Treatment of Heavy Menstrual Bleeding

Spotlight on tranexamic acid

Getty Images

Heavy menstrual bleeding is often under-treated, and consequently, many suffer not only from the hassle of heavy bleeding but also from health consequences due to the resulting anemia and/or iron deficiency. What makes this worse is that many women have their anemia dismissed as “not that bad” or their iron deficiency ignored altogether. However, iron deficiency is a medical condition in its own right and needs to be treated whether there is anemia (low hemoglobin) or not. 

About 17% of teens and women between the ages of 14 and 50 are iron deficient, primarily due to due to heavy menstrual bleeding. For girls and young women between the ages of 12 and 21, it’s a staggering 40%. As heavier periods are more common during the menopause transition, iron deficiency should also be on the radar for anyone over age 40.

Common symptoms of iron deficiency include the following, ranging from most common to least common (but to put “least common” into perspective, 45% of people with iron deficiency, the last item on the list, report depression):

• Fatigue

• Exhaustion

• Brain fog

• Muscle weakness

• Shortness of breath

• Feeling Cold

• Dizziness

• Anxiety

• Heart palpitations

• Irritability

• Hair loss 

• Trouble sleeping

• Dry skin

• Headache

• Brittle nails

• Joint pain

• Restless less

• Muscle pain

• Depression

The symptoms of iron deficiency overlap so much with those experienced by many women in the menopause transition that I believe it’s essential for women with any of the above symptoms to be tested. If you aren’t menstruating, for example, because of a hysterectomy or a hormone IUD, the risk of iron deficiency is certainly less, but it’s still worth checking. There are other causes besides menstruation.

Whether someone has been diagnosed with iron deficiency or simply has heavy periods that are bothersome, there are a variety of therapies that can reduce menstrual blood loss. Hormones, like the birth control pill, a hormone IUD, or the Nexplanon implant, are all great options. There are also “on-demand” medications, meaning therapies that someone only takes during menstruation. One of those categories is non-steroidal anti-inflammatory drugs or NSAIDs, like ibuprofen, which can reduce menstrual blood loss by about 20-25%. You can read more about that therapy here. 

There is also another “on-demand” medication, tranexamic acid, which I think is under-prescribed, at least in the United States. It’s a good option because A) it works, and B) it is an option for people who can’t or don't want to take hormones or NSAIDs or when these options don’t work. 

Tranexamic acid is a synthetic analog of the amino acid lysine. It reduces bleeding by slowing the body's breakdown of blood clots. It is also used in other situations where bleeding is a concern, such as in some surgeries and as treatment of postpartum hemorrhage.

Tranexamic acid is taken three times a day during menstruation (the dose in the United States is 1.3 g orally three times a day for up to five days, but the dose can vary a little by country). In studies, it reduces menstrual blood loss by up to 50% compared with placebo. When asked in studies, most people have what is considered a “clinically meaningful reduction in bleeding,” which I think can be translated into “most people think this helps a lot.”

While tranexamic acid requires a prescription in the United States, Canada, and Australia, it’s over the counter in many countries, such as the United Kingdom, Sweden, and India. I hear awful stories in the United States of scrambling to get a prescription and insurance approval every month, and it shouldn’t be that way. My impression is that it’s underused in the United States, and I bet the lack of over-the-counter access plays a role in this disparity. I also wonder if some providers in the United States don’t offer it because it’s also used in the hospital for severe bleeding, for example, during surgery, and I suspect some erroneously think of heavy periods as “not serious.” Super emphasis on erroneously. 

