{"paper_id":"81fa34b2-2b72-461d-bd6b-2fa67529c377","body_text":"INTRODUCTION\nEndometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. It is reported in approximately 10% of women of reproductive age.[] While endometriosis typically involves pelvic structures, it can rarely present as bleeding from extrauterine sites, including distant organs, in tandem with menstruation. This aberrant bleeding is termed vicarious menstruation.[,] Vicarious menstruation has been seen from extragenital sites, such as the nose, eyes, skin, or lungs, during menstruation.[,] The nasal mucosa is reported as the most common site, manifesting as catamenial epistaxis, but virtually any organ can be involved.[] Ocular bleeding (hemolacria) is one of the more frequently documented presentations in the literature,[] whereas bleeding from skin or extremities (such as the fingers) is exceedingly rare. The condition typically occurs in women of reproductive age. Cases have been reported in both the third and fourth decades of life.[] Often, there is concomitant pelvic endometriosis. Vicarious bleeding may occasionally occur even in the absence of identifiable pelvic lesions.[]\nThe pathophysiology of vicarious menstruation remains incompletely understood. Ectopic endometrial implants in distant tissues are one proposed mechanism, with hormonal stimulation causing these implants to bleed concurrently with the endometrium.[] Endometrial cells may reach extrapelvic sites via retrograde menstruation with subsequent hematogenous or lymphatic dissemination. It could also originate from coelomic metaplasia.[,] Interestingly, evidence also suggests that some tissues (e.g., conjunctival or nasal mucosa) express estrogen and progesterone receptors and can exhibit hemorrhage in response to hormonal fluctuations even without actual endometrial implants.[] In all reported cases, the hallmark of vicarious menstruation is the cyclical nature of bleeding synchronized with menstrual bleeding. Since lesions are often microscopic or inaccessible, definitive histological confirmation is seldom achieved, and vicarious menstruation remains largely a diagnosis of exclusion and clinical correlation.[] Here, we are reporting a challenging case of multisite vicarious menstrual bleeding from the nose, ears, and fingertips, highlighting the diagnostic process and its management.\nCASE REPORT\nA 28-year-old primiparous woman presented with a 10-year history of recurrent bleeding from her nose, ears, and fingertip pulps, consistently coinciding with menstruation. Each episode began with menstrual flow and lasted 10–12 days, resolving with cessation of menses. Her menstrual cycles were otherwise regular, lasting 4–5 days with moderate flow. She denied spontaneous bruising, gum bleeding, hematuria, melena, or a family history of bleeding disorders. Previous evaluations, including coagulation profiles, were normal.\nOn initial mid-cycle examination, general and systemic findings were unremarkable, with no cutaneous lesions or vascular anomalies. Nasal, otoscopic, and finger examinations showed no active bleeding. Due to the cyclical pattern, she was advised to follow up during menstruation.\nOn Day 2 of her next cycle, she returned with active fingertip bleeding—from the pulp of her left index finger and nail beds of other fingers.\nFigure 1: Bleeding from skin fissures on the fingertip during the menstrual cycle, a feature of vicarious menstruation.\nFigure 2: Bleeding from the nail beds during menstruation in the same patient, illustrating an extragenital cyclic hemorrhage.\nDuring the same visit, she had left-sided epistaxis, managed with superficial cauterization by ENT. While ear bleeding was not seen, she provided photographs from previous cycles showing blood at the nostril and fingertips.\nA multidisciplinary evaluation followed. Nasal endoscopy, otoscopic, and ophthalmologic examinations were normal. A punch biopsy from the bleeding fingertip showed nonspecific subdermal fibrosis, with no endometrial tissue, vasculitis, or other pathology.\nDue to strong clinical suspicion, a therapeutic trial with leuprolide acetate depot (GnRH analogue) 3.75 mg IM monthly was started. After the first dose, she had only minimal spotting and no extragenital bleeding. Following six monthly doses, she remained symptom-free and amenorrheic, confirming the diagnosis.\nFigure 3: Episodic epistaxis (nosebleed) coinciding with the patient’s menses, consistent with vicarious menstruation.\nFigure 4: Clinical photograph of a finger pulp lesion actively bleeding during menstruation (taken during gynecological examination).\nGiven her desire for future fertility, long-term GnRH use and surgical oophorectomy were avoided. She was transitioned to oral dienogest 2 mg daily to maintain an anovulatory state while preserving fertility. Surgical options were reserved for future consideration after family completion.\nOver the next 12 months, she remained symptom-free with no uterine or ectopic bleeding, and her fingertips had completely healed. Her quality of life improved significantly, highlighting both the diagnostic challenge and therapeutic benefit of hormonal suppression in vicarious menstruation.