In clinical practice, the rate of visits to the doctor for excessive menstruation is increasing every year, and 60% of patients with excessive menstruation have unexplained or functional uterine bleeding (DUB) as the cause.
”Pharmacological treatment of menorrhagia allows patients to preserve their reproductive function.”
Drug therapy should be preferred for patients with heavy menstruation
A recent study in Hong Kong, China, showed that 87% of women with heavy menstruation wanted medication as a first-line treatment option. Pharmacologic treatment of menorrhagia may allow patients to preserve their fertility. In primary care clinics, aggressive patient education on medication management and improved efficacy of medication management can reduce the rate of patients treated with surgery and norethindrone tablets by 50%.
According to the 1998 guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), the clinical status of a patient with menorrhagia should be assessed by taking a complete medical history to determine whether the patient has had severe menstrual blood loss for several consecutive menstrual cycles, excluding intermenstrual bleeding and postcoital bleeding.
A multicenter, open study showed that tranexamic acid was the most effective and well tolerated in patients with primary menorrhagia. Patients included in the study were 18-45 years old with ovulatory menorrhagia. After 2 cycles of treatment and 1 cycle of follow-up in the tranexamic acid group (1 g, tid, day 1-5 of the menstrual cycle), menstrual blood loss was reduced by 42.5% on average during the follow-up cycle, whereas in the mefenamic acid group (500 mg, tid, day 1-5 of the menstrual cycle) and the norethindrone group (5 mg. bid, day 19 of the menstrual cycle), menstrual blood loss was reduced by 42.5% on average during the follow-up cycle, The menstrual blood loss in the mefenamic acid group (500 mg, tid, day 1-5 of the menstrual cycle) and the norethindrone group (5 mg, bid, taken on days 19-26 of the menstrual cycle) was only reduced by 10.2% and 8.2%, respectively, during the follow-up cycle (P values <0.001 for both). Compared with mefenamic acid and norethindrone, tranexamic acid resulted in a significant reduction in the duration of menstruation in patients with menorrhagia (P=0.002), and the success rate of this treatment was significantly higher during the follow-up period, and the hemoglobin level was better maintained in this group. In the study, tranexamic acid treatment alone significantly improved the patients' quality of life and improved their social activity, work capacity, productivity, appetite, and depressive status.
Options for pharmacological treatment of menorrhagia
Treatment options for menorrhagia should be individualized according to the patient’s need for fertility and contraception. The physician should recommend at least one medication before referring the patient to a secondary care clinic. Tranexamic acid is the first-line drug for the non-hormonal treatment of patients with menorrhagia. Second-line drugs, such as danazol and gonadotropin-releasing hormone (GnRH) analogs, have more adverse effects and are therefore limited in their use. These drugs can be used in combination with long-acting progestin analogs for the treatment of menorrhagia, but they may cause unpredictable irregular vaginal bleeding when first used, and even severe bleeding in 1 to 2 percent of patients. Phenylsulfonamide and low doses of norethindrone during the luteal phase are not effective treatments for menorrhagia.
Relative efficacy of various drug regimens
Clinical studies have shown that tranexamic acid is more effective than phenazopyridine, mefenamic acid, and norethindrone in patients with menorrhagia. In a randomized study in which the mean menstrual blood loss was >80 ml over 3 consecutive cycles, patients taking tranexamic acid had 54% less bleeding compared to 20% less bleeding in patients taking mefenamic acid, and phenoxynil was ineffective. In patients with DUB, tranexamic acid (1 g, qid, taken on days 1-4 of the menstrual cycle) was effective after two cycles, whereas norethindrone (5 mg, bid, taken on days 19-26 of the menstrual cycle) resulted in increased menstrual blood loss.
Common adverse effects of tranexamic acid include dose-related gastrointestinal discomfort, but this rarely leads to discontinuation of the drug. Long-term studies have shown that patients taking tranexamic acid develop thrombophilia at a rate comparable to that of normal women with spontaneous thrombosis.
Conclusion
Tranexamic acid treatment is generally well accepted by patients and results in reduced menstrual blood loss, increased hemoglobin levels, and improved quality of life. In addition, tranexamic acid is administered only during the first 3 days of the menstrual cycle, preserves the patient’s reproductive function, and is safe and well tolerated.
Clinical issues related to the use of medications for the treatment of menorrhagia
Relative efficacy of various drug regimens for the treatment of menorrhagia in Asian women
According to the World
Tranexamic acid is a safe and well-tolerated drug for patients with menorrhagia, with an incidence of 0-3.6% for tranexamic acid and 1.8%-7.1% and 7.1%-8.9% for mefenamic acid and norethindrone, respectively.
Conclusion
The available evidence suggests that tranexamic acid is effective in the treatment of primary menstrual cramps. The amount of menstrual blood loss and the duration of menstruation were significantly reduced, while the hemoglobin remained at a stable level. Tranexamic acid is well tolerated by patients, and it is the only drug available for the treatment of menorrhagia that can significantly improve the quality of life of patients.
According to the World Health Organization (WHO), 19% of women of childbearing age suffer from excessive menstruation. In Thailand, 10% of patients in obstetrics and gynecology clinics come to the clinic with heavy menstruation. The proportion of ovulatory and anovulatory menstrual periods is equal in Thailand, 43% and 57% respectively.