|Year : 2018 | Volume
| Issue : 5 | Page : 330-336
Does the phase of the menstrual cycle really matter to anaesthesia?
Madhuri S Kurdi, Ashwini H Ramaswamy
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
|Date of Web Publication||10-May-2018|
Dr. Madhuri S Kurdi
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka
Source of Support: None, Conflict of Interest: None
The menstrual cycle is a physiological phenomenon that is accompanied by several hormonal fluctuations involving oestrogen and progesterone. Oestrogen and progesterone exert several physiological effects. There are many questions pertaining to the influence of the physiology of menstruation on anaesthesia. We attempted to find out whether the phase of the menstrual cycle can alter the physiological functions during anaesthesia, the perioperative management and outcomes. We performed a literature search in Google Scholar, PubMed and Cochrane databases for original and reviewed articles on the phases of the menstrual cycle and their relation to anaesthesia-related physiological parameters to find an answer to these questions. Many studies have shown that women, perimenstrually, may have increased pain perception, exacerbation of systemic diseases, vocal cord/peripheral oedema and post-operative nausea and vomiting (PONV). Some of the other notable findings in most studies were sleep disturbances in the luteal phase (LP), increased occurrence of PONV in the ovulatory phase and a lower requirement of intravenous sedative and anaesthetic drug requirements in the LP. We found contradictory results concerning pain perception and PONV in relation to the follicular and LPs. However, we found that literature regarding the phase of the menstrual cycle and the haemodynamic response to intubation, anaesthesia-induced hypnosis and perioperative blood loss is relatively scarce. Thus, there is a need to conduct good quality research on these topics.
Keywords: Follicular phase, luteal phase, menstruation, nausea, ovulation, pain, physiology, vomiting
|How to cite this article:|
Kurdi MS, Ramaswamy AH. Does the phase of the menstrual cycle really matter to anaesthesia?. Indian J Anaesth 2018;62:330-6
| Introduction|| |
The eminent endocrinologist Estelle Ramey once said 'in man, the shedding of blood is always associated with injury, disease or death. Only the female half of the humanity is seen to have the magical ability to bleed profusely each month and still rise phoenix-like from the gore'. Human menstruation has been regarded both negatively and positively in different aspects. Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to shedding of the endometrium following an invisible interplay of hormones. Menstruation is often least revealed by women preoperatively; nevertheless, as anaesthesiologists, we can perioperatively encounter women patients in different phases of the menstrual cycle and are expected to ask leading questions about menstruation during the pre-anaesthetic evaluation. Fluctuations in many physiological functions occur throughout the different phases of the menstrual cycle due to hormonal fluctuations. Considering this, one cannot help wondering whether the physiological changes due to the menstrual cycle can have a positive or negative impact on anaesthesia. Should surgical procedures be scheduled according to the menstrual phase? In this article, we detail the physiological changes during the menstrual cycle relevant to the anaesthesiologist and discuss various research studies conducted on this subject in relation to anaesthesia with a goal to find out how and whether the phase of the menstrual cycle could alter anaesthesia-related perioperative management and outcomes.
Literature search and selection
We performed an electronic search in Google Scholar, PubMed and Cochrane databases for original and review articles on phases of the menstrual cycle and their relation to anaesthesia-related physiological parameters published in humans until March 2018. The search terms included phases of the menstrual cycle and sedation, sleep and menstruation, menstruation and anaesthesia, pain and the menstrual phase, menstruation and post-operative vomiting, menstrual phases and anxiety, menstrual phase and pharmacokinetics. We also searched for information on this topic in textbooks of gynaecology and anaesthesiology in our institutional library. From the 75 articles retrieved in the first few search rounds, additional articles were found among the cross-references cited. The articles for potential inclusion included both full-text articles and abstracts. We excluded articles that were not written in English. We eventually included the results of 126 articles.
