In a 45-year-old woman with menorrhagia lasting more than 10 days, a negative pregnancy test, and a normal pelvic ultrasound, which medication is most appropriate?

Tranexamic Acid is the Most Appropriate Medication

For a 45-year-old woman with menorrhagia lasting more than 10 days, negative pregnancy test, and normal ultrasound, tranexamic acid is the most appropriate medication among the options provided. This is a nonhormonal antifibrinolytic agent specifically indicated for heavy menstrual bleeding without structural uterine pathology 1.

Why Tranexamic Acid is the Correct Answer

Tranexamic acid reduces menstrual blood loss by 26-60% and is significantly more effective than placebo or NSAIDs for treating heavy menstrual bleeding 2, 3. The recommended dosage is 3.9-4 g/day for 4-5 days starting from the first day of menstruation 2.

• The 2024 CDC guidelines specifically list tranexamic acid (antifibrinolytic agents) as a treatment option for heavy or prolonged bleeding, with a recommended 5-day course 1.
• The 2024 ACR guidelines on fibroid management identify tranexamic acid as a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids, even though this patient's ultrasound is normal 1.
• Multiple research studies confirm tranexamic acid is particularly useful when hormonal treatment is inappropriate or when immediate pregnancy is desired 3, 4.

Why the Other Options Are Incorrect

Oxytocin (Option A)

Oxytocin is used for postpartum hemorrhage and labor induction, not for menorrhagia management. It has no role in treating cyclic heavy menstrual bleeding in a non-pregnant woman.

Carboprost (Option B)

Carboprost is a prostaglandin analog used for postpartum hemorrhage and pregnancy termination. It is not indicated for menorrhagia and would be inappropriate in this clinical scenario.

Misoprostol (Option C)

Misoprostol is a prostaglandin used for cervical ripening, labor induction, and medical abortion. It has no established role in treating heavy menstrual bleeding and could potentially worsen bleeding.

Clinical Implementation

The standard regimen is tranexamic acid 1.3 g (two 650 mg tablets) three times daily for up to 5 days during menstruation 1. This can be repeated with each menstrual cycle as needed.

Important Safety Considerations

• Active thromboembolic disease is an absolute contraindication to tranexamic acid 2.
• In the United States, FDA labeling also contraindicates tranexamic acid in women with a history of thrombosis or thromboembolism, or an intrinsic risk for thrombosis 1, 2.
• Adverse effects are generally mild and primarily gastrointestinal (nausea, vomiting, diarrhea), occurring in approximately 12% of patients 5.
• No evidence exists of increased thrombotic events with tranexamic acid use for menorrhagia in women without pre-existing thrombotic risk factors 2, 5.

Common Pitfalls to Avoid

• Do not assume all heavy bleeding requires hormonal therapy—tranexamic acid provides effective nonhormonal treatment 3, 4.
• Do not overlook contraindications to tranexamic acid, particularly active or history of thromboembolic disease 1, 2.
• Do not confuse medications used for postpartum hemorrhage (oxytocin, carboprost, misoprostol) with those indicated for menorrhagia management.
• Always rule out underlying pathology before attributing heavy bleeding to idiopathic menorrhagia, though this patient's normal ultrasound makes structural causes less likely 1.

Alternative Considerations

If tranexamic acid fails or is contraindicated, first-line alternatives include:

• NSAIDs (5-7 days during menstruation) for modest reduction in menstrual blood loss 1.
• Combined oral contraceptives or levonorgestrel IUD for women desiring contraception, though these are hormonal options 1, 4.