Fibrinolytic activity of menstrual blood in normal and menorrhagic women and in women wearing the Lippes Loop and the Cu-T (200)

Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety

Tranexamic acid has proven to be an effective treatment for heavy menstrual bleeding (HMB). It reduces menstrual blood loss (MBL) by 26%-60% and is significantly more effective than placebo, nonsteroidal anti-inflammatory drugs, oral cyclical luteal phase progestins, or oral etamsylate, while the levonorgestrel-releasing intrauterine system reduces MBL more than tranexamic acid. Other treatments used for HMB are oral contraceptives, danazol, and surgical interventions (endometrial ablation and hysterectomy). Medical therapy is usually considered a first-line treatment for idiopathic HMB. Tranexamic acid significantly improves the quality of life of women treated for HMB. The recommended oral dosage is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle. Adverse effects are few and mainly mild. No evidence exists of an increase in the incidence of thrombotic events associated with its use. An active thromboembolic disease is a contraindication. In the US, a history of thrombosis or thromboembolism, or an intrinsic risk for thrombosis or thromboembolism are considered contraindications as well. This review focuses on the efficacy and safety of tranexamic acid in the treatment of idiopathic HMB. We searched for medical literature published in English on tranexamic acid from Ovid Medline, PubMed, and Cinahl. Additional references were identified from the reference lists of articles. Ovid Medline, PubMed, and Cinahl search terms were "tranexamic acid" and "menorrhagia" or "heavy menstrual bleeding." Searches were last updated on March 25, 2012. Studies with women receiving tranexamic acid for HMB were included; randomized controlled studies with a description of appropriate statistical methodology were preferred. Relevant data on the physiology of menstruation and the pharmacodynamics and pharmacokinetics of tranexamic acid are also included.

On the correlation between local fibrinolytic activity in menstrual fluid and total blood loss during menstruation and effects of desmopressin

The primary objective of this study was to investigate the correlation between fibrinolytic activity in menstrual fluid and total menstrual blood loss during menstruation. We also wanted to evaluate the influence of desmopressin nasal inhalation on the local fibrinolytic activity in menstrual fluid. Six women with objectively verified menorrhagia and six women with normal menstrual blood loss were examined. With a slender catheter introduced through the cervical canal, menstrual fluid was collected on the day in the cycle when the most intense bleeding occurred. The fibrinolytic activity in menstrual fluid was measured both as plasmin content using an amidolytic method with chromogenic substrate and with a fibrin plate method. A significant correlation between the amount of menstrual blood loss and fibrinolytic activity was found in menstrual fluid of both groups and with both methods. We could not find an increased fibrinolytic activity in menstrual fluid when the women with menorrhagia were treated with desmopressin nasal inhalation. Knowledge of the local factors influencing monthly blood loss can be valuable when searching for more effective medical treatment of menorrhagia. Apprehension that desmopressin should increase local fibrinolytic activity in menstrual fluid could not be confirmed.

Treatment of increased menstrual blood loss in IUD users

Although bleeding problems represent the commonest side effect of IUDs and an important medical reason for discontinuation of use, its pathogenesis still remains incompletely understood and a standard universally acceptable therapy is not yet available. Proper insertion, change in size, material or shape of the IUD, as well as custom fitting to avoid dimensional incompatibilities, did not significantly improve the IUD-associated bleeding problems. Addition of copper to inert devices seemed to slightly improve the bleeding by reducing the antifibrinolytic activity but probably more was achieved through reducing the device size. Hormone-releasing devices appear to reduce the amount of bleeding significantly but a post-insertion phase of irregular spotting is a common complaint. Locally released antifibrinolytic agents were tried in limited investigations but a short period of drug release restricted further evaluation. Systemic administration of antifibrinolytic agents and non-steroidal anti-inflammatory drugs hold promise for the control of IUD-induced menorrhagia. The duration of bleeding and intermenstrual spotting still remains an unresolved clinical problem that requires further evaluation. This area of clinical concern in IUD use needs more in depth understanding and testing of new agents, particularly in the area of local release of antihemorrhagic agents.

The fibrinolytic enzyme system in normal menstruation and excessive uterine bleeding and the effect of tranexamic acid

The fibrinolytic enzyme system of menstrual and peripheral blood was studied in three groups of women: Group 1, 20 subjects (mean age 37.2 years) with normal menstrual loss; Group 2, 20 patients (mean age 39 years) with dysfunctional uterine bleeding studied before treatment, and Group 3, during treatment with a fibrinolytic inhibitor, tranexamic acid (AMCA) (1 g 8-hourly). The fibrinolytic activity (plasminogen activator and plasmin) of menstrual blood was significantly higher than that of peripheral blood in the three groups (p less than 0.001). Both plasminogen activator and plasmin were higher in the menstrual blood of patients with menorrhagia (Group 2) compared with the control subjects (Group 1) (p less than 0.001 and p less than 0.1 respectively). Treatment with AMCA significantly reduced both plasminogen activator (p less than 0.01) and plasmin (p less than 0.05) in the menstrual blood of patients with menorrhagia (Group 3). No significant differences in fibrinolytic activity were found in peripheral blood between Groups 1 and 2; however, both plasminogen activator and plasmin were significantly lower (p less than 0.01) in Group 3 than in Group 2. Plasmin activity was also significantly lower (p less than 0.05) in Group 3 compared to Group 1. These findings confirm the presence of increased fibrinolytic activity in the uterus in excessive (dysfunctional) bleeding.

Haemostasis in menstrual endometrium in the presence of an intrauterine device

The histology and ultrastructure of the haemostatic response in the endometrium have been studied in 12 uteri containing an inert or copper wound intrauterine contraceptive device (IUCD). The uteri were removed during the premenstrual phase or during the first 96 hours of menstruation. The results have been compared to earlier observations in non-IUCD influenced endometrium. In all uteri the tissue shedding proceeded more slowly in the presence of an IUCD and considerably fewer haemostatic plugs were found. The platelets in these plugs were more loosely packed and less degranulated, and the plugs contained less fibrin than in the absence of an IUCD. Haemostatic plugs were still observed at times when no such plugs were seen in uteri without an IUCD. Unoccluded vessel lesions were regularly seen and vessels open to the shedding surface were occasionally encountered. These observations suggest that IUCD-induced menorrhagia is caused by the combination of delayed shedding and a decreased haemostatic reaction in the endometrium.

Fibrin and platelets in menstrual discharge before and after the insertion of an intrauterine contraceptive device

Eighteen samples of menstrual blood, taken before and after the insertion of an intrauterine contraceptive device (IUD), were collected from the uterine cavity during the first 32 hours of menstruation and studied with light and electron microscopy for the presence of fibrin and platelets. In 12 of the 18 samples extravascular fibrin and platelet aggregates with a high degree of transformation were found. Intravascular thrombi were seen in pieces of tissue in two preinsertion samples. The absence of any intravascular platelets or fibrin was the only consistent difference in postinsertion samples compared to preinsertion samples. This study demonstrates that, contrary to the current belief, clot formation and platelet aggregation do occur in menstrual blood. This process is uninfluenced by the presence of an IUD.