| The Menstrual Cycle|| |
The menstrual cycle includes the ovarian cycle and the endometrial cycle [Figure 1]. The 4 stages of the endometrial cycle include the phase of regeneration (2–3 days after the end of menstruation), the phase of proliferation (5th–6th day to 14th day till ovulation), the secretory phase (15th day to menstruation) followed by the menstrual phase. The menstrual cycle is divided into three phases: menstrual or follicular, ovulatory and luteal. The pre-ovulatory phase is known as follicular phase (FP), and the post-ovulatory phase is known as luteal phase (LP). The oestrogen level is at its peak during the proliferative phase, high during ovulation; progesterone is high during the secretory phase, and the early LP and both oestrogen and progesterone are low due to withdrawal in the menstrual phase., Blood progesterone starts to increase on the 18th day, reaches a peak on the 21st day and starts to decrease on the 24th day of the menstrual cycle.
|Figure 1: Phases of the menstrual cycle and associated hormonal fluctuations. A – Oestrogen; B – Progesterone; O – Ovulation; M – Menstruation|
Click here to view
| Physiological Changes in the Menstrual Cycle of Interest to the Anaesthesiologist|| |
In healthy women, plasma norepinephrine levels and sympathetic activity have been found to be significantly higher in the LP than in the FP. Higher levels of heart rates and systolic blood pressure and lower diastolic pressure have been observed in the LP. During ovulation there is an oestrogen-induced increase in nitric oxide production which leads to an increase in the cardiac output and a decrease in systemic vascular resistance, systolic and diastolic blood pressure. Researchers have found a significant decrease in the arterial stiffness indices like reflection index, stiffness index and pulse wave velocity during the mid-cycle probably because of oestrogen. The haemodynamic response to physiological and psychological stress is elevated during the LP. The QTc interval might be influenced and may change with the phase of the menstrual cycle, and a prolonged QTc may predispose to cardiac arrhythmias. A prolongation of the QTc interval in the FP has been reported by some researchers.
Idiopathic or cyclic oedema characterised by excessive diurnal weight gain with peripheral oedema especially when the patient is in the upright position, headache and increased irritability can occur in obese women just before menstruation.
Some studies have found an exacerbation (21%–50%) of acute bronchial asthma during the pre-ovulatory (33%) and premenstrual phases.,, Seizures in women with epilepsy can increase in frequency perimenstrually. Several reports have documented fluctuations in the symptom severity of systemic diseases such as glaucoma, bipolar illness and allergies during menstruation.,,
Catamenial pneumothorax includes spontaneous and recurrent episodes of pneumothorax occurring within 72 h from the onset of menstruation. It accounts for 3%–6% of the causes of spontaneous pneumothorax in women. Catamenial haemothorax, too, can occur as a part of thoracic endometriosis.
Several researchers have found that the pulmonary function significantly improves in the luteal or secretory phase of the menstrual cycle, probably due to the bronchodilatory effect of progesterone. A significant increase in the cardiorespiratory efficiency has been found to occur in the LP in normal weight women. Skeletal muscle contractile characteristics and muscle strength do not change with different phases of the menstrual cycle.
The larynx is affected by fluctuations in the level of oestrogen and progesterone in the menstrual cycle. Swelling of the vocal folds due to water retention and engorgement of subepithelial capillaries leading to laryngeal oedema are seen in the FP and premenstrually leading to hoarseness of voice and a change in vocal tones. The increase in oestrogen and progesterone during ovulation produces thick and dry vocal folds which reduces the tonicity of the laryngeal muscles.,
Ovarian hormones can modulate the sleep-wake cycle. Disturbed sleep, a decrease in rapid eye movement (REM) sleep, increased microarousals per hour and a less percentage of slow wave (non-REM) sleep have been observed during the LP.,,
Nervous system and psychology
Soliz–Ortiz S et al. while investigating the neuropsychological performance of healthy women with regular menstrual cycles found that sustained attention showed an increase in the early LP while visuospatial memory was increased and verbal fluency was decreased during the ovulatory phase. Studies have found that diseases such as migraine, preexisting mental health disorders including anxiety, bipolar, psychotic and eating disorders exacerbate premenstrually. Premenstrual dysphoric disorder affects 6% of premenopausal women.
