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Menometrorrhagia PDF
Menometrorrhagia PDF
Case Report
ABSTRACT
Widespread and uncontrolled use of ginseng has raised the question of its side effects and
drug interactions. A 39-year-old female patient experienced menometrorrhagia. Her com-
plaints had started 5 months earlier. The laboratory tests revealed follicle-stimulating hor-
mone (FSH) and estradiol levels to be 10 mIU and 90 mIU, respectively. Endometrial biopsy
was planned for the diagnosis of abnormal uterine bleeding. During the preoperative evalu-
ation, the patient stated that she had been using both oral and topical ginseng for cosmetic
reasons. The ECG revealed sinus tachycardia with occasional atrial premature beats. The pro-
cedure was postponed for 2 weeks so that the patient would stop taking ginseng, smoking,
and drinking coffee. Arrhythmia stopped 10 days later. Tachycardia continued during the pro-
cedure but did not require treatment, as it did not cause any hemodynamic instability. An en-
dometrial biopsy specimen showed a disordered proliferative pattern. The patient was ad-
vised to stop using oral and topical ginseng. During a follow-up visit, she had no sign of
menometrorrhagia or tachyarrhythmia and her hemoglobin levels were in the normal range.
Smoking and coffee consumption, along with ginseng use, can be responsible for arrhyth-
mogenic effects. Abnormal uterine bleeding can cause tachycardia secondary to anemia. The
clinical progress of this patient is consistent with our hypothesis that ginseng is responsible
for menometrorrhagia, although this could be coincidental. Patients should always be asked
prior to surgery if they use herbal medications, food supplements, or cosmetics as well as pre-
scription drugs. This is of great importance for both diagnosis and avoidance of drug inter-
actions and side effects during anesthesia.
INTRODUCTION for the last few years in Turkey. There are vairous
types of ginseng according to the origin of its cul-
1Department of 1st Anesthesiology and Reanimation and 2Department of Obstetrics and Gynecology, Ministry of
Health, Ankara Numune Training and Research Hospital, Sihhiye, 06100, Ankara, Turkey.
830
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ginsengs are similar in their chemical composi- been using oral Korean red ginseng capsules
tion, and they both contain ginsenosides. The ac- (1000–1500 mg/day) (GNC, Pittsburgh, PA) and,
tive ingredients are eleutherosides in Siberian at the same time, face cream, mask, and toner
ginseng.1,2 All types of ginseng are used espe- (Royal Hongsam, Saul, Korea) containing Korean
cially by people with higher socioeconomic sta- red ginseng for the last 7 months. She consumed
tus in order to increase mental, physical, and sex- 4–6 cups of coffee per day and smoked 20 ciga-
ual activities. The medical stimulant, antiaging, rettes per day. The patient complained of having
antioxidant, aphrodisiac, and antistress features palpitations for 4 months, and her ECG showed
of ginseng are well known.2–4 Oral and topical sinus tachycardia (106 beats/min). She also had
use of ginseng is sometimes recommended by occasional atrial premature beats. Her previous
dermatologists to decrease skin-aging symptoms ECG, about a year ago, showed sinus rhythm
of perimenopausal women.5 Ginseng is available with a heart rate of 76 beats/min. Her previous
in different forms, including fresh or dried roots, Hb value was 12.9 g/dl. The patient was referred
extracts, solutions, capsules, tablets, cosmetics, to a cardiologist, and cardiac examination was
sodas, and teas.6 Within the last few years, in- found to be normal. She was advised to stop
tensive use of ginseng without physician control smoking and drinking coffee and to have a gy-
has raised the question of its side effects and drug necological examination for abnormal uterine
interactions.7,8 We present a case report of a pa- bleeding as a possible cause of anemia. The en-
tient with unexplained tachyarrhythmias and dometrial biopsy procedure was postponed until
menometrorrhagia, which eventually was attrib- the patient stopped using ginseng, cigarettes, and
uted to combined use of ginseng cosmetics and coffee for 2 weeks. Her arrhythmia ended, but
ginseng capsules. tachycardia was still present 10 days later.
In the preoperative holding area, the patient
was very anxious and requested sedation. Be-
CASE REPORT cause of her status and the uncertainty of the du-
ration of the procedure, we decided to proceed
A 39-year-old woman, gravida 2 (at age 26 and with monitored anesthetic care. The patient was
34), with 1 elective abortion (at age 35), com- taken into the operating room and monitored for
plained of menometrorrhagia. The patient re- ECG, heart rate (HR), blood pressure (BP), and
ported that she did not have any previous sys- peripheral oxygen saturation (SpO2). After intra-
temic or gynecological problems, and she denied venous (i.v.) access was established, balanced
using drugs. She stated that her menometrorrha- electrolyte solutions were infused. Preoperative
gia had started about 5 months earlier. She com- HR, BP, and SpO2 were 102 beats/min, 129/82
plained of prolonged (exceeding 7–9 days) and mm Hg, and 99%, respectively. Anesthesia was
excessive uterine bleeding. Examination of the provided with i.v. 2 mg/kg propofol (Fresenius
patient revealed no pathology related to her com- Kabi, Hamburg, Germany), 1 mg/kg fentanyl
plaints. The b-human chorionic gonadotropin (b- (Abbott, Abbot Park, IL), and O2 via mask air-
hCG) level was normal, and her follicle-stimulat- way. Endometrial biopsy was performed under
ing hormone (FSH) and estradiol measurements monitored anesthetic care, and the procedure
on the third day of menstruation were 10 mIU took 15 minutes. The patient’s HR under anes-
(normal 14–18 mIU) and 90 mIU (normal 30–40 thesia was between 90 and 102 beats/min. Sinus
pg/ml), respectively. Her hemogram showed tachycardia existed during the procedure but did
mild hypochromic microcytic anemia, with he- not require treatment because it did not cause any
moglobin (Hb) 11.4 g/dl, hematocrit (Htc) 33.2 hemodynamic instability. The procedure was un-
g/dl, and red blood cells (RBC) 3.7 million/ml. eventful, and there were no complications related
Other laboratory findings and coagulation tests to either surgery or anesthesia. The patient was
were normal. then taken to the postanesthesia care unit, where
Endometrial biopsy was planned for diagnosis she was fully awakened. She was hemodynami-
of abnormal uterine bleeding. During the exami- cally stable and had no respiratory problems in
nation, before being anesthetized, the patient was the postanesthesia care unit. She was discharged
asked whether she had been using any drugs, in- after 2 hours.
