Bleeding from the Nail: A Rare and Curious Case of Vicarious Menstruation

Dear Editor, Vicarious menstruation is a rare and intriguing phenomenon characterized by cyclical bleeding from extrauterine sites during menstruation. It predominantly affects women in their third or fourth decade of life and is hypothesized to result from hormone-mediated vascular changes, with or without the presence of ectopic endometrial tissue. Estrogen and progesterone are believed to increase capillary permeability, resulting in hyperemia, congestion, and subsequent bleeding at distant sites such as the nasal mucosa, conjunctiva, eyelids, external ear canal, gastrointestinal tract, lungs, nipples, and skin.[] We present a rare case of vicarious menstruation manifesting as cyclic bleeding from the nail beds. A 26-year-old woman, gravida 2 para 2, presented with a history of recurrent bleeding from the nail beds coinciding with the onset of menstruation. These symptoms had been present since menarche at age 12 and were consistently associated with itching and periungual pain. In addition, she reported cyclical episodes of epistaxis, otorrhagia, menstrual-related headaches, and cervical swelling. Her menstrual cycles were regular, lasting 4–5 days with normal flow. Notably, these symptoms completely resolved during both of her pregnancies and recurred postpartum. Clinical examination performed during her menstrual period revealed distal onycholysis, periungual eczematous changes, and multiple well-demarcated linear fissures over both ring fingers. Active bleeding was noted from the distal nail beds of both ring fingers, along with concurrent right-sided nasal bleeding. The toenails were spared [Figure 1a-c]. A short trial of topical corticosteroids for 3 weeks provided no symptomatic relief. The initial differential diagnosis included dermatitis, bleeding disorders, vicarious menstruation, and autoimmune progesterone dermatitis. Given the cyclical nature of her symptoms, a diagnosis of vicarious menstruation was strongly considered. A nail matrix biopsy demonstrated marked hyperkeratosis, focal parakeratosis with plasma accumulation (scale-crust formation), and irregular epidermal hyperplasia. The dermis showed papillary edema, dilated capillaries, and perivascular lymphocytic infiltration – findings suggestive of subacute dermatitis. No ectopic endometrial tissue, cystic spaces, hemorrhage, basal cell vacuolation, eosinophils, or atypical lymphocytes were identified [Figure 2]. Laboratory investigations revealed anemia (hemoglobin: 9.2 g/dL), with normal liver and renal function tests, coagulation profile, and negative viral serology. Autoimmune workup, including anti-cardiolipin antibodies, anti-β2 glycoprotein, and rheumatoid factor, was negative. Nasal mucosal biopsy performed due to recurrent epistaxis revealed only seromucinous glandular tissue, excluding nasal endometriosis. There was no clinical history of urticaria, eczema, erythema multiforme-like lesions, or angioedema during the luteal phase, effectively ruling out autoimmune progesterone dermatitis.[] Based on the clinical history and consistent symptomatology, the patient was initiated on intramuscular leuprolide acetate (3.75 mg monthly), a gonadotropin-releasing hormone agonist. Following two doses, she experienced complete resolution of nail, nasal, and ear bleeding. Periungual lesions also showed marked improvement [Figure 3]. A total of six monthly doses were administered, resulting in sustained remission. She was subsequently transitioned to a combined oral contraceptive pill containing ethinylestradiol and levonorgestrel for maintenance therapy. Vicarious menstruation remains an uncommon and under-recognized condition. Its clinical presentation varies based on the site of involvement – pulmonary cases may present with hemoptysis and dyspnea, whereas cutaneous involvement may result in erythematous lesions, fissures, or pruritus. Involvement of the nail bed, as in our patient, is exceptionally rare and scarcely documented. Although classically linked with ectopic endometrial tissue, the absence of such tissue does not preclude a diagnosis of vicarious menstruation. Hormone-induced changes in vascular permeability may be independently sufficient to cause cyclical bleeding.[] The dramatic clinical improvement with hormonal suppression in our case further substantiates this hypothesis. This case underscores the need to consider vicarious menstruation in the differential diagnosis of cyclical bleeding from atypical anatomical sites. Early identification and hormonal modulation can significantly improve the quality of life in affected individuals. Financial support and sponsorship Nil. 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