Post-Menopausal bleeding after triamcinolone containing interventional procedures

 

Post-menopausal bleeding (PMB) following corticosteroid-based interventions for pain management has been described in the literature mostly in the form of case reports. Although menstrual irregularities are a known side effect of administration of triamcinolone [triamcinolone Package insert], postmenopausal women are noted to have an increased risk of experiencing this side effect.  Various theories have been proposed for the triamcinolone-associated, including disruption of circulating hormone levels, adrenal suppression from the triamcinolone and subsequent decrease in endogenous estrogen from decreased peripheral conversion.  We describe four cases of postmenopausal women who experienced a bleeding episode following a pain intervention using triamcinolone and underscores the critical importance of informed consent in the management of such risks.

 

A 71 year old female underwent bilateral L4-5, and L5-S1 facet joint injections and a sacral ala medial branch block on 1/24/2011 with triamcinolone and Bupivacaine and repeated on 4/6/2011.  She experienced vaginal bleeding and spotting after each injection occurring approximately 10 to 14 days. Although she had this procedure performed approximately 2 times per year until 2016, she did not have any further documented vaginal bleeding. Endometrial biopsy was negative for malignancy.

 

A 54 year old female with lumbar facet arthropathy underwent bilateral L3-L5 medial branch blocks on 2/9/16. The initial procedure resulted in 100% pain relief for 4 weeks, which prompted a second set of injections. Both sets of injections included 40mg of triamcinolone and 2% lidocaine. She had an episode of vaginal bleeding 1-2 weeks after the first Kenalog injection. 

 

A 53 year old female with bilateral pudendal neuralgia underwent a pudendal nerve block with 40mg triamcinolone and 0.25% bupivacaine used. She reported complete pain relief for at least two weeks after the block. She noted clear vaginal discharge three weeks after her injections.  She underwent TVUS four days after her procedure which revealed an endometrial stripe measuring 2.6 mm.  No endometrial biopsy was taken at that time. 

 

 A 60 year old female received bilateral intra-articular hip with triamcinolone and Dexamethasone solution on 5/14/24 and about 6 days later on 5/21/24 developed vaginal spotting that turned into a full menstrual period despite this patient going through menopause. This promoted a workup by her PCP that was overall negative for malignancy. Transvaginal ultrasound revealing normal endometrium thickness.

 

Triamcinolone, as a corticosteroid, influences systemic and local inflammatory pathways, which may impact hormone levels and endometrial stability. The rarity of this side effect underscores the need for heightened awareness among clinicians.  Although not dangerous, the potential impact on patient quality of life and the psychological distress associated with unexplained bleeding, careful consideration and communication are essential and typically promotes full malignancy workups. Informed consent is a cornerstone of ethical medical practice, particularly when administering medications with known or potential side effects. This case series highlights the need for increased awareness of Kenalog-induced postmenopausal bleeding. By emphasizing the importance of informed consent, healthcare providers can enhance patient understanding and uphold ethical standards in patient care.

 

Reference:

Scherer J, Rainsford KD, Kean CA, Kean WF. Pharmacology of intra-articular triamcinolone. Inflammopharmacology. 2014 Aug;22(4):201-17. doi: 10.1007/s10787-014-0205-0. Epub 2014 May 14. PMID: 24824076.

 

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