Catamenial hemoptysis

Specialty: Gynecology and breast.

• Coughing up blood during menstruation
• menstrual hemoptoic sputum
• symptomatic pulmonary endometriosis

Why it occurs

• Bronchopulmonary endometriosis (presence of endometrial tissue implants in the lung parenchyma or airways that bleed coinciding with uterine shedding of the period)
• Pleuroparenchymal fistula secondary to deep diaphragmatic endometriosis
• Active pulmonary tuberculosis with incidental hemoptoic exacerbation coinciding with menstruation
• Unilateral colonized bronchiectasis that bleeds due to hormonal vascular congestion

Initial workup

Immediate chest x-ray (may show transient nodular opacities that disappear after menstruation). High Resolution Computed Tomography (HRCT) of the chest performed during menstrual days (targets foci of ground glass attenuation or small subpleural nodules in the affected areas). Diagnostic bronchoscopy to directly visualize the foci of endobronchial endometriosis (active red-violet areas).

Standard management

• GnRH analogues (Triptorelin 3.75 mg intramuscularly monthly or Goserelin 3.6 mg subcutaneously monthly) for an initial period of 6 months to drastically suppress endogenous estrogen levels and cause regression of pulmonary endometrial tissue
• Dienogest 2 mg orally daily continuously. In cases of refractory, abundant or recurrent hemoptysis despite hormonal treatment, segmental resection of the affected lung parenchyma using video-assisted thoracoscopic surgery (VATS) or selective embolization of bronchial arteries is considered (note: avoid the use of high-potency NSAIDs if pulmonary bleeding is abundant).