The changes in drug pharmacokinetics and dynamics, renal, coagulation, gastrointestinal, immune and haematological systems are variable and not very conclusive.
| Research Studies on the Influence of Various Menstrual Cycle Phases on Anaesthesia|| |
In most of the research studies that we analysed, women on the 20th–24th day after the first day of the last menstruation were considered to be in the LP and those on the 1st–12th day or 8th day –12th day after the 1st day of the last menstrual cycle were considered to be in the FP. The premenstrual phase was 7–8 days before menstruation or on the 25th and 26th day of the menstrual cycle. The menstrual phase was considered as the period between 1–7/8 days or 1-3 days from the beginning of menstrual bleeding; days 13–15 were considered as the ovulatory phase. The menstrual cycle ranged from 23 to 35 days in most of the studies. Patients with irregular menstrual cycles were excluded in most of the studies. Plasma oestrogen and progesterone levels were monitored in most of the studies. There were only limited studies on most of the topics except on pain and vomiting. Although we tried to select standard journal articles, the studies probably had design problems; nevertheless, most of the studies were conducted on only one menstrual cycle and the sample size was very small in some studies.
Oestradiol and progesterone have shown promising pro-nociceptive and antinociceptive actions, respectively. It has been suggested by some researchers that the fluctuations in sex hormones during the menstrual cycle can cause fluctuations in pain perception.
Several studies have been conducted on this topic.,,,,,,,,,,,,,,, The parameters tested included experimental pain sensitivity, cold pressor, heat and ischaemic pain perception, test pain intensity suppression, pain inhibition during conditional pain modulation, injection pain and post-operative pain scores [Table 1]. The results of these studies were variable and not very conclusive; nevertheless, many studies showed lowered pain perception in the FP and increased pain perception perimenstrually. We found only one study on local anaesthetic requirement which found that the injection discomfort and clinical effectiveness of local anaesthetics were not related to the phases of the menstrual cycle.
Anaesthesia-induced hypnosis, sedation and anaesthetic drug requirements
Only four studies have tried to directly study the influence of the phase of the menstrual cycle on anaesthetic requirement [Table 2].,,, Erden et al. found a decreased sevoflurane requirement in the LP compared to the FP. The minimum alveolar anaesthetic concentration (MAC)-hour value of sevoflurane was 1.55 ± 0.18 MAC-h in patients in the FP and was 1.3 ± 0.13 MAC-h in patients in the LP. Zhou et al. showed that in patients during the LP, pre-operative intravenous dexmedetomidine 1 μg/kg for 10 min followed by induction with propofol target controlled infusion could lead to a more significant sedative effect than in those during the FP, with or without dexmedetomidine. The propofol requirement was least and the duration of action was shortest with the use of pre-operative intravenous dexmedetomidine in women in the LP. Fu et al. found that the median effective effect concentration (EC50) of propofol to induce loss of consciousness during general anaesthesia was higher in the FP than in the LP. The propofol requirement in the LP group was 0.128 mg/kg/min whereas it was 0.148 mg/kg/min in the FP patients. The emergence time was longer in the follicular group than in the luteal group.
|Table 2: Details on studies on anaesthetic drug requirements in different menstrual phases|
Click here to view
In another study on dexmedetomidine sedation in surgical patients, the lowest bispectral index value in the LP was lower than that in the FP. Thus, the sedative effect of dexmedetomidine was more significant during the LP than during the FP. Hoshino et al. found in a study that the passive collapsibility of the upper airway was higher in the mid-LP than in the FP during propofol anaesthesia. The active collapsibility decreased more in the FP. The decreased sedative requirements in the LP in all the studies were attributed to the sedative effect of progesterone and its metabolites through action on the GABA receptor complex and a decrease in the oxidative metabolism of anaesthetic drugs in the LP. In all the studies, women of the American Society of Anaesthesiologists grade 1–2 with regular menstrual cycles and aged between 18 and 40 years were included. Women receiving hormones affecting ovulation/psychotropic drugs/steroids, breastfeeding women and women having pregnancy/obesity/renal impairment were excluded from the study. The studies had some unique parameters monitored along with some limitations [Table 2]. This subject of the accentuation of the hypnotic effects of different anaesthetic agents in the LP is an area which warrants serious research.
