Of course, for women undergoing surgery, the question needs to be asked – what should be done about the use of complementary medicine? Many people start taking CAM at this time and it is important to know the implications for CAM and surgery. The standard advice is to stop taking all complementary medicines two to three weeks prior to surgery and whilst this is reasonable due to minimising risks associated with negative drug interactions, it does prevent women receiving the benefits of their complementary medicines. The following information is provided to assist in making informed choices on CAM – it is important to highlight that there are some complementary medicines not discussed here that may be associated with high risks when used in conjunction with surgery. You should discuss any specific issues with your health team.
The main feature distinguishing CAM from conventional medicine is that it is based on theories of vitality. Many CAM interventions are chemically complex and cause interaction between cells, organs and whole body systems – for example a CAM that improves mental health might also be used to treat bowel disease. Whole herbal medicine extracts contain a range of chemicals that act on various body systems and are ‘synergistic’, meaning that they produce one effect when used in isolation and a different effect when combined that may either stronger or weaker than when used singularly.
Although a long history of use supports the notion that most herbal medicines are safe, some of these medicines have been associated with serious harm. The regulation of herbal medicines is not the same as pharmaceutical agents, with supplements listed with the TGA rather than registered. A CAM supplement manufacturer needs to demonstrate a lack of harm in order for the product to be listed, which is different to the very rigorous requirements for TGA registration of pharmaceuticals. What happens after marketing regarding the frequency and exact nature of adverse reactions is often unknown. In addition, adverse reactions may be under-reported by doctors who don’t always recognise the signs and symptoms and women may not report usage due to self-diagnosis and administration of these medicines.
Adverse effects during the peri-operative period may be due to a variety of factors and we discuss some of these medicines below.
Echinacea: The first herbal medicine we will consider is Echinacea purpurea or angustifolia, commonly known as purple cone flower. Studies suggest immune-stimulating effects when this medicine is used for prevention and treatment of bacterial, viral and fungal infections. This medicine is most often used to prevent or treat upper respiratory infections (colds). There are no studies investigating the interactions of Echinacea with peri-operative immune suppression.
Echinacea has a dose dependant effect that stimulates the immune system in the short term but suppresses the immune system when used for more than eight weeks, and chronic post-operative use may lead to poor wound healing. Echinacea is also associated with allergic reactions and should be used with caution in people with asthma, eczema or allergic rhinitis. In addition there have been some concerns about liver disease and women with pre-existing liver dysfunction should be cautious when taking Echinacea. We suggest that for women having surgery with compromised liver function or blood flow to avoid Echinacea as far in advance of surgery as possible due to the secondary effects of anaesthetic drugs and organ (liver) movement during surgery.
Ginkgo: Ginkgo is used to support patients with Alzheimer’s disease and dementia and it is often used in other disorders that affect memory, for peripheral vascular disease, age related eye disease such as macular degeneration, vertigo, tinnitus and altitude sickness.
The primary effects of Ginkgo seem to be through improved blood flow to the tissues due to an effect on the tiny clots created by products in the blood stream – this is the greatest concern for the perioperative period since there may be a greater possibility of bleeding. Whilst there are no clinical trials investigating complications from taking Ginkgo and bleeding, there are reports of patients on Ginkgo having problems with bleeding following brain or eye surgery and even gall bladder surgery. If you are taking Ginkgo, we recommend that you stop its use at least 36 hours prior to surgery.
Ginseng: Ginseng is a popular herb used to protect against stress and restore internal body balance. Exactly how it works in the body is not completely understood since it has a complex structure. This herb is used for glucose regulation and therefore it is possible that it might lead to unintended hypoglycaemia in patients who have been fasting before surgery. It may also have an anticoagulation effect, similar to that of warfarin and because this effect seems to be on the platelets in the bloodstream that help cause clotting, it is important that Ginseng be stopped at least 14 days prior to surgery.
St Johns wort: St Johns wort is often used to treat mild to moderate depression. The active components of this medicine have an effect on the central nervous system and alter the balance of various chemicals that effect both nerve transmission and mood. It may also have an effect with many pharmaceuticals used around the time of surgery such as alfentonil, midazolam, hydrochloride, lidocaine, calcium channel blockers and serotonin antagonists. For these reasons, St Johns Wort should be discontinued at least five days before surgery and avoided post-operatively by organ transplant patients.
Kava: Kava is used to reduce anxiety, improve relaxation and as an antispasmodic. This herb is likely to be used by people feeling anxious about surgery. The active constituents in Kava are fat-soluble and therefore they are able to cross into the brain and influence central nervous system activity by interacting with various chemical receptors there. Kava does have abuse potential and long-term use may result in addiction, so care should be taken and treatment should be short-term only. Heavy use causes Kava dermopathy – a skin condition that is characterised by reversible scaly and reddened lesions over the body. The potentiation of sedative effects of anaesthetic drugs means that patients should avoid Kava for at least 24 hours prior to surgery.
Valerian: Valerian is used as a sedative with most extracts standardised according to the amount of valerianic acid (the active component) that produces sedation and hypnosis by influencing the central nervous system actions. Valerian withdrawal may mimic acute benzodiazepine withdrawal syndrome, post surgery cardiac complications and delirium. Valerian is likely to increase the sedative effects of anaesthetics such as midazolam that also act on the central nervous system. This medicine has a short effect and women should use caution against abrupt discontinuation and we recommend reducing intake over several weeks pre-surgery so that there is none taken on the day before surgery.
Nutritional supplements: Fish oil omega three is a popular nutritional supplement used to treat a wide range of conditions including inflammation and behavioural disorders in children. The main therapeutic action is the reduction of inflammation. Whilst there is a theoretically increased risk of bleeding for surgical procedures when taking this supplement, many scientific studies have failed to show that this actually occurs. It is currently believed that the increased risk of perioperative bleeding is virtually non-existent. There is some scientific evidence that fish oils plus the amino acid arginine improve post-surgical immunity and wound healing and restriction. We therefore recommend that in the peri-operative period, you only need to stop fish oil capsules in conjunction with your fasting recommendations.
Garlic: Garlic may be used to reduce blood pressure and clot formation, lower cholesterol and reduce blood lipids. It contains sulphur-containing compounds that are commercially standardised. Garlic may reduce clotting in the body and it interacts with other medications used around the time of surgery. It is possible that it has some effect in increasing bleeding around this time, although there are few scientific studies that demonstrate this effect. So, for safety, we recommend that the best advice is to discontinue garlic 7 days before surgery, especially if post-operative bleeding is of particular concern or you are using other platelet inhibitors (such as aspirin).
Summary
Although standard advice is to cease all CAM 2-3 weeks before surgery, taking a targeted approach may improve your satisfaction and identify herbal medicines that should be discontinued earlier than three weeks. It may also enable you to continue to use your CAM therapies closer to surgery and improve your surgical experience outcome. It is important to consider that discontinuation of CAM may lead to increased post-operative problems and a tailored approach improves patient care.
Many women are unable to properly identify the CAM supplements they are taking and they may not volunteer information about their use. It is an important conversation welcomed at Alana Healthcare for Women – particularly if you are planning a surgical procedure.