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Vicarious menstruation
568
Communications
October 15, 1972 Am. J. Obstet. Gym-co1
in brief
REFERENCES
1.
2.
3.
4.
5. 6.
M&fat, M. A., Massie, A., Laing% A. G., Mackenzie, R. M., and Robinson, H. G.: Lancet 2: 1025, 1970. DuPont, H. L., Hornick, R. B., L&n, H. S., Ranonort. M. I.. and Woydward. T. E.: Ann. In&n. Med. 74; 198, 1971. ’ Picchi, J., Nelson, A. R., Wailer, E. E., Razavi, M., and Clizer, E. E.: Ann. Intern. Med. 53: 1065, 1960. Bernstein, M., Edmondson, H. A., and Barhour, B. H.: Arch. Intern. Med. 116: 491, 1965. Powell. 0. W.: Amt. Ann. Med. 10:52. 1961. Alkan,’ W. J., Evenchik, Z., and Eschar, J.: Am. 1. Med. 38: 54. 1965. Corm, H. F., and Corm, R. B.: In Current Diagnosis, Philadelphia, 1971, W. B. Saunders Company. Tunstall Pcdoe, H. D.: Heart J. 32: 568, 1970. Wisniewski, H. J., and Krumbiegel, E. R.: Arch. Environ. Health 21: 58, 1970. Schachter, J., Sung, M., and Meyer, K. F.: J. Infect. Dis, 123: 301, 1971. Johnson, J. E., and Kadull, P. J.: Am. J. Med. 41: 391, 1966. ”
7.
8. 9. 10. 11.
Vicarious JAMES
menstruation M.
DUNN,
Defiartment of Obstetrics Intercommunity Memorial Fairfield, California
M.D. and Gynecology, Hosjital,
VI c A R I o u s menstruation is rhythmic extragental bleeding occurring at the time a normal menstrual period would be expected. Two forms have been described. The supplementary type, when bleeding occurs coincident to a regular menstrual flow, and the substitutive form, when bleeding occurs regularly in the absence of menstruation. The latter of these two types accounts for only 30 per cent of the cases.1 The following case demonstrates substitutive vicarious nasal menstruation in a girl with congenital aplastic anemia. A 13-year-old girl was first seen because of severe epistaxis occurring every 28 to 30 days. The child was first noted to have bleeding difficulties at 13 months of age when surgical correction of an umbilical hernia resulted in excessive bleeding. She was given 10 U. of whole blood. At age 3, a tonsillectomy resulted in extensive bleeding, and she required 52 U. of blood. She was then seen by and congenital aplastic anemia a hematologist, Reprint rquests: Fakfkld, California
Dr. James M. Dunn, 94533.
16Ml Travis
Blvd.,
was discovered, Following a 5 month course of there was no further difficulty with cortisone, bruising or bleeding. The steroid was stopped after 6 months because of excessive weight gain and edema. From age 5 until age 12, when cyclic nasal bleeding began, the patient was asymptomatic. Physically, the child appeared less mature than her stated age. Ecchymosis and purpura were present on the arms and legs. The retina and conjunctiva were clear. The nasal turbinates were injected and hyperemic, but there was no evidence of ulceration or specific bleeding points. The breasts were poorly formed and had only discoid areolar development. Axillary hair was absent, and there was no perineal or vulvar hair. The labia minora were well formed, the hymen was intact, and there was good vaginal depth. The cervix and uterus were infantile. and the ovaries could not be palpated. The hematocrit was 30 per cent, and the platelet count was 40,000. Prothrombin, partial thromboplastin time, and Coombs test were normal. The fibrinogen was 200 mg. per cent, and the clot retraction was reduced by 50 per cent. Clotting time was 6.5 minutes, and the reticulocyte count was 1.1 per cent. The bleeding time was 8 minutes, and the serum iron was 159 mcg. per cent. Electrocardiochest film, and pelvic pneumogram were ww normal. A hematologist substantiated the diagnosis of congenital aplastic anemia. Because of the bleeding defects, it seemed unwise to allow spontaneous menstruation, An anabolic steroid, Dianabol,* 5 mg. daily, was given as well as 5 mg. of Enovid? on an uninterrupted basis. It is significant that during the first 12 months on this regimen the patient grew 3.5 inches in height. Marked maturation occurred, the breast size increasing from preadolescent to a mature stage of development. Of even more interest is that no further episodes of epistaxis occurred. After 14 months, Dianaboi was discontinued and Enovid was increased to 10 mg., and every 3 months a 3 day withdrawal was allowed. The last blood indices were hematocrit 47 per cent, hemoglobin 16.2 Gm., and platelets 200,000. After 2 years, the patient has had no further nose bleeding. Approximately 30 per cent of extragenital bleeding is from the nose. This finding is based on the observation that the mucous membranes of the nose and the uterus respond to the same hormonal stimuli. When blood estrogen is elevated, the mucosa becomes congested and swollen. This hyperemia either separately or superimposed on a pre-existing lesion can lead to bleeding. Cyclic bleeding from organs other than the nose may be explained by an unusual sensitivity *Ciba I’harm. tG. D. Sea&
Co., Summit, New Jersey. & Co., Chicago, Illinois.
