Heavy menstrual bleeding but also “normal” menstruation are the main reasons why women are prone to iron deficiency while men are not. The menstruating women looses every month between 50 and 150 mg of iron, depending on the quantity and duration of menstrual loss. It is known that iron therapy alone does not compensate sufficiently these iron losses. Various additional measures can be taken, e.g. influencing prostaglandin synthesis, influencing the clotting of the blood, using gestagen-containing intrauterine devices or using surgical interventions.

The study by Muse et al. shows that tranexamic acid (TA), taken on a regular basis, improves hemoglobin and ferritin levels in women with heavy menstrual bleeding (HMB). The fact that TA reduces blood loss by inhibiting fibrinolysis is well known. The novel aspect in this study is that a new TA formulation was developed that has a good tolerability profile. Actually, this is mandatory because women have to take three tablets a day over 5 days every month during more than two years (27 cycles) to increase their haemoglobin concentration by 0.71 g/dL and their ferritin by 5.34 µg/L ! While this is certainly statistically significant, what does it mean clinically? That a woman with a ferritin below 10 µg/L will have a ferritin around 15 µg/L after 27 cycles. Today we know that with a ferritin of 15 µg/L this lady will not show any improvements of life quality or symptoms if she is iron deficient. The figures show nicely that additional iron has no or a very limited effect on the parameters, since absorption is low and compliance is poor.

The conclusion is that HMB is certainly a morbidity factor in women but improvement concerning iron losses and iron stores can only be achieved by a) considerably reducing blood loss; b) considerably increasing iron supply, not only with oral iron but also intravenous iron and nutrition counselling. The main issue is to reduce blood loss and TA alone has surely an effect but in many cases will not be sufficient. However, it is the merit of this study to show that the new TA preparation is safe and has a certain effect. Therefore, the clinician should have its use in mind as an additive to a multimodal approach.

– Christian Breymann