What are the common causes of blood clots during menstruation. How can you differentiate between normal and abnormal clotting. When should you seek medical attention for menstrual blood clots. What are the treatment options for excessive menstrual bleeding and clotting.

The Menstrual Cycle and Blood Clots: What’s Normal?

The menstrual cycle is a natural process that occurs in women of reproductive age. During this cycle, the uterine lining thickens in preparation for a potential pregnancy. If pregnancy does not occur, the uterus sheds this lining, resulting in menstrual bleeding, commonly known as a period.

While the average menstrual cycle is often cited as 28 days, it’s important to note that every woman’s cycle is unique. The duration of menstrual flow typically ranges from 5 to 7 days, but this can vary as well. Some women may experience irregular periods, heavier flows, or the presence of blood clots during menstruation.

What exactly are menstrual blood clots?

Menstrual blood clots are different from the clots that form when you cut yourself or those that develop in deep veins. They are typically composed of congealed blood that has pooled in the vagina or a mixture of blood, fluid, mucus, and endometrial tissue. These clots often form when blood flow is heavier, allowing more blood to collect in the vagina before being expelled.

When are blood clots considered normal during menstruation?

According to the Centers for Disease Control and Prevention (CDC), blood clots smaller than a quarter are generally considered normal during menstruation and do not require medical treatment. However, if you consistently pass clots larger than a quarter or experience clotting between periods, it’s advisable to consult a healthcare professional.

Causes of Abnormal Menstrual Clotting

While some clotting during menstruation is normal, excessive or unusual clotting may indicate an underlying issue. Here are some potential causes of abnormal menstrual clotting:

Birth Control Methods

• Birth control pills: Breakthrough bleeding, which may include clots, is common in the first six months of starting a new pill.
• Morning-after pill: This emergency contraception may cause heavy menstrual bleeding or breakthrough bleeding with clots.
• Intrauterine devices (IUDs): Both hormonal and copper IUDs can lead to irregular bleeding or heavier periods with clots, especially in the first few months after insertion.

Medical Conditions

• Fibroids or polyps: These benign growths in the uterus can cause heavier periods and increased clotting.
• Endometriosis: This condition, where uterine tissue grows outside the uterus, may lead to heavier periods and clotting.
• Polycystic ovary syndrome (PCOS): PCOS can cause irregular periods and sometimes heavier bleeding with clots.

Infections

• Sexually transmitted infections (STIs): Chlamydia, gonorrhea, and trichomoniasis can cause abnormal bleeding and clotting.
• Pelvic inflammatory disease (PID): This infection of the upper female reproductive system may result in heavy bleeding and clotting.

Pregnancy-Related Issues

• Ectopic pregnancy: This condition can cause abnormal bleeding and clotting, often accompanied by abdominal pain.
• Miscarriage: Unusually heavy bleeding with clots can be a sign of miscarriage.

When to Seek Medical Attention for Menstrual Clots

While some clotting during menstruation is normal, there are instances when you should consult a healthcare provider. Consider seeking medical attention if you experience:

• Blood clots larger than a quarter
• Heavy bleeding that soaks through a pad or tampon every 1-2 hours
• Bleeding that lasts longer than 7 days
• Severe abdominal pain
• Signs of anemia, such as fatigue, weakness, or shortness of breath
• Bleeding or clotting between periods

Diagnosing the Cause of Abnormal Menstrual Clotting

If you’re experiencing unusual menstrual clotting, your healthcare provider may use various methods to determine the underlying cause:

Physical Examination

A pelvic exam can help detect any abnormalities in the reproductive organs that might be causing excessive bleeding or clotting.

Blood Tests

These can check for hormonal imbalances, anemia, or other systemic issues that might contribute to abnormal menstrual bleeding.

Imaging Tests

Ultrasounds, MRIs, or CT scans may be used to visualize the uterus and detect any structural abnormalities like fibroids or polyps.

Endometrial Biopsy

In some cases, a small sample of the uterine lining may be taken to check for abnormal cells or conditions like endometriosis.

Treatment Options for Excessive Menstrual Bleeding and Clotting

The treatment for abnormal menstrual clotting depends on the underlying cause. Here are some common approaches:

Hormonal Treatments

• Birth control pills: These can help regulate menstrual cycles and reduce heavy bleeding.
• Hormonal IUDs: These devices can significantly reduce menstrual flow in many women.
• Progesterone therapy: This can help balance hormones and reduce excessive bleeding.

Non-Hormonal Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs): These can help reduce menstrual blood flow and alleviate pain.
• Tranexamic acid: This medication can help reduce heavy menstrual bleeding.

Surgical Interventions

• Endometrial ablation: This procedure destroys the uterine lining to reduce menstrual flow.
• Myomectomy: This surgery removes fibroids while preserving the uterus.
• Hysterectomy: In severe cases, removal of the uterus may be recommended.

Lifestyle Changes to Manage Menstrual Clotting

In addition to medical treatments, certain lifestyle changes can help manage menstrual clotting:

Dietary Adjustments

• Increase iron intake: This can help prevent anemia caused by heavy menstrual bleeding.
• Consume vitamin C: This nutrient enhances iron absorption.
• Stay hydrated: Proper hydration can help maintain blood volume and prevent clot formation.

