Tranexamic Acid Dosing for Heavy Menstrual Bleeding
For heavy menstrual bleeding, administer tranexamic acid 3.9 grams daily (typically divided into 2-3 doses) for up to 5 days during menstruation, starting on the first day of bleeding. 1, 2
Standard Dosing Regimen
The recommended oral dose is 3.9-4 grams per day, divided into multiple doses (typically 1.3 grams three times daily or 650 mg four times daily), taken for 4-5 days starting from the first day of menstruation. 1, 2, 3
This dosing regimen reduces menstrual blood loss by 26-60% compared to baseline and is significantly more effective than placebo, NSAIDs, or oral progestins. 2, 3
A dose-response study specifically demonstrated that the 3.9 g/day dose met all three primary efficacy endpoints (mean reduction in menstrual blood loss, meaningful reduction as judged by patients, and >50 mL reduction from baseline), while the lower 1.95 g/day dose was less effective. 4
Alternative Dosing for Specific Situations
For women with von Willebrand disease or severe refractory menorrhagia, higher doses up to 3 grams daily in four divided doses for the first 5 days may be necessary when standard dosing fails. 5
The standard 1 gram daily dose is insufficient for most patients with heavy menstrual bleeding and should not be used. 5
Duration and Timing
Treatment should be limited to 5 days maximum during each menstrual cycle, starting on the first day of bleeding. 1, 2, 4
The medication should be taken only during days of active bleeding, not throughout the entire menstrual cycle. 2, 3
Safety Considerations and Contraindications
Active thromboembolic disease is an absolute contraindication; in the United States, a history of thrombosis/thromboembolism or intrinsic risk for thrombosis is also considered a contraindication. 1, 2
Use with extreme caution in women taking oral contraceptives due to increased thrombotic risk—consider alternative therapy or discontinue one agent. 6, 7
Dose adjustment is required in renal dysfunction based on serum creatinine levels. 6, 7
Discontinue 5 days before high bleeding risk procedures or surgery in confined spaces. 6, 7
Clinical Efficacy Context
Tranexamic acid is more effective than NSAIDs (mefenamic acid, flurbiprofen), etamsylate, and oral luteal phase progestins for reducing menstrual blood loss. 2, 3
The levonorgestrel-releasing intrauterine system (LNG-IUS) produces greater reduction in menstrual blood loss (96% after 12 months) compared to tranexamic acid, though 44% of LNG-IUS users develop amenorrhea which may be unacceptable to some patients. 3
Combined oral contraceptives show comparable efficacy to tranexamic acid for heavy menstrual bleeding, with no statistically significant difference in mean blood loss reduction. 8
Adverse Effects
The most common adverse effects are gastrointestinal (nausea, vomiting, diarrhea, dyspepsia), occurring in approximately 12% of patients, which is not significantly different from placebo rates. 3
No evidence exists of increased incidence of thrombotic events with appropriate use in patients without contraindications. 2
Both the 3.9 g/day and 1.95 g/day doses were well tolerated with no serious study-related adverse events reported in clinical trials. 4