Journal Mobile Options
Table of Contents
Vol. 79, No. 4, 2010
Issue release date: February 2010
Section title: Clinical Investigations
Respiration 2010;79:296–301
(DOI:10.1159/000228831)

Catamenial Hemoptysis: A Nationwide Analysis in Korea

Kim C.-J.a · Nam H.-S.b · Lee C.-Y.c · Yum H.-K.d · Yang S.-H.g · Seo K.-H.h · Son C.-H.i · Kim D.-J.h · Jang S.-H.e · Chung M.-P.b · Park Y.-B.e · Lee J.-C.f · Ryu J.-S.j
Departments of Internal Medicine,aNational Health Insurance Corporation, Ilsan Hospital, Koyang, Colleges of Medicine, Universities of bSungkyunkwan, cYonsei, dInje and eHallym, and fKorea Cancer Center Hospital, Seoul, and Colleges of Medicine, gWonkwang University, Iksan, hSoonchunyang University, Chunan, iDong-A University, Busan, and jInha University, Incheon, South Korea
email Corresponding Author

Prof. Jeong-Seon Ryu, MD, PhD

Pulmonary Division, Department of Internal Medicine

Inha University Hospital

7-206, 3-Ga, Shinheung Dong, Jung Gu, Incheon, 400-103 (South Korea)

Tel. +82 32 890 3738, Fax +82 32 882 6578, E-Mail jsryu@inha.ac.kr


Abstract

Background: Hemoptysis is a potentially serious clinical problem. However, there is no consensus on the clinical characteristics, treatment and patient outcome of catamenial hemoptysis. Objective: Clinical characteristics, treatments and outcome in patients of catamenial hemoptysis were evaluated. Methods: We conducted a retrospective nationwide observational analysis of Korean patients with catamenial hemoptysis. Results: Nineteen patients with catamenial hemoptysis were evaluated from 13 tertiary-care hospitals in Korea. The median age of the patients was 25 years; 8 (42%) were ever-smokers. Eight patients were pathologically diagnosed; 11 were diagnosed by clinical criteria. Sixteen (84%) patients had a history of obstetric or gynecological procedures before developing hemoptysis. The mean amount of hemoptysis (mean ± SD) was 58.3 ± 71.3 for surgery, 46.4 ± 33.2 for hormonal and 29.1 ± 26.3 for conservative treatment groups. Hemoptysis did not recur in 8 (89%) of 9 patients after surgery. None of the patients in the hormonal or conservative treatment groups had persistent hemoptysis. There was an excellent outcome (complete remission and partial responses) in all patients with conservative treatment, suggesting that endometrial cells implanted into the lung may have a benign course. Conclusion: Patients without massive hemoptysis can be treated conservatively or with hormonal agents.

© 2009 S. Karger AG, Basel


Related Articles for ""

Close Related Articles


Introduction

Catamenial hemoptysis is a rare disorder that is characterized by hemoptysis occurring concomitant with menstruation in female patients. It is presumed to be due to intrabronchial or parenchymal endometrial tissue deposits, and is considered a subset of extrapelvic endometriosis [1]. Currently, there are about 40 cases reported in the English literature. There are no large-scale systematic studies on catamenial hemoptysis due to its scarcity. Most of the information available on this disorder is based on anecdotal evidence. The etiological mechanisms remain to be elucidated, and optimal management is debated. Various treatment modalities such as surgery, hormonal therapy or conservative management have been attempted [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16]. However, the current knowledge on treatment outcomes of catamenial hemoptysis is largely based on case reports of patients with pelvic endometriosis. There is no consensus on the clinical characteristics, treatment and patient outcome of catamenial hemoptysis.

Therefore, we conducted a retrospective nationwide observational study and identified 19 patients with catamenial hemoptysis. Here, we report their clinical characteristics, treatments and outcome.

