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Menstruation- still a contraindication to elective surgery?

Article  in  Polish Journal of Surgery · February 2014

DOI: 10.2478/pjs-2014-0010 · Source: PubMed

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POLSKI
PRZEGLĄD CHIRURGICZNY 10.2478/pjs-2014-0010
2014, 86, 1, 57–59

Menstruation- still a contraindication to elective

surgery?

Jakub Kenig, Piotr Richter, Łukasz Sikora

3 Department of General Surgery, Jagiellonian University Collegium Medicum in Cracow
rd

Kierownik: prof. dr hab. W. Nowak

Menstruation is a physiological phenome- fibrinogen level. In most studies cyclic changes

non of cyclic endometrial exfoliation caused by
changes in the level of sex hormones (estrogens
and progesterone), under the system of mu-
tual feedback between the gonads, the ante-
rior pituitary gland, and the hypothalamus.
Amongst surgeons, there is belief that men-
struation is a contraindication to elective
surgery. This is attributed to the functional
impairment of the coagulation system and ac-
companying pain during the postoperative
period, which may interfere with the general
picture, and thus, possibly delay the diagnosis
of postoperative complications.
In view of the contraindications the aim of
the study was to review literature data for
evidence confirming or negating this thesis,
according to evidence-based medicine.
The PubMed, Ovid Medline, Science Direct
and Springer databases were browsed through
using a combination of the following words:
“menstrual cycle”, “intraoperative bleeding”,
“contraindication to elective surgery”, and
“blood loss”. Considering the above-mentioned,
452 studies were found. After abstract analysis,
421 were discarded. Thirty-one studies were
qualified for full-text analysis, off which 12 were
rejected. Finally, 19 studies were included in
the methodology of the mentioned problem.
Amongst the many complications concerning
the functioning of the coagulation system dur-
ing the menstrual cycle, one should initially
quote the systematic review undertaken by
Konol et al. in 2012. The authors gathered 30
of the best publications concerning the issue.
Analysis considered studies assessing platelet
function, von Willebrand’s factor (VWF), factors
VIII, IX, X, XI, XIII, D-dimers, plasminogen
activator inhibitor (PAI-I), tissue plasminogen
activator (tPA), alpha2-antyplasmin, and the
of the above-mentioned were not observed. In
isolated cases where such changes were ob-
served the lowest level of these factors (espe-
cially VWF, FVIII, and platelet factor activity)
was diagnosed during menstruation. It should
be noted, however, that the above-mentioned
reduction did not exceed 10% of initial values,
not having any clinical implications. The main
conclusion following the systematic review of
the above-mentioned is that diagnosis of coagu-
lation factor disturbances should be performed
during the menstruation cycle (1).
Hormonally dependent organs
It has been shown that the menstrual cycle
causes periodic changes in hormonally-sensi-
tive female tissues, such as the uterus, vagina,
mammary glands, oral mucosa, conjunctiva,
and the Eustachian tube. Thus, most studies
concerned the above-mentioned organs (2-7).
Findikcioglu et al. determined the influence
of the phase of the menstrual cycle on intra-
operative blood loss during nose plasty. There
was a statistically significant greater blood loss
during the peri-ovulatory phase. However, it
had no influence on the course and final result
of the operation (8).
Hrushesky et al. published there study in
1989, evaluating the correlation between the
length of survival in case of breast cancer sur-
gery and the phase of the menstrual cycle. The
retrospective analysis of 44 female patients
with breast cancer after surgery showed that
recurrence and mortality were higher in case
of patients subjected to surgery during the
initial phase of the menstrual cycle, as com-
pared to those patients operated later on (9).

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58 J. Kenig et al.
Subsequent studies showed contradictory re-
sults concerning the optimal time when to
perform breast cancer surgery. In 2009, a pro-
spective study was published comprising data
analysis of a group of 834 female patients. The
observation period was 6.6 years. Both the
disease-free time and survival duration showed
statistically insignificant differences, consider-
ing women operated during the luteal and fol-
licular phases (82.7 vs. 82.1% and 91.9% vs.
92.2%). The advantage of this study consists in
the determination of the phase of the men-
strual cycle, based on hormone levels, and not
as is the case in many studies, on the basis of
the last menstrual period (10). Another study
concerning the mammary gland is the prospec-
tive analysis of 35 patients subjected to breast
reduction surgery. Both peri- and postoperative
blood loss was statistically significantly greater
in patients operated during the peri-menstrual
phase. The authors of the study recommend
that patients be qualified for the above-men-
tioned procedure between the 8-th and 20-th
day of the cycle (11). Endoscopy of the mam-
mary ducts should also be avoided during the
luteal phase, due to statistically significant
greater pain, as compared to the procedure
performed during a different phase (average
pain level was evaluated on the basis of the VAS
scale: 6.86±1.07 vs. 5.17±1.40; p<0.05) (12).
In case of a retrospective analysis of 24 fe-
male patients (12 in the luteal and 12 in the
follicular phase) subjected to hysterectomy,
their was no statistically significant difference
between both groups, considering the pre- and
postoperative hemoglobin level, duration of
surgery, intraoperative blood loss, recovery
time, and hospitalization period (13). In case
of laparoscopic resection of peritoneal endo-
metriosis, the procedure should not be per-
formed during the luteal phase, during which
the authors observed twice as many recur-
rences, as compared to other phases of the
menstrual cycle (14).
Hormonally-independent organs
In case of organs independent or slightly
dependent of sex hormones only one study was
published. The study comprised 41 patients
subjected to abdominoplasty during the peri-
ods between 0-7 and 21-28 days (group A),
between the 8 and 20 day of the cycle (group
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B), and after menopause (group C). The au-
thors of the study showed no statistically
significant differences between the groups,
considering intra- and postoperative blood loss.
However, there was a significant correlation
between the BMI and amount of removed tis-
sue, and the time of drain removal and intra-
and postoperative blood loss (15).
Other investigations
In case of nausea and vomiting occurring
during the postoperative period, study results
are contradictory. In case of middle ear surgery
the above-mentioned were observed less fre-
quently during menstruation, as compared to
the periovulatory phase (16). In case of a pro-
spective study comprising 60 female patients
subjected to general anesthesia surgery nausea
and vomiting were observed more often during
the initial 14 days of the menstrual cycle (76.8%
(1-14 days) vs. 32.35% (15–28 days). (17). In a
group of 159 patients, those with menstrual
cycle irregularity were at increased risk of nau-
sea and vomiting during the postoperative
period (20.5% vs. 40.5%) (19).
There was no statistically significant differ-
ence considering pain perception during 13 dif-
ferent time intervals in the first postoperative
day, regardless whether they were operated dur-
ing the luteal or follicular phase. Additionally,
there was no statistically significant difference
between analgesic (tramadol and morphine)
requirement, between both groups (18).
Another study analysed the hemodynamic
response of 62 female patients depending on
the phase of the menstrual cycle (31-follicular
and 31-luteal). Propophol and rocuronium
were used during intubation. During the luteal
phase one observed a statistically significant
higher blood pressure during the first minute
after intubation. In case of the remaining pa-
rameters no statistically significant differ-
ences were observed (20).
Conclusion
Based on available literature data, there is
no evidence that menstruation can be a contrain-
dication to elective surgery. Currently however,
there are no studies directly devoted to the issue
of the menstrual cycle in general surgery.
 Menstruation- still a contraindication to elective surgery?
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Received: 13.03.2013 r.
Adress correspondence: 31-202 Kraków, ul. Prądnicka 35-37
e-mail: jkenig@cm-uj.krakow.pl
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