What is the recommended treatment for a healthy female patient of reproductive age with heavy menstrual bleeding, considering potential underlying conditions and contraindications?

Tranexamic Acid 500mg for Heavy Menstrual Bleeding

Recommended Dosing and Positioning

Tranexamic acid is an effective second-line treatment for heavy menstrual bleeding, but NSAIDs should be tried first unless contraindicated, and the correct dose is 3.9-4 grams per day (not 500mg), taken for 4-5 days during menstruation only. 1, 2

Correct Dosing Protocol

• The therapeutic dose of tranexamic acid is 3.9-4 grams per day divided into multiple doses (typically 1 gram four times daily), taken for 4-5 days starting from the first day of menstruation 2, 3
• A single 500mg dose is substantially subtherapeutic and will not provide adequate blood loss reduction
• Treatment should be limited to days of active bleeding only, not taken continuously throughout the cycle 1, 2

Treatment Hierarchy

First-line treatment: NSAIDs (mefenamic acid, naproxen, indomethacin) taken for 5-7 days during menstruation reduce menstrual blood loss by 20-50% and should be the initial pharmacologic approach 1, 4

Second-line non-hormonal option: Tranexamic acid reduces menstrual blood loss by 26-60% (approximately 80 mL per cycle) and is significantly more effective than NSAIDs 1, 2, 3

Most effective medical treatment: The levonorgestrel-releasing intrauterine device (LNG-IUD) reduces menstrual blood loss by 71-95% and is superior to all oral medications 1, 4

Efficacy Evidence

• Tranexamic acid reduces mean menstrual blood loss by 54% compared to baseline (from 164 mL to 75 mL in controlled trials) 3
• It is significantly more effective than placebo, NSAIDs, oral cyclical progestins, and ethamsylate 2, 4
• The LNG-IUD is more effective than tranexamic acid and should be considered for women not actively seeking pregnancy 4

Critical Contraindications and Safety

Absolute Contraindications

• Active thromboembolic disease (deep vein thrombosis, pulmonary embolism, stroke) 5, 2
• History of thrombosis or thromboembolism 5, 2
• Intrinsic risk factors for thrombosis including cardiovascular disease 1, 5
• Concomitant use with hormonal contraceptives increases thromboembolic risk and requires alternative (non-hormonal) contraception 5

Important Safety Considerations

• No evidence exists of increased thrombotic events in women without pre-existing risk factors using tranexamic acid for menstrual bleeding 2
• Adverse effects are generally mild and include gastrointestinal symptoms (nausea, vomiting, diarrhea) 5, 2
• Tranexamic acid is substantially excreted by the kidney; dose reduction is required in renal impairment 5
• Screen for cardiovascular disease and thrombotic risk factors before initiating therapy 1

Essential Initial Assessment

Before prescribing any treatment for heavy menstrual bleeding:

• Rule out pregnancy with beta-hCG testing in all reproductive-age women 1, 6
• Assess for structural causes: fibroids, polyps, adenomyosis, endometrial pathology, or malignancy through pelvic examination and transvaginal ultrasound 1, 7
• Evaluate for coagulopathies if clinically indicated, as up to 20% of women with heavy menstrual bleeding may have an underlying inherited bleeding disorder 1
• Screen for cardiovascular risk factors before initiating NSAID or tranexamic acid therapy 1

Treatment Algorithm

Step 1: NSAIDs (mefenamic acid 500mg three times daily, or naproxen) for 5-7 days during menstruation 1, 4

• Avoid in women with cardiovascular disease, history of myocardial infarction, or spontaneous coronary artery dissection 1, 6

Step 2: If NSAIDs are ineffective or contraindicated, use tranexamic acid 3.9-4 grams daily for 4-5 days during menstruation 2, 3

• Contraindicated in women with thromboembolic disease or cardiovascular risk factors 1, 5

Step 3: Consider LNG-IUD as the most effective medical option, particularly for women not seeking immediate pregnancy 1, 4

• Reduces menstrual blood loss by 71-95% and many women eventually experience amenorrhea 1

Step 4: If medical management fails, consider endometrial ablation or hysterectomy for definitive treatment 6, 4

Common Pitfalls to Avoid

• Underdosing tranexamic acid: 500mg is inadequate; the therapeutic dose is 3.9-4 grams per day 2, 3
• Using aspirin: Aspirin does not reduce menstrual bleeding and may increase blood loss in some women 1
• Prescribing short-course progestins (≤14 days per cycle): These are less effective than tranexamic acid or NSAIDs 4
• Combining tranexamic acid with hormonal contraceptives: This increases thromboembolic risk and requires alternative contraception 5
• Failing to assess for structural pathology: Fibroids, polyps, and adenomyosis require specific evaluation and may need different management 1, 7