Exercise

Regular physical activity can help regulate hormones and improve overall menstrual health. However, it’s important to avoid overexertion during heavy flow days.

Stress Management

Chronic stress can disrupt hormonal balance and affect menstrual cycles. Techniques like meditation, yoga, or counseling can help manage stress levels.

Tracking Menstrual Symptoms for Better Management

Keeping a detailed record of your menstrual symptoms can be incredibly helpful in managing abnormal clotting and identifying patterns. Consider tracking the following:

Menstrual Flow

• Duration of bleeding
• Heaviness of flow (number of pads or tampons used per day)
• Presence and size of clots

Associated Symptoms

• Pain or cramping
• Mood changes
• Fatigue or weakness

Lifestyle Factors

• Diet
• Exercise
• Stress levels

This information can be valuable when consulting with your healthcare provider and can help in determining the most effective treatment plan.

The Impact of Age on Menstrual Clotting

It’s important to note that menstrual patterns, including the presence of clots, can change throughout a woman’s reproductive years.

Adolescence

In the first few years after menarche (the first menstrual period), irregular cycles and heavy bleeding with clots are not uncommon as the body adjusts to hormonal changes.

Reproductive Years

During the prime reproductive years, menstrual cycles typically become more regular. However, events like pregnancy, childbirth, and the use of hormonal contraceptives can affect menstrual patterns and clotting.

Perimenopause

As women approach menopause, hormonal fluctuations can lead to changes in menstrual flow, including heavier bleeding and increased clotting. It’s particularly important to monitor these changes and consult with a healthcare provider if they become disruptive.

Emotional and Psychological Aspects of Menstrual Disorders

Dealing with abnormal menstrual clotting and heavy bleeding can have significant emotional and psychological impacts. It’s important to address these aspects as part of a comprehensive approach to menstrual health.

Quality of Life

Heavy menstrual bleeding and clotting can significantly affect a woman’s quality of life, impacting work, social activities, and personal relationships. It’s crucial to seek treatment not only for physical symptoms but also to improve overall well-being.

Anxiety and Depression

The unpredictability and discomfort associated with abnormal menstrual bleeding can lead to anxiety and depression in some women. If you’re experiencing these feelings, don’t hesitate to discuss them with your healthcare provider.

Body Image and Self-Esteem

Menstrual disorders can sometimes affect body image and self-esteem. It’s important to remember that these issues are medical conditions and not a reflection of personal worth or femininity.

Support Systems

Building a support system of friends, family, or support groups can be beneficial in coping with the challenges of menstrual disorders. Sharing experiences and advice can provide emotional relief and practical tips for managing symptoms.

Remember, menstrual health is an important aspect of overall well-being. If you’re experiencing concerns about menstrual clotting or any other menstrual irregularities, don’t hesitate to seek professional medical advice. With proper diagnosis and treatment, most menstrual disorders can be effectively managed, allowing you to lead a healthy, comfortable life.

Why Am I Passing Blood Clots Between Periods? – Knix

JANE FLANAGAN
/
YOUR BODY

Approximately every month, a woman’s uterine lining thickens to prepare for pregnancy. If implantation does not occur, the uterus sheds its lining. This shedding is what we call a period or menses.

Most women have a period on a monthly cycle (a commonly referenced frequency is 28 days, though it is not the average frequency for most women is 28 days). The duration of period flow is usually 5-7 days. Every woman’s cycle is different, and some women experience irregular periods, heavier periods, and/or periods with clotting.

Seeing some small clots in your period flow is not necessarily unusual. However, it’s never considered normal to experience heavy bleeding or to pass large quarter-sized clots.

What Is a Period Blood Clot?

The period blood clots that you see during your cycle are different from:

• Normal blood clotting that occurs when you cut yourself 
• Clots that form in deep veins (that can be potentially life-threatening)

Clots that occur during menstrual flow can either be congealed blood that pooled in the back of the vagina while lying or sitting and then all come out at once upon standing OR it can be blood, fluid, or mucous mixed with endometrial tissue.

If you have a heavy flow, there’ll be more blood collecting in the vagina, and this can congeal and form clots.

Clotting: What’s Considered Normal

So, some clotting is considered normal when you’re on your period. According to the CDC, blood clots smaller than a quarter are nothing to be concerned about and don’t require medical treatment.

However, the CDC says “blood clots the size of a quarter or larger” should be further investigated. This stands whether they’re showing up as part of your period or not; you’ll want to see a doctor for medical advice.

If you’re seeing blood clots when you’re not on your period, you may be bleeding heavily, and this is also something you’ll want a doctor to investigate. 

Keep track of the number of pads or tampons (saturated and not saturated) used when you’re bleeding. Abnormal blood loss can be estimated by tracking pad or tampon use and how quickly they become soaked.