The haemodynamic response to laryngoscopy and tracheal intubation
A single study on this topic has demonstrated that the rate-pressure product at 1 min after tracheal intubation is significantly more in the LP than in the FP. There was a statistically significant higher blood pressure during the 1st min after intubation [Table 3]. Although there is an increased vulnerability to sedation in the LP, some studies have shown that there is an increased pain perception in the LP. Furthermore, there is an increased sympathetic activity in the LP. All this could account for the increase in the rate pressure product at intubation; nevertheless, we recommend further studies on this topic.
|Table 3: Studies on post-operative nausea and vomiting; perioperative blood loss and haemodynamic response|
Click here to view
Post-operative nausea and vomiting
A number of studies have been conducted on the effect of the menstrual cycle phase on PONV [Table 3].,,,,,,, Most studies have revealed that females subjected to general anaesthesia for surgery had more nausea and vomiting in the FP compared to the LP with the greatest risk during menstruation.,, In contrast, a few studies have found the highest incidence of PONV during the LP  and in the periovulatory and premenstrual periods, while a few studies have shown that no relationship exists between the menstrual phase and the incidence of emesis., No conclusions can thus be drawn. As mentioned in some studies, the increase or decrease in vomiting could have been due to the effect of the changing concentrations of follicle stimulating hormone and oestrogen on sensitising the chemoreceptor trigger zone or vomiting centre; nevertheless, whether an increased requirement of anaesthetic drugs in the concerned menstrual phase leads to an increased incidence of vomiting is not known because this aspect has not been investigated. Fu et al. did notice a decrease in post-operative nausea and vomiting along with a decrease in the hypnotic drug requirement in the LP, but they have attributed this to the changing levels of sex hormones in the cycle. We suggest that this topic is open for research.
Perioperative blood loss
Very few studies have addressed this topic.,,,, Surgery on hormonally sensitive female tissues such as the breast and uterus may produce more perioperative blood loss depending on the menstrual phase; however, there are conflicting results. Among studies on surgery in hormonally independent organs too, like the nose and abdomen, there are conflicting results [Table 3].
| Conclusion|| |
Based on the limited data available, the anaesthesiologist should keep in mind the possibility of the occurrence of unfavourable physiological and systemic events in the surgical patient in the premenstrual, menstrual, preovulatory and ovulatory phases. A decreased requirement of intravenous sedative and anaesthetic drug requirements and an improvement in pulmonary function in the LP are noteworthy findings. As regards the question of choosing a favourable phase (FP/LP) for anaesthesia and surgery, the evidence is currently scarce with mixed results suggesting a few favourable points and a few draw backs in both phases. We cannot really suggest any phase favourable for surgery and anaesthesia; nevertheless, we urge anaesthesiologists to conduct good quality research including randomised clinical trials on this very promising subject.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Maybin JA, Critchley HO. Menstrual physiology: Implications for endometrial pathology and beyond. Hum Reprod Update 2015;21:748-61.
Chakravorty BN. Menstruation. In: Konar H, editor. DC Dutta's Textbook of Gynaecology. 7th
ed. New Delhi: Jaypee the Health Sciences Publisher; 2016. p. 66-79.
Kashuba AD, Nafziger AN. Physiological changes during the menstrual cycle and their effects on the pharmacokinetics and pharmacodynamics of drugs. Clin Pharmacokinet 1998;34:203-18.
Solís-Ortiz S, Corsi-Cabrera M. Sustained attention is favored by progesterone during early luteal phase and visuo-spatial memory by estrogens during ovulatory phase in young women. Psychoneuroendocrinology 2008;33:989-98.
Hanci V, Yurtlu S, Hakimoglu S, Yilmaz M, Ayoglu H, Basaran M, et al.
Brief report: The effects of the menstrual cycle on the hemodynamic response to laryngoscopy and tracheal intubation. Anesth Analg 2010;111:362-5.
Nakagawa M, Ooie T, Takahashi N, Taniguchi Y, Anan F, Yonemochi H, et al.
Influence of menstrual cycle on QT interval dynamics. Pacing Clin Electrophysiol 2006;29:607-13.
