Hormonal Therapy and Epistaxis
Hormonal therapy is not listed as a recognized cause of epistaxis in current clinical practice guidelines, and there is no evidence linking it to nosebleeds. 1, 2
Usual Causes of Epistaxis
The American Academy of Otolaryngology-Head and Neck Surgery identifies the following as established risk factors and causes:
Local/Anatomic Causes
- Local trauma including digital manipulation (nose picking), nasal foreign bodies, or facial trauma 2
- Mucosal dryness and inflammation from dry environments, nasal oxygen use, or CPAP use 1, 2
- Prior nasal or sinus surgery affecting nasal mucosa 1
- Intranasal drug use including topical medication overuse or illicit drug snorting 1, 2
- Localized infection such as rhinosinusitis 2
- Nasal tumors (suspect with unilateral epistaxis plus nasal obstruction, facial pain, or visual changes) 2
Medication-Related Causes
- Anticoagulant medications (warfarin, direct oral anticoagulants) - these are the primary drug-related cause 1, 3
- Antiplatelet agents (aspirin, clopidogrel) 1, 3
- Selective serotonin reuptake inhibitors (SSRIs) 3
- Intranasal corticosteroids 3
Systemic Causes
- Hypertension (associated with 24-64% of epistaxis cases, though causality not established) 2
- Bleeding disorders including von Willebrand disease and hemophilia 1, 2
- Chronic kidney or liver disease 1
- Hereditary hemorrhagic telangiectasia (HHT) - presents with recurrent bilateral nosebleeds and visible telangiectasias 2
Key Clinical Distinctions
Anterior epistaxis (90-95% of cases) originates from the Kiesselbach plexus and is more common in children, often related to trauma, dry air, or inflammation 2, 4
Posterior epistaxis (5-10% of cases) is more common in older patients with hypertension, more difficult to control, and has higher likelihood of requiring hospitalization 2, 5
Critical Point About Hormonal Therapy
The comprehensive 2020 American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline on epistaxis does not list hormonal therapy among documented risk factors or causes 1. A 2018 systematic review on drug-induced epistaxis identified anticoagulants, antiplatelets, SSRIs, and intranasal corticosteroids as culprits, but did not mention hormonal therapy 3. If a patient on hormonal therapy develops epistaxis, look for the usual causes listed above rather than attributing it to the hormonal medication.