the lung function starts with the first moment of life and ceases with death
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The Menstrual Cycle & The Lung . 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. - PowerPoint PPT PresentationTRANSCRIPT
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• 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
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Menarche and the lung
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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
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Menstruation and the Lungs • Respiratory symptoms during
menstruation
• Catamenial lung disorders
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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
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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.
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Catamenial lung disorders
• SOB – TIC – Chest pain
• Exacerbation / deterioration of already present lung diseases
• Pulmonary endometriosis
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• 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
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Between 2:10 % of females at reproductive age world wide have Endometriosis
In USA between 5.5:6 Million females suffer from Endometriosis
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• Baron Carl von Rokitansky 1804 – 1878 • Austerian physician,
pathologist, humanist, philosopher and liberal politician • 1st to describe systemic
Endometriosis
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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)
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Etiology 2. Endometrial implants over the diaphragm induce the
defects
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Etiology 3. PGF2 excessively released during menstruation causes
bronchiolar and alveolar constriction and rupture
PGF2
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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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
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Imaging in Thoracic Endometriosis
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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
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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
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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
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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
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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
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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
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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
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Endometriosis has variable and often subtle clinical and macroscopic features that include
Catamenial pneumothorax Catamenial haemothorax Catamenial haemoptysisLung nodules
CONCLUSION
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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
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Thank you