Manhem K, Jern C, Pilhall M, Shanks G, Jern S. Haemodynamic responses to psychosocial stress during the menstrual cycle. Clin Sci (Lond) 1991;81:17-22.
Adamopoulos S, Leftheriotis D, Sbarouni E, Karavolias G, Kremastinos DT. Acute haemodynamic effects of oestrogen administration in male patients with chronic heart failure. Eur J Heart Fail 2002;4:719-26.
Madhura M, Sandhya TA. Effect of different phases of menstrual cycle on reflection index, stiffness index and pulse wave velocity in healthy subjects. J Clin Diagn Res 2014;8:BC01-4.
Sugishita K, Asakawa M, Usui S, Takahashi T. Cardiac symptoms related to paroxysmal atrial fibrillation varied with menstrual cycle in a premenopausal woman. Int Heart J 2013;54:107-10.
Rodriguez I, Kilborn MJ, Liu XK, Pezzullo JC, Woosley RL. Drug-induced QT prolongation in women during the menstrual cycle. JAMA 2001;285:1322-6.
Rebar RW. Disorders of menstruation, ovulation and sexual response. In: Becker KL, editor. Principles and Practice of Endocrinology and Metabolism. 3rd
ed. Philadelphia, USA: Lippincott Williams and Wilkins; 2001. p. 947-67.
Brenner BE, Holmes TM, Mazal B, Camargo CA Jr. Relation between phase of the menstrual cycle and asthma presentations in the emergency department. Thorax 2005;60:806-9.
Zimmerman JL, Woodruff PG, Clark S, Camargo CA. Relation between phase of menstrual cycle and emergency department visits for acute asthma. Am J Respir Crit Care Med 2000;162:512-5.
Agarwal AK, Shah A. Menstrual-linked asthma. J Asthma 1997;34:539-45.
Qureshi IA. Intraocular pressure: Association with menstrual cycle, pregnancy and menopause in apparently healthy women. Chin J Physiol 1995;38:229-34.
Kalogeromitros D, Katsarou A, Armenaka M, Rigopoulos D, Zapanti M, Stratigos I, et al.
Influence of the menstrual cycle on skin-prick test reactions to histamine, morphine and allergen. Clin Exp Allergy 1995;25:461-6.
Pinkerton JV, Guico-Pabia CJ, Taylor HS. Menstrual cycle-related exacerbation of disease. Am J Obstet Gynecol 2010;202:221-31.
Marjański T, Sowa K, Czapla A, Rzyman W. Catamenial pneumothorax – A review of the literature. Kardiochir Torakochirurgia Pol 2016;13:117-21.
Kaur H, Arora R, Maini S. Efect of different phases of menstrual cycle on pulmonary functions. Indian J Basic Appl Med Res 2015;5:266-9.
Samsudeen N, Rajagopalan A. Effect of different phases of menstrual cycle on cardio-respiratory efficiency in normal, overweight and obese female undergraduate students. J Clin Diagn Res 2016;10:CC01-4.
Janse de Jonge XA, Boot CR, Thom JM, Ruell PA, Thompson MW. The influence of menstrual cycle phase on skeletal muscle contractile characteristics in humans. J Physiol 2001;530:161-6.
Hari Kumar KV, Garg A, Ajai Chandra NS, Singh SP, Datta R. Voice and endocrinology. Indian J Endocrinol Metab 2016;20:590-4.
Prelevic GM. The effects of sex hormones on the female voice. Music Perform 2000;2:93-104.
Lamarche LJ, Driver HS, Wiebe S, Crawford L, DE Koninck JM. Nocturnal sleep, daytime sleepiness, and napping among women with significant emotional/behavioral premenstrual symptoms. J Sleep Res 2007;16:262-8.
Baker FC, Kahan TL, Trinder J, Colrain IM. Sleep quality and the sleep electroencephalogram in women with severe premenstrual syndrome. Sleep 2007;30:1283-91.
de Zambotti M, Willoughby AR, Sassoon SA, Colrain IM, Baker FC. Menstrual cycle-related variation in physiological sleep in women in the early menopausal transition. J Clin Endocrinol Metab 2015;100:2918-26.
