Cautions for Using Tranexamic Acid (TXA) in Idiopathic Menorrhagia
Tranexamic acid should be used with caution in patients with idiopathic menorrhagia who are taking oral contraceptive pills due to increased thrombotic risk, and is contraindicated in patients with disseminated intravascular coagulation, active thromboembolic disease, or history of thrombosis. 1, 2
Key Contraindications and Cautions
Thromboembolic risk: TXA should not be used in patients with active thromboembolic disease, history of thrombosis, or intrinsic risk for thrombosis 2
Combined hormonal contraceptives: Patients using hormonal contraception should use effective alternative (non-hormonal) contraception during TXA therapy due to potentially increased risk of thromboembolic events 2, 3
Disseminated intravascular coagulation (DIC): TXA is contraindicated in DIC as it may worsen the condition 1
Massive hematuria: Use with caution due to risk of ureteric obstruction 1
Renal dysfunction: Reduced doses are recommended as renal clearance is the major mechanism of excretion; higher risk of neurotoxicity and ocular toxicity in renal impairment 1
Timing and Administration Considerations
Dosing schedule: The recommended oral dosage for menorrhagia is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 4
Duration of therapy: TXA should be limited to the days of heavy bleeding, typically the first 3-5 days of the menstrual cycle 4, 5
Discontinuation before surgery: If surgery is planned, consider discontinuing TXA 5 days before procedures with high bleeding risk or surgery in confined spaces (brain, posterior chamber of eye, medullary canal) 1
Monitoring and Adverse Effects
Seizure risk: TXA may cause seizures, particularly at high doses; patients should be monitored for any signs or symptoms suggestive of seizures 2
Visual disturbances: Patients should report any eye symptoms or changes in vision and follow up with an ophthalmologist if needed 2
Hypersensitivity reactions: Monitor for signs of hypersensitivity, which can occur with TXA administration 2
Dizziness: Patients should be cautioned about driving, operating machinery, or performing hazardous tasks while taking TXA 2
Gastrointestinal effects: The most commonly reported adverse events are gastrointestinal in nature, including nausea, vomiting, diarrhea, and dyspepsia 6
Efficacy Considerations
Reduction in blood loss: TXA reduces menstrual blood loss by 26%-60% in women with idiopathic menorrhagia 4, 7
Quality of life improvement: TXA significantly improves quality of life parameters by 46-83% in women treated for heavy menstrual bleeding 7
Lower-dose option: Some evidence suggests that a lower dose of 2 g/day may still be effective in reducing blood loss (60.3% reduction) 5
Special Considerations
Recurrence after discontinuation: Be aware that menorrhagia may recur after stopping treatment; studies show recurrence rates of approximately 66.7% three months after discontinuation 5
Alternative treatments: Consider that the levonorgestrel-releasing intrauterine system reduces menstrual blood loss more than TXA, but may cause amenorrhea in some patients 4, 6
Benefit-risk assessment: The benefit-risk balance is more favorable in severe bleeding conditions than in minor bleeding, where the thrombotic risk may be proportionally higher 3