What is the best course of action for a 39-year-old female with frequent epistaxis (nose bleeds)?

Management of Frequent Epistaxis in a 39-Year-Old Female

For a 39-year-old woman with frequent nosebleeds, begin with daily nasal saline gel or spray for prevention, document risk factors (medications, bleeding disorders, nasal trauma), and perform anterior rhinoscopy to identify any bleeding sites or underlying pathology. 1, 2

Immediate Assessment and Risk Stratification

Document critical risk factors that increase bleeding frequency or severity: 1

• Anticoagulant or antiplatelet medications (warfarin, aspirin, clopidogrel, DOACs) 1, 3
• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia) 1, 3
• Hypertension (present in 33% of epistaxis patients) 3
• Nasal oxygen or CPAP use 3
• Intranasal medications or illicit drug use 3
• Prior nasal or sinus surgery 3
• Chronic kidney or liver disease 3

Assess for hereditary hemorrhagic telangiectasia (HHT) if she reports recurrent bilateral nosebleeds or has a family history of recurrent epistaxis, as this requires specialized management. 1, 3

Diagnostic Evaluation

Perform anterior rhinoscopy after removing any blood clots to identify the bleeding source—this is essential for all patients with recurrent epistaxis. 1, 3

Consider nasal endoscopy (or refer to ENT) if: 1, 3

• Bleeding is difficult to control despite initial treatments
• Unilateral bleeding with concerning features (nasal obstruction, facial pain, visual changes suggesting possible mass lesion) 3
• Recurrent bleeding despite appropriate anterior treatment
• Posterior bleeding source is suspected

Prevention Strategy (Primary Intervention)

Prescribe daily nasal saline spray or gel applied multiple times daily to maintain mucosal moisture—this resolves up to 65% of recurrent cases and is the cornerstone of prevention. 2, 3

Recommend environmental humidification, particularly during winter months or in dry climates, to prevent mucosal desiccation. 2, 4

Continue moisturization indefinitely, even after bleeding episodes resolve, to prevent recurrence. 2

Acute Bleeding Management (When Episodes Occur)

First-line treatment: 1, 2, 3

1. Apply firm, sustained compression to the soft lower third of the nose for a full 5-10 minutes without interruption
2. Patient should sit upright with head tilted slightly forward to prevent blood from entering the airway
3. Do not check if bleeding has stopped before the full 5-10 minutes

If bleeding persists after compression: 2, 3

• Apply oxymetazoline 0.05% (Afrin) or phenylephrine nasal spray (2 sprays per nostril) directly to the bleeding site
• Resume firm compression for another 5 minutes
• This achieves control in 65-75% of cases

Critical warning: Do not use oxymetazoline or phenylephrine continuously for more than 3-5 days due to risk of rhinitis medicamentosa (rebound congestion). 2 These vasoconstrictors can also cause systemic complications in patients with hypertension, cardiovascular disease, or glaucoma. 2

Definitive Treatment for Identified Bleeding Sites

If a specific bleeding site is identified on rhinoscopy: 1, 3

• Perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine
• Restrict cautery application only to the active or suspected bleeding site(s)
• Avoid bilateral septal cautery to prevent septal perforation
• Chemical cautery with silver nitrate is effective with lower recurrence rates (14.5%) compared to no treatment (35.1%) 5

If bleeding site cannot be identified or bleeding persists: 1

• Proceed to nasal packing using resorbable materials (Nasopore, Surgicel, Floseal) as first choice
• Resorbable packing is specifically recommended for patients with suspected bleeding disorders or those on anticoagulant/antiplatelet medications 1

Post-Treatment and Follow-Up

Apply petroleum jelly or moisturizing agents to the nasal mucosa after any bleeding episode and continue regular saline nasal sprays. 3

Document outcome within 30 days or arrange follow-up to assess treatment effectiveness. 1

Educate the patient about: 1

• Preventive measures (daily saline moisturization, humidification)
• Home treatment for acute bleeding (proper compression technique)
• Warning signs requiring immediate medical attention (bleeding >20 minutes despite compression, signs of hemodynamic instability)

Indications for Specialist Referral

Refer to ENT if: 1

• Persistent or recurrent bleeding despite nasal packing or cauterization (may require surgical arterial ligation or endovascular embolization)
• Suspected HHT based on bilateral recurrent bleeds or family history
• Unilateral bleeding with concerning features suggesting possible tumor
• Posterior epistaxis requiring specialized packing or intervention

Common Pitfalls to Avoid

Do not aggressively lower blood pressure during active epistaxis, as this can cause end-organ ischemia (renal, cerebral, or coronary). Blood pressure should be monitored but not routinely reduced acutely. 3

Do not overlook anticoagulation status—check INR if on warfarin and consider reversal only for severe refractory bleeding. First-line local hemostatic measures should be initiated before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications. 1, 3

Do not place tissues or cotton inside the nose as they can be aspirated and do not provide adequate compression. 4