Article Type: Case Reports
Intermenstrual Vaginal Bleeding Due to Sertraline Treatment: A Case Report
Omer Asan, Erol Goka
Sertraline and other serotonin reuptake inhibitors are widely used in the treatment of psychiatric disorders such as anxiety disorders and depression. Hematological adverse effects related to sertraline are uncommon; most of the reported cases presented with vaginal bleeding, epistaxis, purpura, hematuria, and rectal bleeding. SSRIs may increase the risk of bleeding through different mechanisms. The most emphasized mechanism is lowering platelet aggregation by reducing serotonin reuptake in platelets. This report includes a case of intermenstrual vaginal bleeding due to the use of sertraline and a review of the relevant literature. We aimed to draw clinician’s attention to this side effect of SSRIs.


1.Bottlender R, Dobmeier P, Möller HJ. The effect of selective serotonin reuptake inhibitors in blood coagulation. Fortschr Neurol Psychiatr 1998;66(1):32-35. (German)

2.Serebruany VL. Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something? Am J Med 2006;119(2):113-116.

3.Alderman CP, Moritz CK, Ben-Towim DI. Abnormal platelet aggregation associated with fluoxetine therapy. Ann Pharmacother 1992;26(12):1517-1519.

4.Nelva A, Guy C, Tardy-Poncet B, Beyens MN, Ratrema M, Benedetti C,Ollagnier M. Bleeding syndromes related to selective serotonin reuptake inhibitors (SSRIs). Seven case reports and literature review. La Revue de Medecine Interne 2000;21(2):152-160.

5.Halperin D, Reber G. Influence of antidepressants on hemostasis. Dialogues in Clinical Neuroscience. 2007;9.1 47.

6.Andrade C, Sharma E. Serotonin reuptake inhibitors and risk of abnormal bleeding. Psychiatr Clin North Am 2016;39(3):413-426.

7.Joaquim HP, Talib LL, Forlenza OV, Diniz BS, Gattaz WF. Long-term sertraline treatment increases expression and decreases phosphorylation of glycogen syntase kinase 3-B in platelets of patients with late-life major depression. J Psychiatr Res 2012;46(8):1053-1058.

8.Andrade C, Sandarsh S, Chethan KB, Nagesh KS. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry 2010;71(12):1565-1575.

9.Schelleman H, Brensinger CM, Bilker WB, Hennessy S. Antidepressant-warfarin interaction and associated gastrointestinal bleeding risk in a case-control study. PLoS One 2011;6(6):e21447.

10. Dall M, Schaffalitzky de Muckadell OB, Lassen AT, Hansen JM, Hallas J. An association between selective serotonin reuptake inhibitor use and serious upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009;7(12):1314–1321.

11.Kose S, Akin E, Cetin M. Adverse drug reactions and causality: the Turkish version of Naranjo Adverse Drug Reactions Probability Scale. Psychiatry and Clinical Psychopharmacology 2017;27(2):205-206.

12.Mathew D, Desmond P, Isaacs D. Bruising and bleeding with ssris. Australian Advers Drug Reactions Bulletin 1998;17:10-12.

13.Mirsal H, Kalyoncu A, Pektas O. Fluoksetin kullanimi ile ilişkili ekimoz: olgu sunumu [Ecchymosis Associated with The Use of Fluoxetine: Case Report]. Türk Psikiyatri Dergisi 2002;13(4):320-324. [Turkish]

14.Ay R. Paroksetin kullanimi ile ilişkili ekimoz: bir olgu sunumu [Ecchymosis associated with the use of paroxetine: a case report]. Klinik Psikiyatri Dergisi 2017;20(3):243-246. [Turkish] 15.Sahingoz M, Sonmez EO. Ecchymosis related to paroxetine and sertraline. European Journal of General Medicine 2015;12(4):356-357.

