Catamenial pneumothorax treated by laparoscopic tubal occlusion using Filshie clips

Abstract

From November 1998 to June 1999 a previously healthy 38-year-old woman experienced seven episodes of recurrent spontaneous right-sided pneumothorax associated with the period of menstruation. The intervals of menstruation were regular and she described neither gynecologic complaints nor pelvic pain. Her obstetric history was three vaginal deliveries and apart from these no hospitalization. There was no history of thoracic disease, and she was a nonsmoker. The woman was each time admitted to hospital because of right-sided chest pain and dyspnoea. Physical and radiological examination confirmed each diagnosis of pneumothorax. Twice she was treated with chest drainage. Thorascopy diagnosed an area apically of different sized blebs/bullae located on the surface of the parietal pleura (subpleural) and thin adhesions from the lung to the parietal pleura. The pulmonary parenchyma appeared normal and in particular no bullae were seen. Pleural abrasion was performed eliminating the pleural blebs. With her next menstruation the woman presented with a pneumothorax located at the basal part of her right lung indicating sufficient efficacy of the apical pleurodesis. Computed tomography revealed no further pathology apart from the pneumothorax and pneumomediastinum. Chemical pleurodesis with administration of tetracycline was done to prevent recurrent basal pneumothorax. The symptoms of catamenial pneumothorax were now commanding and suspecting thoracic endometriosis a laparoscopy was performed and tubal occlusion planned. At laparoscopy the left ovary had several purplish-red nodules owing to endometriosis of the ovary and along the sacrouterine ligaments tiny bullae and minor chronic inflammation of the peritoneum were noted consistent with the diagnosis of pelvic endometriosis. The diaphragmatic surface was normal with no abnormalities or fenestrations to be seen. The histological evaluation revealed hemorrhagic foci but no exact diagnosis of endometriosis could be stated. Cytological examination of the pleural fluid offered no diagnosis either. Tubal occlusion using Filshie clips was carried out. The woman has had no recurrent pneumothorax. Endometriosis is a common gynecologic disease probably affecting 6–25% of fertile women. The knowledge of the epidemiology is limited owing to some women being asymptomatic and to different prevalence among the various groups of symptomatic women (infertility, chronic pelvic pain, sterilization) (1). Extra-pelvic endometriosis occurs in the presence or absence of pelvic disease, and thoracic endometriosis occurs in more than half of these cases (2, 3). Catamenial (Katamenios, Greek meaning menses/monthly) pneumothorax, i.e. spontaneous recurrent pneumothorax associated with the menstrual period mainly right-sided (93%), represents 2.8–5.6% of spontaneous pneumothoraces in women (3, 7). Spontaneous recurrent pneumothorax related to menstruation was first described in 1958 (4) and named Catamenial pneumothorax in 1972 (5). Since then approximately 100 cases have been reported. The age at onset of symptoms is mid-thirties. The diagnosis is clinical and the mean time before diagnosis is 8 months because of delay until attention is brought to the relationship to menstruation. Histological verification is dependant on an invasive procedure, and cytology is seldom helpful (3). The etiology and pathogenesis remain controversial. It has been hypothesized that diaphragmatic fenestrations of various sizes allow air from the peritoneal cavity to enter the pleural space and cause Catamenial pneumothorax. The air presumably gains access to the peritoneal cavity via the genital tract with the onset of menstruation. Widely accepted also is the theory of dissemination of endometrial tissue by microembolization through vascular or lymphatic channels. Swelling in response to hormonal changes may cause bronchial obstruction leading to increased intra-alveolar pressure and pleural rupture. Diaphragmatic fenestrations are found in some cases. Pleural or diaphragmatic endometrial implants are demonstrated in less than 50% of cases 4-7). Traditional therapy has involved surgical procedures as first-line treatment. Hormonal treatment suppresses ovulation and Catamenial pneumothorax is thereby prevented; however, a certain risk of recurrence is possible when treatment is stopped. Ultimately hysterectomy and bilateral oophorectomy have been performed 5-7). A less invasive procedure is tubal occlusion at laparoscopy only described once in the literature by Eckford and Westgate in 1996 (7). Theoretically the procedure hinders the air leakage through the genital tract. We describe a case where a woman suffered Catamenial pneumothorax with each menstruation and has not had any recurrence after tubal occlusion with Filshie chips. Address for correspondence: Lone Laursen Department of Gynecology and Obstetrics Odense University Hospital DK-5000 Odense C Denmark e-mail: [e-mail]