Contraindications to Tranexamic Acid (TXA) in Menorrhagia
The primary contraindication to tranexamic acid in menorrhagia is a known thromboembolic event during pregnancy or history of thrombosis, as TXA's antifibrinolytic properties may increase thrombosis risk in susceptible individuals. 1
Major Contraindications
Known thromboembolic disease or history of thrombosis - TXA should be avoided in women with active thromboembolic disease or with a history or intrinsic risk for thrombosis or thromboembolism 1, 2
Beyond 3 hours after onset of bleeding in acute settings - While this applies more to postpartum hemorrhage than menorrhagia, TXA administration beyond 3 hours after onset of acute bleeding may be potentially harmful 1
Thrombotic Risk Considerations
Increased risk of thrombotic events - Evidence suggests women taking TXA for menorrhagia may have a 3-fold higher risk of developing deep vein thrombosis, though confidence intervals were wide (0.7 to 15.8) 2
Documented increased rates of thrombosis with high-dose TXA - High-dose IV TXA (4g/24h or greater) has been associated with increased rates of:
Clinical Application in Menorrhagia
Benefit-risk assessment - The harm-benefit balance of TXA differs between severe and minor bleeding. For non-life-threatening conditions like menorrhagia, the expected benefits are smaller, and the risk of thromboembolism may be higher without the hemodilution associated with severe bleeding 2
Effective dosing - Standard dosing for menorrhagia is typically 2-4.5 g/day for 4-7 days during menstruation, which has been shown to reduce menstrual blood loss by 34-59% 3, 4
Monitoring considerations - Though no specific monitoring protocol is universally established, clinicians should remain vigilant for signs and symptoms of thrombosis in patients using TXA for menorrhagia 2
Special Populations
Patients with intrauterine devices (IUDs) - TXA has been shown to significantly reduce menstrual blood loss in women with IUD-associated menorrhagia compared with other treatments 3
Patients with von Willebrand disease - Higher doses of TXA (3g daily in divided doses) may be effective for menorrhagia in patients with von Willebrand disease, but require careful monitoring for thrombotic complications 5
Common Side Effects (Not Contraindications)
Gastrointestinal effects - The most commonly reported drug-related adverse events are gastrointestinal, including nausea, vomiting, diarrhea, and dyspepsia (approximately 12% incidence) 3
Seizures - An increased rate of seizures has been reported with high-dose TXA use 1
Clinical Decision-Making
When considering TXA for menorrhagia, physicians should:
- Screen for history of thromboembolism or risk factors for thrombosis
- Consider alternative treatments in high-risk patients
- Use the lowest effective dose (typically 1.5g three times daily for 5 days during menstruation) 3
- Monitor for signs of thrombotic complications during treatment
While TXA is generally effective and well-tolerated for menorrhagia, the potential thrombotic risk must be carefully weighed against benefits, particularly in patients with pre-existing risk factors for thrombosis 2, 4.