title: Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature.
abstract: OBJECTIVE
  Spontaneous recurrent pneumothorax during menstruation is reported as catamenial pneumothorax. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women. The percentage among women referred for surgery is significantly higher (25-30%). Although it usually involves the right-side (85-95%) it can be left-sided or bilateral. It is associated with diaphragmatic perforations and/or thoracic endometriosis. There is pelvic endometriosis in up to 30-51% of cases. The lesions that are not always found may present as small or larger holes at the central tendon of the diaphragm, as red, blueberry, brown spots or larger nodules at the diaphragm, the visceral or parietal pleura. Lesion histology may reveal endometriosis. We present 5 cases of catamenial pneumothorax treated surgically during the last 6 years.
  
  
  METHODS
  Five women, with a mean age of 34+/-9.9 years (median 38, range, 19-45 years) presented with right-sided recurrent catamenial pneumothorax. In 3 patients diaphragmatic perforation(s) were found; perforation suturing (n=1), and diaphragmatic plication reinforced with bovine pericardial patch (n=1) were performed. All patients underwent atypical resection of upper and/or middle lobe segments of lung parenchyma that appeared abnormal (haemorrhagic/emphysematous or blebs). Four patients underwent pleurodesis and 1 patient underwent pleurectomy. Four interventions were performed through video assisted thoracoscopic surgery, while diaphragmatic plication was performed through a video assisted mini-thoracotomy. Histology did not reveal endometriosis tissue.
  
  
  RESULTS
  The postoperative course was uneventful. The patients were extubated in theatre and were discharged home at a mean of 7+/-4 days (median 6 days, range, 4-14 days). Two of them received hormonal therapy [Gonadotropin Releasing Hormone (GnRH) analogue] postoperatively. At a follow-up of 14.16 patient-years (mean 2.83+/-1.08 years, range, 1.33-3.83 years) there was recurrence, 6.5 months postoperatively, in one patient that had not undergone closure of a tiny diaphragmatic hole and had not received hormonal treatment postoperatively. She was treated medically (amenorrhea for 6 months with GnRH analogue) and had no further recurrences (in 3.3 years).
  
  
  CONCLUSIONS
  Surgery is the treatment of choice of catamenial pneumothorax. It should aim to complete management of all lesions. The most common complication is recurrence. Early diagnosis and multidisciplinary treatment including hormonal therapy may be beneficial in high risk patients.
authors.affiliation: Cardiothoracic Department, St Luke's Hospital, Panorama, Thessaloniki, Greece;
authors.forename: Aikaterini N
authors.initials: AN
authors.lastname: Visouli
authors.forename: Kaid
authors.initials: K
authors.lastname: Darwiche
authors.forename: Andreas
authors.initials: A
authors.lastname: Mpakas
authors.forename: Paul
authors.initials: P
authors.lastname: Zarogoulidis
authors.forename: Antonios
authors.initials: A
authors.lastname: Papagiannis
authors.forename: Kosmas
authors.initials: K
authors.lastname: Tsakiridis
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Machairiotis
authors.forename: Aikaterini
authors.initials: A
authors.lastname: Stylianaki
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Katsikogiannis
authors.forename: Nicolaos
authors.initials: N
authors.lastname: Courcoutsakis
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Zarogoulidis
keywords: Catamenial pneumothorax; thoracic endometriosis; video-assisted thoracoscopic surgery