What is the recommended tranexamic acid dosing regimen for acute menorrhagia?

Tranexamic Acid Dosing for Menorrhagia

For menorrhagia (heavy menstrual bleeding), tranexamic acid should be dosed at 1.3 grams orally three times daily (total 3.9 g/day) for 4-5 consecutive days starting on the first day of menstrual bleeding. 1, 2

Standard Dosing Regimen

• The recommended dose is 3.9 grams per day divided into three or four doses, taken only during days 1-5 of menstruation 3, 2, 4
• Treatment should be initiated on the first day of menstrual bleeding and continued for 4-5 consecutive days only 1
• This dosing reduces menstrual blood loss by 26-60% compared to baseline 3

Evidence Supporting This Dose

• A dose-response study demonstrated that 3.9 g/day met all three primary efficacy endpoints, while the lower 1.95 g/day dose met only two endpoints 2
• The 3.9 g/day regimen produces meaningful reductions in menstrual blood loss as judged by patients and achieves reductions >50 mL/cycle 2
• This dose is significantly more effective than placebo, NSAIDs, oral luteal phase progestins, and etamsylate 3, 4

Critical Distinction from Postpartum Hemorrhage Dosing

This menorrhagia dosing is completely different from postpartum hemorrhage treatment, which uses 1 gram IV over 10 minutes and must be given within 3 hours of birth 1, 5

• The oral menorrhagia regimen is cyclic and non-urgent 1
• The IV postpartum regimen is time-critical for mortality benefit 5
• Do not confuse these two distinct clinical scenarios and dosing protocols 1

Treatment Duration and Reassessment

• Therapy should be reassessed after 2-3 menstrual cycles to evaluate efficacy 1
• If bleeding remains unacceptable after an adequate trial period, consider alternative therapy 1
• Long-term use involves taking the medication only 4-5 days per month during menses, not continuously 1, 3

Absolute Contraindications

Do not prescribe tranexamic acid if the patient has: 1, 3

• Active thromboembolic disease
• History of thrombosis or thromboembolism
• Intrinsic risk factors for thrombosis or thromboembolism

Mechanism and Rationale

• Tranexamic acid competitively inhibits plasminogen activation, preventing fibrin degradation and stabilizing clots 1
• This mechanism specifically addresses the increased fibrinolytic activity in menstrual endometrium that contributes to heavy bleeding 4

Special Populations

• In patients with von Willebrand disease and severe menorrhagia, higher doses up to 3 grams daily in four divided doses may be required if standard dosing fails 6
• Dose adjustment is necessary in patients with impaired renal function based on serum creatinine levels 7, 5

Safety Profile

• Adverse effects are few and mainly mild, with gastrointestinal symptoms (nausea, diarrhea) being most common 3, 4
• The incidence of drug-related adverse events (12%) is not significantly different from placebo 4
• No evidence exists of increased thrombotic events associated with tranexamic acid use in menorrhagia treatment 3
• Both the 3.9 g/day and 1.95 g/day doses were well tolerated with no serious study-related adverse events 2

Common Pitfalls to Avoid

• Do not prescribe continuous daily dosing—tranexamic acid for menorrhagia should only be taken during the 4-5 days of menstrual bleeding each cycle 1, 3
• Do not use the lower 1.95 g/day dose as first-line therapy, as it is less effective than 3.9 g/day 2
• Do not confuse the oral menorrhagia protocol with the IV postpartum hemorrhage protocol 1
• Do not withhold treatment due to unfounded concerns about thrombosis in patients without contraindications 3