Clin. Cardiol.

15, 625-626 (1992)

Editor’s Note
Is Menstruation a Contraindication to
Thrombolytic Therapy?
Recently, a cardiologist colleague in private practice asked my advice about
management of a patient who was evolving a myocardial infarction while
actively menstruating.
The patient was a 40-year-old female in the second day of her menstrual
cycle. She presented within an hour or so to a community emergency room
complaining of severe chest discomfort. An electrocardiogram revealed an
obvious evolving anterior myocardial infarction and an echocardiogram con-
firmed an anteroseptal wall motion abnormality. The community hospital had
a diagnostic cardiac catheterization laboratory but no facilities for performing
angioplasty. I was asked whether or not the patient should receive thrombolyt-
ic therapy. I told my colleague that I had never encountered this clinical situa-
tion nor had I read anything in the literature about it; in fact, I had never even
thought of this clinical scenario. Intuitively, however, I felt that it might be ap-
propriate to treat the patient with thrombolytic therapy. The refemng physician
remained concerned (as did I) about the probability of precipitating a major
bleeding episode, and thought it best to transfer the patient to our facility for an
interventional procedure. Two hours later she was in our laboratory. The patient
had an occluded left anterior descending coronary artery, proximal to the first
septa1 perforator. Clot was present in the vessel. No collaterals to the distal
circulation were seen. Urokinase 200,000 units was given by the intracoro-
nary route, but the vessel remained occluded. The patient did not have any in-
creased menstrual bleeding. A guide wire was passed through the clot to the distal LAD and Balloon Angioplasty with a
long balloon was performed. Despite multiple balloon inflations, patency was never achieved. Thus, we failed to recanal-
ize this patient despite delayed thrombolytic therapy and mechanical intervention with angioplasty.
Since I had never experienced this clinical problem before (and I suspect not many have), I thought I might share with
the reader what I subsequently found out about it.
The following morning I talked with one of our obstetricians who was not sure whether thrombolytic therapy was con-
traindicated but added that heparin and coumadin are given frequently and safely to patients who are actively menstruat-
ing. If menstrual bleeding is increased, estrogens are usually administered. The acute use of estrogen in a patient with an
evolving myocardial infarction with obvious clot in the left anterior descending coronary artery is another situation for which
the information is scanty.
As one might imagine, the literature on thrombolysis in this instance is not abundant. In fact, I could only find four arti-
cles that address the issue of thrombolytic therapy in an actively menstruating patient.
The real issue here seems to relate to the physiopathology of menstruation vis-a-vis uterine bleeding from other sources.
Menstruation is not considered pathology, whereas bleeding from a uterine tumor obviously is pathological. The mechanism
of bleeding with menstruation is due primarily to contraction of endometrial arterioles. Intense vasospasm occurs in the spi-
ral arterioles that nourish the endometrium. As I have subsequently learned, locally made prostaglandins produce an intense
vasospastic response resulting in ischemic necrosis which then sloughs the endometrium, producing bleeding. Thus, one
might predict that bleeding from a normal menstruating uterus in a patient given thrombolytic therapy might not be as severe
as in a patient with a bleeding uterine tumor, since physiologic control of uterine bleeding is not necessarily related to clot
formation.
A few days after this incident, one of my fellows in training called Genentech, Inc., to inquire about this situation. In addi-
tion to supplying us with the few references that are available, they did indicate that they had received anecdotal reports
involving 2 1 menstruating females who received Activase. They noted that most patients developed increased menstrual
flow but without subsequent major bleeding complications, while a few showed no changes in flow pattern.
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626 Clin. Cardiol. Vol. 15, September 1992

The minimal literature available seems to indicate that there are no major complications due to the administration of
thrombolytic therapy to a patient who is actively menstruating. Two case reports of successful therapy and two editorial
comments are the only literature I could find in English.
de Gregorio ef al. reported a case of a 43-year-old female who evolved a myocardial infarction on the second day of her
menstrual cycle.’ The patient received streptokinaseinto the left anterior descending coronary artery (10,OOO units as a bolus
followed by 4000 U/min), and had no bleeding complications. The artery recanalized. The patient received a total of
240,000 units.
Chop and colleagues reported a patient with an evolving myocardial infarction to whom they administered 100 mg of
Activase and heparin on the second day of her menstrual cycle. Although menstruation increased slightly, the duration of
menstruation was not prolonged.*
Donovan, in an article entitled “How to Give Thrombolytic Therapy Safely,” recommended that menstruation should not
exclude therapy with thrombolytic drugs.3No data or cases were presented to support the recommendation.
In an editorial, Topol supports the use of thrombolytic therapy in these patients and recommends collaboration with a
gynecologist.“ If available, however, he does think that immediate angioplasty is preferred to intravenous thrombolysis
unless there is an inordinate delay involved with the transfer of the patient to a facility where angioplasty is available.
I would be interested to know from readers if anyone has had an adverse experience given this rather rare situation. It is
hard to imagine that there are many menstruatingfemales who present with acute myocardial infarction during their menses.
However, in these days of cocaine abuse, we may see more of these patients and should be prepared to manage them in a
logical way based on data derived from what little clinical experience is available.
The communication from Genentech included some advice on monitoring vaginal bleeding in the menstruating patient.
They suggested that patients not be allowed to wear a tampon but instead use a sanitary napkin in order to check saturation
frequently during thrombolytic therapy.
In summary, there are no clinical trials that provide guidance on the use of thrombolytic therapy in the actively men-
struating patient. In fact, women of child-bearing potential are excluded from most clinical trials. The accumulation of a
large clinical experience by any one center is highly unlikely since the number of cases of acute myocardial infarction that
occur during menstruation in women of child-bearing potential must be very rare. However, considering the morbidity and
mortality of a myocardial infarction versus the morbidity and mortality of increased uterine bleeding, one has to conclude
that it is worth using thrombolytic therapy in this situation. Based on what I know now, I will in the future recommend
thrombolytic therapy for similar patients when seen in a community hospital. In this patient, however, I am not sure whether
the outcome would have been different-that answer will never be known.

C. R. Conti, M.D.
Editor-in-Chief

References
1. Chop WM, Evans PJ, Felty K: Thrombolytic therapy during active menstruation: A case report. J Family Practice 33( I), 79-81 (1991)
2. de Gregorio B, Goldstein J, Haft JI: Administration of intracoronary streptokinase during menstruation. Am Heart J. 109,908-910 (1985)
3. Donovan BC: How to give thrombolytic therapy safely. Chest 95,290s-292s (1989)
4. Topol EJ: Thrombolytic therapy in acute MI: Safe during menses? J Cn‘t Illness 7( I), 14 (1992)