Reversible Cerebral Vasoconstriction Syndrome After Starting Medroxyprogesterone Acetate Therapy for Heavy Menstrual Bleeding: A Case Report

We highlight an unusual side effect of medroxyprogesterone acetate (MPA) associated with reversible cerebral vasoconstriction syndrome (RCVS) in a young patient. We describe the case of a 36-year-old lady with a significant history of heavy menstrual bleeding (HMB) secondary to adenomyosis presenting with new onset migranous headaches and right upper limb weakness after being started on MPA treatment 2 months prior. Magnetic resonance imaging (MRI) of the brain revealed acute infarcts in the left frontal lobe and right parieto-occipital region while magnetic resonance angiography (MRA) demonstrated widespread luminal irregularities throughout the anterior and posterior circulations with more severe involvement of the proximal and mid-portion of the arteries. After stopping the MPA, her headaches and weakness resolved, and a repeat MRA 2 months later showed resolution of the multi-focal intracranial stenoses. The patient was diagnosed with RCVS secondary to MPA given the onset of headaches and strokes with multi-focal intracranial stenoses shortly after initiation of MPA and resolution of the clinical and radiological abnormalities after the drug was stopped. To the best of our knowledge, this is the first case of RCVS that has been associated with the use of MPA. Although the exact pathophysiology of RCVS has yet to be determined, this case might contribute to the understanding of its underlying mechanisms.