What Could Cause Abnormal Clotting

If you’re passing large clots either during or between periods, it’s something you may need to investigate with your doctor. What follows are some possible causes of abnormal clotting:

Birth Control Cause

• Birth control: According to Medical News Today, bleeding often occurs in the first 6 months of taking a new birth control pill. Doctors sometimes refer to this as breakthrough bleeding. Abnormal uterine bleeding is more likely if you miss a pill, start a new medication, or experience vomiting or diarrhea as the result of illness, according to the Mayo Clinic. 
• Morning-after pill: According to the Mayo Clinic, the morning-after pill may cause breakthrough bleeding or heavy menstrual bleeding. Under normal circumstances, you don’t need to consult your doctor. But if bleeding continues for longer than a week, you are saturating a pad or tampon every 1-2 hours, passing clots greater than a quarter-size, you are experiencing signs of symptomatic anemia, or you are experiencing serious abdominal pain, seek medical advice. 
• Intrauterine device (IUD): Some women with an IUD for birth control could also experience non-period bleeding. Side effects of hormonal IUDs include irregular bleeding—which often decreases or stops within 6 months—mood changes, acne, and breast tenderness. The use of copper IUDs can sometimes result in cramps, heavy bleeding, and bleeding between periods. 

External Causes

• Medications: Certain medications may cause abnormal vaginal or uterine bleeding. Your pharmacist should advise you of any serious side effects of the medication.

Common Infections

The following infections may cause vaginal bleeding between periods. It’s worth noting that most infections are treatable. However, an infection may also become more serious if ignored.

• Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and trichomoniasis, may cause abnormal bleeding
• Pelvic inflammatory disease (PID), an ascending infection of the upper  female reproductive system, can cause abnormal or heavy bleeding

Pregnancy-Related Causes

• Ectopic pregnancy: Signs and symptoms of an ectopic pregnancy include abdominal pain and vaginal bleeding
• Miscarriage: Abnormal uterine bleeding is one of the symptoms of miscarriage

Other Causes

• Fibroids or polyps: These benign tumors can cause irregular or heavier periods and vaginal bleeding between periods.
• Endometriosis: According to the Mayo Clinic, women with endometriosis may experience heavier periods or bleeding between periods (intermenstrual bleeding).
• Polycystic ovary syndrome (PCOS): PCOS is a syndrome that is associated with anovulation which can make it difficult to get pregnant. It may also cause irregular uterine bleeding.
• Blood clotting disorders, like von Willebrand disease, may cause heavy menstrual bleeding.
• Other health conditions, like hypothyroidism, liver disease, or chronic kidney disease, can cause heavy menstrual bleeding and clotting.
• Cancer: Cancer or precancer of the cervix, uterus, or (very rarely) fallopian tube may cause abnormal uterine bleeding.

Perimenopause & Menopause

• Perimenopause: The time before menopause is known as perimenopause. During perimenopause, hormones fluctuate greatly. These hormonal shifts can have an effect on ovulation and your entire menstrual cycle. Some women notice irregular or skipped periods and abnormal bleeding between periods during perimenopause. 
• Cancer: According to the Dana-Farber Cancer Institute, spotting in post-menopausal women can, in some cases, be an early sign of cancer and should always be investigated further.

Risks of Heavy Bleeding and Blood Clots Between Periods and Clotting

Depending on the cause of intermenstrual bleeding and blood clots, the risks to your health will be different. However, anemia is one risk that is common to all causes.

Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body’s tissues. It can have many causes, including heavy menstrual bleeding or vaginal bleeding between periods (intermenstrual bleeding).

Anemia doesn’t always have symptoms. But, according to the Mayo Clinic, signs and symptoms of anemia include:

• Fatigue
• Weakness
• Pale or yellowish skin
• Irregular heartbeats
• Shortness of breath
• Dizziness or lightheadedness
• Chest pain
• Cold hands and feet
• Headaches

When to Seek Medical Advice for Abnormal Vaginal Bleeding

If you experience heavy vaginal or uterine bleeding or clotting during or outside of your period, it is important to seek medical care and advice.

If heavy bleeding or clotting is accompanied by any of the following symptoms, you’ll want to consult your doctor immediately for their advice:

• Heavy periods and/or passing blood clots
• Irregular periods
• Abdominal pain or cramping
• Pain or a burning sensation when peeing
• Abnormal vaginal discharge and/or redness, irritation, and itchiness of the vulva (external genitalia) or vagina.

Even if you don’t have any of the above symptoms, don’t ever ignore abnormal vaginal bleeding or abnormal uterine bleeding in the following situations:

• If you think you’re pregnant: You should always seek medical advice as soon as you think you may be pregnant to be administered a pregnancy test
• When it happens unpredictably or frequently: If spotting seems to happen frequently and randomly, you should definitely look into it
• It begins after unprotected sex: Unprotected sex can put you at risk for STIs and other infections, so if you notice spotting after unprotected sex, it’s wise to see your doctor
• You are on medication that may cause spotting: If spotting can be a side effect of any medication you are on, you should seek out professional help
• Spotting occurs post-menopause: It is never considered normal for anybody post-menopause to experience abnormal vaginal bleeding

How to Prepare for Your Medical Appointment

When you see your doctor, she may need to know the following:

