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J Thorac Cardiovasc Surg 1999;117:632-633
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Consideration of anatomic defects in the etiology of catamenial pneumothorax

Henry F. Tripp, MD, Lieutenant Colonel, James A. Obney, MD, Captain, San Antonio, TX

Department of Thoracic and Cardiovascular Surgery, Brooke Army Medical Center, San Antonio, TX, 78234-6200

To the Editor:

We read with interest the recent report of Fonseca,Go 1 "Catamenial Pneumothorax: A Multifactorial Etiology." We certainly agree that the etiology of this disorder is uncertain, and Fonseca's report is a timely contribution to our understanding of this condition, which is becoming increasingly recognized. In fact, a recent report by Blanco and associatesGo 2 estimated that catamenial pneumothorax accounts for 2.8% to 5.6% of pneumothoraces in women. Indeed, because spontaneous pneumothorax occurs overwhelmingly in men, we conclude that this entity should be considered in all premenopausal women who have pneumothorax, especially with recurrence. A search of the literature reveals that this disorder is becoming increasingly appreciated.

Although we concur that multiple causes may account for the occurrence of recurrent pneumothoraces in these patients, we cannot overlook the role of anatomic abnormalities. WeGo 3 recently reported a case of catamenial pneumothorax in which diaphragmatic endometrial implants and fenestrations were encountered. In addition, other recent reports have documented similar findings.Go Go 2,4 Likewise, Slasky and coworkersGo 5 reported on 3 patients with catamenial pneumothorax and diaphragmatic involvement in whom the central tendon of the diaphragm was resected with good results. We think that the estimates of the incidence of diaphragmatic implants or fenestrations quoted by Fonseca are low, and we refer to the more recent meta-analysis performed by Joseph and Sahn.Go 6 These authors found that in 48 women who underwent surgery for catamenial pneumothorax, 42 had diaphragmatic fenestrations, endometrial implants, or both, an incidence of nearly 88%. If these findings do indeed turn out to be more consistent than previously appreciated, then it would seem logical to implicate their presence in the etiology of this condition.

We also acknowledge the effects of systemic factors in the etiology of this disorder. Indeed, although not used in the case report by Fonseca, we note the excellent results reported in the systemic management of catamenial pneumothorax with gonadotropin-releasing hormone analogs. These might be the agents of choice in systemic therapy for this increasingly recognized syndrome.Go Go 3,7

References

  1. Fonseca P. Catamenial pneumothorax: a multifactorial etiology. J Thorac Cardiovasc Surg 1998;116:872-3. [Free Full Text]
  2. Blanco S, Hernado F, Gomez A, et al. Catamenial pneumothorax caused by diaphragmatic endometriosis. J Thorac Cardiovasc Surg 1998;116:179-80. [Free Full Text]
  3. Tripp HF, Thomas LP, Obney JA. Current therapy of catamenial pneumothorax: Heart Surgery Forum 1998;1:21980.
  4. Cowl CT, Dunn WF, Deschamps C. Diaphragmatic fenestration identified in a patient with recurrent catamenial pneumothorax Chest 1998;114:413S.
  5. Slasky BS, Siewers RD, Lecky JW, Zajko A, Burkholder JA. Catamenial pneumothorax: the roles of diaphragmatic defects and endometriosis. AJR Am J Roentgenol 1982;138:639-43. [Abstract/Free Full Text]
  6. Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996;100:164-9. [Medline]
  7. Dotson RL, Peterson M, Doucette RC, et al. Medical therapy for recurring catamenial pneumothorax following pleurodesis. Obstet Gynecol 1993;82:656-8. [Medline]



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