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JOURNAL OF WOMEN’S HEALTH

Volume 13, Number 7, 2004
© Mary Ann Liebert, Inc.

Case Report

Menometrorrhagia and Tachyarrhythmia after

Using Oral and Topical Ginseng

AYLA A. KABALAK1 OZLEM B. SOYAL,1 AYKUT URFALIOGLU,1 FERIT SARACOGLU,2

and NERMIN GOGUS1

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-

G INSENG IS AN HERBAL ROOT that has been used

by the Chinese for treatment purposes for
over 5000 years. It has been on the market as a
drug since the 1900s in the United States but only
tivation. The three major types of ginseng are
American ginseng (Panax quinquefolius), Asian
ginseng (Panax schlinseng), and Siberian ginseng
(Eleutherococcus senticosus). American and Asian

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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GINSENG AND MENOMETRORRHAGIA AND TACHYARRHYTHMIA
ginsengs are similar in their chemical composi-
tion, and they both contain ginsenosides. The ac-
tive ingredients are eleutherosides in Siberian
ginseng.1,2 All types of ginseng are used espe-
cially by people with higher socioeconomic sta-
tus in order to increase mental, physical, and sex-
ual activities. The medical stimulant, antiaging,
antioxidant, aphrodisiac, and antistress features
of ginseng are well known.2–4 Oral and topical
use of ginseng is sometimes recommended by
dermatologists to decrease skin-aging symptoms
of perimenopausal women.5 Ginseng is available
in different forms, including fresh or dried roots,
extracts, solutions, capsules, tablets, cosmetics,
sodas, and teas.6 Within the last few years, in-
tensive use of ginseng without physician control
has raised the question of its side effects and drug
interactions.7,8 We present a case report of a pa-
tient with unexplained tachyarrhythmias and
menometrorrhagia, which eventually was attrib-
uted to combined use of ginseng cosmetics and
ginseng capsules.
CASE REPORT
A 39-year-old woman, gravida 2 (at age 26 and
34), with 1 elective abortion (at age 35), com-
plained of menometrorrhagia. The patient re-
ported that she did not have any previous sys-
temic or gynecological problems, and she denied
using drugs. She stated that her menometrorrha-
gia had started about 5 months earlier. She com-
plained of prolonged (exceeding 7–9 days) and
excessive uterine bleeding. Examination of the
patient revealed no pathology related to her com-
plaints. The b-human chorionic gonadotropin (b-
hCG) level was normal, and her follicle-stimulat-
ing hormone (FSH) and estradiol measurements
on the third day of menstruation were 10 mIU
(normal 14–18 mIU) and 90 mIU (normal 30–40
pg/ml), respectively. Her hemogram showed
mild hypochromic microcytic anemia, with he-
moglobin (Hb) 11.4 g/dl, hematocrit (Htc) 33.2
g/dl, and red blood cells (RBC) 3.7 million/ml.
Other laboratory findings and coagulation tests
were normal.
Endometrial biopsy was planned for diagnosis
of abnormal uterine bleeding. During the exami-
nation, before being anesthetized, the patient was
asked whether she had been using any drugs, in-
cluding herbal drugs. She recalled that she had
831
been using oral Korean red ginseng capsules
(1000–1500 mg/day) (GNC, Pittsburgh, PA) and,
at the same time, face cream, mask, and toner
(Royal Hongsam, Saul, Korea) containing Korean
red ginseng for the last 7 months. She consumed
4–6 cups of coffee per day and smoked 20 ciga-
rettes per day. The patient complained of having
palpitations for 4 months, and her ECG showed
sinus tachycardia (106 beats/min). She also had
occasional atrial premature beats. Her previous
ECG, about a year ago, showed sinus rhythm
with a heart rate of 76 beats/min. Her previous
Hb value was 12.9 g/dl. The patient was referred
to a cardiologist, and cardiac examination was
found to be normal. She was advised to stop
smoking and drinking coffee and to have a gy-
necological examination for abnormal uterine
bleeding as a possible cause of anemia. The en-
dometrial biopsy procedure was postponed until
the patient stopped using ginseng, cigarettes, and
coffee for 2 weeks. Her arrhythmia ended, but
tachycardia was still present 10 days later.
In the preoperative holding area, the patient
was very anxious and requested sedation. Be-
cause of her status and the uncertainty of the du-
ration of the procedure, we decided to proceed
with monitored anesthetic care. The patient was
taken into the operating room and monitored for
ECG, heart rate (HR), blood pressure (BP), and
peripheral oxygen saturation (SpO2). After intra-
venous (i.v.) access was established, balanced
electrolyte solutions were infused. Preoperative
HR, BP, and SpO2 were 102 beats/min, 129/82
mm Hg, and 99%, respectively. Anesthesia was
provided with i.v. 2 mg/kg propofol (Fresenius
Kabi, Hamburg, Germany), 1 mg/kg fentanyl
(Abbott, Abbot Park, IL), and O2 via mask air-
way. Endometrial biopsy was performed under
monitored anesthetic care, and the procedure
took 15 minutes. The patient’s HR under anes-
thesia was between 90 and 102 beats/min. Sinus
tachycardia existed during the procedure but did
not require treatment because it did not cause any
hemodynamic instability. The procedure was un-
eventful, and there were no complications related
to either surgery or anesthesia. The patient was
then taken to the postanesthesia care unit, where
she was fully awakened. She was hemodynami-
cally stable and had no respiratory problems in
the postanesthesia care unit. She was discharged
after 2 hours.
Results of the endometrial biopsy specimen
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832
