Epidural Corticosteroid Injections as a Possible Cause of Menorrhagia: A Case Report

Abstract

A 47-year-old female was referred for evaluation of chronic lower back pain. A magnetic resonance imaging of her lumbar spine revealed a broad-based disc herniation at L4-L5 with bilateral neural foraminal narrowing. A decision was made to treat her with bilateral L4-5 transforaminal epidural steroid injections. Following moderate pain relief, the procedure was repeated. Several days after each injection, the patient experienced unusually heavy and painful menstrual bleeding. We postulate that the introduction of exogenous corticosteroids directly into the neuraxial space can initiate a negative feedback loop on the hypothalamic-pituitary-ovarian axis. As a result, this may lead to decreased levels of circulating hormones, resulting in episodes of menorrhagia in the premenopausal population.

Systemic Absorption and Side Effects of Locally Injected Glucocorticoids

“…Sex hormone levels after ESI have not been measured. Although physicians have noted patient complaints of menstrual abnormalities after ESI, dysfunctional uterine bleeding after ESI has been described in only one case report …”

An unusual cause of postmenopausal bleeding

“…Uterine bleeding following epidural triamcinolone was reported by Yoon and Lee 2. Gitkind et al 3 described a 47-year-old with menorrhagia following an injection of epidural corticosteroid injection. A history similar to this was reported by Willey et al 4 in a study of comparison of oral prednisolone and intramuscular depot triamcinolone in patients with severe chronic asthma.…”

Abnormal Uterine Bleeding Following Lumbar Epidural Corticosteroid Injections and Facet Medial Branch Blocks in Both Pre- and Postmenopausal Women: A Case Series: Table 1

“…Gitkind et al. described severe menorrhagia lasting nearly 2 weeks in a premenopausal woman, ∼1 week following bilateral transforaminal (TF) lumbar ESIs for chronic low back pain on two occasions [1]. Çok et al.…”

“…The potential effects of corticosteroids on the endocrine system when used in interventional pain management have been studied in the last 50 years [1]. Clinicians have theorized that corticosteroids injected directly into the epidural space could diffuse into the plasma, possibly modulating the hypothalamic–pituitary axis, initiating a negative feedback loop for up to 3 weeks [1]. The literature, however, focuses on the relationship of the hypothalamic–pituitary axis to the adrenal glands as opposed to ovaries [1].…”