Volun1e 114 Number 4
of certain tissues to an elevated level of blood estrogen. Cytologic changes demonstrating this have been described in the oral cavity, urinary bladder, and stomach.1 These alterations may be due to generalized vasospasm and increased capillary permeability which occurs a few days before menstruation. With these vascular disturbances, bleeding may occur from the retina, conjunctiva, skin, hands, or stomach. Endometriosis may cause either the substitutive or supplementary form of vicarious menstruation-it may arise from implants following an incision, which accounts for bleeding from scar tissue after pelvic surgery, particularly myomectomy, and cesarean sections, as well as episiotomies and vaginal operative procedures. Endometriosis may also arise from blood- and lymph-
Communications
in
brief
569
born metastasis of endometrial tissue. This explains extragenital bleeding in such diverse organs as the kidney, stomach, and lung. The initial evaluation of this condition should be directed at the hemostatic mechanism and any underlying local disturbances, In the present case, stabilization of the patient’s bone marrow and treatment with an anabolic steroid plus an estrogen-progestin combination resulted in control of the cyclic nasal bleeding. REFERENCE
1. Israel, S. L.: Zn Diagnosis and Treatment of Menstrual Disorders and Sterility, ed. 4, New York, 1963, Paul B. Hoeber, Inc., Medical Book Division of Harper & Row, Publishers, pp. 213 and 215.
Communications
October 15, 1972 Am. J. Obstet. Gym-co1
in brief
REFERENCES
1.
2.
3.
4.
5. 6.
M&fat, M. A., Massie, A., Laing% A. G., Mackenzie, R. M., and Robinson, H. G.: Lancet 2: 1025, 1970. DuPont, H. L., Hornick, R. B., L&n, H. S., Ranonort. M. I.. and Woydward. T. E.: Ann. In&n. Med. 74; 198, 1971. ’ Picchi, J., Nelson, A. R., Wailer, E. E., Razavi, M., and Clizer, E. E.: Ann. Intern. Med. 53: 1065, 1960. Bernstein, M., Edmondson, H. A., and Barhour, B. H.: Arch. Intern. Med. 116: 491, 1965. Powell. 0. W.: Amt. Ann. Med. 10:52. 1961. Alkan,’ W. J., Evenchik, Z., and Eschar, J.: Am. 1. Med. 38: 54. 1965. Corm, H. F., and Corm, R. B.: In Current Diagnosis, Philadelphia, 1971, W. B. Saunders Company. Tunstall Pcdoe, H. D.: Heart J. 32: 568, 1970. Wisniewski, H. J., and Krumbiegel, E. R.: Arch. Environ. Health 21: 58, 1970. Schachter, J., Sung, M., and Meyer, K. F.: J. Infect. Dis, 123: 301, 1971. Johnson, J. E., and Kadull, P. J.: Am. J. Med. 41: 391, 1966. ”
7.
8. 9. 10. 11.
Vicarious JAMES
menstruation M.
DUNN,
Defiartment of Obstetrics Intercommunity Memorial Fairfield, California
M.D. and Gynecology, Hosjital,
VI c A R I o u s menstruation is rhythmic extragental bleeding occurring at the time a normal menstrual period would be expected. Two forms have been described. The supplementary type, when bleeding occurs coincident to a regular menstrual flow, and the substitutive form, when bleeding occurs regularly in the absence of menstruation. The latter of these two types accounts for only 30 per cent of the cases.1 The following case demonstrates substitutive vicarious nasal menstruation in a girl with congenital aplastic anemia. A 13-year-old girl was first seen because of severe epistaxis occurring every 28 to 30 days. The child was first noted to have bleeding difficulties at 13 months of age when surgical correction of an umbilical hernia resulted in excessive bleeding. She was given 10 U. of whole blood. At age 3, a tonsillectomy resulted in extensive bleeding, and she required 52 U. of blood. She was then seen by and congenital aplastic anemia a hematologist, Reprint rquests: Fakfkld, California
Dr. James M. Dunn, 94533.