cluding herbal drugs. She recalled that she had Results of the endometrial biopsy specimen
5206_e10_p830-833 9/5/04 12:56 PM Page 832
showed a disordered proliferative pattern con- elevation of estrogen levels. The duration of her
sistent with the patient’s phase of the menstrual menstrual cycles and the amount of uterine
cycle. The patient was advised to stop using oral bleeding returned to normal after cessation of
and topical ginseng. On the follow-up visit 1 oral and topical ginseng, which made us conclude
month later, her complaints were over, and her that the endometrial hyperplasia was a result of
FSH and estradiol levels were consistent with the the estrogenlike effects of ginseng.
phase of her menstrual cycle. Her ECG was nor- Among the other side effects are hypersensi-
mal (82 beats/min). The follow-up Hb levels post- tivity reactions, hemodynamic instability, hypo-
operatively were 12.2 and 13 g/dl after 1 and 6 glycemic attacks, arrhythmia, insomnia, rest-
months, respectively. Her menometrorrhagia did lessness, diarrhea, asthma, Stevens-Johnson syn-
not recur during the next 6 months, and the FSH drome, fibrocystic breast sickness, mastalgia, and
and estradiol levels were within the normal range. fever.7 In addition, ginseng may inhibit platelet
activity and increase the risk of bleeding during
or after surgery. Therefore, it should probably not
DISCUSSION be used with aspirin.7,8,14 Ginseng also may in-
teract with other drugs, such as insulin, sulfony-
Korean red ginseng is the root of the perennial lurea, monoamine oxidase inhibitors (MAOIs),
herb P. schinseng, which contains a series of tetra- and warfarin.8,9,15 Ginseng use was shown to de-
cyclic triterpenoid saponins (ginsenosides) as ac- crease the anticoagulant effects of warfarin in a
tive ingredients. Ginsenosides’s effects on the im- reported case.16 While using ginseng, it is wise to
mune system, learning, and memory occur avoid caffeine, cigarettes, and other substances
through various neurotransmitters, such as the that stimulate the central nervous system because
cholinergic, dopaminergic, and serotoninergic ginseng may potentiate their effects (via neuro-
systems and even the GABAergic system.8 The transmitters), such as nervousness, sweating, in-
adaptogenic properties of ginseng are believed to somnia, tachycardia, or irregular heartbeat.17
be due to its effects on the hypothalamic-pituitary- We do not know any special adverse effects of
adrenal axis, causing elevated plasma corti- ginseng related to anesthetic drugs, although it
cotropin and corticosteroids levels.4 However, may block the analgesic effect of morphine18 and
herbs contain active substances that can trigger interfere with anesthetic drug-metabolizing en-
side effects and interact with other medications.9,10 zyme systems.10 It also may cause hypoglycemia
Punnonen and Lukola11 indicated that ginseng during anesthesia.14 The American Society of
extracts compete with estrogen binding sites on Anesthesiologist (ASA) has warned that using
the human myometrial cytosol and have estro- sympathomimetics with ginseng can cause ar-
genlike effects on vaginal epithelium.11 rhythmia and tachycardia. In addition, because
Greenspan12 reported the case of a 72-year-old of other side effects and drug interactions of gin-
patient with vaginal bleeding after daily inges- seng, ASA has announced that ginseng must be
tion of 200 mg ginseng for 1 month. Hopkins et stopped 2–3 weeks before anesthesia is adminis-
al.13 examined the vaginal bleeding etiology of a tered.19 That is why we recommended that our
44-year-old postmenopausal patient. They ob- patient stop using ginseng 2 weeks before
served low FSH and a disordered endometrial surgery. The arrhythmia in our case disappeared
proliferative pattern. It was found during ques- when the patient stopped using ginseng, smok-
tioning of the patient that she had been using gin- ing, and drinking coffee, and we concluded that
seng face cream. When she stopped using the face her symptoms were to ginseng and other stimu-
cream, FSH increased and the bleeding stopped. lants. Tachycardia can also be associated with
Upon reuse, it was confirmed that the cream, anemia related to bleeding or to hypoglycemia.
which contained ginseng, was responsible for Our patient did not have hypoglycemia either be-
repetition of the bleeding etiology.13 The patients fore or during the procedure. This made us to
of Greenspan12 and of Hopkins et al.13 were post- think that the tachycardia could be secondary to
menopausal. Our patient was a 39-year-old pre- anemia. The clinical progress of our patient is
menopausal woman who had abnormal uterine consistent with our hypothesis that ginseng is re-
bleeding resulting from endometrial hyperplasia. sponsible for menometrorrhagia, although it can
She had no pathologic condition that could cause still be coincidental.
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