Is tranexamic acid (TXA) effective for treating heavy menstrual bleeding during periods?

Tranexamic Acid for Heavy Menstrual Bleeding

Tranexamic acid is highly effective for treating heavy menstrual bleeding, reducing menstrual blood loss by 34-60% and significantly improving quality of life, making it a first-line treatment option especially when hormonal therapy is contraindicated or unwanted. 1, 2, 3

Efficacy and Clinical Evidence

Tranexamic acid demonstrates superior efficacy compared to other non-hormonal options:

• Reduces menstrual blood loss by 34-60% compared to baseline, which is significantly more effective than placebo, NSAIDs (mefenamic acid, flurbiprofen), oral luteal phase progestins, or etamsylate 2, 3, 4

• Improves quality of life parameters by 46-83% in women with idiopathic menorrhagia, with 81-94% of patients reporting satisfaction and decreased bleeding 3, 4

• The CDC specifically recommends tranexamic acid as a first-line treatment for idiopathic menorrhagia, particularly when hormonal treatment is not recommended or desired, noting its superior efficacy compared to NSAIDs for heavy bleeding 1

• For women with IUD-associated heavy bleeding, tranexamic acid decreases blood loss by 70% compared to placebo 5, 4

Dosing and Administration

Standard dosing is 3.9-4 grams per day for 4-5 days starting from the first day of menstruation 2, 3:

• Typically administered as 1.3 grams three times daily or 1 gram four times daily 3
• Treatment is limited to days of active bleeding only, not continuous throughout the cycle 2
• Modified-release formulations are available and can be taken for up to 5 days per cycle 6

Safety Profile and Contraindications

Absolute contraindications include active thromboembolic disease, history of thrombosis or thromboembolism, and intrinsic risk for thrombosis or thromboembolism 1, 7:

• The FDA specifically warns against use in women with these thrombotic risk factors 5, 1
• Despite theoretical concerns, no evidence exists of increased thrombotic events in clinical trials for menorrhagia treatment 2, 3, 4
• Most adverse effects are mild and gastrointestinal (nausea, vomiting, diarrhea, dyspepsia), occurring in approximately 12% of patients 3
• Other common side effects include menstrual discomfort, headache, and back pain 6

Important Clinical Context

Tranexamic acid should generally be avoided in women with cardiovascular disease, specifically those with spontaneous coronary artery dissection (SCAD), given the association with MI and thrombosis risk 5:

• In SCAD patients on antiplatelet therapy who develop heavy menstrual bleeding, levonorgestrel-releasing IUDs (20 μg/day) are preferred, reducing menstrual blood loss by 71-95% 5
• The levonorgestrel IUD is actually more effective than tranexamic acid (96% reduction after 12 months vs. 34-60%), though it may cause amenorrhea in 44% of patients 3

Comparative Effectiveness

When comparing treatment options for heavy menstrual bleeding:

• Tranexamic acid is more effective than all NSAIDs and oral progestins for reducing blood loss 2, 3
• Combined oral contraceptives show comparable efficacy to tranexamic acid, with no significant difference in mean blood loss reduction 8
• For patients with leiomyomas, combined oral contraceptives may be more effective than tranexamic acid 8
• Efficacy is highest in younger age groups and decreases with advancing age 8

Practical Implementation

Dose adjustments are necessary for renal impairment based on serum creatinine levels 7:

• Screen for contraindications including personal or family history of thromboembolism before initiating therapy 1, 7
• Consider pregnancy testing in all reproductive-age women before treatment 5
• Tranexamic acid does not affect duration of menses, only volume of blood loss 3