Letter: Epidural Steroid Injection-Induced Menorrhagia: An Under-recognized Complication Associated With a Common Spinal Intervention

Field: Medicine (Health Sciences)

To the Editor: Epidural steroid injections (ESIs) are a commonly used intervention in the management of various spinal pathologies.1 Although generally safe, rare but devastating complications have been previously reported, including stroke, paralysis, and infarctions.2,3 Here, we would like to raise awareness of menorrhagia as a serious and under-recognized complication of ESIs. Recently, we had a 47-year-old premenopausal female patient present with lumbar disc herniation, and was subsequently treated with an ESI. The patient subsequently complained of excessive uterine bleeding that required evaluation by gynecology, who pointed to ESI as the cause for menorrhagia after a thorough workup. Due to the rare occurrence of such a complication in our anecdotal experience, we performed a comprehensive literature search in various medical databases (including Pubmed, EMBASE, and Cochrane Library) and found few papers on this phenomenon, which we would like to share with the readers (Table). TABLE. - Previous Reports of Epidural Injection-Induced Menorrhagia Article Type No. of Patients with ESI-IM Gitkind et al4 Case Report 1 Çok et al5 Letter to the Editor 2 Hirsch and Hsu6 Case Report 3 Suh-Burgmann et al7 Paired Observation Cohort Study 201 ESI-IM = epidural steroid injection-induced menorrhagia. Gitkind et al4 and Çok et al5 both presented premenopausal patients who suffered from menorrhagia 2 to 5 d following administration of ESIs. These patients did not have any known pre-existing endocrine disorders, suggesting that the exogenous corticosteroids somehow disrupted the female hormone cascade. Hirsch and Hsu6 reported premenopausal patients and a postmenopausal patient, all of whom displayed abnormal vaginal bleeding 1 to 2 wk following the injection. This was reported as the first occurrence of vaginal bleeding for the postmenopausal patient after the onset of menopause. Although the association between ESIs and subsequent menorrhagia was only reported anecdotally, Suh-Burgmann et al7 sought to formally analyze this occurrence among a population-based cohort of 8166 nonhysterectomized women undergoing ESI. They found that women were almost 3 times more likely to display abnormal vaginal bleeding postinjection as compared to preinjection. About 70% of women with postinjection bleeding were premenopausal, while the other 30% were postmenopausal. Although postinjection menorrhagia appears to be rare, it may remain under-reported if some premenopausal patients experienced ESI-induced uterine bleeding during their normal menstrual cycle. The overall incidence for ESI-induced menorrhagia was found to be 2.5% in this study. Neuraxial administration of corticosteroids has been previously reported to influence the hypothalamic-pituitary-adrenal (HPA) axis.8 Although systemic side effects of such epidurally introduced steroids–including fluid retention, and adrenal suppression–have been reported, no definitive relationship has been established for their effect on the female hormonal system.9 However, previous groups postulated that negative feedback to the HPA axis may cause a decrease in female sex hormones, resulting in an eventual lack of progesterone, leading to high estrogen levels, thus culminating in menorrhagia.4 To date, the mechanism remains poorly resolved. Given the prevalence of ESI for the treatment of various spinal disorders, it is increasingly important for ESI-administering physicians and gynecologists to recognize menorrhagia as a potential side effect of such spinal interventions. These findings should contribute to the clinical decision-making tree of ESI administration, and consider whether both pre- and postmenopausal patients have additional risk factors for abnormal uterine bleeding, prior to intervention. This potential rare complication should be discussed with female patients undergoing ESI. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.