• How long have you been experiencing blood clots between periods been happening: Is it something you’ve always experienced, or did it start recently?
• How often it happens: Is it monthly or irregular? Is this the first time it’s happened?
• If there’s a pattern to the bleeding: Have you observed the bleeding happens on certain days in your menstrual cycle or seemingly at random?
• How long did the bleeding last: 1–2 days or more?
• If you’re passing blood clots, are they large blood clots? (coin sizes can be a handy reference)
• How heavy was the blood flow: Did you use any protection? Was a panty liner insufficient?
• Do you usually have a heavy menstrual flow/blood flow? (how many tampons do you use a day, and whether those tampons are super absorbency; do you often saturate your tampons quickly or experience leaks?)
• Was there anything unusual about the blood: Color, texture, or odor?
• Did you also experience pain or other symptoms while you were bleeding?
• Did the bleeding coincide with any increased physical exertion (sex, exercise, etc. )?
• Was there anything you did that seemed to make the spotting worse or better?

Your doctor may also examine you and conduct a pelvic exam. The tests your doctor might recommend will depend on your age and other factors. If you could be pregnant, they will likely obtain a pregnancy test.

They will most likely order bloodwork to check your blood count and see if you’re anemic.

Other tests your doctor may recommend in order to determine a cause of abnormal uterine bleeding may include:

• Endometrial biopsy: An endometrial biopsy is used to screen for abnormal cells in the uterus. Learn more from Johns Hopkins Medicine.
• Hysteroscopy: A hysteroscopy allows your doctor to look inside your uterus in order to diagnose and treat the causes of abnormal bleeding. Learn more from the Cleveland Clinic.
• Pelvic Ultrasound: A pelvic ultrasound allows quick radiographic visualization of the female pelvic organs and structures, including the uterus, cervix, vagina, fallopian tubes, and ovaries. Learn more from Johns Hopkins Medicine.

Possible Treatments for Abnormal Uterine Bleeding or Clotting

The treatment of any unusual vaginal bleeding, blood clots or abnormal uterine bleeding will depend on the cause. Your doctor will first want to diagnose the problem and then they will help you understand your treatment options and determine the right course of action.

Some treatment options for blood clots that your doctor might explore with you may include:

Intrauterine Device (IUD)

It may seem unusual that one possible cause of the bleeding may also be used as a treatment. But hormone-releasing IUDs can help. A hormonal IUD “can decrease menstrual bleeding after three or more months of use,” according to the Mayo Clinic. After one year of use, roughly 20% of women stop having periods altogether.

According to the Medical Journal of Australia, one in 20 women will experience abnormal uterine bleeding, such as heavy or long periods or bleeding in between periods. The 2018 study by Dr. Annabelle Brennan found that “hormone-releasing IUDs is the most effective form of non-surgical treatment for abnormal menstrual bleeding.”

Birth Control Pill

Different types of hormonal contraceptives (birth control pills) can reduce bleeding and related problems. Hormonal contraceptives are medicine for the uterus and can lessen the amount of uterine bleeding.

D&C: Dilation and Curettage

Dilation and curettage (D&C) is a procedure to remove tissue from inside your uterus. Learn more on the Mayo Clinic’s website.

Myomectomy

According to the Mayo Clinic, in a myomectomy, your surgeon removes the fibroids, leaving the uterus in place. This can be performed laparoscopically or via hysteroscopy.

Hysterectomy

Hysterectomy (the removal of the uterus) is 100% effective in stopping uterine bleeding. A hysterectomy is considered a major surgery that requires a hospital stay. Although it will permanently solve uterine bleeding, including heavy periods or bleeding between periods, it also means you won’t be able to become pregnant.

Endometrial Resection or Ablation

Another treatment option is to temporarily remove or cauterize the top layer of the uterine lining (endometrium). Here the tissue is removed using surgical instruments (endometrial resection) or destroyed, for instance, using laser beams or microwave energy (endometrial ablation). After this procedure, you’ll often stop having periods for several years or have much lighter periods. This option can affect future fertility.

Medically reviewed by Dr. Chimsom T. Oleka, M.D, Written by Jane Flanagan — Updated on January 30, 2023.

Menstrual Clots and How They Are Linked to Endometriosis

Menstrual clots are lumps of coagulated blood or tissue. They are discharged from the uterus during menstruation when the lining of the uterus or endometrium sheds and is expelled from the uterus through the cervix.

Normally, the body produces anticoagulants or blood thinners to allow the thickened endometrium fragments and blood mixture to pass more freely through the cervix and leave the body. However, sometimes, the body is not able to produce enough thinning agents, causing blood clots to form.

Menstrual clots resemble pieces of mashed-up red fruit. They can be bright red or burgundy and may vary in size. They are usually mixed with liquid blood. The longer the blood stays inside the uterus, the darker it is in color, and the likelier it is to form clots.

Menstrual Clots

Causes of menstrual clots

Blood clot formation is the body’s way of controlling bleeding. Blood cells called platelets play an important role in blood clot formation. They release chemicals that start the “clotting cascade.” The fibrin protein is the last step in this cascade, which crosslinks and forms a mesh-like structure that results in a clot.

Platelets can produce these clotting factors. This occurs during menstruation, as well as because of an injury to a blood vessel wall.

