AAOS Now

Published 2/1/2015
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Caroline H. Hu, BA; Emily Brook; Elizabeth G. Matzkin, MD

Sex-related Side Effects of Corticosteroid Injections

Corticosteroid injections are a nonsurgical treatment modality, frequently used when other conservative treatments are ineffective. Corticosteroids are often used to treat knee and shoulder osteoarthritis, rotator cuff tendinopathy, adhesive capsulitis, and acute inflammation. By reducing vascular permeability and inhibiting the production and accumulation of inflammatory mediators such as prostaglandins and leukotrienes, corticosteroids are clinically effective in increasing joint mobility, reducing joint inflammation, and decreasing erythema, swelling, and acute pain.

Although corticosteroid injections are simple to perform and the risk-benefit ratio is highly favorable, some adverse side effects are not unusual. Commonly discussed side effects include postinjection flare, skin changes (hypopigmentation), fatty atrophy, infection, facial flushing/allergic reaction, tendon damage, and transient increase in blood glucose. Furthermore, female patients may face additional sex-related adverse effects, most notably abnormal menstruation. This article discusses these potential side effects to increase awareness of their existence among orthopaedic surgeons.

Abnormal menstruation
Several review articles and many case reports identify abnormal menstruation as a side effect of intra-articular and epidural corticosteroid injections. Previous literature reports suggest that triamcinolone acetonide (TA) injections may cause a disturbance in female sex hormones, including luteinizing hormone and progesterone.

In one study, 51 percent of women who had received either an intra-articular, epidural, or soft-tissue TA injection with a mean dose of 24 mg reported a disturbance in menstrual pattern. These disturbances ranged from the timing of menses (earlier or later than expected) to more loss of blood and longer duration of menstruation. TA may interfere with female sex hormones, causing disturbances in levels that manifest as irregular menstruation. Medical professionals should inform female patients that abnormal menstrual bleeding is a potential side effect for the procedure.

Both intra-articular and epidural corticosteroid injections have resulted in postinjection abnormal vaginal bleeding. In a comprehensive paired observational cohort study of 6,926 women who had not had hysterectomies, 197 (2.8 percent) had abnormal vaginal bleeding after the injection. Of these women, 137 (70 percent) were premenopausal and 60 (30 percent) were postmenopausal.

Facial flushing
Facial flushing after steroid injections is more common in women than in men. Facial flushing may occur a few hours postinjection and is present in up to 15 percent of patients. However, these symptoms usually do not last longer than 3 or 4 days.

Lactation disturbance
Animal studies have demonstrated that a high-dose exogenous corticosteroid intra-articular injection diminishes milk production.

Hirsutism
According to a report from a drug safety and monitoring board in the Netherlands, transient hirsutism, or coarse, male-pattern hair growth, has been reported after extra-articular corticosteroid injections.

Conclusions
Orthopaedic surgeons may be unaware of these sex-related adverse effects after corticosteroid injections because these topics have not been extensively investigated. Furthermore, patients might not associate transient bleeding or irregular menses with receiving a corticosteroid injection.

Corticosteroid injections have been a simple and effective treatment for joint or spine inflammation in orthopaedic patients since the 1950s. Although injecting corticosteroids is a simple procedure in theory, clinicians must be familiar with and inform their patients of the potential likelihood of side effects such as those discussed in this article.

One or more of the authors reported potential conflicts of interest; visit www.aaos.org/disclosure for more information.

Caroline Hu, BA, is a research assistant for women’s sports medicine in the department of orthopaedic surgery at Brigham and Women’s Hospital, and a medical student at the University of Minnesota Medical School. Emily Brook was a summer research assistant in the department of orthopaedic surgery at Brigham and Women’s Hospital and attends Colby College. Elizabeth G. Matzkin, MD, is surgical director of women’s musculoskeletal health at Brigham and Women’s Hospital, and a member of the AAOS Women’s Health Issues Advisory Board. She can be reached at ematzkin@partners.org

Bottom Line

  • Orthopaedic surgeons need to be aware of sex-related side effects of corticosteroid injections such as abnormal vaginal bleeding and facial flushing.
  • Female patients should be informed of potential sex-related side effects of corticosteroid injections.
  • The actual incidence of such effects is very low, and corticosteroid injections remain a viable and popular treatment for inflammation.

Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.

References

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