What is the maximum dose of tranexamic acid (TXA) for perimenopausal abnormal uterine bleeding (AUB)?

Maximum Dose of Tranexamic Acid for Perimenopausal AUB

For perimenopausal abnormal uterine bleeding, the maximum daily dose of tranexamic acid is 3-4 grams per day, divided into 2-3 doses, taken only during menstruation for 4-5 days. 1, 2

Recommended Dosing Regimen

The standard therapeutic approach for perimenopausal AUB involves:

• Total daily dose: 3-4 grams maximum 1, 2
• Divided dosing: 2-3 times daily (typically 1-1.5 grams per dose) 1, 2
• Duration: 4-5 days starting from the first day of menstruation 2, 3
• Weight-based alternative: 30-50 mg/kg/day in divided doses, not exceeding 3-4 grams daily 1

For older perimenopausal women (>12 years from menarche), a practical regimen is 500 mg twice daily, gradually increasing up to 1000 mg 3-4 times daily as needed, staying within the 4-gram maximum 1.

Clinical Efficacy

Tranexamic acid at these doses reduces menstrual blood loss by 34-59% over 2-3 cycles in women with idiopathic menorrhagia 2. In perimenopausal populations specifically, oral tranexamic acid demonstrates a 65.9% response rate when used at 500 mg three times daily during menses 4.

Critical Safety Considerations

Absolute contraindications include:

• Active thromboembolic disease (recent thrombosis) 1
• Known hypersensitivity to tranexamic acid 5

Relative contraindications include:

• Atrial fibrillation 1
• Known thrombophilia 1
• History of seizures (use with caution) 5

Dose Adjustments

Renal impairment requires dose reduction since tranexamic acid is primarily eliminated through renal clearance 5, 1. For patients with chronic or acute renal failure, consider reducing the total daily dose below the 3-4 gram maximum 5.

Common Pitfall to Avoid

The most important error is exceeding the 3-4 gram daily maximum, particularly in cardiac surgery where doses up to 100 mg/kg have been associated with neurotoxicity and seizures 6, 7. For menorrhagia management, there is no evidence supporting higher doses, and the risk-benefit ratio favors staying within established limits 2, 3.

Do not prescribe tranexamic acid for continuous daily use—it should only be taken during active menstruation (typically 4-5 days per cycle), not throughout the entire month 2, 3. This cyclical approach maximizes efficacy while minimizing cumulative exposure and potential adverse effects.

The gastrointestinal side effects (nausea, vomiting, diarrhea, dyspepsia) occur in approximately 12% of patients at standard doses and are generally mild 2.