Tranexamic Acid and Desmopressin for Heavy Menstrual Bleeding and Their Impact on Iron Level Tests: The West-Central Mexican Experience

Introduction

Heavy menstrual bleeding (HMB) is a cause of iron deficiency anemia (IDA) in patients with von Willebrand disease (vWD). HBM has a concrete definition and causes a decrease in the quality of life (Am J Obstet Gynecol 2009;201:12.e1-12.e8 and Blood 2018;132:2134-2142). We reported treatment of IDA in patients with vWD and HMB with iron replacement, hormonal therapy, tranexamic acid (TxA) and desmopressin (Blood (2022) 140 (Supplement 1): 11332–11333). There are different approaches to treat HBM improving quality of life and prevent IDA (Haemophilia 2021;27 Suppl3:66-74 and Blood Adv 2022;6:228-237). Here we report our experience for this issue.

Objectives

Valuate the efficacy of TxA or desmopressin alone and in combination to decrease HMB and improve quality of life in patients with vWD, and the impact on the iron level tests.

Material and Methods

Prospective study from January 2022 to December 2023 of women with type 1 vWD previously identified from our database, with HMB assessed with pictorial blood loss assessment chart (Gynecol Surg 2015;12:157-163). All completed treatment for IDA and had a normal CBC and iron level tests. Randomized to receive 12 cycles of: A) oral TxA 1300 mg tid for five days initiating the first day of menstruation, B) desmopressin 0.3 mcg/kg SC on days 1 and 3 of menstruation, and C) combination of TxA and desmopressin same days as first and second group. Improvement of HMB assessed with the chart in everyone from 12 cycles. Quality of life improvements were asked to measure the percentage of normal physical, emotional and social activities. Iron level tests were measure at randomization and one month after the end of treatment.

Results

Ten women assigned to each arm of treatment (A, B or C), age from 18 to 54, median in each group: 32, 34 and 31 years old, and all received 12 months of treatment. The daily score from the pictorial chart before treatment was more than 100 points in all patients. The daily score from the 12 cycles diminishes in Group A to an average of 90 points, group B to 60 points and group C to 40 points; the days with menstruation diminished in 50% in all groups, from a 10 to 5 days. The percentage of normal quality of life reaches 100% in all groups from cycle 2 to the end of treatment; group C had the most confidence to have exhausting physical activities (ie: hiking, biking, running long distances, etc) during menstrual period as related to the daily bleeding score. Iron serum levels, transferrin saturation and ferritin were maintained along the study in all groups, mean of 96 mcg/dL, 37% and 81 ng/mL respectively. No thrombotic event was identified and the D-Dimer levels never reach double upper limits.

Conclusions

Use of TxA and desmopressin alone or in combination in our population provides a useful strategy to diminish HMB. The use of two doses of desmopressin provides an extra protection due an increase of vW factor levels along the menstrual period. An objective tool to demonstrate de reduction of HMB is the chart and it incorporation in the daily practice is advised. Combination therapy had the better outcome, allowing the patients had a normal life even with high energy activities, following the two doses of desmopressin and in third place the Txa treatment. There are other options for HMB (Blood Adv 2023;7:7501-7505): plasma derived products, recombinant vW factor, bridging therapies as emicizumab, investigational (rondoraptivon pegol, VGA039, HMB-001 and platelet inspired hemostatic nanoparticles), but these have high financial costs or are not available in clinical trial in developing countries. We recommend the use of these drugs to provide either of the treatments, as they are easy to administrate low cost access and have a good security profile. This is an original report from Mexico, no other results were find in PubMed.