Iacovides S, Avidon I, Baker FC. Does pain vary across the menstrual cycle? A review. Eur J Pain 2015;19:1389-405.
Sari S, Kozanhan B, Egilmez AI, Soyder A, Aydin ON, Galimberti F, et al.
The influence of the menstrual cycle on acute and persistent pain after laparoscopic cholecystectomy. Rev Bras Anestesiol 2018. pii: S0034-7094(17)30598-6.
Ozçaka O, Biçakçi N, Köse T. Effect of the menstrual cycle on pain experience associated with periodontal therapy: Randomized, pilot study. J Clin Periodontol 2005;32:1170-4.
Collins N, Crossley K, Vincenzino B. Anterior knee pain severity fluctuates over the female menstrual cycle. J Sci Med Sport 2010;13:e22. Available from: https://doi.org/10.1016/j.jsams. 2010.10.507
. [Last accessed on 2018 Feb 19].
Fatima N, Babu PR, Sisinty VS, Tarakji B. Pain perception and anxiety levels during menstrual cycle associated with periodontal therapy. Int J Dent 2014;2014:472926.
Ileri Z, Baka ZM, Akin M, Apiliogullari S, Basciftci FA. Effect of menstrual cycle on orthodontic pain perception: A controlled clinical trial. J Orofac Orthop 2016;77:168-75.
Stening K, Eriksson O, Wahren L, Berg G, Hammar M, Blomqvist A, et al.
Pain sensations to the cold pressor test in normally menstruating women: Comparison with men and relation to menstrual phase and serum sex steroid levels. Am J Physiol Regul Integr Comp Physiol 2007;293:R1711-6.
Viana Ede S, da Silva SB, de Sousa MB. Perception of ischemic and pressing pain in young women during menstrual cycle. Association with humor and cortisol levels. Acta Cir Bras 2005;20 Suppl 1:220-6.
Klatzkin RR, Mechlin B, Girdler SS. Menstrual cycle phase does not influence gender differences in experimental pain sensitivity. Eur J Pain 2010;14:77-82.
Rezaii T, Hirschberg AL, Carlström K, Ernberg M. The influence of menstrual phases on pain modulation in healthy women. J Pain 2012;13:646-55.
Ribeiro-Dasilva MC, Shinal RM, Glover T, Williams RS, Staud R, Riley JL 3rd
, et al.
Evaluation of menstrual cycle effects on morphine and pentazocine analgesia. Pain 2011;152:614-22.
Hanci V, Ayoǧlu H, Yilmaz M, Yurtlu S, Okyay RD, Erdoǧan G, et al.
Effect of menstrual cycle on the injection pain due to propofol. Eur J Anaesthesiol 2010;27:425-7.
Tófoli GR, Ramacciato JC, Volpato MC, Meechan JG, Ranali J, Groppo FC, et al.
Anesthetic efficacy and pain induced by dental anesthesia: The influence of gender and menstrual cycle. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e34-8.
Honca M, Purtuloglu T, Honca T, Sizlan A, Deniz S, Kose A, et al.
Effects of the menstrual cycle on injection pain due to rocuronium. J Clin Anesth 2013;25:399-402.
Ahmed A, Khan F, Ali M, Haqnawaz F, Hussain A, Azam SI, et al.
Effect of the menstrual cycle phase on post-operative pain perception and analgesic requirements. Acta Anaesthesiol Scand 2012;56:629-35.
Fu F, Chen X, Feng Y, Shen Y, Feng Z, Bein B, et al.
Propofol EC50 for inducing loss of consciousness is lower in the luteal phase of the menstrual cycle. Br J Anaesth 2014;112:506-13.
Arab M, Mirkheshti A, Noghabaei G, Ashori A, Ghasemi T, Hosseini-Zijoud SM, et al.
The effect of premenstrual syndrome and menstrual phase on postoperative pain. Anesth Pain Med 2015;5:e19333.
Lenzmeier B, Moore RL, Cordts P, Garrett N. Menstrual cycle-related variations in postoperative analgesia with the preemptive use of N-methyl D-aspartate antagonist ketamine: A pilot study. Dimens Crit Care Nurs 2008;27:271-6.
