Catamenial dyspnea due to diaphragmatic or pleural endometriosis

Specialty: Respiratory.

• menstrual cyclical shortness of breath
• catamenial dyspnea

Why it occurs

• Diaphragmatic endometriosis (functional endometrial tissue implants on the surface of the diaphragm, usually on the right side, which cyclically bleed and inflame during menstruation, causing localized pain and limitation of diaphragmatic movement)
• Visceral or parietal pleural endometriosis (leads to recurrent pleural microbleeds and recurrent catamenial pneumothorax due to passage of air through diaphragmatic pores)
• Catamenial pneumothorax associated with direct pulmonary endometriosis (intraparenchymal endometrial implants that erode the alveoli or visceral pleura coinciding with the menstrual cycle).

Initial workup

Thoracic and pleural ultrasound during the menstrual period (search for pneumothorax or right pleural effusion); High-resolution chest computed tomography (CT) or thoracic/diaphragmatic magnetic resonance imaging (MRI) (more sensitive for identifying diaphragmatic endometrial implants); Surgical videothoracoscopy (VATS) (diagnostic and therapeutic, allowing direct visualization of the purple implants in the diaphragm and pleura).

Standard management

• Medroxyprogesterone acetate — 10 mg orally daily, or intramuscular depot formulation to induce anovulation and atrophy of ectopic endometrial tissue
• Goserelin — GnRH analogue, 3.6 mg subcutaneously every 28 days for complete ovarian suppression, under close monitoring
• Ibuprofen (400-600 mg orally every 8 hours to control pain and cyclical diaphragmatic inflammation).