Is sclerotherapy (injection of a solution, such as sodium tetradecyl sulfate or polidocanol, into a vein) safe to perform during menstruation?

Sclerotherapy During Menstruation

Sclerotherapy can be safely performed during menstruation and should not be withheld or delayed based solely on menstrual status. 1

Evidence-Based Recommendation

• Active menstruation is not a contraindication to sclerotherapy with sodium tetradecyl sulfate or polidocanol. 1 A review of the limited literature on thrombolytic therapy (which carries higher bleeding risk than sclerotherapy) concluded that intravenous alteplase can be administered relatively safely in menstruating women, and the same principle applies to sclerotherapy. 1

• Patients may experience increased menstrual flow during the procedure day, but this rarely requires intervention. 1 Women with a history of dysfunctional uterine bleeding or those treated on the first day of menses may have slightly higher rates of increased flow. 1

Clinical Considerations

When to Proceed Without Concern

• Standard sclerotherapy for varicose veins, telangiectasias, and tributary veins can proceed as scheduled during menstruation. 1 The sclerosants (sodium tetradecyl sulfate and polidocanol) work through local endothelial damage and do not significantly affect systemic coagulation. 1, 2, 3

• Foam sclerotherapy techniques, including Varithena (polidocanol), are safe during menstruation. 1, 4 These procedures have occlusion rates of 72-89% at 1 year regardless of menstrual timing. 1, 4

Situations Requiring Caution

• Women with known bleeding disorders or those on anticoagulation require standard pre-procedure assessment regardless of menstrual status. 1 The menstruation itself is not the concern—the underlying coagulopathy is. 1

• Patients with severe menorrhagia (soaking through a large pad hourly for ≥4 hours) should have their procedure rescheduled until bleeding normalizes. 1 This represents abnormal uterine bleeding requiring separate evaluation, not normal menstruation. 1

Practical Algorithm

Day of Procedure Assessment:

1. Ask about current menstrual flow intensity 1

   • Light to moderate flow → Proceed with sclerotherapy 1
   • Heavy flow (normal for patient) → Proceed with sclerotherapy 1
   • Abnormally heavy flow (saturating pad hourly) → Defer procedure and evaluate for bleeding disorder 1

2. Document baseline hemoglobin if patient reports heavy menses 1

   • This is for medicolegal documentation, not a contraindication to proceeding 1

3. Counsel patient about potential increased flow 1

   • Increased menstrual bleeding may occur but is typically self-limited 1
   • Transfusion is exceedingly rare 1

Common Pitfalls to Avoid

• Do not routinely delay sclerotherapy appointments due to menstruation. 1 This causes unnecessary treatment delays and has no evidence-based justification. 1

• Do not confuse normal menstruation with "active bleeding" as listed in contraindications. 1 The contraindication refers to active gastrointestinal bleeding, hematuria, or other pathologic bleeding—not physiologic menses. 1

• Do not order unnecessary coagulation studies in menstruating women without other risk factors. 1 Standard pre-procedure assessment is sufficient. 1

Special Populations

Pregnancy Considerations (Not Menstruation)

• Pregnancy is an absolute contraindication to sclerotherapy. 5 All reproductive-age women should have pregnancy excluded before sclerotherapy, regardless of menstrual history. 5

• If sclerotherapy was inadvertently performed during undetected early pregnancy, current evidence shows no increased risk to mother or fetus, and pregnancy termination is not indicated. 5 However, sclerotherapy should be avoided once pregnancy is known. 5

Hormonal Considerations

• Women on oral contraceptives or hormonal therapy can undergo sclerotherapy during withdrawal bleeding. 1 The phase of menstrual cycle may affect vascular function minimally, but this does not impact sclerotherapy safety or efficacy. 1