Transient menorrhagia without adalimumab discontinuation in a patient with Crohn's disease.

Menstrual disorders are listed as possible rare side effects during infliximab or adalimumab administration but very few case reports regarding the management of such menstrual side effects exist.1 A 32-year-old woman with ileal Crohn's disease was switched to adalimumab because of an allergic reaction during infliximab maintenance therapy. The patient was started on adalimumab but during the third dose of adalimumab induction scheme the patient developed severe menorrhagia lasting four days. In detail, the patient had to use approximately three times more pads daily as opposed to her previous ‘normal’ menstruation days. Menorrhagia resolved spontaneously in the fourth day and the patient was advised to continue adalimumab use and to use oral contraceptives in case of menorrhagia relapse. In next menstruations the patient had no recurrence of menorrhagia. Inflammatory bowel disease, and more specially Crohn's disease have been related to menstrual abnormalities. These abnormalities are encountered either in the panel of disease extraintestinal manifestations or as the presenting or triggering factor of relapsing Crohn's disease.2 Abnormalities of endometrial blood vessels are among possible causes of anti-TNFa therapy related menorrhagia as many different factors affect endothelial cell growth, function and vessel remodeling in uterus, including TNFa. TNFa is a proinflammatory cytokine involved in a wide range of important physiologic processes. Increased production of proinflammatory mediators is considered central in the manifestation of events leading to irregular uterine bleeding or the polycystic ovary syndrome.3 Of note, adalimumab has been previously related to menstrual abnormalities but also to restorationofmenstruation. Of interest, a woman who used adalimumab for psoriatic arthritis and experienced optimal response to adalimumab developed menorrhagia and severe menstrual pain.1 By contrast, restoration of menstruation in premature ovarian failure after initiation of adalimumab has been also reported.4 Post-marketing data has noted that between 2003 and 2006 there were 1335 reports of side effects to adalimumab in 693 patients. Of these, five reports involved menstruation and uterine bleeding in patients using adalimumab, specif-