There is a theoretical concern that tranexamic acid could increase the risk of dangerous blood clots in the lungs, but most studies haven’t shown this to be true. Tranexamic acid has been over the counter in Sweden for over 20 years, where 1% of menstruating people use the medication, and yet observational data has not identified an increased risk of clots. Other safety data comes from using tranexamic acid for postpartum bleeding. In one study, over 10,000 women received the drug, and there was no increase in blood clots. Considering the postpartum time poses the greatest risk of blood clots, this is very reassuring. However, in Denmark, where researchers tracked the records of women prescribed tranexamic acid, a very small increased risk of blood clots was identified, meaning for every 78,549 women who take the medication for 5 days, one might have a blood clot. To be clear, given this is observational data, we don’t know if this is a true effect or an artifact, and given how rare the risk is, proving this to be a true effect will be almost impossible given the number of people who would need to be enrolled in a clinical trial. 

What does this mean for you? Most studies show no increased risk, but if there is one, it is likely very low–at most, about one in almost 80,000, which is considered very rare.

What about combining tranexamic acid with estrogen-containing oral contraception? As estrogen-containing contraceptives do increase the risks of blood clots and stroke, it’s a reasonable question. According to the package labeling in the United States, “Women using hormonal contraception should use LYSTEDA only if there is a strong medical need and the benefit of treatment will outweigh the potential increased risk of a thrombotic event.” It’s always important to remember that product monographs and package labeling are legal documents and don’t always align with evidence-based medicine for a variety of reasons. Also, the benefits of treatment should outweigh the risks for EVERY medication.

In one survey of OB/GYNs, of the 214 who replied, 138 or 64% had prescribed tranexamic acid in conjunction with estrogen-containing contraceptives in the previous year when hormone medication alone wasn’t adequate. Among those who replied, 57% of those who had prescribed tranexamic acid and estrogen-containing contraceptives together stated that at least 50% of the women who were treated this way had a resolution in their refractory heavy menstrual bleeding, and only one reported a blood clot. Admittedly, this isn’t the most accurate way to get the data, but it’s clear many doctors are comfortable prescribing the two together. The potential risks need to be put in perspective because heavy bleeding can also have serious medical consequences, and, of course, a hysterectomy also comes with risks as well. 

In general, most experts don’t believe that combining tranexamic acid with estrogen-containing hormonal contraception significantly increases the risk of blood clots. In addition, in the UK, the NHS page on tranexamic acid does not mention estrogen-containing medications as a contraindication. However, if someone has other risk factors for blood clots in addition to taking an estrogen-containing contraceptive, that might require individualization.

A history of previously having a blood clot or being at higher risk for blood clots because of a disorder of blood clotting is a contraindication to tranexamic acid.

I suspect a lot of people with heavy bleeding could benefit from tranexamic acid, so hopefully, this information will help some people. And honestly, the fact it’s not available over the counter everywhere is problematic. Interestingly, phosphodiesterase inhibitors (drugs like Viagra) also aren’t available over the counter in the United States, although that may soon change. Regardless, the fact that drugs for erectile dysfunction are easier and cheaper to get as a prescription than a medication to treat heavy bleeding is, well, peak patriarchy. 

References

Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J; ECLIPSE Trial Collaborative Group. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10;368(2):128-37

Lukes AS, Freeman EW, Van Drie D, Baker J, Adomako TL. Safety of tranexamic acid in women with heavy menstrual bleeding: an open-label extension study. Womens Health (Lond). 2011 Sep;7(5):591-8. doi: 10.2217/whe.11.55. PMID: 21879827.

Lim M, Olson L, Rajpurkar MA, Weyand AC. Concomitant use of combined hormonal contraceptives and antifibrinolytic agents for the management of heavy menstrual bleeding: A practice pattern survey. Thrombosis Research 2021;204:95-100.

Thorne JG, James PD, Reid RL. Heavy menstrual bleeding: is tranexamic acid a safe adjunct to combined hormonal contraception? Contraception. 2018;98:1-3. 

Leminen H, Hurskainen R. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Women’s Health 2012:4 413–421

Meaidia A, Mørchc L, Torp-Pedersend C, Lidegaard O. Oral tranexamic acid and thrombosis risk in women. EClinical Medicine 2021;35:100882.

Lysteda (Tranexamic acid) US FDA Prescribing information Accessed at https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022430lbl.pdf