Thoracic endometriosis

Last revised by Yuranga Weerakkody on 18 Mar 2021

Thoracic endometriosis is an uncommon location for endometriosis and the main cause of catamenial pneumothorax

Most often occurs in the third and fourth decades of life 3.

Symptoms may include:

  • catamenial pleuritic chest pain
  • catamenial hemoptysis: when endometrial tissue is in the bronchial tree

Patients may also present with a catamenial pneumothorax or catamenial hemothorax when endometrial tissue is in the lung periphery. The presentation may also be with a lung nodule.

Endometriosis is the presence of functioning endometrial tissue in extrauterine locations. It is most often confined to the pelvis; however extrapelvic sites like umbilicus, scar sites in abdomen, breasts, extremities and thorax may also be involved. In thorax the sites to be involved are pleura, parenchyma, airways and the diaphragm 1.

The exact pathogenesis of thoracic endometriosis is elusive. The theories postulated are:

  • due to in utero pleural metaplasia into pleural endometrial tissue
  • retrograde menstruation with further thoracic implantation of endometrial tissue by transdiaphragmatic passage  
  • hematogenic migration post a surgical gynecological procedure

Post-implantation of endometrial tissue there is extensive decidual adhesions and distortion of tissue, which leads to the classical catamenial pain and hemoptysis 2.

There is a predilection for right-sided involvement in case of pleural endometriosis, however in parenchymal involvement there is no such predilection seen.

Chest CT is the modality of choice for thoracic endometriosis, which may demonstrate presence of pneumothorax, hemothorax or nodules which may change in nature cyclically. There may sometimes be vague areas of bronchial wall thickening, thin-walled cavities, bullous formation or ground glass opacities. CT may also be used to provide guidance for targeted biopsy. Imaging should be carried out during menstruation for higher sensitivity.

The treatment options are medical or surgical. Gonadotropin releasing hormone agonists are recommended for treatment of extrapelvic endometriosis. The other options are lung resection using VATS.

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Cases and figures

  • Figure 1: histology
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  • Case 1
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  • Figure 2: pleuroscopic image
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