16.Cinar O, Cevik E, Kilic E, Kesim ME, Ak M. Ecchymosis due to sertraline use: a case report. Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Psychopharmacology 2010;20(4):321-323.

17.Vardar MK, Tezcan B, Belli H, Öztürk HN, Aker DA. Essitalopram kullanımı sonrasında doza bağlı gelişen spontan ekimotik lezyonlar: olgu sunumu [Dose-dependent spontaneous ecchymotic lesions after use of escitalopram: a case report]. Anadolu Psikiyatri Dergisi 2017;18(5):503-506. [Turkish]

18.Weinrieb RM, Auriacombe M, Lynch KG, Lewis JD. Selective serotonin re-uptake inhibitors and the risk of bleeding. Expert Opin Drug Saf 2005;4(2):337-344.

19.Ramasubbu R. Cerebrovascular effects of selective serotonin reuptake inhibitors: a systematic review. J Clin Psychiatry 2004;65(12):1642–1653.

20.Kharofa J, Sekar P, Haverbusch M, Moomaw C, Flaherty M, Kissela B, et al. Selective serotonin reuptake inhibitors and risk of hemorrhagic stroke. Stroke 2007;38(11):3049–3051.

21.Douglas I, Smeeth L, Irvine D. The use of antidepressants and the risk of haemorrhagic stroke: a nested case control study. Br J Clin Pharmacol 2011;71(1):116–120.

22.Auerbach AD, Vittinghoff E, Maselli J, Pekow PS, Young JQ, Lindenauer PK. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA 2013;173(12):1075–1081.

23.Shahrbabki ME, Shahrbabaki AE. Sertraline-related bleeding tendency: could it be dose-dependent?. Iran J Psychiatry Behav Sci 2014;8(3):81-83.

24.Smith M, Robinson D. Sertraline and vaginal bleeding-a possible association. J Am Geriatr Soc 2002;50(1):200-201.

25.Linnebur SA, Joseph JS, Wilson DP. Venlafaxine‐associated vaginal bleeding. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 2002;22(5):652-655.

26.Yildirim A, Tureli D, Karaman E, Karaman Y. Escitalopram and intermenstrual vaginal bleeding: a probable association. Klinik Psikofarmakoloji Bulteni-Bulletin of Clinical Psychopharmacology 2015;25(3):317-318.

27.Kaya I, Kocas S, Suleyman F, Coskun M. Vaginal bleeding in a preadolescent girl possibly related to sertraline. J Clin Psycopharmacol 2014;34(6):760-761.

28.Durmaz O, Celik S. Vaginal bleeding associated with antidepressants. Int J Gynaecol Obstet 2015;130(3):284.

29.Uguz, Sahingoz M, Kose SA, Ozbebit O, Sengul C, Selvi Y, et al. Antidepressants and menstruation disorders in women: a cross-sectional study in three centers. Gen Hosp Psychiatry 2012;34(5):529–533.

30.Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database of Systematic Reviews 2013;6:CD001396.

31.Lupattelli A, Spigset O, Koren G, Nordeng H. Risk of vaginal bleeding and postpartum hemorrhage after use of antidepressants in pregnancy: a study from the Norwegian Mother and Child Cohort Study. J Clin Psychopharmacol. 2014;34(1):143–8.

32.Lindqvist PG, Nasiell J, Gustafsson LL, Nordstrom L. Selective serotonin reuptake inhibitör use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study. J Thromb Haemost 2014;12(12):1986–1992.

33.Na KS, Jung HY, Cho SJ, Cho SE. Can we recommend mirtazapine and bupropion for patients at risk for bleeding?: A systematic review and meta-analysis. J Affect Disord 2018;225:221-226.

Key words: Adverse effect, sertraline, vaginal bleeding.
Psychiatry and Behavioral Sciences 2019;9(3):139-142
Online ISSN: 2636-834X
Creative Commons License This work is licensed under a Creative Commons Attribution 3.0 Unported License