Can a patient with prolonged menstrual bleeding use tranexamic acid (TXA)?

Tranexamic Acid for Prolonged Menstrual Bleeding

Yes, tranexamic acid is an effective and safe first-line treatment for prolonged menstrual bleeding, reducing menstrual blood loss by 26-60% when taken at 3.9-4 g/day for 4-5 days starting from the first day of menstruation. 1, 2

Efficacy and Dosing

• Tranexamic acid significantly reduces menstrual blood loss by 26-60% and is more effective than placebo, NSAIDs, oral cyclical progestins, or etamsylate for heavy menstrual bleeding 1
• The recommended dosing is 3.9-4 g/day (typically 1.3 g three times daily) for 4-5 days starting from the first day of the menstrual cycle 1
• Treatment should be taken only during menstruation, not continuously throughout the month 3
• Response rate is approximately 66% in patients with dysfunctional perimenopausal bleeding, with median bleeding time reducing from 9 days to 5 days after three cycles 4
• Tranexamic acid significantly improves quality of life by reducing limitations on physical, social, and leisure activities 1, 3

Absolute Contraindications - Screen Before Prescribing

Before initiating tranexamic acid, you must screen for these absolute contraindications: 5

• Active thromboembolic disease (current DVT, PE, or arterial thrombosis) 1, 5
• History of thrombosis or thromboembolism (FDA contraindication in the US) 6, 5, 1
• Intrinsic risk for thrombosis or thromboembolism 6, 5
• Disseminated intravascular coagulation (DIC) - tranexamic acid may worsen DIC by inhibiting breakdown of widespread clots 5, 7
• Spontaneous coronary artery dissection (SCAD) - the American Heart Association recommends avoiding tranexamic acid due to association with myocardial infarction and thrombosis 5

Special Precautions and Dose Adjustments

Renal impairment requires mandatory dose reduction because tranexamic acid is primarily renally excreted, with higher risk of neurotoxicity and ocular toxicity in renal dysfunction 5

• Assess renal function before initiating therapy and adjust dosing accordingly 5
• Use with caution in patients with massive hematuria due to risk of ureteric obstruction from clot formation 5
• Discontinue 5 days before elective surgery with high bleeding risk or procedures in confined spaces (brain, posterior chamber of eye, medullary canal) 5
• Use with caution when combined with oral contraceptive pills due to increased thrombotic risk 5

Safety Profile - Reassuring Evidence

Despite theoretical thrombotic concerns, large-scale evidence demonstrates tranexamic acid is safe:

• A 2025 meta-analysis of 216 trials (125,550 participants) found no evidence of increased thromboembolic complications 8
• In 20,211 trauma patients, tranexamic acid showed a lower rate of thrombosis, especially myocardial infarction, compared to placebo 8
• Adverse effects are few and mainly mild, most commonly menstrual discomfort, headache, and back pain 9, 1
• No evidence exists of increased incidence of thrombotic events in women treated for heavy menstrual bleeding in the absence of contraindications 1

Comparative Effectiveness

• The levonorgestrel-releasing intrauterine system (LNG-IUS) reduces menstrual blood loss more than tranexamic acid (71-95% reduction), making it the most effective option if acceptable to the patient 5, 1
• Tranexamic acid is particularly useful in women who desire immediate pregnancy or for whom hormonal treatment is inappropriate 2
• It provides a nonhormonal alternative that addresses the excessive fibrinolysis implicated in many cases of heavy menstrual bleeding 3

Clinical Algorithm for Use

1. Screen for absolute contraindications (active thrombosis, history of thromboembolism, DIC, SCAD) 5
2. Assess renal function and adjust dose if impaired 5
3. Prescribe 3.9-4 g/day for 4-5 days starting from first day of menstruation 1
4. Reassess after 3 cycles - if unresponsive (34% of patients), consider alternative treatments such as LNG-IUS or hormonal therapy 4, 5
5. Monitor hemoglobin levels and supplement with iron if Hb <10 g/dL 4