Carpal tunnel syndrome ascribed to low-dose combined oral contraceptive pills.

A 21-year-old unmarried girl presented to our hospital with irregular cycles since menarche. Sonographic examination revealed polycystic ovaries on both sides. Investigations showed raised luteinizing hormone: follicle-stimulating hormone ratio and an elevated serum testosterone level. She was prescribed low-dose OCPs once polycystic ovarian disease was identified to be the cause. The OCPs, which contained combined ethinylestradiol 0.03 mg and levonorgestrel 0.15 mg, were recommended once daily for 21 days. After 2 months, she presented with complaints of tingling sensation and pain in the right wrist joint and the lateral four fingers of the right hand. There was no history of diabetes mellitus, hypothyroidism, rheumatoid arthritis, or osteoarthritis. On examination, dry skin on the thumb, index, and middle finger was noted. There were no sensory abnormalities or loss of sensation along the median nerve distribution, and there was no atrophy of the muscles of the thenar eminence. Phalen's test was positive. Complete blood count; total T3, T4, and thyroid-stimulating hormone; blood sugar value; and levels of serum prolactin were normal. We suspected CTS, and after ruling out other causes of neuropathy, OCPs were assumed to be the probable cause and the drug was stopped. Her symptoms resolved completely within a week of stopping OCPs, and she was on regular follow-up. The Naranjo Adverse Drug Reaction Probability Scale was used to analyze the causative of the case. The score on the Naranjo Adverse Drug Scale was 7, indicating a “probable” drug-reaction link.

Oral contraceptive pills (OCPs) are frequently prescribed for contraception, polycystic ovarian syndrome, amenorrhea, menorrhagia, dysmenorrhea, endometriosis, and other conditions.[ 1 ] They are often linked with adverse effects such as nausea, throwing up, headache, abdominal discomfort, tenderness in the breast, pedal edema, increase in body weight, intermenstrual spotting, and thromboembolism of the veins.[ 2 3 ] Migraine, depression, psychosis, and cerebral infarction are the neurological consequences related to OCPs. Carpal tunnel syndrome (CTS) caused by OCPs is rather common but unrecognized complication, and only very few cases are reported in the literature.[ 2 4 5 ] Here, we report a 21-year-old female who was on low-dose OCPs for irregular cycles with polycystic ovarian disease and developed CTS within 2 months, and symptoms resolved in a week after the drug was discontinued.

CTS, although common, underreported side effects of the OCPs, which clinicians should be aware of. We recommend that people who are prone to premenstrual edema, weight gain, or who gain weight excessively in pregnancy be recommended to take one of the progesterone-dominant pills from the beginning and suggest consuming less fluids and salt, particularly in the second part of the cycle. VS managed the case, and VS, DY, and AB were involved in conception, literature search, analysis of data, and drafting of the manuscript. All authors had access to the data and a role in writing this manuscript. The authors certify that they have obtained written informed consent from the patient for publishing the case details in a journal. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Nil. There are no conflicts of interest.

CTS is the most prevalent compressive focal mononeuropathy brought on by median nerve compression and usually manifests as pain in the wrist joint, decreased sensations along the distribution of the median nerve, a reduction in two-point discrimination, nighttime awakening, and, in more advanced stages, thenar muscle wasting and weakening.[ 1 ] A case–control study done by Al Shahrani et al .[ 6 ] showed CTS is more common in females, especially among women aged 45 years and above. Diabetes mellitus, obesity, hypertension, thyroid disorders, and arthritis are common medical problems that have been considered to be related to CTS.[ 6 ] OCPs, menopause, hormonal-replacement therapy, and interactions with parity and pregnancy were analyzed but did not reveal any associations in the study, probably as a result of the small sample size.[ 6 ] Here, we report a case of a 21-year-old female who was on low-dose OCPs for irregular cycles with polycystic ovarian disease and developed CTS within 2 months, and her symptoms resolved in a week after the drug was discontinued. As there were no other apparent causes of CTS in this case, and as the symptoms resolved completely after stopping the medication, we attribute CTS to be due to OCPs. Patients with mild-to-moderate CTS can be prescribed conservative therapy initially, which includes splints, corticosteroids, physical therapy, therapeutic ultrasonography, and yoga. Patients who suffer severe CTS and those in whom complaints have not subsided despite 4–6 months of conservative treatment should be recommended surgical decompression.[ 7 ] The proposed mechanism was most likely the accumulation of the fluid, which can result in median nerve compression because of swelling of the median nerve and other parts of the rigid osteofibrous carpal tunnel.[ 2 ] The estrogen component of the OCPs is assumed to be the cause of fluid retention, whereas the natriuretic impact is due to the progesterone component. The final outcome when both estrogen and progesterone are given concurrently depends on the dosage and relative potency of each ingredient.[ 2 ] Albani et al .[ 5 ] suggested an association between OCPs and CTS and that there is a lower incidence of CTS in women taking low-dose OCPs and monophasic preparations. It was observed that chances of experiencing CTS serious enough to warrant hospital referral increased with a longer duration of intake of OCPs.[ 5 ]