Erden V, Yangin Z, Erkalp K, Delatioǧlu H, Bahçeci F, Seyhan A, et al.
Increased progesterone production during the luteal phase of menstruation may decrease anesthetic requirement. Anesth Analg 2005;101:1007-11.
Zhou X, Wang T, Huang S. Effects of the menstrual cycle on bispectral index and anesthetic requirement in patients with preoperative intravenous dexmedetomidine following propofol induction. Int J Clin Exp Med 2014;7:5663-8.
Han C, Ge SJ, Huang SQ, Lu YJ, Li N. Influence of different menstrual phases on the bispectral index during dexmedetomidine sedation. Kaohsiung J Med Sci 2016;32:586-92.
Hoshino Y, Ayuse T, Kobayashi M, Kurata S, Kawai M, Schneider H, et al.
The effects of hormonal status on upper airway patency in normal female subjects during propofol anesthesia. J Clin Anesth 2011;23:527-33.
Panditrao AM, Panditrao MM. A prospective study to compare the incidence of post- operative nausea, vomiting (PONV) in female patients undergoing surgical procedures under general anaesthesia during proliferative and secretory phase of menstrual cycle. Int J Stud Res 2011;1:51-6. [Full text]
Beattie WS, Lindblad T, Buckley DN, Forrest JB. Menstruation increases the risk of nausea and vomiting after laparoscopy. A prospective randomized study. Anesthesiology 1993;78:272-6.
Šimurina T, Mraovic B, Skitarelić N, Andabaka T, Sonicki Z. Influence of the menstrual cycle on the incidence of nausea and vomiting after laparoscopic gynecological surgery: A pilot study. J Clin Anesth 2012;24:185-92.
Honkavaara P, Pyykkö I, Rutanen EM. Increased incidence of retching and vomiting during periovulatory phase after middle ear surgery. Can J Anaesth 1996;43:1108-14.
Bacić A, Rumboldt Z, Gluncić I, Buklijas J. The impact of the menstrual cycle and ondansetron on postoperative nausea and vomiting. Int J Clin Pharmacol Res 1998;18:153-8.
Matchock RL, Levine ME, Gianaros PJ, Stern RM. Susceptibility to nausea and motion sickness as a function of the menstrual cycle. Womens Health Issues 2008;18:328-35.
Ramsay TM, McDonald PF, Faragher EB. The menstrual cycle and nausea or vomiting after wisdom teeth extraction. Can J Anaesth 1994;41:798-801.
Gratz I, Allen E, Afshar M, Joslyn AF, Buxbaum J, Prilliman B, et al.
The effects of the menstrual cycle on the incidence of emesis and efficacy of ondansetron. Anesth Analg 1996;83:565-9.
Sariguney Y, Demirtas Y, Findikcioglu F, Ayhan S, Latifoglu O, Cenetoglu S, et al.
Proper timing of breast reduction during the menstrual cycle. Ann Plast Surg 2004;53:528-31.
Baron DA, Hardie T, Leventhal JL, Della Badia CR. Timing of hysterectomy surgery during the menstrual cycle – Impact of menstrual cycle phase on rate of complications: Preliminary study. J Am Osteopath Assoc 1999;99:25-7.
Findikcioglu K, Findikcioglu F, Sezgin B, Demirtas Y, Yavuzer R. The impact of the menstrual cycle on intra-operative and postoperative bleeding in abdominoplasty patients. J Plast Reconstr Aesthet Surg 2012;65:e338-43.
Lin Z, Moonasar N, Wu RH, Seemongal-Dass RR. The impact of the menstrual cycle on perioperative bleeding in vitreoretinal surgery. J Ophthalmol 2017;2017:9549284.
Findikcioglu K, Findikcioglu F, Demirtas Y, Yavuzer R, Ayhan S, Atabay K. Effect of the menstrual cycle on intraoperative bleeding in rhinoplasty patients. Eur J Plast Surg 2009;32:77-81.
[Table 1], [Table 2], [Table 3]