Baby or Breathing? Management of Thoracic Endometriosis in a Patient Seeking Pregnancy

Abstract

Introduction: The most common site for endometriosis outside of the abdominopelvic cavity is the thoracic cavity. We report a case of thoracic endometriosis (TES) presenting as recurrent pleural effusions, with treatment confounded by the patient’s desire for pregnancy. Case Presentation: A 41-year-old female with a past medical history of uterine fibroids and endometriosis complicated by peritoneal nodules and hemorrhagic ascites was referred to Pulmonology in 2020 for a chronic right pleural effusion first seen in 2017. Thoracentesis showed an orange, lymphocyte-predominant, exudative effusion; cytopathology and infectious work-up were normal. She returned to clinic in September 2021 and ultrasound showed reaccumulation of the effusion. Thoracic surgery performed a decortication and pleurodesis in October 2021, and post-surgical chest radiograph showed resolution of the effusion. Intraoperative biopsies confirmed thoracic endometriosis. Despite encouraging her to initiate medications for ovulation suppression, the patient had a strong desire for pregnancy and declined. Unfortunately, a CT chest scan in August 2022 showed recurrence of the right sided effusion. The patient was asymptomatic and her effusion was monitored with serial imaging and ultrasound. Additional thoracentesis was deferred due to stability of the effusion, minimal symptomatology, and the increasing risk associated with serial thoracentesis for an effusion that would certainly recur without ovulation suppression. The patient continued her desire for pregnancy and declined medical management. Recently, she became more dyspneic and developed chest pain. Repeat chest CT scan in October 2024 showed a stable, moderate-sized, loculated pleural effusion. Repeat drainage is planned but due to the chronicity of the effusion, the patient is at higher risk for re-expansion pulmonary edema and trapped lung. Discussion: Postoperative ovulation suppression, often in the form of GnRH analogues, is used to prevent recurrence of complications of TES, such as pleural effusions, hemoptysis, and pneumothoraces. For TES, medical and surgical management alone have an approximately 40% and 25% recurrence rate, respectively. Although there are no randomized control trials evaluating combined surgical-medical management, many physicians use this approach with promising results. One small study demonstrated a 0% recurrence rate of catamenial pneumothorax when GnRH analogues were used after surgical treatment. Because endometriosis causes complications in women of child-bearing age, family planning should be addressed in management of TES. Early combined surgical and medical management is the most effective approach to prevent recurrence of pleural effusions.