Can hormonal fluctuations during the menstrual cycle exacerbate sinusitis symptoms in a female patient of reproductive age with a history of sinusitis?

Hormonal Fluctuations During the Menstrual Cycle Can Exacerbate Sinusitis Symptoms

Yes, hormonal fluctuations during the menstrual cycle may worsen sinusitis symptoms in some women, though the evidence is limited and the relationship is not as well-established as pregnancy-related sinus disease. 1

Evidence for Menstrual Cycle-Related Sinonasal Worsening

The Journal of Allergy and Clinical Immunology recognizes menstrual cycle-related rhinitis as a form of hormonal rhinitis, noting that there may be an association of nasal congestion with ovulation and the rise in serum estrogen during the normal menstrual cycle in some women. 1 However, the guideline explicitly states that while symptoms during menstrual cycles have long been considered hormonally induced, there is no convincing evidence to definitively prove this mechanism. 1

The proposed mechanism involves nasal vascular pooling caused by vasodilation and increased blood volume during hormonal fluctuations, similar to what occurs during pregnancy. 1 This same mechanism is documented to worsen both allergic rhinitis and increase sinusitis during pregnancy. 1

Recent Research Findings

A 2025 scoping review in The Laryngoscope found that early menarche (representing higher lifetime estrogen exposure) may be associated with higher rhinitis likelihood, suggesting a pro-inflammatory estrogen effect. 2 However, this same review noted that menopause (a low estrogen state) is also associated with worse sinonasal outcomes, creating a paradoxical relationship that remains poorly understood. 2

Research from 2012 demonstrates that the menstrual cycle modulates immune cell numbers and activity throughout the 4-week cycle, with most chronic diseases displaying worsening of symptoms premenstrually or during menses. 3 This provides a plausible immunologic mechanism for symptom exacerbation.

Clinical Management Approach

For Women Reporting Cyclical Sinus Symptom Worsening:

First-line treatment should consist of intranasal corticosteroids used continuously or prophylactically before anticipated symptom worsening. 4 Specifically:

• Intranasal budesonide, fluticasone, or mometasone can be used safely in reproductive-age women 5
• Nasal saline irrigation 2-3 times daily for mechanical clearance 6, 4
• Intranasal anticholinergics (ipratropium bromide) if rhinorrhea is the predominant symptom 4

Critical Pitfalls to Avoid:

• Do not use oral antihistamines for vasomotor or hormonal rhinitis—they are ineffective 4
• Avoid topical decongestants beyond 3 days to prevent rhinitis medicamentosa 4, 7
• Oral decongestants require caution in women with hypertension, arrhythmias, or other contraindications 4

Important Clinical Caveats

The diagnosis of menstrual cycle-related sinusitis worsening requires careful exclusion of other causes. 4 You must differentiate between:

• True bacterial sinusitis requiring antibiotics (yellow-green discharge persisting >10 days, frontal headache, swollen turbinates) 6
• Allergic rhinitis exacerbation (which worsens in approximately 1/3 of cases with hormonal changes) 1
• Vasomotor rhinitis triggered by other factors 4
• Rhinitis medicamentosa from decongestant overuse 1

The evidence base for menstrual cycle-related sinonasal disease remains weak compared to pregnancy rhinitis. 8, 7, 2 The 2025 scoping review concluded that the validity of findings is limited due to lack of rigorous and standardized study design, though it acknowledged growing evidence of inflammatory-modulating effects of sex hormones. 2

When to Suspect True Bacterial Sinusitis Requiring Antibiotics:

If symptoms include yellow-green nasal discharge persisting beyond 10 days, frontal/glabellar headache, and swollen turbinates on examination, treat as acute bacterial rhinosinusitis with azithromycin 500 mg once daily for 3 days (if pregnant) or standard antibiotics per local guidelines. 6