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.

You may call us at (212) 988-1444 or have your case reviewed by clicking here.

Review My Case

Menstrual clots and heavy periods

The normal menstrual cycle lasts 25 to 32 days. A normal flow lasts between four and seven days and may be accompanied by blood clots. A normal period should normally cause mild to moderate discomfort beginning the first day and then subside.

A period is considered heavy if it soaks through a pad or tampon every hour for several hours or if it lasts for over seven days. Large clots in period blood are also considered signs of heavy periods. Moreover, heavy periods can cause constant pain in the lower abdomen.

Heavy menstrual bleeding can negatively affect a woman’s quality of life and lead to other conditions such as anemia where the body lacks enough healthy red blood cells that can carry oxygen to different organs and tissues in the body. Anemia can make a person feel weak and tired.

Menstrual clots and disease

Blood clots during a period can be normal or a sign of an underlying problem such as:

• a blockage in the uterus
• fibroids or non-cancerous growths in the wall of the uterus
• hormonal imbalance
• a miscarriage

Menstrual blood clots can also indicate the presence of more serious conditions such as:

• endometriosis
• adenomyosis
• cancer

Should I worry?

Clots in menstrual blood are considered normal if they are quarter-sized or smaller and only occur occasionally. However, if they frequently occur (more than three times in a row) accompanied by heavy periods and are larger than a quarter, you should seek medical advice.

Menstrual clots and endometriosis

Endometriosis is usually accompanied by heavy bleeding during a woman’s period and chronic pelvic pain. This is because the endometrium-like tissue that has grown outside the uterus reacts to the hormones secreted from the ovaries in the same way as the normal endometrium and starts to bleed.

Treatment

Hormonal medications such as the contraceptive pill can help regulate heavy bleeding and reduce the formation of blood clots. These work by inhibiting the growth of the endometrium. An intrauterine device (IUD) that releases the hormone progestin can also help.

Other treatment options include Cyklokapron and Lysteda. These medications stop blood clots from breaking down and therefore may reduce heavy menstruation. Likely less blood will pool in the uterus and menstrual clot formation will diminish.

Laparoscopic surgery often used both to diagnose and treat endometriosis, can also treat heavy bleeding and the formation of blood clots during periods.

Our approach

Endometriosis is associated with heavy periods, prolonged menstrual flow, and large clots. We believe that a transvaginal sonogram, and, if needed, hysteroscopy and endometrial biopsy are necessary for diagnosis. It is also necessary to rule out the diagnoses of myoma, uterine fibroid, polyp, endometrial hyperplasia, and endometrial cancer.  

Patient story

“My research led me to locate an excision specialist, Dr. Seckin. I had excision surgery with Dr. Seckin in March 2015. I had advanced endometriosis removed in 18 places, including my appendix, intestines, ovary, and uterus. It turns out that the cyst was the least of my problems! Dr. Seckin was wonderful throughout my experience.” —M. Wilson

Read More

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (646) 960-3080 or have your case reviewed by clicking here.

Review My Case

Author
Tamer Seckin, MD
Date: September 20, 2019

Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.

Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.

He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.

Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.

Why nose bleeds

Contents

• 1 Causes of nosebleeds
• 2 Precautions

Often people are very frightened when they discover blood clots from the nose. If this happens infrequently, the anxiety is not permanent. For the treatment of this, simple folk methods may be suitable. However, when traces of blood or clots begin to appear regularly, it is best to see a doctor, as in this case, the cause may be an acute or chronic illness.

Causes of bleeding in the nose

If you stay in a very dry room with hot air for a long time, there is a risk that by the morning the blood clots will dry up, covering the mucous membrane with a bloody crust (this can happen both before and after nosebleeds) ). If a person damages this crust (for example, with a finger), then when washed out, it will come out in small lumps.

When nosebleeds come from the front of the nose, it is usually epistaxis and minor bleeding. It is much worse if there is bloody discharge from the back of the nose. This may indicate damage to blood vessels, serious injury, or bleeding from other internal organs (lungs). Finding no way out, the blood begins to flow down the throat and nose.

It is in posterior bleeding that nasal discharge often takes the form of clots. It is quite difficult to stop such bleeding, but even if it was possible to do this without medical intervention, the crust formed on the walls of the nose will still come out of the nose for some time. Such bleeding can lead to large blood loss and even hemorrhagic shock.

Causes of blood clots in the nose are conventionally divided by doctors into two categories: local and general. Everything related to the nose and nasal passages is local:

1. All kinds of injuries. Nosebleeds can leak from an accidental light blow or a fracture. It all depends on the individual characteristics of the organism. If after an injury a severe swelling, wound or a change in the shape of the nose appears, you should immediately go to the hospital.
2. Consequences of surgical operations. Unfortunately, they do not always pass without consequences, but even if everything is fine, then the first day or two after the removal of polyps and tonsils, puncture of the maxillary sinus and other invasive manipulations, blood clots may appear.
3. Ingress of foreign bodies. If they are small and hard (grains of sand, calluses, insects), they can constantly scratch or irritate the nasal passage, damaging the capillaries and causing nosebleeds.
4. Exposure to external irritants, including allergens. This causes relaxation, swelling, and then atrophy and bleeding from the mucous membranes of the nose, the formation of polyps.
5. Chronic diseases of the nose and sinuses. In acute cases, purulent inflammatory processes often flare up, during which traces and blood clots are constantly present in the mucus discharged from the nose.
6. Polyps, angiomas and other formations. These are remodeled nasal tissues that are easily damaged. Angioma is a kind of plexus of tiny blood vessels, which, even with light pressure, begins to bleed.
7. Deviated septum. If it is strong enough, it leads to mucus stasis, mucosal atrophy and chronic inflammation.

