What is the treatment for heavy menstrual bleeding with Lysteda (tranexamic acid)?

Treatment of Heavy Menstrual Bleeding with Lysteda (Tranexamic Acid)

Lysteda (tranexamic acid) is dosed at 1,300 mg (two 650 mg tablets) orally three times daily for a maximum of 5 days during menstruation, reducing menstrual blood loss by 26-60%. 1

Dosing Regimen

• The FDA-approved dose is 3.9 g/day (1,300 mg three times daily) taken only during days of active menstrual bleeding, for up to 5 consecutive days per cycle 1, 2
• Treatment begins on the first day of menstrual bleeding and is discontinued after 5 days or when bleeding stops, whichever comes first 2, 3
• The 3.9 g/day dose met all three primary efficacy endpoints in clinical trials, while the lower 1.95 g/day dose was less effective 1
• Dosage adjustments are required for women with renal insufficiency 2

Efficacy Outcomes

• Tranexamic acid reduces menstrual blood loss by 26-60% compared to baseline 4, 5
• It is significantly more effective than placebo, NSAIDs, oral cyclical progestins, and etamsylate for reducing menstrual blood loss 4
• The levonorgestrel-releasing intrauterine device (LNG-IUD) is more effective than tranexamic acid, reducing blood loss by 71-95% 6, 7
• Tranexamic acid significantly improves quality of life by reducing limitations on physical, social, and leisure activities 5, 3

Critical Contraindications

Tranexamic acid is absolutely contraindicated in women with active thromboembolic disease, history of thrombosis or thromboembolism, or intrinsic risk for thrombosis 8, 7, 4

• The FDA specifically warns against use in women with cardiovascular disease due to association with myocardial infarction and thrombosis 8, 7
• Screen all patients for personal or family history of thrombotic events before prescribing 7
• Avoid in women with SCAD (spontaneous coronary artery dissection) or other cardiovascular conditions 8

Treatment Algorithm Position

Tranexamic acid serves as a second-line, non-hormonal alternative for heavy menstrual bleeding when first-line options are inappropriate 6, 7:

First-Line Options:

• NSAIDs (naproxen, mefenamic acid) for 5-7 days during menstruation for women seeking short-term symptom management 6, 7
• LNG-IUD for women desiring long-term solution or contraception 6, 7

Second-Line Options:

• Tranexamic acid for women who cannot use hormonal therapy or NSAIDs, or who desire immediate pregnancy 4, 5
• Combined hormonal contraceptives when hormonal options are appropriate 6
• Cyclic oral progestins (reduce bleeding by 87% but cause irregular patterns) 6

Essential Pre-Treatment Assessment

Before initiating tranexamic acid, perform the following evaluations 7:

• Rule out pregnancy in all reproductive-age women 8, 7
• Assess for structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy 7
• Screen for coagulopathies, as up to 20% of women with heavy menstrual bleeding have underlying inherited bleeding disorders 6, 7
• Evaluate cardiovascular risk factors and thrombotic history 7
• Assess for hemodynamic instability (bleeding saturating large pad hourly for ≥4 hours warrants urgent evaluation) 8

Safety Profile

• Adverse effects are mild to moderate, most commonly menstrual discomfort, headache, and back pain 2
• No evidence exists of increased thrombotic events in women without pre-existing risk factors 4
• Treatment is well-tolerated with no significant differences in adverse events compared to placebo 1
• No serious study-related adverse events occurred in clinical trials 1

Clinical Pearls

• Enhanced counseling about expected bleeding patterns improves treatment adherence and reduces discontinuation 8, 7
• Tranexamic acid is particularly useful for women desiring immediate pregnancy or for whom hormonal treatment is inappropriate 5
• The medication is cost-effective and addresses the excessive fibrinolysis implicated in many cases of heavy menstrual bleeding 5, 3
• Treatment is administered only during menstruation, not continuously throughout the cycle 2, 3