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Intranasal oestrogen cream for the prevention of epistaxis in patients with bleeding disorders

Conventional interventions such as humidifiers during the winter, topical petroleum jelly and even cauterization frequently fail to control epistaxis in patients with bleeding disorders. Furthermore, the use of coagulation factor concentrates and antifibrinolytic agents and physician office or emergency department visits add to the overall cost of care and reduce quality of life. Topical and systemic oestrogen preparations have been used for the treatment of epistaxis primarily in hereditary haemorrhagic telangiectasia, a disorder characterized by small subepithelial blood vessels that bleed easily [1–4]. The suggested mechanism of action is the conversion of ciliated columnar epithelium to stratified keratinizing squamous epithelium, preventing epistaxis if the nasal mucosa is thickened. One topical oestrogen preparation (Premarin Vaginal Cream, Wyeth Pharmaceuticals Inc., Philadelphia, PA, USA) has been used to treat epistaxis in patients without a bleeding disorder [5] and has been shown to reduce the frequency and duration of epistaxis [1–3,5]. On the basis of these data, we have prescribed topical Premarin cream applied to the nares in patients experiencing recurrent or refractory epistaxis. As a result of the concerns of potential systemic absorption of topical oestrogens, we prescribed once daily application to the nares for a total of 3 days per month. Herein, we present the outcome. Eighteen patients between the ages of 9 and 54 years were prescribed oestrogen cream for the treatment of epistaxis (eight females, ten males). Diagnoses included von Willebrand s disease (type 1, 2 and 3) (n = 14), haemophilia A (n = 2) and Glanzmann thrombasthaenia (n = 2). Mayo Clinic Institutional Review Board approval was obtained prior to the conduction of the study. Participants provided informed consent for this study. Eleven of the 18 patients agreed to participate in this retrospective study. Four of the 11 patients (36%) reported using oestrogen cream as prescribed and reported a reduction in the frequency of nosebleeds (Table 1). This limited survey of our practice suggests that nasal application of topical oestrogens, in patients with bleeding disorders, reduces the frequency and severity of epistaxis and potentially reduces the need for medical visits. Our study has several limitations. Compliance was not uniform in all patients. Patients who reported regular use of the agent also reported subjective previous epistaxis frequency, duration and need for medical attention before and after the use of topical oestrogen. To address efficacy, cost-effectiveness and adverse effects, a randomized study in a larger cohort of patients will need to be conducted. Topical oestrogens for the prevention of epistaxis in patients with bleeding disorders may reduce the need for coagulation factor concentrate to treat this complication.