Menstruation triggers asthma and sinus symptoms in aspirin-exacerbated respiratory disease

Published online: September 30, 2019

Perimenstrual worsening of asthma symptoms, or perimenstrual asthma, is troubling for many women and is reported in 11-44% of the general asthma population. Women with perimenstrual asthma experience a predictable worsening of asthma symptoms around menses and are prone to increased emergency department visits and increased hospitalizations compared to women without perimenstrual asthma. A recent study found perimenstrual asthma is strongly associated with aspirin-sensitive asthma, nasal polyposis, and chronic sinusitis, with aspirin-sensitive asthma proving to be the characteristic most strongly associated with perimenstrual asthma. Aspirin-sensitive asthma, better known as aspirin-exacerbated respiratory disease, is a condition of the upper and lower respiratory tract characterized by chronic rhinosinusitis with nasal polyps, asthma, tissue eosinophilia, and respiratory reactions to nonsteroidal anti-inflammatory drugs such as aspirin. While aspirin-sensitive asthma is thought to be closely associated with perimenstrual asthma, this relationship is poorly understood and underappreciated by clinicians.

In an article recently published in The Journal of Allergy & Clinical Immunology: In Practice, Eid and coauthors sought to evaluate and better characterize the factors associated with perimenstrual asthma in a large cohort of females with aspirin-exacerbated respiratory disease.
Women enrolled in the Brigham and Women's Hospital aspirin-exacerbated respiratory disease registry, a registry comprised of 695 women with a physician confirmed diagnosis of aspirin-exacerbated respiratory disease, were surveyed. Participants were invited to complete an electronic questionnaire about their menstrual history. Existing clinical data from the aspirin-exacerbated respiratory disease registry was extracted and analyzed for survey respondents and non-respondents. Women who reported perimenstrual asthma and those without perimenstrual asthma were compared across several demographic and clinical variables.

Among the 322 women who developed aspirin-exacerbated respiratory disease before menopause, 24% reported perimenstrual asthma. Those with perimenstrual asthma reported earlier development of each feature of the aspirin-exacerbated respiratory disease clinical triad: asthma, chronic rhinosinusitis with nasal polyps and respiratory reactions to aspirin and similar drugs. In an adjusted model, earlier age of onset of each feature increased the odds of perimenstrual asthma. In addition, women with perimenstrual asthma demonstrated increased emergency room visits and hospitalizations. Furthermore, this study was the first to describe a worsening of sinus symptoms associated with menstruation. Among women with perimenstrual asthma, 83% reported menstruation-related increase in sinus symptoms, most often concurrent with their increase in asthma symptoms. It is important for clinicians to recognize that the overlap of aspirin-exacerbated respiratory disease and perimenstrual asthma represent a population at risk for increased healthcare utilization. Women with aspirin-exacerbated respiratory disease need to be counseled about a possible deterioration in asthma and sinus symptoms in relationship to menstruation. Future studies are required to determine the biologic mechanism(s) underlying the perimenstrual increase in respiratory symptoms and to identify interventions which can reduce healthcare utilization in this subgroup of women.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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