showed a disordered proliferative pattern con-
sistent with the patient’s phase of the menstrual
cycle. The patient was advised to stop using oral
and topical ginseng. On the follow-up visit 1
month later, her complaints were over, and her
FSH and estradiol levels were consistent with the
phase of her menstrual cycle. Her ECG was nor-
mal (82 beats/min). The follow-up Hb levels post-
operatively were 12.2 and 13 g/dl after 1 and 6
months, respectively. Her menometrorrhagia did
not recur during the next 6 months, and the FSH
and estradiol levels were within the normal range.
DISCUSSION
Korean red ginseng is the root of the perennial
herb P. schinseng, which contains a series of tetra-
cyclic triterpenoid saponins (ginsenosides) as ac-
tive ingredients. Ginsenosides’s effects on the im-
mune system, learning, and memory occur
through various neurotransmitters, such as the
cholinergic, dopaminergic, and serotoninergic
systems and even the GABAergic system.8 The
adaptogenic properties of ginseng are believed to
be due to its effects on the hypothalamic-pituitary-
adrenal axis, causing elevated plasma corti-
cotropin and corticosteroids levels.4 However,
herbs contain active substances that can trigger
side effects and interact with other medications.9,10
Punnonen and Lukola11 indicated that ginseng
extracts compete with estrogen binding sites on
the human myometrial cytosol and have estro-
genlike effects on vaginal epithelium.11
Greenspan12 reported the case of a 72-year-old
patient with vaginal bleeding after daily inges-
tion of 200 mg ginseng for 1 month. Hopkins et
al.13 examined the vaginal bleeding etiology of a
44-year-old postmenopausal patient. They ob-
served low FSH and a disordered endometrial
proliferative pattern. It was found during ques-
tioning of the patient that she had been using gin-
seng face cream. When she stopped using the face
cream, FSH increased and the bleeding stopped.
Upon reuse, it was confirmed that the cream,
which contained ginseng, was responsible for
repetition of the bleeding etiology.13 The patients
of Greenspan12 and of Hopkins et al.13 were post-
menopausal. Our patient was a 39-year-old pre-
menopausal woman who had abnormal uterine
bleeding resulting from endometrial hyperplasia.
She had no pathologic condition that could cause
KABALAK ET AL.
elevation of estrogen levels. The duration of her
menstrual cycles and the amount of uterine
bleeding returned to normal after cessation of
oral and topical ginseng, which made us conclude
that the endometrial hyperplasia was a result of
the estrogenlike effects of ginseng.
Among the other side effects are hypersensi-
tivity reactions, hemodynamic instability, hypo-
glycemic attacks, arrhythmia, insomnia, rest-
lessness, diarrhea, asthma, Stevens-Johnson syn-
drome, fibrocystic breast sickness, mastalgia, and
fever.7 In addition, ginseng may inhibit platelet
activity and increase the risk of bleeding during
or after surgery. Therefore, it should probably not
be used with aspirin.7,8,14 Ginseng also may in-
teract with other drugs, such as insulin, sulfony-
lurea, monoamine oxidase inhibitors (MAOIs),
and warfarin.8,9,15 Ginseng use was shown to de-
crease the anticoagulant effects of warfarin in a
reported case.16 While using ginseng, it is wise to
avoid caffeine, cigarettes, and other substances
that stimulate the central nervous system because
ginseng may potentiate their effects (via neuro-
transmitters), such as nervousness, sweating, in-
somnia, tachycardia, or irregular heartbeat.17
We do not know any special adverse effects of
ginseng related to anesthetic drugs, although it
may block the analgesic effect of morphine18 and
interfere with anesthetic drug-metabolizing en-
zyme systems.10 It also may cause hypoglycemia
during anesthesia.14 The American Society of
Anesthesiologist (ASA) has warned that using
sympathomimetics with ginseng can cause ar-
rhythmia and tachycardia. In addition, because
of other side effects and drug interactions of gin-
seng, ASA has announced that ginseng must be
stopped 2–3 weeks before anesthesia is adminis-
tered.19 That is why we recommended that our
patient stop using ginseng 2 weeks before
surgery. The arrhythmia in our case disappeared
when the patient stopped using ginseng, smok-
ing, and drinking coffee, and we concluded that
her symptoms were to ginseng and other stimu-
lants. Tachycardia can also be associated with
anemia related to bleeding or to hypoglycemia.
Our patient did not have hypoglycemia either be-
fore or during the procedure. This made us to
think that the tachycardia could be secondary to
anemia. The clinical progress of our patient is
consistent with our hypothesis that ginseng is re-
sponsible for menometrorrhagia, although it can
still be coincidental.
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GINSENG AND MENOMETRORRHAGIA AND TACHYARRHYTHMIA
CONCLUSIONS
We recommended that nonprescription drugs,
such as ginseng, should be used under medical
control. Otherwise, they can cause various types of
complications. Therefore, patients should be asked
whether they use prescription drugs and herbal
drugs, food additives and cosmetics. This is im-
portant in both diagnosis and avoidance of drug
interaction and side effects during the periopera-
tive period. Our case is reported as a warning that
abnormal uterine bleeding and arrhythmias can be
caused by the use of oral and topical ginseng.
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Address reprint requests to:
Ayla A. Kabalak, M.D.
Cigdem Mah., 337. sok., Tugba apt., 5/2
Karabusunlar, 06530, Ankara
Turkey
E-mail: drayla2002@yahoo.com