Catamenial Epistaxis

Between adolescence and menopause, menstruators have a unique ebb-and-flow of the major reproductive hormones produced by the ovaries. The ebb-and-flow of these hormones are associated with a variety of events that occur in the body. Some of these events are regular inconveniences, and can have a small impact on daily life. Nosebleeds are one of these events. Among members of the support groups I participate in, concerns surrounding nosebleeds routinely come up. Most often the question relates to the possibility of nasal endometriosis. This paper provides an overview of nosebleeds as they relate to women. Specific focus is given to nosebleeds that occur with menstruation.

Nosebleeds are also known as Epistaxis. Nosebleeds are more common in pre adolescent children (tweeners) and younger geriatrics. Specific to those assigned female sex at birth, epistaxis may also increase around menopause. However, recurrent nosebleeds can occur around the monthly menses, regardless of age. These are know as Catamenial Epistaxis.

In ‘ancient times’ it was believed that ‘Nature searches for an exit route for the menstrual blood’ (Parthenologia historico-medica; Martin Schurig, 1729), implying that blood exiting the tear ducts, nose, mouth or ears at time of menses was normal. In the 1880’s, Dr. Robert Barnes article ‘On vicarious menstruation’ was challenged by the British Gynaecological Society. Dr. Barnes supported idea that bleeding from the nose, ears and other atypical sites during menses was the result of “blood taking the path of least resistance if ‘the normal route fails’”. (Excerpt ‘Vicarious Menstruation’; Wonders and Marvels-A community for Curious Minds who love History, in Odd Stories, and Good Reads. Accessed online 02/21/2018 It’s a good thing medicine has made some advances in the past 130+ years, providing explanation for these events. However, it is a classic example of myths that surround females and our anatomy.

For most persons, nosebleeds with menstruation are due to hormone fluctuations. The mucosa inside the nose is sensitive to hormone changes. When estrogen in the body decreases (which occurs each menstrual cycle), the small capillaries in the nose are more ‘fragile’. (The human nasal mucosa in the menstrual cycle: A histochemical and electron microscopic study. The Journal of Laryngology and Otology. Dec. 1981 Vol 95;1237-1247). Nosebleeds are very rarely a serious concern. However, if a bleed continues more than 10-15 minutes despite applied pressure, it is appropriate to seek medical attention. A few disorders and disease should be considered when cyclical nosebleeds occur with menstruation. These include endometriosis, thrombocytopenia and Von Willebrand disease.

Endometriosis has been identified in the nasal mucosa in a handful of cases (limited to online data base availability through search engines). Presence of endometriosis was associated with PAIN with the nosebleeds in two of three cases identified online. The first case, a 35 yo female reported 5 consecutive months of ‘catamenial epistaxis’ (nosebleeds that coincided menses). This occurred after continuous oral contraceptives was discontinued after 6 months to manage symptoms from pelvic endometriosis. A nasal endoscopy revealed multiple lesions confirmed with histology. (A Case Report of Nasal Endometriosis in a Patient Affected by Behcet’s Disease Journal of Minimal Invasive Gynecology. Misnemia G et al. 2012;Vol 19(4):514-516). The second case, reported by Laghazaoui L and Laghazaoui M (Nasal endometriosis: apropos of 1 case J Gynecol Obstet Biol Reprod. 2001;30:786-788) – not available in English).

With only a few case studies in print, we can infer that nasal endometriosis is a very rare location. Therefore, we look at two other disorders that are often associated with nosebleeds with menstruation. These disorders are ‘more than a hormonal fluctuation’. These include Thrombocytopenia and Von Willebrand Disease. If thrombocytopenia is present, persons with cyclic nosebleeds during menstruation may be the cause. It is hypothesized that the drop in estrogen levels affect the immune system’s ability to regulate platelets. Platelets are needed to clot bleeding. Those with this disorder are found to have increased bruising and regular menstrual cramping. Thrombocytopenia has been found to be cyclical in its presence at the time of menstruation with normal parameters at other times of the cycle. If you have increased bruising, which cannot be attributed to other sources, and regular ‘catamenial nosebleeds’, discussion with your care provider is appropriate. Note, if you suffer from Endometriosis and use medications that reduce blood coagulation or other disorders, it may be more difficult recognize. This also applies to presence of regular menstrual cycle pain with endometriosis. (Menstrual cyclic thrombocytopenia British J Haematology. 1989;71(4):519-524.)

The remaining bleeding disorder: Von Willebrand Disease, is hereditary. By the time menstruators are adults, most with the disease are aware. It is not a common disease (up to 1.3% women in the USA but increases to approximately 16% in the same population but specific to women with chronic, heavy menstruations). In adolescents who have not undergo extensive dental surgery, suffered injury with bleeding or undergone other surgery, may not be identified until investigation for very heavy menstrual cycles. This is an important consideration and careful attention should be given to this population.  To date, there is no known association of Von Willebrand Disease with endometriosis, fibroids or ovarian cysts.

If you regularly experience heavy menstrual periods and regular nosebleeds, bleeding of the gums and prolonged bleeding with minor cuts or abrasions it is worth discussing with your provider. Other signs the disease needs consideration include: history of post-operative prolonged bleeding, bleeding in your joints (ie knees and ankles) or gastrointestinal tract. There are multiple types of this disease. As noted above, it is important for your provider to determine other variables which impact bleeding and clotting concerns and other disorders that present in similar fashion (Von Willebrand Disease in Women. Committee Opinion. No.580 Dec.2013. The American College of Obstetricians and Gynecologists).  The next time you encounter a nosebleed around the time of your menstruation, you are equipped with a better understanding of the most likely cause(s).

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