Problems with local causes are usually solved by the ENT. It is he who can quickly and efficiently conduct tests, if necessary, recommend additional tests and diagnostic procedures, as well as choose the best course of treatment.

Sometimes the regular appearance of blood clots in the nose is one of the symptoms of complex diseases of the respiratory system.

People working in mines, hot shops, foundries, textile and chemical plants often suffer from chronic respiratory diseases. They need to see a doctor regularly and take measures to restore irritated mucous membranes.

Common causes are much more difficult to identify and eliminate. In many cases, one of the symptoms can be bloody rhinitis or persistent blood clots in the nose. Below are the most common cases, but do not forget that each case is individual. Therefore, if similar symptoms are found, diagnostic tests should be carried out.

1. Hemophilia or thrombocytopenia. Diseases in which the blood does not clot well and can flow for hours. A slight lesion of the mucous membrane is enough for the discharge from the nose to stretch for a long time. Usually people suffering from such diseases know about this: they often have bruises that persist for a long time; even with a light blow, hematomas form under the skin.
2. Hypertension. Consistently high blood pressure puts additional stress on the heart and blood vessels. The tiny capillaries that are used to hold the nasal mucosa in place cannot withstand the pressure and are damaged. Often this happens at night, and in the morning a blood clot comes out of the nose.
3. Atherosclerosis. Fragility of vessels caused by structural changes. A serious disease that is difficult to completely cure. If you do not slow down its development, then the likelihood of a stroke is high.
4. Vasculitis. An autoimmune disease (hereditary or acquired) that can be prolonged by a strong allergen. In this case, there are large and small blood vessels, and subcutaneous hemorrhage may occur.
5. Bronchial asthma. Its characteristic symptom is a strong choking cough of an aggressive nature. This puts a lot of strain on the blood vessels in the head, and tiny capillaries can burst.
6. Cardiovascular diseases. They cause sharp jumps in blood pressure, which quickly wear out blood vessels and capillaries. This leads to their systematic rupture and the formation of bloody clots and crusts in the nose.
7. Cancer. Malignant neoplasms quickly destroy not only the organ in which they appeared, but can also spread to the entire body. In this case, they cause fragility of blood vessels and a sharp decrease in immunity.

To make an accurate diagnosis with such symptoms, it is necessary to conduct a series of tests and undergo appropriate diagnostic procedures. This is necessary if blood clots are constantly present in the nose.

The problem is not only that the mucous membrane, which constantly bleeds, is an open gate for any infection, but also that if the underlying disease is not treated in time, serious complications can arise.

Preventive measures

Chronic diseases can only be prevented by regular preventive examinations. But, unfortunately, recently more and more people neglect these simple rules and do not want to spend time and money on them. The regular appearance of blood clots in the nose is a serious sign, so when it occurs, you should consult a doctor to determine the type of disease and, if possible, avoid serious complications.

Additional prophylaxis:

• giving up bad habits, and above all from smoking, which strongly destroys the nasal mucosa;
• use of personal respiratory protective equipment when working in “bad” places;
• timely treatment of the common cold and other symptoms of respiratory diseases;
• prudent and moderate use of nasal vasoconstrictor drops;
• a balanced diet rich in vitamins and microelements, if necessary, an additional course of multivitamins;
• clean and moderately humid air in the room, without dust and strong odors;
• proper use of chemicals, storing them in tightly closed containers, in a specially designated place.

Proper and regular care of the nasal cavity is equally important. If crusts form constantly, they cannot be removed, and you need to rinse the nose with oil, then gently clean it with a piece of cotton pad and rinse.

A healthy strong immune system is the body’s best defense against colds and respiratory diseases. Therefore, it is best not to overdo it with difficult procedures, pouring medicines indiscriminately into the nose. It is also desirable to maintain the body with minimal physical exertion, to ensure being in the fresh air. And then the only reason why blood clots can appear in the nose is accidental injuries that could not be avoided.

Analysis of complications of biliary interventions and measures to prevent them

Over a long period of time, a large number of complications of biliary interventions caused a restrained attitude to percutaneous transhepatic drainage in patients with obstructive jaundice. There is a strong and reasonable opinion that percutaneous transhepatic cholangiostomy is generally a complex and rather dangerous procedure, often accompanied by serious complications [1, 2].

