The Assessment of Tranexamic Acid in Women With Menorrhagia Who Have Bleeding Disorders
Condition: Menorrhagia
MeSH terms: Menorrhagia; Hemostatic Disorders; Blood Coagulation Disorders
Study type: Interventional
Phase: Phase 4

Summary: 
      Many women have heavy periods and this can be associated with low blood, tiredness and
      inability to carry out normal activities. Approximately 10-30% of these women will have an
      underlying bleeding disorder. There is a drug called tranexamic acid which is commonly used
      and is effective in reducing menstrual flow. However, up to 1/3 of women have side effects
      and they are more common at higher doses. In the medical literature, there are different
      dosing schedules and there is one commonly recommended in Canada. Women with underlying
      bleeding disorders may require higher doses of this medication compared to those who do not.
      In this study, the investigators want to find the lowest effective dose of tranexamic acid
      for girls and women with heavy periods who have bleeding disorders and the investigators
      think this will be lower then the usual recommended dose. If the investigators' results
      support this, it may contribute to changing how the investigators presently prescribe this
      medication and may provide a better option for women with heavy periods in particular those
      with bleeding disorders. The investigators have just started a Women with Bleeding Disorders
      Clinic and hope that this project will lead to better care for the patients and more research
      in the future.
    

Detailed description: 
      Menorrhagia, or heavy menstrual bleeding, represents an important health issue for
      premenopausal women and is a common cause for primary care consultations. Approximately
      10-15% of women have heavy periods. This may be associated with iron deficiency anemia,
      fatigue, and time lost from school, work and regular activities. Up to 50% of women with
      menorrhagia who have an underlying bleeding disorder have functional limitations and
      reduction of quality of life during their menstrual period.

      The literature reports that 10-30% of women with menorrhagia have an underlying bleeding
      disorder. The American Society of Hematology highlighted this as a major public health issue
      in 2006, and there have been ongoing efforts to address this problem. The prevalence of a
      bleeding disorder in the normal population is 1 in 100; von Willebrand Disease (VWD) being
      the most common. Studies have shown between 57% and 93% of women with bleeding disorders have
      menorrhagia. Therefore, women, who present with menorrhagia, should be considered for
      investigation of a bleeding disorder.

      Obtaining an accurate history of menorrhagia from women is often difficult for several
      reasons. Women may be reluctant to initiate discussion about their heavy periods. Also, women
      with underlying hereditary bleeding disorders may have heavy periods but since they are the
      same as other affected women in their families they consider their menses "normal." Not
      infrequently,a mild bleeding disorder may go undiagnosed until adulthood.

      Menorrhagia is objectively defined as menstrual blood loss of > 80mls. It is well known that
      assessment of menstrual blood loss by history alone is unreliable and inaccurate. The
      alkaline hematin method provides an objective and accurate technique for the measurement of
      menstrual blood loss and is considered the gold standard. However this method is
      time-consuming, not readily available for clinical use and impractical, as it requires women
      to collect all of their sanitary products for an entire menstrual cycle. The pictorial blood
      assessment chart (PBAC) is a simple, non-laboratory method that provides a semi-quantitative
      assessment of menstrual flow. Using this method, the patient records the number and degree of
      saturation of pads and/or tampons used for up to 8 days of their menstrual cycle on a
      pictorial chart and a corresponding score is calculated. In their original report, Higham et
      al defined menorrhagia as a PBAC score of > 100 with a sensitivity of 86% and a specificity
      of 81 %. Janssen et al later reported that a cut-off score of 185 provides high positive and
      negative predictive values for 'true' menorrhagia as opposed to the score of > 100 that was
      not validated by Reid et al, in a more recent publication. In both the Higham and the Janssen
      studies the confidence intervals of the estimates of sensitivity were not reported, therefore
      it is difficult to select either one as being definitively better to use as a cut-off score.
      In our study we have decided to use a cut-off PBAC score of 100 as a more conservative
      approach that will allow the inclusion of more patients with heavy menstrual flow.

      There are a number of treatment options for women with menorrhagia including hormone therapy
      (combined oral estrogen/progesterone, progesterone alone), tranexamic acid (and other
      antifibrinolytic agents), danazol, non steroidal anti-inflammatory drugs (NSAIDs),
      progesterone releasing intrauterine devices, and, finally, the surgical options of
      endometrial ablation and hysterectomy. An additional therapy, for women with certain bleeding
      disorders (VWD, platelet dysfunction and Hemophilia A carriers) is desmopressin (DDAVP)
      (intranasal or subcutaneous). Tranexamic acid is a first line therapy for women with
      menorrhagia who do not require contraception and who prefer non-hormonal therapy. It is
      considered standard therapy around the world and in most countries (e.g. Canada), it is
      available by prescription only, but interestingly in Sweden it is obtained
      'over-the-counter.'

