What is the best approach to manage menorrhagia in a 50-year-old female patient with a history of stroke, on Eliquis (apixaban) for anticoagulation?

Management of Menorrhagia in a 50-Year-Old on Apixaban for Stroke History

Continue apixaban for stroke prevention while implementing gynecologic interventions to control menorrhagia, as the stroke prevention benefit outweighs bleeding risk in the absence of clinically significant anemia or hypotension.

Initial Assessment

Immediately evaluate for:

• Hemoglobin/hematocrit to quantify anemia severity 1
• Hemodynamic stability (blood pressure, orthostatic changes) 2
• Gynecologic causes requiring urgent intervention (structural lesions, malignancy) 1

Decision Algorithm Based on Clinical Severity

If Clinically Significant Anemia or Hypotension Present:

• Emergency gynecology consultation is indicated before continuing apixaban 2
• Consider temporary apixaban interruption (3 days for CrCl >30 mL/min) only if urgent gynecologic procedure required 2
• Bridge with alternative hemostatic measures during interruption 2

If No Clinically Significant Anemia or Hypotension:

Continue apixaban without interruption while implementing medical management of menorrhagia 2

Medical Management Options (While Continuing Apixaban)

First-Line Hemostatic Agents:

• Tranexamic acid (oral): Directly reduces menstrual blood loss without affecting anticoagulation 3
• Intranasal desmopressin (DDAVP): Particularly if underlying von Willebrand factor deficiency suspected (13% incidence in menorrhagia) 3

Hormonal Options:

• Levonorgestrel intrauterine system: Provides local endometrial suppression with minimal systemic effects 3
• Oral contraceptives or medroxyprogesterone: Regulate menstrual cycle and reduce flow 1

NSAIDs:

• Prostaglandin inhibitors: Reduce menstrual blood loss, though use cautiously with anticoagulation 1

Critical Considerations for DOACs and Menorrhagia

Apixaban specifically increases abnormal uterine bleeding risk in women of reproductive age, with registry data showing 32% incidence with factor Xa inhibitors 2. However, at age 50 (perimenopausal), this patient faces:

• Higher stroke recurrence risk (0.5-1.3% per day in first 14 days post-stroke) that necessitates continued anticoagulation 2
• Apixaban demonstrated superior stroke prevention versus aspirin (1.27% vs 1.60% annually) with acceptable bleeding profile 2
• Recent 2025 data confirms apixaban benefit even in subclinical AF with stroke history: 7% absolute risk reduction in recurrent stroke over 3.5 years versus only 3% absolute increase in major bleeding 4

When to Consider Apixaban Dose Reduction

Reduce to apixaban 2.5 mg twice daily if patient meets ≥2 of the following 2, 5:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL

This 50-year-old likely does not meet dose reduction criteria unless significantly underweight or has renal impairment 5.

Surgical Options if Medical Management Fails

If menorrhagia persists despite medical therapy:

• Hysteroscopic endometrial ablation: Can be performed while continuing anticoagulation with careful planning 1
• Hysterectomy: Last resort, requires apixaban interruption per perioperative guidelines (3-5 days depending on renal function) 2

Common Pitfalls to Avoid

• Do not discontinue apixaban without gynecology consultation unless life-threatening bleeding occurs 2
• Do not switch to aspirin - apixaban is superior for secondary stroke prevention and the bleeding difference is marginal 4
• Do not assume menorrhagia alone warrants anticoagulation cessation - the stroke risk from stopping anticoagulation far exceeds the bleeding risk in most cases 2
• Screen for underlying bleeding disorders (von Willebrand disease, platelet dysfunction) which are 3-4 times more common than recognized 3

Monitoring Strategy

• Counsel patient that increased menstrual flow is expected with apixaban 2
• Monitor hemoglobin monthly until menorrhagia controlled 1
• Close gynecologic follow-up to assess response to medical therapy 2
• Ensure patient understands not to abruptly stop apixaban due to rebound thrombotic risk 2