What are the indications for oral Tranexamic Acid (TXA) in the treatment of menorrhagia?

Indications for Oral Tranexamic Acid in Menorrhagia

Oral tranexamic acid is indicated as a first-line treatment for idiopathic menorrhagia, reducing menstrual blood loss by 34-59% compared to placebo and other non-hormonal treatments. 1

Primary Indication

• Tranexamic acid is effective for the treatment of heavy menstrual bleeding (HMB), with demonstrated reduction in menstrual blood loss by 26-60% compared to placebo 2
• It is more effective than NSAIDs, oral cyclical luteal phase progestins, and etamsylate for managing menorrhagia 1
• The recommended oral dosage is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 2

Clinical Effectiveness

• In clinical studies, tranexamic acid at doses of 2-4.5 g/day for 4-7 days reduced menstrual blood loss significantly more than placebo, mefenamic acid, flurbiprofen, etamsylate and oral luteal phase norethisterone 1
• Even at lower doses (2 g/day), tranexamic acid has shown a mean reduction of blood loss by 60.3% after 3 months of treatment 3
• Quality of life improvements have been documented, with 81% of women reporting satisfaction with tranexamic acid treatment and 94% reporting decreased menstrual blood loss 1

Treatment Algorithm for Menorrhagia

1. First-line treatment options:

   • Oral tranexamic acid (3.9-4 g/day for 4-5 days) 2
   • NSAIDs (though less effective than tranexamic acid) 1

2. Second-line treatment options (if first-line fails):

   • Hormonal treatments (oral contraceptives, progestins) 1
   • Levonorgestrel-releasing intrauterine system (more effective than tranexamic acid but with higher rates of amenorrhea) 1

3. Third-line treatment options:

   • Surgical interventions (endometrial ablation, hysterectomy) 2

Safety Considerations

• The most common adverse events are gastrointestinal in nature (nausea, vomiting, diarrhea, dyspepsia) 1
• Active thromboembolic disease is a contraindication to tranexamic acid use 2
• In the US, a history of thrombosis or thromboembolism, or an intrinsic risk for thrombosis are considered contraindications 2
• The risk of thrombosis with tranexamic acid remains poorly documented for non-severe bleeding conditions 4
• In a case-control study, women taking tranexamic acid had a potentially higher risk of developing deep vein thrombosis (though with wide confidence intervals) 4

Clinical Pearls and Caveats

• Tranexamic acid may be considered as a first-line treatment for the initial management of idiopathic menorrhagia, especially for patients in whom hormonal treatment is either not recommended or not wanted 1
• The harm-benefit balance is favorable in serious bleeding conditions but should be carefully considered in minor bleeding since the expected benefits are smaller and the risk of thromboembolism may be higher 4
• When comparing treatment options, note that while levonorgestrel-releasing intrauterine systems reduce menstrual blood loss more than tranexamic acid (96% vs 34-59%), they also cause amenorrhea in 44% of patients, which may be unacceptable to some women 1
• Tranexamic acid has been shown to reduce the need for hysterectomy compared to some other treatments (4% vs 17.8% with medroxyprogesterone acetate) 3