A range of herbal supplements -- from the popular St. John's wort and ginkgo biloba to garlic, ginger, ginseng and feverfew -- can cause increased bleeding during surgery, contends Dr. Philip Miller, a clinical assistant professor at New York University's School of Medicine who specializes in facial plastic and reconstructive surgery. So, he says, can vitamin E.

That's not only risky during the actual operation, he says, but can lead to complications later.

"Patients in the operating room are just oozing as if they're on aspirin," Miller says of a trend he's noticed in the past six to nine months. Surgeons routinely warn people away from aspirin before an operation, he says, because aspirin tends to keep blood from clotting.

But people are taking herbal supplements unbeknownst to their doctors, Miller says.

"They swear they didn't take anything, and I trust my patients," he says. But after further checking, he says, "I've been able to elicit a history of herbal use that they've not disclosed to their physicians."

About 70 percent of people slated for surgery don't disclose herbal use, says Miller, citing a recent survey. Herbs generally aren't prescribed by a doctor, and people just don't consider them a medication, he says.

But herbs and vitamins do affect the inner workings of the body -- and not always in a positive way when it comes to surgery, Miller says.

Ginkgo biloba -- which people take to improve their memory -- "can cause spontaneous bleeding," he says, "and interferes with the process by which the body causes blood clots." It's also been blamed for post-operative bleeding.

"Underneath the skin, [it] can ooze itself into the tissue, much like mud or water might invade itself into a rug if you have a flood, ultimately causing a diffused discoloration," he says, referring to the black-and-blue of bruising.

Some bruising, he says, is part of the process. "But after having performed enough surgeries, there's a certain level you expect and anticipate and, beyond that, you go, 'Hmm, that seems a little strange,' " Miller says.

"I'm the same doctor, doing the same operations, but you guys [the patients] are the difference," he says.

A growing number of people now take herbal supplements of one kind or another. One medical group estimates that Americans will spend about $5 billion this year on herbal products they believe will help them treat depression, raise their energy level, improve their memory or otherwise improve their well-being. A survey last summer showed that nearly a quarter of all Americans regularly take some herbal supplement.

But anyone going in for surgery should stop risky medications -- including herbs -- at least two weeks before their operation, Miller says. Herbal advocates generally agree with that.

"It's a good idea to stop taking all medication, including herbal supplements, before surgery," says Mindy Green, director of education for the Herb Research Foundation, a nonprofit educational library located in Boulder, Colo.

Even some foods, she says, interact with medications and can affect bleeding.

"But surgeons should know that if they're doing surgery, they should do some kind of test for bleeding time before the surgery," Green says. "The surgeon is blaming [the problem] on herbs, and the patient is not relaying [important details], either out of ignorance or fear. But surgeons should ask specifically about dietary supplements."

But even when they do, Miller says, sometimes things sneak through.

"Some of these supplements [like ginseng] are finding themselves into iced teas, herbal energy drinks, herbal teas," he says. Because of this, people can be honest with their doctors and say they're not taking anything, yet still be at risk, Miller says.

And it's not just people scheduled for surgery who need to worry, he says.

Anyone who's having nosebleeds might want to check their herb use, Miller says, as should anyone at risk for a stroke and anyone who must take the blood-thinning drug Coumadin.

One of the first times Miller noticed the herb-bleeding link, he says, was when a man on whom he did a facelift developed "a collection of blood."

"He swore he didn't take anything," Miller says, "but on further investigation, [we learned] he'd taken diet pills with ephedrine in them."

Ephedrine comes from the herb ephedra, also called ma huang, which has been implicated in heart attacks and strokes. It also causes the blood pressure to rise, Miller says, and that can cause bleeding during an operation.

St. John's wort can cause that same effect, he says. An estimated 7.5 million Americans take this supplement to ease anxiety, mild depression and sleep disorders.

The problem with vitamin E, on the other hand, appears to be more like that with aspirin, Miller says. Many people take a vitamin E supplement regularly because they believe it helps prevent heart disease.

But people who "mega-dose" on vitamin E, which Miller says can happen simply by taking a 400-unit pill regularly, can "get sort of an acquired clotting disorder, which results in excessive bleeding [and] interferes with platelets sticking to one another and forming the clot." Platelets are fragments of blood cells that help the blood clot, or form a scab.

Miller isn't alone in his observations. The American Society of Anesthesiologists also wants people to stop taking herbal supplements at least two weeks before surgery, saying that just because something is considered "natural," it's not automatically "safe." A survey the group did of people awaiting surgery reveals that 22 percent had used herbal remedies of some sort and 51 percent had taken vitamins.

And earlier this month, doctors attending an Atlanta conference of the American College of Physicians and American Society of Internal Medicine were advised of the need to be more aware of the interactions between vitamins, herbs and traditional prescribed medications because more and more of their patients are turning to alternative therapies.

The blood-thinning effect of some herbs, in fact, "is very useful in many cases, but not if you're going under the knife," Green says. "That's very often how and why they're used."

"That doesn't mean any of these things are bad," she says.

But for people anticipating cosmetic surgery, Miller says, the results can be particularly upsetting.

"They're undergoing a purely 100 percent elective procedure, and right or wrong they have an expectation to be back out in public … and back to work … as soon as possible," he says. "Significant bruising can really impair their recovery."

Physicians have to start asking -- specifically -- about vitamin and herbal supplement use in their pre-operative evaluations, Miller says.

"If you have more bleeding than normal [during an operation], you'll spend a fair amount of time stopping that bleeding, and visualization can be impaired, too," Miller says. "Never mind just the short-term influence on the post-operative course, but this [bleeding] can interfere with the entire result, based on your inability to perform the surgery to the best it can be done."

What To Do

Anyone scheduled for surgery, medical experts agree, should stop taking herbal supplements two weeks before an operation. They also should avoid aspirin. And perhaps equally important, they should fully disclose to their doctor everything they take, prescribed or not.

For people anticipating cosmetic surgery, Miller also recommends that they stop smoking, because it, too, can contribute to excessive bleeding during surgery, and that they stay out of the sun because burned skin must heal before it can be operated on.

He also suggests that his patients do try one particular herbal preparation -- arnica, sold as SinEcch -- after surgery to help reduce bruising and swelling.

To find out more about herbal health products, the risks and benefits, visit the American Academy of Family Physicians or the American Botanical Council online. To learn more about specific herbs and vitamins, go to the Herbal Information Center or the Herb Research Foundation.

If you're contemplating surgery, check out information on what you should find out from your doctor, provided by the Agency for HealthCare Research and Quality and on what to expect, provided by the Food and Drug Administration.

Reference Source 101