Patients and Methods

We conducted a retrospective nationwide survey in 2006. Forty tertiary-care hospitals were initially contacted; pulmonary physicians were asked whether they had experience with catamenial hemoptysis. The study protocol was explained and if they had experience with such patients they were invited to participate. For inclusion in the study, subjects were required to have at least one of the two following diagnostic criteria: pathological findings consistent with the diagnosis or a clinical history of at least six synchronous occurrences of hemoptysis with menstruation, characteristic findings on a chest CT performed both during menstruation and between menstruation, and exclusion of other causes of hemoptysis. Of 24 patients diagnosed between March, 1995, and July, 2006, 5 were excluded from this study because of lack of accordance with the inclusion criteria.

The following information (referring to the time of the diagnosis) was requested and obtained by reviewing the medical record, and radiologic and bronchoscopic examinations by a chest physician and radiologist in each institution: smoking habits, maximal amount of hemoptysis per day, number of occasions with synchronous hemoptysis, history of obstetric or gynecological procedures before hemoptysis, results of a chest CT scan and bronchoscopic examination, treatment, response to treatment, follow-up and survival. Response to treatment was evaluated arbitrarily with the following criteria: complete remission was defined as absence of hemoptysis during follow-up; a partial response was defined as a decrease in the amount or frequency of hemoptysis; stable disease was defined as persistence of hemoptysis without any changes in the amount and frequency. The duration of follow-up was calculated from the end of treatment in patients that received either hormonal treatment or surgery, and from the diagnosis in patients who received conservative treatment. The clinical characteristics, treatment and responses were analyzed. To make up for the retrospectively collected data, we tried to contact patients with incomplete data on obstetric and gynecologic history or follow-up by telephone or mail. Of 11 patients, 4 patients (patient 7, 9, 15 and 16) were not contactable. The Institutional Review Board of the Inha University Hospital (Incheon, South Korea) approved this study.

Results

Clinical Characteristics of the Patients with Catamenial Hemoptysis

A total of 19 patients were finally recruited from 13 tertiary care hospitals in South Korea (table 1). The median age of the patients was 25 (range 16–52 years). The mean follow-up lasted 33 months (range 3–82). Eleven (58%) patients were single women and 8 (42%) were ever-smokers. Eight (patients 1–7 and 14) were diagnosed by pathological findings, and 11 (patients 8–13 and 15–19) by clinical findings. Hemoptysis occurred monthly in 16 patients; bimonthly in 2 (patients 3 and 15) and irregularly in 1 (patient 5). The maximal amount of hemoptysis at presentation varied from 5 to 200 ml/day. The mean duration of hemoptysis was 21 months (range 6–120). Sixteen patients (84%) had a history of obstetric or gynecological procedures before developing hemoptysis. The median number of procedures before diagnosis was two (range 0–4).

Table 1

Clinical characteristics of patients with catamenial hemoptysis at diagnosis

http://www.karger.com/WebMaterial/ShowPic/234981

Chest CT Scan and Bronchoscopic Examination at Diagnosis

On the chest CT scan, ground glass opacities were the findings most often identified (n = 16; 84%), consolidation was observed in 6 patients (32%) and a nodule in 4 (21%). No cavitary lesions were found. The size of the lesions was smaller or disappeared between menses. The lesions were more commonly located in the right lung field rather than the left, and favored the distribution in the lower lobe compared to the upper or middle lobes (fig. 1). No lesions were noted in the trachea or bronchi that were suspicious for endometriosis by bronchoscopic examination during episodes of hemoptysis in 16 patients (84%). Sputum examination among 11 patients failed to demonstrate endometrial cells (data not shown).

Fig. 1

Topographic location of lesions seen on chest CT scans at diagnosis. Numbers in the left and right lobes refer to the lesion site of the corresponding patient.

http://www.karger.com/WebMaterial/ShowPic/234979

Treatment Outcome

The mean follow-up duration was 33 months (range 3–81) for the total study group, and for subgroups according to first-line treatment: 41.5 months for surgery, 26.7 months for hormonal treatment and 31.7 months for conservative treatment. The mean amount of hemoptysis (±SD) was 58.3 (±71.3) for the surgery group, 46.4 (±33.2) for the hormonal and 29.1 (±26.3) for the conservative treatment groups. No patient died during the follow-up. Surgery was performed in 6 (31.5%) patients as first-line treatment (5 wedge resections and 1 lobectomy). Three patients who had a partial response to other treatment methods received surgery as second-line treatment (table 2). A complete response was observed in most patients receiving surgical resection, except 1 patient (No. 19), in whom endometrial tissue was not found on pathology. Hormonal treatment was initially provided in 7 (37%) patients; a complete response occurred in 3 (43%) patients and a partial response in 4 (57%). Six (31.5%) patients were treated conservatively; 3 of them (50%) had a complete response and 3 (50%) a partial response. Two with a partial response subsequently underwent surgical treatment; despite this, 1 patient (No. 19) still only experienced a partial response.

