# ‘The monthly curse’: menstrual-associated coronary artery vasospasm in a premenopausal woman—a case report

## TL;DR

A premenopausal woman experienced life-threatening heart spasms linked to her menstrual cycle, highlighting the need for early hormonal treatment and gynecological collaboration.

## Contribution

This case report highlights catamenial coronary vasospasm as a rare but severe condition requiring early hormonal therapy and gynecological involvement.

## Key findings

- Chest pain episodes occurred consistently before menstruation and were linked to low estrogen levels.
- The patient's condition worsened despite treatment, leading to fatal cardiopulmonary arrest due to vasospasm.
- Estrogen replacement therapy is suggested as a potential treatment to prevent fatal outcomes.

## Abstract

Catamenial coronary vasospasm has recently been recognized as a refractory form of vasospastic angina, characterized by recurrent episodes of chest pain that are temporally associated with the menstrual cycle.

A 38-year-old premenopausal woman presented to our hospital with chest pain. Upon entering the cold examination room, she experienced chest pain identical in character to her previous episodes. Electrocardiography revealed ST-segment elevation in the inferior leads. Sublingual administration of nitroglycerin resulted in the prompt relief of symptoms and resolution of ST-segment changes. Subsequent coronary angiography revealed no obstructive coronary lesions, leading to the diagnosis of coronary vasospasm. A comprehensive clinical history revealed that all episodes of chest pain occurred consistently in the days preceding the onset of menstruation. She was closely monitored in an outpatient setting and was prescribed a combination of benidipine and nicorandil. Unfortunately, the patient was transferred to our hospital following an episode of cardiopulmonary arrest. Emergency coronary angiography revealed critical stenosis due to vasospasm in the ostium of the right coronary artery. The patient died despite receiving intensive care.

During the late luteal and menstrual phases, circulating oestrogen levels decline to their lowest point, potentially increasing susceptibility to coronary vasospasms. In recent years, oestrogen replacement therapy has been reported to confer therapeutic benefits in this patient population. Early multidisciplinary collaboration involving gynaecologists and timely initiation of hormonal therapy may alter the clinical course and prevent fatal outcomes in such patients.