Pelvic girdle pain may be an overlooked hormone adverse effect

Abstract

A high proportion of pregnant women report low back or pelvic girdle pain during pregnancy (1). The location of the pain can be verified by pain provocation tests (2,3). In most women, the pregnancy-related pain ceases within 6 months. However, among women who have experienced pain from all three pelvic joints (symphysis and sacroiliac joints), one-fifth still have disabling pelvic girdle pain 2 years postpartum (4). The etiology of the pain is uncertain. A 42-year-old woman was admitted to the Department of Rheumatology because of disabling pelvic girdle pain and arthralgia. In childhood, she had swollen knees after German measles. She has had psoriasis since her teens but is asymptomatic today. She had used oral contraception from 16 until 33 years of age. She was gravida 2, para 2 with parturition in 1991 and 1994. During her pregnancies, she suffered from pelvic girdle pain from the first trimester. In the second trimester, she was bedridden due to disabling pain. Her first delivery was performed vaginally at term and the second by caesarean section preterm owing to preeclampsia. Six months after the deliveries she had improved. Six months after her last delivery, she had a levonorgestrel intrauterine system (LNG IUS) inserted. It was replaced in the autumn of 1999. From December 1999, she experienced increasing pelvic girdle pain, without being pregnant, with the same pain location as during previous pregnancies. She worked at this time as an assistant nurse, often performing heavy lifting tasks. She tried to remain at work by using analgesics and reducing physical activity during leisure time but the severe pain made her unable to continue working. Despite sick-leave, the pain increased to a disabling level. She was unable to load her pelvis at all, even straining at stool. She was dependent on help for her daily living activities. Investigation at the Department of Rheumatology showed no clinical or laboratory signs of inflammatory rheumatic disease. X-ray of her spine, pelvis and hips was normal. On the recommendation of the Department of Rheumatology, the LNG IUS was removed in January 2002. Afterwards, she experienced gradually diminishing pelvic girdle pain and could participate in a rehabilitation program. Ten months after the extraction, she could manage daily living activities and could go for a walk of 3 km. A remarkable deterioration and later improvement was experienced by this woman with previous pregnancy-related pelvic girdle pain after replacement and removal of an LNG IUS. During treatment with hormone contraceptives, that is both pills and intrauterine implants, symphysiolysis has been reported in a few cases. The three cases reported to the Swedish Registry for Adverse Effects of Drugs from 1982 until 2002 were all disabled owing to symphysiolysis. However, their pelvic girdle pain was reversible after ceased exposure. The woman presented here had used the pill for 16 years before her first pregnancy. During her pregnancies, she had disabling pelvic girdle pain and then her uterine device was changed at a time when she had a heavy mechanical load on her back and pelvis. If there was an additional hormonal contribution to the exacerbation of the pelvic girdle pain, an increased level of circulating levonorgestrel after reinsertion of the LNG IUS could be of importance. Whether there is a causal relationship between the exposure to this implant and development of pelvic pain cannot be assessed in this case. In view of the dramatic deterioration in this case, we consider it necessary to draw prescribers' attention to this possibility and to the importance of reporting any other similar cases to their registry of adverse effects of drugs.