Table 2

Response to treatment in patients with catamenial hemoptysis

http://www.karger.com/WebMaterial/ShowPic/234980

Discussion

Hemoptysis is a very common clinical problem. Treatment of hemoptysis is usually decided based on its etiology and severity. However, unlike most other causes of hemoptysis, the treatment of catamenial hemoptysis has no specific guidelines because little is known about the characteristic clinical findings, most appropriate treatment and patient outcome. It has been reported that thoracic endometriosis is either pleural (83%) or parenchymal (17%) [2]. The pleura is the most commonly involved thoracic location of endometriosis, whereas reports of catamenial hemoptysis suggesting intrapulmonary or bronchial involvement are uncommon [1].

The pathogenesis of thoracic endometriosis is not clear. However, several hypotheses have been proposed, including differentiation of mesothelial cells into endometrial cells (coelomic metaplasia), retrograde flow of the endometrial tissue through diaphragmatic defects (transplantation) and microembolization via pelvic veins [17]. The theory of coelomic metaplasia or transplantation does not explain the presence of endometrial tissue within the lung parenchyma.

The history of an obstetric or gynecological procedure (especially induced abortion) was common in patients with catamenial hemoptysis. This finding suggests that such procedures may be an important risk factor for the development of catamenial hemoptysis. Yeh [18] suggested that pleural endometriosis is caused by retrograde flow of the endometrial tissue through diaphragmatic defects, and that intrapulmonary endometriosis is caused by microembolization of endometrial cells. The findings that the right and lower lung fields were preferred sites, which was confirmed by chest CT in this study, is in support of the microembolization theory because these findings can be explained by the largest quantity of blood perfusion found in the right and lower lung fields [19].

Interestingly, the frequency of ever-smokers among the patients was found to be much higher than in the general population – the average smoking rate among Korean women aged ≥20 years being estimated to be 3.9% in 2006 [20]. This finding does not appear to be related to the disorder.

There has been no report of a patient with catamenial hemoptysis with massive or fatal hemoptysis [17]. In this study, however, 2 patients presented with massive hemoptysis. The severity of hemoptysis may be influenced by the amount of endometrial tissue and the biological activity of this tissue, e.g. hormonal effects, since hemoptysis is observed only during menstruation, and the size of the lesions changes during the menstrual cycle [21]. The fact that hemoptysis was present bimonthly or irregularly in some patients suggests that endometrial tissue in the lungs was not regularly influenced by hormonal effects. Currently, we do not know how long endometrial tissue can survive in the lungs or what factors affect its biological activity. Future studies are warranted to answer these questions.

Ground glass opacities were most commonly encountered on chest CT scans in this study. These lesions might represent parenchymal endometrial tissue or blood only. Tracheobronchial endometriosis is a subtype of catamenial hemoptysis, and the timing of the bronchoscopic examination is important for diagnosis in these cases [3,4]. Bronchoscopic examination at the time of hemoptysis, however, failed to demonstrate the presence of any central airway lesions in this study. This suggests that tracheobronchial endometriosis accounts for a small subset of patients with catamenial hemoptysis.

Eight of 9 patients that had surgery showed a complete response; the only failure might have been due to difficulty in localizing the lesion (patient 19). This finding suggests that localization is important for the success of surgery. Therefore, every effort should be made to accurately locate the source of bleeding [22]. Among the 9 patients undergoing surgery, 7 patients presenting with non-massive hemoptysis seemed to be over-treated for the following reasons. First, excellent control (complete remission plus partial response) was achieved in all patients with hormonal or conservative treatment. The results of the conservative treatment suggest that endometrial tissue in the lungs might have a benign course. Second, most patients are of reproductive age and sexually active. Third, there was no mortality although 2 patients presenting with massive hemoptysis were subjected to surgery. However, surgery, even including limited resection, can be associated with morbidity and mortality [23] and should be carefully considered before choosing it as the first-line treatment in patients with non-massive hemoptysis.

Even though hormonal treatment with gonadotropin-releasing hormone analogues, oral contraceptives, progestational drugs or danazol is commonly used for catamenial hemoptysis [5,6], it is expensive, and the symptoms often recur after the treatment is discontinued [7]. Furthermore, since these drugs inhibit ovulation, patients who want to become pregnant refuse to undergo hormonal treatment [7,24]. Therefore, hormonal treatment would not be indicated for young women of reproductive age considering pregnancy. The results of conservative treatment were similar to those of hormonal treatment in this study. Therefore, conservative treatment might be considered as first-line treatment in these women, especially those with mild symptoms.

This study may be potentially limited by its retrospective nature and thus the results must be interpreted with some caution. First, follow-up was not regularly conducted and the data on the effects of treatment and relapse were insufficient to draw definite conclusions in some patients. Second, the central form of endometriosis was not observed in this study. Although the diagnostic yield from the bronchoscopic examinations was low, intrapulmonary endometriosis involves more commonly the distal parenchyma; lavages and biopsy specimens often yield inconclusive results [3,25]. Possibly, clinicians who are not familiar with this disorder might ignore suspicious mucosal lesions from bronchoscopic examinations. Third, none of the patients had a laparoscopic examination or ultrasound at diagnosis; these are standard methods used to detect the concurrent presence of endometriosis [26,27].

In spite of these limitations, this study reports the clinical characteristics and treatment outcome of the largest number of patients with catameninal hemoptysis published to date. The findings suggest that aggressive treatment should be performed in carefully selected patients with more severe hemoptysis and well-localized lesions, whereas hormonal or conservative treatment appears to be adequate first-line treatment for patients with less severe hemoptysis.

Acknowledgment

This study was supported by an INHA University Research Grant.


References

  1. Joseph J, Sahn SA: Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996;100:164–170.
  2. Elliot DL, Barker AF, Dixon LM: Catamenial hemoptysis. New methods of diagnosis and therapy. Chest 1985;87:687–688.
  3. Wang HC, Kuo PH, Kuo SH, Luh KT: Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology. Chest 2000;118:1205–1208.
  4. Puma F, Carloni A, Casucci G, Puligheddu C, Urbani M, Porcaro G: Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis. Chest 2003;124:1168–1170.
  5. Espaulella J, Armengol J, Bella F, Lain JM, Calaf J: Pulmonary endometriosis: conservative treatment with GnRH agonists. Obstet Gynecol 1991;78:535–537.
  6. Suginami H, Hamada K, Yano K: A case of endometriosis of the lung treated with danazol. Obstet Gynecol 1985;66(suppl 3):68S–71S.
  7. Kristianen K, Fjeld NB: Pulmonary endometriosis causing haemoptysis. Report of a case treated with lobectomy. Scand J Thorac Cardiovasc Surg 1993;27:113–115.
  8. Terada Y, Chen F, Shoji T, Itoh H, Wada H, Hitomi S: A case of endobronchial endometriosis treated by subsegmentectomy. Chest 1999;115:1475–1478.
  9. Yu Z, Fleischman JK, Rahman HM, Mesia AF, Rosner F: Catamenial hemoptysis and pulmonary endometriosis: a case report. Mt Sinai J Med 2002;69:261–263.
  10. Katoh O, Yamada H, Aoki Y, Matsumoto S, Kudo S: Utility of angiograms in patients with catamenial hemoptysis. Chest 1990;98:1296–1297.
  11. Hope-Gill B, Prathibha BV: Catamenial haemoptysis and clomiphene citrate therapy. Thorax 2003;58:89–90.
  12. Cassina PC, Hauser M, Kacl G, Imthurn B, Schröder S, Weder W: Catamenial hemoptysis. Diagnosis with MRI. Chest 1997;111:1447–1450.
  13. Park YB, Heo GM, Moon HK, Cho SJ, Shin YC, Eom KS, Kim CH, Lee JY, Mo EK, Jung KS: Pulmonary endometriosis resected by video-assisted thoracoscopic surgery. Respirology 2006;11:221–223.
  14. Ronnberg L, Ylostalo P: Treatment of pulmonary endometriosis with danazol. Acta Obstet Gynecol Scand 1981;60:77–78.
  15. Johnson WM 3rd, Tyndal CM: Pulmonary endometriosis: treatment with danazol. Obstet Gynecol 1987;69:506–507.
  16. Ryu JS, Song ES, Lee KH, Cho JH, Kwak SM, Lee HL: Natural history and therapeutic implications of patients with catamenial hemoptysis. Respir Med 2007;101:1032–1036.
  17. Alifano M, Trisolini R, Cancellieri A, Regnard JF: Thoracic endometriosis: current knowledge. Ann Thorac Surg 2006;81:761–769.
  18. Yeh TJ: Endometriosis within the thorax: metaplasia, implantation or metastasis? J Thorac Cardiovasc Surg 1967;53:201–205.
  19. Kervancioglu S, Andic C, Bayram N, Telli C, Sarica A, Sirikci A: Bronchial artery embolization in the management of pulmonary parenchymal endometriosis with hemoptysis. Cardiovasc Intervent Radiol 2008;31:824–827.
  20. Korea National Statistical Office, Report on the Social Statistics Survey 2006, http://www.kosis.kr/OLAP/Analysis/stat_OLAP.jsp?tbl_id=DT_1W6C03A&org_id=101& vwcd=MT_TM2_TITLE&path=&oper_YN=Y&item=&keyword=&lang_mode= kor&list_id=101_B1702 (accessed Sep 5, 2008).
  21. Chung SY, Kim SJ, Kim TH, Ryu WG, Park SJ, Lee DY, Paik HC, Kim HJ, Cho SH, Kim JK, Park KJ, Ryu YH: Computed tomography findings of pathologically confirmed pulmonary parenchymal endometriosis. J Comput Assist Tomogr 2005;29:815–818.
  22. Lu MS, Liu YH, Wu YC, Hsieh MJ, Liu HP: What we see is not what we get in catamenial haemoptysis. Int J Clin Pract 2006;60:232–233.
  23. Hayes JP, Williams EA, Goldstraw P, Evans TW: Lung injury in patients following thoracotomy. Thorax 1995;50:990–991.
  24. Augoulea A, Lambrinoudaki I, Christodoulakos G: Thoracic endometriosis syndrome. Respiration 2008;75:113–119.
  25. Guidry GG, George RB: Diagnostic studies in catamenial hemoptysis. Chest 1990;98:260–261.
  26. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan E: ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005;20:2698–2704.
  27. Abrao MS, Gonçalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R: Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod 2007;22:3092–3097.

Author Contacts

Prof. Jeong-Seon Ryu, MD, PhD

Pulmonary Division, Department of Internal Medicine

Inha University Hospital

7-206, 3-Ga, Shinheung Dong, Jung Gu, Incheon, 400-103 (South Korea)

