Balancing Catamenial Pneumothorax Management with Fertility: Insights from GnRH Agonist Use

Abstract

BACKGROUND Catamenial pneumothorax (CP) is the most common manifestation of thoracic endometriosis syndrome, typically managed with hormonal therapy to suppress ovarian function and prevent recurrence. However, this approach conflicts with pregnancy planning, creating a therapeutic dilemma. While previous reports have discussed CP management, limited evidence exists on long-term strategies that balance disease control with fertility preservation. This case report discusses the use of a GnRH agonist as an alternative to conventional hormonal therapy, demonstrating its potential to delay CP progression while maintaining reproductive potential. CASE REPORT A 37-year-old woman, P0A0, presented with shortness of breath and a history of dysmenorrhea. A decade earlier, she had been diagnosed with pelvic endometriosis and a similar pneumothorax episode. She declined continuous hormonal therapy to preserve fertility and was instead treated with a gonadotropin-releasing hormone (GnRH) agonist. Ten years later, she developed CP and underwent pleurodesis with excision of endometriosis implants. Her postoperative course was uneventful, and she resumed pregnancy planning. This outcome aligns with emerging evidence suggesting that GnRH agonists offer prolonged CP control without compromising fertility, contrasting with the higher recurrence rates seen in patients who do not receive medical management. CONCLUSIONS This case demonstrates that prolonged CP control is feasible using a GnRH agonist, providing an alternative to continuous hormonal therapy in women prioritizing fertility. Future research should focus on defining the optimal duration of GnRH agonist treatment, identifying patient selection criteria, and evaluating long-term reproductive outcomes in CP patients who do not receive standard hormonal suppression.

Figure 1

Chest X-ray on first hospital admission. Yellow arrow indicates increased rib separation; red arrow shows the deep sulcus sign; black arrow highlights air in the right hemithorax displacing both the diaphragmatic dome and the anterior costophrenic angle, indicating a large right-sided pneumothorax; the green arrow demonstrates lucency outlining the lung margin.

Figure 2

Follow-up chest X-ray from Soesilo Slawi Tegal Hospital shows a massive right pneumothorax. Yellow arrow indicates increased rib separation; green arrow highlights lucency along the lung margin.

Figure 3

Follow-up chest X-ray shows minimal pneumothorax with water seal drainage in place. Yellow arrow indicates the drainage tube; red arrow shows reappearance of bronchovascular markings in the previously avascular pulmonary region.

Figure 4

MSCT Thorax CT scan with contrast showing minimal right pneumothorax (on chest tube), and no masses/consolidations were seen in the bilateral lung. Red arrow shows a minimal pneumothorax.

Figure 5

Ultrasonography result in referral hospital. (A) Gray-scale ultrasonography shows hyperechoic islands (red arrows) within the uterine parenchyma, a globular uterine shape, and asymmetrical thickening of the uterine walls (dashed white circle), indicative of possible adenomyosis and endometriosis. (B) Doppler ultrasonography demonstrates increased vascularity (red arrows) within the uterine lesion (perilesion), suggesting endometriosis.

Figure 6

Intraoperative findings. (A) Before endometriosis resection. (B) After endometriosis resection. Red arrow indicates endometriosis implant on the thoracic cavity.

Figure 7

Specimen findings of endometriosis tissue from thoracotomy.

Figure 8

Histopathology result of diaphragm wall. (A) Endometrial glands and stroma (red circle) located between diaphragmatic muscle bundles (green arrow), fibrous connective tissue stroma (black arrow), and adipose tissue (red arrow) (hematoxylin and eosin stain, 40× magnification). (B) Endometrial stroma with hemorrhage and hemosiderin-laden macrophage infiltration (yellow circle) (hematoxylin and eosin stain, 100× magnification). (C) Hemosiderin-laden macrophages with brownish-red stained cytoplasm (yellow arrow) (hematoxylin and eosin stain, 400× magnification).

Figure 9

(A, B) Edematous alveolar tissue with vascular proliferation and dilation (green arrow). Severe alveolar distension (black cross) indicates pneumothorax. (A) Hematoxylin and eosin stain, 40× magnification. (B) Hematoxylin and eosin stain, 100× magnification.

Figure 10

Postoperative chest X-ray shows no signs of progressive pneumothorax. The red arrow indicates visible bronchovascular markings.