      Antifibrinolytic therapy has been used for almost forty years for menorrhagia - the first
      publication was in 1965. It has previously been described that fibrinolysis is increased in
      the menstrual fluid and endometrium in women with heavy menstrual flow. Tranexamic acid,
      which is a fibrinolytic inhibitor, competitively blocks the activation of plasminogen to
      plasmin and thereby reducing fibrinolysis. Tranexamic acid reduces menstrual blood loss by up
      to 50% and it has been shown to be at least as equally as effective as oral contraceptives,
      NSAIDs, and intranasal desmopressin. There is no consensus as to the minimal effective dose,
      the dose scheduling and the optimal duration of therapy. In the published literature, the
      effective dose is variable and ranges from 1000 mg/day to 6000 mg/day. The recommended dose
      by the Compendium of Pharmaceuticals and Specialties (CPS), 2009, published by the Canadian
      Pharmacists Association, is 3000 mg/day to 6000 mg/day. The current recommended dose as per
      the Clinical Practice Guidelines for the Management of Abnormal Uterine Bleeding by the
      Society of Obstetricians and Gynecologists of Canada and the Canadian Hemophilia Society
      document on the Management of Women with Bleeding Disorders is 1000 mg orally four times a
      day. Interestingly, in China, it is recommended to give 2000 mg/day. The recommended duration
      of therapy is also variable; the CPS states the medication should be started "when the flow
      is copious" and taken for "several days." Most clinical trials have used a 4-5 day duration
      of therapy. It is given in different schedules, most commonly 3 to 4 times per day. A recent
      study compared two doses of tranexamic acid, 2000 mg/day vs. 1000 mg/day, both doses given on
      a twice-a-day schedule, with an additional placebo arm, assessing the effect on prevention of
      menorrhagia in women with intrauterine devices (IUDs). The women randomized to the tranexamic
      acid arms had significantly less menstrual flow compared with the placebo group and there was
      no significant difference in efficacy between the two doses of tranexamic acid. Women with
      underlying bleeding disorders may need higher doses than women without bleeding disorders;
      however, this is uncertain. This medication is not without toxicity and up to one-third of
      women experience side effects that are dose dependant. The most common adverse effects are
      nausea, vomiting, diarrhea and, less common, are headaches, dizziness and allergic reaction.
      Tranexamic acid is expensive; the retail price is $1.34/500-mg capsule. For example a dose of
      4000 mg/day for 5 days would cost a patient $64.34/month including the dispensing fee. Common
      reasons for discontinuing the medication include side effects, cost and the inconvenience
      associated with multiple dosing. Many patients will adjust their dose - finding a balance of
      efficacy, minimal toxicity, cost, and frequency of dosing. It is our experience that some
      patients find this balance with a minimal dose of 500 mg taken twice daily. In this study we
      propose to investigate whether the minimal effective and tolerated dose of tranexamic acid,
      based on the PBAC score, quality of life factors, and tolerability of side effects is less
      than the current Canadian recommended dose of 1000 mg orally four times a day.

      Study Objectives:

        -  Primary Objective

             -  To determine if the minimal effective and tolerated dose of tranexamic acid for
                girls and women with menorrhagia who have bleeding disorders is lower than the
                current dose of 1000 mg orally, four times a day, as recommended by the Clinical
                Practice Guidelines for the Management of Abnormal Uterine Bleeding by the Society
                of Obstetricians and Gynecologists of Canada and the Canadian Hemophilia Society
                document on the Management of Women with Bleeding Disorders.

        -  Secondary Objectives

             -  To determine an accurate estimate of the proportion of women who present to our
                clinics with menorrhagia who have an underlying bleeding disorder. Based on the
                literature this is expected to be 10%-30%.

             -  To determine the effect of body mass index (BMI), age, dose-related side effects,
                concurrent medications and quality of life factors on the optimal dose of
                tranexamic acid.

      Study hypotheses:

        -  Primary hypothesis

             -  The minimal effective and tolerated dose of tranexamic acid required by women with
                menorrhagia who have bleeding disorders is lower than the current Canadian
                recommendation of 1000 mg orally, four times daily (4000 mg/day).

        -  Secondary hypotheses

             -  The true proportion of women with menorrhagia who have bleeding disorders is
                under-reported.

             -  Women with menorrhagia without bleeding disorders require a lower dose of
                tranexamic acid than women with menorrhagia with bleeding disorders.

             -  In addition to the presence of a bleeding disorder, there are likely other factors
                including age, BMI, tolerance of side effects, subjective assessment of bleeding,
                quality of life issues and compliance that impact on the dosing of tranexamic acid
                in women with menorrhagia.

             -  A decision tool can be developed to aid in dosing women with menorrhagia based on
                risk factors such as the presence of a bleeding disorder, age and BMI.
    

Intervention name(s): tranexamic acid
Intervention type(s): Drug
Intervention description(s): After The starting dose of tranexamic acid will be 500 mg twice daily beginning the first day of menstrual flow for a total of 6 days per menstrual cycle. If after 2 days there is still menorrhagia without significant side effects the will be increased. The women will be assessed again at day 4 and 9 and dose escalation will continue until they have reached the optimal dose.The dose of tranexamic acid will be increased as follows: 1000 mg twice daily, 1000 mg three times daily, 1500 mg/1000 mg/1000 mg, 1000 mg four times daily, 1500 mg three times daily, and 1500 mg four times daily (maximum dose).Each patient will be followed for a minimum of one menstrual cycle and a maximum of 3 cycles.
Other intervention name(s): Cyklokapron
Intervention MeSH terms: Tranexamic Acid
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment