HPE HPE 85 – Spring 2017 - Page 54

Practical therapeutics needs be individualised based on each woman’s unique clinical circumstance. Non-hormonal pharmacological treatment Tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs) are the two most commonly used non- hormonal medications for bleeding and pain associated with uterine fibroids. Tranexamic acid is a synthetic antifibrinolytic agent and it is often the first line medication for management of menorrhagia in primary care setting. 5–7 52 Evidence Eder et al 7 evaluated the efficacy and safety of oral, modified-release tranexamic acid in women with heavy menstrual bleeding and fibroids. In women with and without fibroids, mean menstrual blood loss was reduced compared with placebo across all treatment cycles (p<0.001). Within the tranexamic acid group, more statistically significant (p<0.001) reductions in blood loss occurred in women with fibroids than in those without fibroids. Adverse events were similar between treatment groups. Concerns have been raised about possible increased risk of venous thromboembolism with tranexamic acid, however the data available so far have been reassuring. A systematic review included 10 trials involving the efficacy of tranexamic acid for the treatment of heavy uterine bleeding. 8 Pregnant, post-menopausal and cancer patients were excluded. The results indicated that tranexamic acid therapy in women with idiopathic menorrhagia resulted in 34–54% reduction in menstrual blood loss. Following tranexamic acid treatment, patient’s quality of life parameters improved by 46–83% compared with 15–45% for norethisterone treatment. When compared with placebo, tranexamic acid use significantly decreased the blood loss by 70% in women with menorrhagia secondary to an intrauterine device (p<0.001). Limited evidence indicated potential benefit in fibroid patients with menorrhagia. No thromboembolic event was reported in all studies analysed. 8 Overall, the data on the therapeutic efficacy of tranexamic acid in patients with symptomatic uterine fibroids are limited and further studies are needed to better define its role in fibroid management. NSAIDs such as mefenemic acid have hospitalpharmacyeurope.com been effective in reducing heavy menstrual bleeding and dysmenorrhoea in women without fibroids; 9,10 however, there are no robust studies showing similar benefits of NSAIDs for menorrhagia in women with uterine fibroids. A systematic review investigated the effectiveness of NSAIDs in achieving a reduction in menstrual blood loss in women of reproductive years with heavy menstrual bleeding and included 18 randomised controlled trials (RCTs). 9 The authors concluded that NSAIDs reduced heavy menstrual bleeding when compared with placebo but were less effective than tranexamic acid, danazol or levonorgestrel intrauterine system. In the limited number of small studies suitable for evaluation, no significant difference in efficacy was demonstrated between NSAIDs and other medical treatments such as oral luteal progestogen, ethamsylate, contraceptive pill or the Progestasert intrauterine system. 9 Combined and progesterone-only contraceptives A review of the epidemiological and clinical evidence for the association between oral contraceptives and uterine fibroids suggests that both combined and progesterone-only contraceptives may decrease t