Tranexamic Acid Dosing for Menorrhagia
For menorrhagia (heavy menstrual bleeding) in reproductive-age women without thromboembolic history, the recommended dose is 1.3 grams orally three times daily (total 3.9 grams/day) for up to 5 days during menstruation, starting on the first day of bleeding. 1, 2
Standard Dosing Regimen
The evidence-based oral dosing for idiopathic menorrhagia is:
- Total daily dose: 3.9-4 grams per day 1
- Divided dosing: 1-1.5 grams three times daily 2, 3
- Duration: 4-5 days per cycle, starting from day 1 of menstruation 1, 2
- Alternative regimen: 1 gram four times daily for 4 days 2, 4
This dosing reduces menstrual blood loss by 34-59% compared to baseline, which is significantly superior to NSAIDs, oral progestins, or placebo. 1, 2
Clinical Efficacy Context
Tranexamic acid works by competitively inhibiting plasminogen activation, thereby preventing fibrin degradation and stabilizing clots. 5, 1 In comparative trials:
- More effective than: mefenamic acid, flurbiprofen, etamsylate, and luteal phase norethisterone 2, 3
- Less effective than: levonorgestrel-releasing IUD (which reduces bleeding by 96% but causes amenorrhea in 44% of users) 3
- Patient satisfaction: 81% of women report satisfaction, with 94% noting decreased menstrual blood loss 2
Absolute Contraindications
Do not prescribe tranexamic acid if the patient has: 5, 1
- Active thromboembolic disease
- History of thrombosis or thromboembolism
- Intrinsic risk factors for thrombosis or thromboembolism
The patient described has no thromboembolic history, making tranexamic acid appropriate.
Important Clinical Distinctions
This menorrhagia dosing is completely different from post-partum hemorrhage dosing. 5 The post-partum regimen uses 1 gram IV over 10 minutes (not oral), must be given within 3 hours of birth, and is time-critical for mortality benefit. 6, 5 Do not confuse these two distinct clinical scenarios—menorrhagia is a chronic outpatient condition requiring oral therapy during menses, while post-partum hemorrhage is an acute emergency requiring immediate IV administration.
Safety Profile
Adverse effects are predominantly mild gastrointestinal symptoms (nausea, vomiting, diarrhea, dyspepsia) occurring in approximately 12% of patients, which is not significantly different from placebo rates. 2 Importantly, no evidence exists of increased thrombotic events with tranexamic acid use for menorrhagia at recommended doses. 1
Practical Implementation
- Start therapy on the first day of menstrual bleeding 1
- Continue for 4-5 consecutive days only (not throughout the entire cycle) 1, 2
- Reassess after 2-3 cycles to evaluate efficacy 2
- Consider alternative therapy if bleeding remains unacceptable after trial period 6
Common Pitfalls to Avoid
Do not prescribe tranexamic acid continuously throughout the menstrual cycle—it should only be taken during days of active bleeding. 1, 2 This is a frequent prescribing error that increases cost and potential side effects without additional benefit.
Do not withhold tranexamic acid while waiting for hormonal therapy to take effect if the patient desires immediate pregnancy or has contraindications to hormonal treatment. 7 Tranexamic acid is particularly valuable in these scenarios as it does not interfere with fertility.