\nFigure 5: Follow-up image of the patient’s fingertip after six months of therapy, showing healed skin and no bleeding, indicating successful treatment.\nThe patient experienced a significant improvement in quality of life, with complete cessation of unpredictable bleeding episodes. The case illustrates both the diagnostic challenge and therapeutic potential of hormone suppression in vicarious menstruation.\nDISCUSSION\nVicarious menstruation is a rare manifestation of endometriosis, which is a hormonally triggered bleeding from extragenital sites along with normal menstruation.[] Fewer than a dozen well-documented cases exist, most involving single-site bleeding, such as hemolacria or catamenial epistaxis. A review of ocular endometriosis identified only four cases of ocular vicarious menstruation,[] while nasal presentations are relatively more frequent, often linked to endometrial implants in the nasal mucosa. Our case of multisite bleeding reports of concurrent nasal, digital, and auricular bleeding is a rare phenomenon.\nDiagnosing vicarious menstruation is challenging and relies primarily on clinical evaluation. Comprehensive ENT and ophthalmology assessments ruled out local lesions or bleeding disorders in our patient. The key diagnostic clue was the consistent temporal association with menstruation and cessation following drug-induced amenorrhea. Similar diagnostic approaches have been noted by Ghosh et al. (2021).[] Histopathological confirmation is rare; the literature reports only a few cases of biopsy-proven diagnoses.[] Due to anatomic constraints and microscopic lesion size, clinicians often depend on clinical presentation and therapeutic response. Cyclic bleeding from extrapelvic sites, after exclusion of other causes, generally suffices for a presumptive diagnosis.[,]\nAlternatively, hormonally sensitive capillaries may exhibit cyclical permeability without true implants, as reported by Rahman et al.[] (2023) in conjunctival bleeding. In our patient, either occult microscopic endometrial implants or hormone-responsive vasculature could account for the findings. Notably, the bleeding persisted longer than uterine menses, a phenomenon previously described, possibly due to slower healing or lingering hormonal effects.\nManagement centers on ovulation suppression to achieve amenorrhea. Progestins and GnRH analogues are effective; GnRH therapy, as used in our case, induces a hypoestrogenic state, leading to resolution of symptoms. Surgical intervention is reserved for identifiable lesions or refractory cases, with bilateral oophorectomy considered only when childbearing is complete due to its irreversible effects.[]\nThis case reinforces that vicarious menstruation is largely a clinical diagnosis requiring careful exclusion and therapeutic confirmation.\nCONCLUSION\nVicarious menstruation is a rare, cyclical bleeding from extragenital sites. Diagnosis depends on clinical suspicion and response to hormonal therapy. Early recognition and timely treatment with GnRH analogues or progestins can improve outcomes and preserve fertility.\nData availability statement\nData will be made available upon request by the journal.\nAuthor contribution\nDr Shabista Shaikh: Conceptualization, Data collection, Writing – original draft. Dr Varshini Vadithala: Clinical management, Supervision, Writing – review and editing. Dr Himadr Bal: Conceptualization, Data collection, Writing – original draft, Literature review, Manuscript editing. Janvi Patel: Literature review, Manuscript proofreading.\nDeclaration of patient consent\nThe authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nFinancial support and sponsorship\nNil.\nConflicts of interest\nThere are no conflicts of interest.\nREFERENCES\n1.\nRahman S, Youssef Y, Maroun G, Inaty D, Kheil MH, Moawad G. Eyes, menstruation and endometriosis. Facts Views Vis Obgyn 2023;15:107-13.2.\nAndres MP, Arcoverde FV, Suza CC, Fernandes LF, Abrão MS, Kho RM. Extrapelvic endometriosis: A systematic review. J Minim Invasive Gynecol 2020;27:373-89.3.\nVeeraswamy A, Lewis M, Mann A, Kotikela S, Hajhosseini B, Nezhat C. Extragenital endometriosis. Clin Obstet Gynecol 2010;53:449-66.4.\nGhosh S, Tale S, Handa N, Bhalla A. Rare case of red tears: Ocular vicarious menstruation. BMJ Case Rep 2021;14:e237294.5.\nGupta PD, Johar K Sr, Nagpal K, Vasavada AR. Sex hormone receptors in the human eye. Surv Ophthalmol 2005;50:274-84.6.\nAliyeva A, Safarova V. Perimenstrual epistaxis caused by nasal septal endometriosis: A very rare case report. J Rhinol 2022;29:182-4.7.\nCelebi ARC, Aygun EG. A rare cause of recurrent subconjunctival hemorrhage: Ocular vicarious menstruation. GMS Ophthalmol Cases 2023;13:Doc05.8.\nBatra N, Gemnani R, Singh Thakur A, Kumar S, Acharya S. Navigating nasal surges: Understanding catamenial epistaxis. Cureus 2023;15:e45767.9.\nLee J, Park HJ, Yi KW. Dienogest in endometriosis treatment: A narrative literature review. Clin Exp Reprod Med 2023;50:223-9.","source_license":"CC0","license_restricted":false}