Catamenial Hemoptysis Managed With Medroxyprogesterone Acetate: A Management Dilemma

Endometriosis can be described as the deposition of functional tissue of the endometrium or glands in areas other than the uterus (1). There are two types of endometrial tissue depositions, namely, pelvic and extrapelvic. The deposition of glands in the ovaries, fallopian tubes, and their associated peritoneum is referred to as pelvic endometriosis. Extra pelvic endometriosis is extremely rare and generally involves the gastrointestinal and urinary tracts. The other involved sites are the lungs, central nervous system, surgical scars, and the skin. Endometriosis is estrogen-dependent, and there are many theories describing its pathogenesis (2). It generally affects 5-10% of women in the third decade of life (3). When glands from the endometrium deposit in the lungs or the pleura, it is called thoracic endometriosis syndrome (TES). It is a rare type of endometriosis characterized by catamenial pneumothorax, hemoptysis, pneumothorax, and pulmonary nodules (4) and is commonly mistaken for tuberculosis endemic in countries such as India. This report describes the scenario of a woman aged 26 years old with endometriosis who was presented with dyspnea, hemoptysis, and chest pain. Case Report A married woman aged 26 years with two previous vaginal births was presented with complaints of hemoptysis, chest pain, and dyspnea for about 4 months which was most severe during menstruation and subsided slowly by day 5 or 6 of the menstrual cycle. There was also a history of dysmenorrhea for the last 3 years although there was no history of fever, loss of weight, or loss of appetite. Her symptoms had initially begun about 8 months after the birth of her second child and the hemoptysis and chest pain had progressively increased over a period of time. Suspecting that she might have contracted pulmonary tuberculosis, she underwent anti-tubercular therapy by a general practitioner 4 months ago although she did not improve symptomatically. Then, she was presented with amenorrhea for about two months. Since she did want to continue with the pregnancy, she requested for the termination of pregnancy and permanent sterilization. On detailed history taking, it was found that during the two months of amenorrhea, hemoptysis had subsided. She did not visit the hospital initially thinking that the hemoptysis had subsided because of anti-tubercular therapy. Her complete blood count, erythrocyte sedimentation rate, coagulation profile, and liver and kidney functions were Abstract Introduction: Endometriosis is the deposition of endometrial glands and stroma outside the uterus and can be of pelvic or extrapelvic type. Thoracic endometriosis syndrome (TES) is associated with endometriosis in the pleura or the lungs, as well as cyclical pneumothorax, chest pain, haemoptysis, and pulmonary nodules. TES can be misdiagnosed for the more prevalent pulmonary tuberculosis in countries such as India. Case Report: A married woman aged 26 years old was presented with complaints of hemoptysis and chest pain during menstruation. On further investigations, she was diagnosed with pulmonary endometriosis after ruling out tuberculosis and Wegener’s granulomatosis. The patient was treated with depot Medroxyprogesterone acetate and regestrone since she was unwilling for surgical management. The significant change in management is that most cases of pulmonary endometriosis have been managed surgically whereas our case has been successfully managed medically. Conclusions: This case is an example for successful medical management of pulmonary endometriosis in patients who cannot or do not want to undergo a bilateral oophorectomy and a possible thoracotomy. Surgical management with bilateral oophorectomy is associated with premature menopausal symptoms, increased risk of cardiovascular diseases, and obesity. In cases of subfertility or in nulliparous women, the medical management of pulmonary endometriosis gives women a chance at fertility in the future.