However, the improvement of techniques and the use of thin flexible needles, conducted to the bile duct under ultrasound control, made it possible to take a different look at the indications for external bile duct in patients with obstructive jaundice. Complications such as fat and air embolism, unplanned punctures of intra-abdominal organs and pleural cavity have become a rarity when using modern means of planning puncture trajectories [3, 4]. Nevertheless, complications of percutaneous transhepatic interventions cannot be completely avoided, and they remain a serious problem, occurring more often in especially difficult cases [5—8].

Complications of decompression interventions were noted by us in 17.4% of cases. All observed complications were divided into severe and non-severe. We considered severe a complication that led to a significant deterioration in the patient’s condition and/or necessitated surgical intervention. Among the severe complications, we singled out hemorrhagic complications requiring intensive therapy for health reasons, purulent-septic ones, among which cholangitis was the most common, as well as bile leakage into the abdominal cavity.

According to the time of development, we subdivided complications into intraoperative, complications of the immediate postoperative period (in the first 24 hours), early, occurring on the 2nd-5th day of the postoperative period, delayed (6-14th day), late (15-28th e days) and remote.

In total, complications developed in 16 patients at the hospital stage of treatment. The incidence of severe complications in percutaneous cholangiography was 0.4%, with external drainage of the biliary system – 3.1%, with endoprosthesis of the bile ducts – 4.1%. In patients with tumor jaundice, severe complications occurred 46.1% more often. In 3 patients, complications occurred twice: after the first biliary intervention — drainage dislocation without the development of peritonitis, and after repeated biliary intervention in 2 — drainage dislocation and peritonitis, and in one hemobilia. More than 80% of complications occurred within 1 week after percutaneous bile ducting, and more than half of them were severe.

Among the early complications, hemorrhagic complications prevailed – 11.2% of all complications of this period, including 2 severe ones. In the immediate postoperative period, hemorrhagic, purulent and purulent-hemorrhagic complications prevailed. Of these, 68.6% were severe.

The most common complication was drainage dislocation, which was noted after 11 interventions. More often, dislocations occurred in the immediate and early postoperative periods. Among the causes of drainage dislocation, the most important were long-term palliative biliary evacuation, the use of catheters without fixing devices at the distal end, insufficient depth of catheter insertion into the biliary system, the use of external biliary evacuation, severe cough and deep breathing of the patient.

The greatest number of dislocations was observed when using catheters without fixing devices and a shallow position of the drainage in the ducts and was a trigger for the development of other, more severe complications, such as bleeding, bile leakage and peritonitis, perforation of the bile ducts, abdominal abscesses. The earlier the drains were displaced, the more often they led to the development of severe secondary complications. Thus, dislocations in the early postoperative period caused 3 severe complications, in the late one — only one. In the long-term period, complications associated with the displacement of the drainage were not noted.

Abdominal bile leakage was the second most common complication of percutaneous bile duct procedures. In 4 cases bile leakage was accompanied by dislocation, biliary peritonitis or bleeding. In one case, bile leakage was an independent complication, not combined with drainage dislocation and the development of peritonitis. In our opinion, the main causes of bile leakage into the abdominal cavity during cholangiostomy were the use of large-diameter needles, several exploratory punctures, unplanned puncture of the superficially located intrahepatic ducts, accidental puncture of the extrahepatic ducts or the gallbladder. High pressure in the biliary system, the presence of ascites, percutaneous arthroplasty without prior drainage, and inadequate external bile excretion also contributed to bile leakage.

Damage to the walls of the bile ducts and liver parenchyma occurred more often when bougies and catheters were passed through flexible conductors. At the same time, even small counter obstacles could lead to lateral displacements and bends of the guidewire and catheter, exit of the guidewire from the biliary system, ruptures of the bile duct wall and liver parenchyma.

Bleeding was the third most common complication and developed in one patient with benign and in 3 patients with malignant jaundice. In 2 patients, bleeding was in the abdominal cavity, in 2 – along the drainage. In one patient, bleeding developed during the intervention, in 3 – in the immediate postoperative period. In 2 cases, the bleeding was massive (more than 1000 ml), in one it was moderate (500 to 1000 ml), and in one case it was small (less than 500 ml). In 2 patients, bleeding was combined with bile leakage into the abdominal cavity. Bleeding developed as a result of trauma to the liver veins during puncture and drainage of the bile ducts (3 cases) and drainage dislocation (1 case).

Hemobilia developed after 3 endobiliary interventions (in 2 patients with tumor occlusion of the bile ducts and in one patient with choledocholithiasis). Abscesses in the right subdiaphragmatic space were detected in 2 patients on the 12-14th day after drainage.

After implantation of plastic endoprostheses, jaundice relapsed due to inlay of the endoprosthesis in 2 cases. The endoprostheses were removed by endoscopic method, after which percutaneous transhepatic cholangiostomy and repeated endoprosthesis were performed. The installation of endoprostheses with a diameter of 12F with the immersion of the outer end into the subcutaneous tissue did not cause technical difficulties and complications.

9 patients were operated on for developed complications. Repeated percutaneous punctures and drainages under ultrasound control were performed in 7 patients.

In our study, 9 (9.8%) patients died after percutaneous biliary interventions. Treatment outcomes and mortality were significantly affected by the severity of the patient’s condition prior to decompression, the duration of jaundice, the level of bilirubinemia, and the presence of cholangitis. The average age of the deceased patients was 62.5 years.

