffer from Endometriosis

• Baron Carl von Rokitansky 1804 – 1878 • Austerian physician,

pathologist, humanist, philosopher and liberal politician • 1st to describe systemic

Endometriosis

Etiology 1. Open communication between the atmosphere

and peritoneal cavity during menstruation can allow air to migrate from

the abdomen via diaphragmatic

fenestrations into the pleura. (cure achieved by

tubal and fenestration obliteration)

Etiology 2. Endometrial implants over the diaphragm induce the

defects

Etiology 3. PGF2 excessively released during menstruation causes

bronchiolar and alveolar constriction and rupture

PGF2

Etiology 4. Lymphatic & or haematogenous embolization of

endometrial tissue from the uterine vessels

Women with bronchopulmonary endometriosis tend to have a history

of uterine manipulation or trauma (e.g., hysteroscopy, dilation and

curettage). This supports the lymphovascular embolization theory, whereas those with pleural disease most often have a history of pelvic

endometriosis.

Concerning the etiology of CPT, it is hypothesized that transgression or erosion of the diaphragm as an anatomic boundary by endometriotic

tissue represents the central pathophysiologic mechanism of CPT. This can be stimulated through a heat-stable factor from

the peritoneal fluid, together with an increased proteolytic capacity. Endometriotic cells can demonstrate a higher

maneuverability with an enhanced potential for local invasiveness

Mechanism of Endometriosis Diaphragmatic Transport

Lillington and associates coined the term

catamenial pneumothorax. They proposed a model in

which the expansion of intraparenchymal

subpleural endometriotic tissue during menses would cause a check-

valve airway obstruction, eventually leading to

alveolar rupture.

Catamenial Pneumothorax

Lillington GA, Mitchell SP, Wood GA. Catamenial pneumothorax. JAMA. Mar 6 1972;219(10):1328-1332.

Patients with CP present with symptoms of spontaneous

pneumothorax that are usually nonspecific such as :

In most cases, symptoms are mild to moderate while severe

presentations are rare

1. Pleurisy, 2. Cough, 3. Shortness of breath 4. Peri-scapular or radiating

neck pain due to diaphragmatic irritation.

Alifano M, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac Surg. Feb 2006;81(2):761-769.

Clinical picture of catamenial pneumothorax

In the largest review of CP cases, more than 50% (52.1%) of patients with CP assessed with VATS were

diagnosed as having thoracic endometriosis. Diaphragmatic abnormalities (fenestrations or

endometriosis, alone or combined) are the most commonly described

lesions (38.8%), followed by endometriosis of the visceral pleura (29.6%). In the remainder of cases,

discrete lesions, such as bullae, blebs, and scarring (23.1%), or no findings

(8.5%) are noted.

Catamenial PneumothoraxEndoscopy

Korom S, Canyurt H, Missbach A, et al. Catamenial pneumothorax revisited: clinical approach and systematic review of the literature. J Thorac Cardiovasc Surg. Oct 2004;128(4):502-508.

Diaphragmatic fenestrations range from a few millimeters to 2 cm. Endometrial deposits in both the diaphragm and pleura have a similar appearance and range from a few millimeters to 1 cm. Their color ranges from violet to brown, depending on the day of menstrual cycle.

Catamenial PneumothoraxEndoscopy

Performance of a combined VATS and laparoscopy procedure in a single session is another diagnostic approach.

Alifano M, Venissac N, Mouroux J. Recurrent pneumothorax associated with thoracic endometriosis. Surg Endosc. Jul 2000;14(7):680.

CHT is an uncommon manifestation of TES accounting for approximately 14% of cases. As with CP, CHt is almost always

unilateral and right sided, although left-sided hemothorax

has been reported. Again, symptoms are nonspecific and

include pleuritic pain, shortness of breath, and cough. The

presence of bloody effusion is variable. Computed tomography

(CT) of the chest may show multiloculated effusions, nodular

lesions of the pleura, or bulky pleural masses.

Catamenial haemothorax

CH and lung nodules are both clinical entities of bronchopulmonary TES and

are very rare manifestations. Hemoptysis is a quite variable

manifestation, with neither massive hemoptysis nor deaths being described so far. An association with menses may

not always be appreciated, and diagnostic delays of up to 4 years from

the onset of symptoms have been reported. CH and lung nodules are interrelated entities. Thus, patients

who present with CH frequently have associated lung nodules on imaging

studies and vice versa.

Catamenial haemoptysis and lung nodules

CP, CHt, CH, and lung nodules represent the main clinical entities in TES. However, they are not the only

manifestations of TES, other manifestations include catamenial phrenic nerve irritation causing a

catamenial pain-only syndrome, namely cyclic shoulder, neck, epigastric, or right

upper quadrant pain

Rare manifestations of TES

Imaging in Thoracic Endometriosis

X ray chest and preferably CT scan can identify menstrual associated pulmonary and bronchial infiltrates and confirm both their amelioration by the end of the cycle and their recurrence with each following cycle. Thus performing imaging studies and bronchoscopy during menses assist in the diagnosis of pleural and bronchopulmonary disease. i.e Repeated imaging studies or bronchoscopy during midcycle typically documents the disappearance of the previously reported findings, thus strengthening the clinical suspicion.

Hope-Gill B, Prathibha BV. Catamenial haemoptysis and clomiphene citrate therapy. Thorax. Jan 2003;58(1):89-90.

Imaging in Thoracic Endometriosis

VATS is the gold standard modality for both the definitive diagnosis and surgical treatment of CP.

Alifano M, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac Surg. Feb 2006;81(2):761-769.

Treatment of Catamenial Pneumothorax

Tissue diagnosis of respiratory endometriosis can be achieved by:

1. FOB forceps biopsy 2. TBNA 3. US/CT guided lung biopsy 4. Surgical lung biopsy

Pathologic diagnosis of respiratory endometriosis

Medical Treatment

1.Danazol

2.Contraceptive pills

3.GnRH analogues

Recurrent rate at 1 y : 50 – 60 %

Medical Treatment often serves as a diagnostic tool with the +ve response

paving the way for more effective surgical treatment

Surgical treatment 1.Thoacentesis and chest tube

2.VATS +/- laparoscopy : with complete inspection of the pleura and both diaphragmatic surfaces for fenestrations and nodules

3.Small, few mms, endometrial nodules can be fulgurated by diathermy or CO2 laser

4.Large nodules should be excised from the pleura and the lungs even if combined with necessary parenchymal resection : segmentectomy or lobectomy

Surgical treatment 5. Large diaphragmatic fenestrations can be sutured +/- mesh

coverage

6. Pleurodesis in combination with any of the previous procedures adds to the efficiency of management

7. Based on the recurrence rate estimates of pervious modalities combined surgical and subsequent hormonal treatment is recommended

TES is a challenging clinical entity. A high

index of clinical suspicion is of

paramount importance as both diagnosis and treatment may often be delayed for years.

CONCLUSION

Endometriosis has variable and often subtle clinical and macroscopic features that include

Catamenial pneumothorax Catamenial haemothorax Catamenial haemoptysisLung nodules

CONCLUSION

A multidisciplinary approach by thoracic and gynecologic surgical teams carries the highest chance of making an accurate diagnosis and providing the appropriate

treatment strategies.

CONCLUSION

Thank you