CONTENTS:
Treatment Of Heavy Menstrual Bleeding (HMB) With Tranexamic Acid (TXA)
In this month’s e-News, Michelle Sholzberg, MD, Hematologist and Medical Director of the Coagulation Laboratory at St. Michael’s Hospital in Toronto, Ontario, Canada, shares insights on the benefits of using tranexamic acid (TXA) to treat heavy menstrual bleeding (HMB), a condition many women with ITP suffer with. Dr. Sholzberg highlights the evidence-based benefits and risks of using TXA on women’s health in addition to understanding the barriers to accessing TXA. HMB can come with consequences, including the risk for iron deficiency leading to iron deficiency anemia. These consequences are common, and the impacts are often underestimated.
HMB is defined as having a menstrual bleed longer than 8 days, soaking through one or more pads/tampons every two hours on multiple days including the need to change a pad/tampon during the night, repeated passing of blood clots, and losing over 80 ml of blood during the menstruation cycle. Due to a lack of knowledge and comfort that patients and health care providers have in discussing menstrual bleeding, only 4 out of 10 women with HMB seek treatment and management options.
Dr. Sholzberg notes that TXA is proven to be an effective treatment for HMB. TXA reduces menstrual blood loss by 26-60% and is significantly more effective than nonsteroidal anti-inflammatory drugs and hormonal therapies, which are both often used to treat HMB. Dr. Sholzberg comments that TXA has been shown in clinical trials to improve overall health-related quality of life in women with HMB, reduce missed days at work/school, is not very expansive, and has few side effects. She recommended that TXA be considered part of standard medical care for women with HMB. However, she also indicated that TXA may increase the risk of thrombosis (blood clots) in women who are taking oral contraceptives.
Comments from PDSA Medical Advisors
There is a normal process by which once blood clots are formed, they are broken down called ‘clot lysis’. One cause of bleeding is a rapid break-down of clots. The genital-urinary tract is rich in enzymes that promote removal of clots. TXA is a drug that slows the rate of lysis and can therefore reduce the intensity and duration of menstrual bleeding in some women. It is also good for bleeding in the mouth and in the nose. TXA is taken at the time of menses and then stopped. TXA does not raise the platelet count and may be of limited benefit to women who are experiencing HMB due to very low platelet counts. However, it can help reduce the need for treatment of ITP when the predominant symptom is HMB. As noted by Dr. Sholzberg, TXA is associated with a low risk of clotting. Other side effects associated with TXA are uncommon.
Ask the Experts
In this month’s e-News, PDSA Medical Advisors James Bussel, MD, Douglas Cines, MD, Terry Gernsheimer, MD, David Kuter, MD, DPhil, Howard Liebman, MD, and John Semple, PhD answer patient questions about various topics important to the ITP and other platelet disorders community.
Q: Do you find a relationship between ITP and osteoporosis. I had chronic ITP for years but never required treatment until starting on an osteoporosis medication, Prolia®. The platelets dropped both times after Prolia® injection.
A: We are not sure if there’s a link between osteoporosis and ITP. In some cases, too much steroid medication (like prednisone) could increase the risk of osteoporosis, but the writer of this question was not on ITP treatment.
Prolia is an antibody-based medication that targets a pathway to limit the production of cells that ‘eat’ bone. Therefore, from a mechanistic standpoint, there doesn’t seem to be a reason for Prolia to cause ITP. Cells that build bone, called osteoblasts, and cells that ‘eat’ bone, called osteoclasts, go back and forth via the macrophage, an immune cell that is also involved in ITP. However, beyond that there doesn’t seem to be much overlap. When something rare like that happens though, make sure your doctor records it.
Q: I have a support group in Florida and about a month ago I lost one of my members. They were told that their red blood cells attacked her platelets or vice versa, how common is that?
A: About 1/5 of ITP patients also have antibodies against their red blood cells, though most of these antibodies aren’t causing your red blood cells to be destroyed. However, there are some cases where these red blood cell antibodies become very aggressive, giving what’s called warm antibody hemolytic anemia. In rare cases, this hemolysis (red blood cell destruction) occurs so rapidly that the patient cannot be supported by blood transfusions. This being said, it isn’t the platelet that attacks the red blood cell, but rather the immune system and the antibodies.
There’s also a condition called Evan’s syndrome, where patients present with hemolytic anemia (low red blood cell count) as well as thrombocytopenia (low platelet count). This is also a possibility.
Q: In your experience, how do second opinions work logistically in terms of insurance? Who’s paying? How does insurance cover that? How do we help influence whether a second opinion in worthwhile?
A: Insurance companies almost always pay for a second opinion as long as the primary care physician writes a referral for it.
If you have a question that you would like answered by one of PDSA’s medical advisors or other ITP experts, please email your question to: pdsa@pdsa.org and enter “Ask the Experts” in the subject line.