Tel. +82 32 890 3738, Fax +82 32 882 6578, E-Mail jsryu@inha.ac.kr


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Joseph J, Sahn SA: Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 1996;100:164–170.
  2. Elliot DL, Barker AF, Dixon LM: Catamenial hemoptysis. New methods of diagnosis and therapy. Chest 1985;87:687–688.
  3. Wang HC, Kuo PH, Kuo SH, Luh KT: Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology. Chest 2000;118:1205–1208.
  4. Puma F, Carloni A, Casucci G, Puligheddu C, Urbani M, Porcaro G: Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis. Chest 2003;124:1168–1170.
  5. Espaulella J, Armengol J, Bella F, Lain JM, Calaf J: Pulmonary endometriosis: conservative treatment with GnRH agonists. Obstet Gynecol 1991;78:535–537.
  6. Suginami H, Hamada K, Yano K: A case of endometriosis of the lung treated with danazol. Obstet Gynecol 1985;66(suppl 3):68S–71S.
  7. Kristianen K, Fjeld NB: Pulmonary endometriosis causing haemoptysis. Report of a case treated with lobectomy. Scand J Thorac Cardiovasc Surg 1993;27:113–115.
  8. Terada Y, Chen F, Shoji T, Itoh H, Wada H, Hitomi S: A case of endobronchial endometriosis treated by subsegmentectomy. Chest 1999;115:1475–1478.
  9. Yu Z, Fleischman JK, Rahman HM, Mesia AF, Rosner F: Catamenial hemoptysis and pulmonary endometriosis: a case report. Mt Sinai J Med 2002;69:261–263.
  10. Katoh O, Yamada H, Aoki Y, Matsumoto S, Kudo S: Utility of angiograms in patients with catamenial hemoptysis. Chest 1990;98:1296–1297.
  11. Hope-Gill B, Prathibha BV: Catamenial haemoptysis and clomiphene citrate therapy. Thorax 2003;58:89–90.
  12. Cassina PC, Hauser M, Kacl G, Imthurn B, Schröder S, Weder W: Catamenial hemoptysis. Diagnosis with MRI. Chest 1997;111:1447–1450.
  13. Park YB, Heo GM, Moon HK, Cho SJ, Shin YC, Eom KS, Kim CH, Lee JY, Mo EK, Jung KS: Pulmonary endometriosis resected by video-assisted thoracoscopic surgery. Respirology 2006;11:221–223.
  14. Ronnberg L, Ylostalo P: Treatment of pulmonary endometriosis with danazol. Acta Obstet Gynecol Scand 1981;60:77–78.
  15. Johnson WM 3rd, Tyndal CM: Pulmonary endometriosis: treatment with danazol. Obstet Gynecol 1987;69:506–507.
  16. Ryu JS, Song ES, Lee KH, Cho JH, Kwak SM, Lee HL: Natural history and therapeutic implications of patients with catamenial hemoptysis. Respir Med 2007;101:1032–1036.
  17. Alifano M, Trisolini R, Cancellieri A, Regnard JF: Thoracic endometriosis: current knowledge. Ann Thorac Surg 2006;81:761–769.
  18. Yeh TJ: Endometriosis within the thorax: metaplasia, implantation or metastasis? J Thorac Cardiovasc Surg 1967;53:201–205.
  19. Kervancioglu S, Andic C, Bayram N, Telli C, Sarica A, Sirikci A: Bronchial artery embolization in the management of pulmonary parenchymal endometriosis with hemoptysis. Cardiovasc Intervent Radiol 2008;31:824–827.
  20. Korea National Statistical Office, Report on the Social Statistics Survey 2006, http://www.kosis.kr/OLAP/Analysis/stat_OLAP.jsp?tbl_id=DT_1W6C03A&org_id=101& vwcd=MT_TM2_TITLE&path=&oper_YN=Y&item=&keyword=&lang_mode= kor&list_id=101_B1702 (accessed Sep 5, 2008).
  21. Chung SY, Kim SJ, Kim TH, Ryu WG, Park SJ, Lee DY, Paik HC, Kim HJ, Cho SH, Kim JK, Park KJ, Ryu YH: Computed tomography findings of pathologically confirmed pulmonary parenchymal endometriosis. J Comput Assist Tomogr 2005;29:815–818.
  22. Lu MS, Liu YH, Wu YC, Hsieh MJ, Liu HP: What we see is not what we get in catamenial haemoptysis. Int J Clin Pract 2006;60:232–233.
  23. Hayes JP, Williams EA, Goldstraw P, Evans TW: Lung injury in patients following thoracotomy. Thorax 1995;50:990–991.
  24. Augoulea A, Lambrinoudaki I, Christodoulakos G: Thoracic endometriosis syndrome. Respiration 2008;75:113–119.
  25. Guidry GG, George RB: Diagnostic studies in catamenial hemoptysis. Chest 1990;98:260–261.
  26. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan E: ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005;20:2698–2704.
  27. Abrao MS, Gonçalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R: Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod 2007;22:3092–3097.