Analysis of lethal outcomes showed that 5 (55.6%) patients died from hepatic-renal insufficiency and its combination with purulent intoxication and cardiovascular insufficiency, 2 – from acute cardiovascular insufficiency. Complications of percutaneous biliary interventions were the cause of death in 2 patients.

Average life expectancy was traced by us in 22 patients. With external and internal bile ducting in patients with malignant neoplasms of the bile ducts and pancreas, the average life expectancy was 7.2 months. The highest life expectancy was observed in patients with gallbladder tumors and metastatic lesions of the liver hilum. Performing bile duct arthroplasty at the second stage of treatment in some patients increased life expectancy up to 9-11 months

The use of 3D imaging allows not only to clearly visualize the intrahepatic bile ducts, but also to immediately direct the needle into the lumen of the desired duct, and also to prevent injury to large blood vessels. We consider the safest tactic to be the use of dual control: puncture of the ducts under ultrasound guidance, followed by the introduction of a guidewire and drainage under fluoroscopic control.

In order to reduce the likelihood of bile leakage into the abdominal cavity for puncture, we tried to choose a deeply located bile duct with a diameter of at least 5 mm. Since repeated punctures of the capsule significantly increase the risk of bleeding, if several test punctures were necessary, the liver capsule was punctured only once. In patients with an intrahepatic level of blockage, as a rule, one of the segmental bile ducts was chosen for puncture, which ensured a longer location of the catheter in the biliary system and reduced the risk of dislocation.

To reduce the risk of drainage dislocation, it was carried out as close as possible to the site of bile outflow blockade, its distal end was twisted in the form of a loop. The use of drains with a fixing thread, in our opinion, is especially important in cholecystostomy, since undesirable displacement of drains in this type of bile duct is more common.

However, the use of catheters with a loop at the end, like balloon catheters, does not provide absolutely reliable protection against dislocation, but only reduces its frequency. From accidental removal of the catheter is best protected by secure fixation on the skin. The risk of accidental removal of the drainage increases significantly with inadequate behavior of the patient, in such cases we sought to perform endoprosthesis of the bile ducts.

To reduce the risk of liver rupture and to prevent bleeding when inserting drains, we performed careful manipulation of the instruments and tried to catheterize the biliary system through the peripheral segments of the right lobe of the liver. At the same time, 3D visualization data made it possible to plan the puncture trajectory along the shortest distance without crossing the branches of the hepatic and portal veins.

In the presence of a large amount of blood in the discharge of bile, cholangiography was performed to determine the discharge of contrast agent into the blood vessels. In most cases, it was possible to stop bleeding by changing the position of the catheter so that the lateral drainage holes did not coincide with the lumen of the vessels. In 2 cases, temporary clamping of the drain was required to stop the bleeding, in one case, it was replaced with a catheter of a larger diameter.

To reduce the risk of complications in bile duct arthroplasty, we installed endoprostheses no earlier than 7–9 days after a full-fledged external or external-internal bile duct. As a rule, by this time the puncture channel had time to form, and the general condition of the patient improved significantly. In addition, the possibility of hemobilia and blockage of the endoprosthesis with blood clots was practically excluded.

In case of prolonged palliative biliary excretion, due to the increased risk of blockage of drains and endoprostheses, they were washed with antiseptic solutions at least once every 3 days, and after 4-6 weeks, prophylactic replacement of drains was performed.

If the patency of the endoprosthesis was impaired, the approach to it was restored using percutaneous or endoscopic access, and then the internal lumen was recanalized using a guidewire or a special brush. In several cases, the lumen of the endoprosthesis was restored by percutaneous puncture of the duct with a 20G needle and passing the needle to the side hole of the prosthesis, followed by flushing the endoprosthesis channel with a strong jet of sterile liquid.

Prevention of recurrence of cholangitis during external bile ducting was carried out by giving doxycycline inside, careful skin care around the drainage, constant monitoring of the patency of the catheter, introducing antiseptic solutions into the biliary tract, preventing aspiration of intestinal contents during the sanitation of external-internal drainages. Before discharge from the hospital, the patient and his relatives were explained the rules for caring for drainage, pointed out the possibility of its displacement and blockage.

In the presence of cholangitis or severe peritumorous infiltration, we were not always able to drain through the dense walls of the intrahepatic ducts. In such a situation, we did not force the pushing of the catheter, but temporarily stopped the intervention, leaving the conductor in the lumen of the duct, and the tip of the drain near its wall. A day later, an attempt to introduce drainage into the lumen of the duct was repeated, while the catheter, as a rule, easily passed through the wall of the duct.

In cholangiostomy, we tried to insert the drain as deep as possible into the bile ducts, which reduced the risk of dislocation. If this failed (especially at a high level of blockade), a metal conductor was left in the lumen of the ducts. The outer end of the conductor was placed inside the extension line. The catheter was sutured to the skin, and the extension line was fixed to the skin with adhesive tape in several places. The left conductor formed one or two turns in the lumen of the ducts, which prevented its displacement.