Advice for cardiology healthcare professionals: management of abnormal uterine bleeding in women with heart disease
- Tranexamic acid is an anti-fibrinolytic medication which acts by preventing the breakdown of fibrin blood clots and it has been shown to reduce menstrual blood loss (Lukes et al., 2011).
- Use in heart disease: The POISE-3 trial examined a one off intravenous (IV) dose of tranexamic acid use in patients undergoing non-cardiac surgery (Devereaux et al., 2022). The primary safety outcome was a composite of myocardial injury, peripheral arterial thrombosis, ischaemic stroke and proximal venous thromboembolism. This outcome occurred in 14.2% of the patients who received tranexamic acid and 13.9% of those that received placebo (hazard ratio=1.02; 95% confidence interval 0.92 to 1.14). The Atacas trial of one dose of IV tranexamic acid in cardiac surgery found that a composite of death and thrombotic complications within 30 days of surgery, occurred in 16.7% of the tranexamic acid group and in 18.1% of the placebo group (relative risk=0.92; 95% CI 0.81 to 1.05) (Myles et al., 2017). A systematic review and meta-analysis of IV tranexamic acid use in surgery found no increased risk of intravascular thrombotic events (Taeuber et al., 2021).
- Prescribing: It should be noted that these studies used IV preparations and one-off dosing of tranexamic acid around the time of surgery. For use in heavy menstrual bleeding, an intermittent dosing regimen of oral medication is recommended (1g oral, three times daily for days 1-5 of menstruation.) Prescribe short term only at time of issue and do not continue as repeat prescription. Regular or cyclical use of tranexamic acid is inappropriate in women at high risk of thrombotic events. This includes those on anticoagulants for cardiac disease. In women with an ongoing need for anticoagulation an alternative strategy may be required. Emergency use of tranexamic acid for catastrophic bleeding is not within the scope of this guidance.
First line treatment options to reduce risk of anaemia in patients with AUB and heart disease whilst awaiting further investigations
First line medical treatments should be offered to those with heavy or frequent menstrual bleeding who are at risk of/or have, iron deficiency or iron deficiency anaemia and include non-hormonal and hormonal medications (see table below).
For each of the personal characteristics or medical conditions considered by the UKMEC a Category 1, 2, 3 or 4 is given, defined in the summary of UKMEC risk categories for use of contraception. The College of Sexual and Reproductive Healthcare (CoSRH) Medical Eligibility Criteria for Contraceptive Use (UKMEC) guidelines 
can be used to guide risk profile when choosing contraception (CoSRH, 2025).
Please note that the table below may need to be scrolled horizontally or vertically in order to view all information, depending on your device.
| Combined hormonal contraception (avoid in patients who are high risk of endometrial pathology***) | Progestogen only pill | Levonorgestrel intrauterine device | Tranexamic acid | NSAID | |
| Example prescription | Ethinylestradiol 20 micrograms, Desogestrel 150 micrograms oral, once daily for 21 days, 7-day pill-free interval and re-commence. | Desogestrel, 75 micrograms oral, once daily continuously. | Can be fitted at some GP practices or self referral to Family Planning service. | Tranexamic acid, 1g oral, three times daily during days 1-5 of menstruation. | Ibuprofen, 400mg oral, three to four times daily during menstruation. |
| Current/history of VTE | 4 | 2 | 2 | *See text for considerations in heart disease. | **See text for considerations in heart disease. |
| Known thrombogenic mutation | 4 | 2 | 2 | ||
| Family history of VTE (First degree relative) |
<45 years 3 >45 years 2 |
1 | 1 | ||
| Multiple risk factors for CVD (such as smoking, diabetes, hypertension, obesity and dyslipidaemias) | 3 | 2 | 2 | ||
| Known dyslipidaemias | 2 | 2 | 2 | ||
| Atrial fibrillation | 4 | 2 | 2 | ||
| Long QT [C-continuation; I-initiation] | 2 | 1 |
I-3 C-1 |
||
| Cardiomyopathy (normal cardiac function) | 2 | 1 | 1 | ||
| Cardiomyopathy (impaired cardiac function) | 4 | 2 | 2 | ||
| Uncomplicated valvular and congenital heart disease | 2 | 1 | 1 | ||
| Complicated valvular and congenital heart disease (eg: pulmonary hypertension, history of subacute bacterial endocarditis) | 4 | 1 | 2 | ||
| Adequately controlled hypertension | 3 | 1 | 1 | ||
|
Systolic BP>140 to 159mmHg or diastolic BP>90 to 99mmHg |
3 | 1 | 1 | ||
| Systolic BP≥160mmHg or diastolic BP≥100mmHg | 4 | 1 | 1 | ||
| Vascular disease | 4 | 2 | 2 | ||
| Current and history of ischaemic heart disease [C-continuation; I-initiation] | 4 |
I-2 C-3 |
I-2 C-3 |
- NSAIDs (including naproxen, ibuprofen and mefenamic acid) have been shown to be more effective than placebo at reducing HMB in a Cochrane review and meta-analysis but are less effective than tranexamic acid and the levonorgestrel-releasing intrauterine system (Lethaby et al., 2013).
- Use in heart disease: Caution may be required when prescribing NSAIDs to those with heart disease and is generally avoided in those with history of myocardial infarction on dual anti-platelet therapy. NSAID use has been linked to increased rates of myocardial infarction when compared with placebo (Trelle et al., 2011). In a meta-analysis involving over 400,000 cases of atrial fibrillation, NSAID use was associated with a 12% increased risk of atrial fibrillation when compared to non-users (RR 1.12, 95% CI 1.06–1.18) (Liu et al., 2014). Use of NSAIDs is not recommended in the presence of heart failure. In a meta-analysis of data from randomized studies, a twofold increase in the risk of heart failure was associated with all NSAIDs (compared with non-use) ( CNT Collaboration et al., 2013).
- Prescribing: Caution may be required when interpreting these findings in the context of NSAID use for heavy menstrual bleeding. Where data is available regarding NSAID dose in the trials included in these meta-analyses, it appears that NSAIDs were taken continuously and some trials used high-dose preparations. For use in heavy menstrual bleeding, an intermittent dosing regimen is recommended (ibuprofen: 400mg oral, three-four times daily for days 1-5 of menstruation, mefenamic acid: 500mg oral, 8 hourly daily for up to 5 days of menstruation.)
High risk for endometrial pathology (as per NICE guidelines): persistent intermenstrual or persistent irregular bleeding, women with infrequent heavy bleeding who are obese or have polycystic ovary syndrome, women taking tamoxifen, women for whom treatment for HMB has been unsuccessful.