Catamenial bilateral conjunctival hemorrhage associated with endometriosis: A rare case report

E. Esmer
In: Northwestern Medical Journal · 2026 · vol. 6(4) , pp. 364–367 · doi:10.54307/nwmj.2026.257 · W7223694737
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A case report describes catamenial bilateral conjunctival hemorrhage in a 24-year-old woman with an ovarian endometrioma, noting that combined oral contraceptive therapy improved both the ocular bleeding and dysmenorrhea.

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This case report describes a 24-year-old woman with a ten-year history of severe dysmenorrhea who experienced recurrent bilateral subconjunctival hemorrhages exclusively during menstruation. Diagnostic imaging identified a right ovarian endometrioma, and treatment with combined oral contraceptives led to marked improvement in both the ocular bleeding and pelvic pain symptoms. The authors propose that this rare presentation is hormonally mediated and suggest clinicians consider underlying endometriosis when evaluating cyclic ocular bleeding. This paper is centrally about endometriosis — specifically presenting a rare extra-pelvic manifestation involving catamenial conjunctival hemorrhage associated with an ovarian endometrioma.

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Abstract

Objective: To present a rare case of catamenial bilateral conjunctival hemorrhage associated with endometriosis in a patient with ovarian endometrioma and to discuss its possible hormonal pathogenesis. Case: A 24-year-old nulliparous woman presented with a 10-year history of severe dysmenorrhea and recurrent bilateral subconjunctival hemorrhage occurring exclusively during menstruation. Ophthalmologic examinations revealed no additional pathology. Pelvic ultrasonography demonstrated a 70×55-mm homogeneous cystic lesion with low-level internal echoes in the right ovary, consistent with an endometrioma. Serum CA-125 was mildly elevated (48.5 U/mL). Orbital magnetic resonance imaging was normal. Combined oral contraceptive therapy containing drospirenone and ethinylestradiol was initiated, resulting in marked improvement in both dysmenorrhea and ocular hemorrhage. Conclusion: Catamenial conjunctival hemorrhage is a rare but clinically relevant manifestation that may be hormonally mediated. In patients presenting with cyclic ocular bleeding, underlying endometriosis should be considered.
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Abstract

Objective: To present a rare case of catamenial bilateral conjunctival hemorrhage associated with endometriosis in a patient with ovarian endometrioma and to discuss its possible hormonal pathogenesis. Case: A 24-year-old nulliparous woman presented with a 10-year history of severe dysmenorrhea and recurrent bilateral subconjunctival hemorrhage occurring exclusively during menstruation. Ophthalmologic examinations revealed no additional pathology. Pelvic ultrasonography demonstrated a 70×55-mm homogeneous cystic lesion with low-level internal echoes in the right ovary, consistent with an endometrioma. Serum CA-125 was mildly elevated (48.5 U/mL). Orbital magnetic resonance imaging was normal. Combined oral contraceptive therapy containing drospirenone and ethinylestradiol was initiated, resulting in marked improvement in both dysmenorrhea and ocular hemorrhage.

Conclusion

Catamenial conjunctival hemorrhage is a rare but clinically relevant manifestation that may be hormonally mediated. In patients presenting with cyclic ocular bleeding, underlying endometriosis should be considered.

Keywords

endometriosis, endometrioma, conjunctival hemorrhage, menstruation, dysmenorrhea Copyright and license Copyright © 2026 The Author(s). This is an open-access article published by Bolu İzzet Baysal Training and Research Hospital under the terms of the Creative Commons Attribution License (CC BY) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited. How to cite

References

- Giudice LC, Kao LC. Endometriosis. Lancet. 2004; 364(9447): 1789-99. https://doi.org/10.1016/S0140-6736(04)17403-5 - Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014; 10(5): 261-75. https://doi.org/10.1038/nrendo.2013.255 - Celebi ARC, Aygun EG. A rare cause of recurrent subconjunctival hemorrhage: ocular vicarious menstruation. GMS Ophthalmol Cases. 2023; 13: Doc05. https://doi.org/10.3205/oc000213 - Bulun SE. Endometriosis. N Engl J Med. 2009; 360(3): 268-79. https://doi.org/10.1056/NEJMra0804690 - Hirsch M, Duffy J, Davis CJ, Nieves Plana M, Khan KS, International Collaboration to Harmonise Outcomes and Measures for Endometriosis. Diagnostic accuracy of cancer antigen 125 for endometriosis: a systematic review and meta-analysis. BJOG. 2016; 123(11): 1761-8. https://doi.org/10.1111/1471-0528.14055 - Abboud IA, Hanna LS. Bleeding from the conjunctiva. Br J Ophthalmol. 1971; 55(7): 487-91. https://doi.org/10.1136/bjo.55.7.487 - Barat M, Kwedar SA. Ocular vicarious menstruation. J Pediatr Ophthalmol Strabismus. 1988; 25(5): 254-5. https://doi.org/10.3928/0191-3913-19880901-13 - Dua P, Pointdujour R, Reich I, Lazzaro DR, Shinder R. Orbital vicarious menstruation. Ophthalmic Plast Reconstr Surg. 2014; 30(2): e35-7. https://doi.org/10.1097/IOP.0b013e3182937527 - Ghosh S, Tale S, Handa N, Bhalla A. Rare case of red tears: ocular vicarious menstruation. BMJ Case Rep. 2021; 14(3): e237294. https://doi.org/10.1136/bcr-2020-237294

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