16Ml Travis
Blvd.,
was discovered, Following a 5 month course of there was no further difficulty with cortisone, bruising or bleeding. The steroid was stopped after 6 months because of excessive weight gain and edema. From age 5 until age 12, when cyclic nasal bleeding began, the patient was asymptomatic. Physically, the child appeared less mature than her stated age. Ecchymosis and purpura were present on the arms and legs. The retina and conjunctiva were clear. The nasal turbinates were injected and hyperemic, but there was no evidence of ulceration or specific bleeding points. The breasts were poorly formed and had only discoid areolar development. Axillary hair was absent, and there was no perineal or vulvar hair. The labia minora were well formed, the hymen was intact, and there was good vaginal depth. The cervix and uterus were infantile. and the ovaries could not be palpated. The hematocrit was 30 per cent, and the platelet count was 40,000. Prothrombin, partial thromboplastin time, and Coombs test were normal. The fibrinogen was 200 mg. per cent, and the clot retraction was reduced by 50 per cent. Clotting time was 6.5 minutes, and the reticulocyte count was 1.1 per cent. The bleeding time was 8 minutes, and the serum iron was 159 mcg. per cent. Electrocardiochest film, and pelvic pneumogram were ww normal. A hematologist substantiated the diagnosis of congenital aplastic anemia. Because of the bleeding defects, it seemed unwise to allow spontaneous menstruation, An anabolic steroid, Dianabol,* 5 mg. daily, was given as well as 5 mg. of Enovid? on an uninterrupted basis. It is significant that during the first 12 months on this regimen the patient grew 3.5 inches in height. Marked maturation occurred, the breast size increasing from preadolescent to a mature stage of development. Of even more interest is that no further episodes of epistaxis occurred. After 14 months, Dianaboi was discontinued and Enovid was increased to 10 mg., and every 3 months a 3 day withdrawal was allowed. The last blood indices were hematocrit 47 per cent, hemoglobin 16.2 Gm., and platelets 200,000. After 2 years, the patient has had no further nose bleeding. Approximately 30 per cent of extragenital bleeding is from the nose. This finding is based on the observation that the mucous membranes of the nose and the uterus respond to the same hormonal stimuli. When blood estrogen is elevated, the mucosa becomes congested and swollen. This hyperemia either separately or superimposed on a pre-existing lesion can lead to bleeding. Cyclic bleeding from organs other than the nose may be explained by an unusual sensitivity *Ciba I’harm. tG. D. Sea&
Co., Summit, New Jersey. & Co., Chicago, Illinois.
Volun1e 114 Number 4
of certain tissues to an elevated level of blood estrogen. Cytologic changes demonstrating this have been described in the oral cavity, urinary bladder, and stomach.1 These alterations may be due to generalized vasospasm and increased capillary permeability which occurs a few days before menstruation. With these vascular disturbances, bleeding may occur from the retina, conjunctiva, skin, hands, or stomach. Endometriosis may cause either the substitutive or supplementary form of vicarious menstruation-it may arise from implants following an incision, which accounts for bleeding from scar tissue after pelvic surgery, particularly myomectomy, and cesarean sections, as well as episiotomies and vaginal operative procedures. Endometriosis may also arise from blood- and lymph-
Communications
in
brief
569
born metastasis of endometrial tissue. This explains extragenital bleeding in such diverse organs as the kidney, stomach, and lung. The initial evaluation of this condition should be directed at the hemostatic mechanism and any underlying local disturbances, In the present case, stabilization of the patient’s bone marrow and treatment with an anabolic steroid plus an estrogen-progestin combination resulted in control of the cyclic nasal bleeding. REFERENCE
1. Israel, S. L.: Zn Diagnosis and Treatment of Menstrual Disorders and Sterility, ed. 4, New York, 1963, Paul B. Hoeber, Inc., Medical Book Division of Harper & Row, Publishers, pp. 213 and 215.