Bleeding from the eyes sure is a gruesome concept, with this bloody visual (pun intended) cropping up in films like Kill Bill: Vol 1. However, this phenomenon also happens outside the realm of fiction, illustrated by a recent paper published in BMJ Case Reports describing a woman who cried tears of blood whenever she menstruated.
Producing tears that contain blood, known as hemolacria, is a shocking symptom but is often harmless itself. It can be caused by eye injuries, blocked tear ducts, or bleeding in the nose or sinuses. Hemolacria can also be a symptom of underlying health issues, such as melanoma in the conjunctiva, a tumor in the lacrimal apparatus (which produces tears), bacterial conjunctivitis, high blood pressure, and blood disorders such as hemophilia. However this unusual bleeding can also be triggered by hormonal changes and menstruation, similarly to endometriosis.
In this recent case report, a 25-year-old woman came into an emergency medicine department in Chandigarh, India, crying red tears. This was her second time experiencing this symptom, with her first episode occurring one month prior – both cases happening while she was menstruating.
A vast array of tests were performed on the woman to get to the root cause of her bleeding eyes, with everything surprisingly coming back normal. There were no injuries to the eyes, no family history of this condition, and no swelling or congested blood vessels in the conjunctiva. Gynecological and ear, nose, and throat evaluations were normal, and she was found to be hemodynamically stable with normal pressure inside her eyes. There was no bleeding from any other site, a capillary fragility test came back negative, and levels of factors involved in blood clotting were normal. A conjunctival swab came back normal, and the eye blood contained no abnormal cells.
Ruling out all other causes for the bloody tears, doctors diagnosed the patient with vicarious menstruation, defined as “cyclical bleeding in extrauterine organs during menstruation.”
While rare, cases of vicarious menstruation have been previously documented in the medical literature. In November 1913, a doctor in Roswell, New Mexico reported a woman with an ulcer on each leg, bleeding profusely and becoming especially large during her menstrual periods. However, the report stated that “She became pregnant, had slight trouble during pregnancy, gave birth to a healthy child, and since has been entirely normal.”
In April 2014, another medical case report described a similar case, with an American woman also presenting with bleeding eyes coinciding with her menstrual cycle. After dealing with menstru-eye-tion for a year, treatment with oral contraceptive pills led to “marked clinical improvement.”
“Vicarious menstruation is considered to be due to response of vasculature to the hormones in the presence or absence of endometrial tissue at extrauterine sites, although its exact pathophysiology is not very clear,” write the authors of the recent case report. “Oestrogen and progesterone can increase permeability of capillaries resulting in hyperaemia, congestion and secondary bleeding from extrauterine tissue.”
Luckily for the patient in this case, hormonal treatment with contraceptives was successful. She was prescribed a combination estrogen-progesterone oral contraceptive pill, and during her 3-month follow-up period the bleeding had stopped – much to her relief, we can assume.