For around five days each month, around nine million British women struggle with severe, long-lasting pain that leaves some unable to work, care for their children or even move around.
I’m referring to menstrual pain, or menstrual cramps, which are severe for two-thirds of those with monthly bleeding, according to the most recent surveys.
As a gynecologist, my job is to offer patients treatments that help their condition and ultimately improve their quality of life.
But when it comes to menstrual pain, family doctors and other health professionals don’t seem to take the same approach.
Most women have never been told that there is a pill that can cut the amount of blood loss in half, thereby dramatically reducing pain.
Studies show that two-thirds of UK women who have periods describe their pain as severe.
It’s called tranexamic acid, it’s a tablet that you take three times a day for up to four days, and it’s available both on prescription and over the counter.
It’s much cheaper on prescription – GPs offer up to 60 tablets for £9.90, compared with a £15 pack of 18 tablets from Boots.
It is also very cheap for the NHS: it costs the health service less than ten pence a pill.
But very few women know this, because medical professionals rarely mention it, according to what I hear from their patients.
And that’s exactly why I decided to write about it last week as part of my weekly newsletter. The Vajenda.
A 2023 report by charity Wellbeing of Women found that half of women who suffer from severe period pain feel that healthcare professionals do not take it seriously.
Much of this is due to the widespread attitude that menstrual periods are “no big deal” and that women are “used” to enduring them.
GP and This Morning host Dr Philippa Kaye agrees: “For too long there has been a perception in society that women have to endure pain,” she says.
‘It’s not just that healthcare professionals fail to inform patients about the options available, but that many women and girls do not even seek help.
“They think it’s normal to be afraid of being away from the bathroom when they have their period.”
But you don’t have to put up with it.
Heavy and painful menstrual periods are not only a nuisance, they can also have serious consequences.
This is because a large loss of blood can lead to anemia or iron deficiency.
Dr. Jen Gunter is often described as the internet’s favorite gynecologist and boasts 293,000 followers on Instagram.
Iron deficiency is a precursor to anemia, which is when a lack of iron results in a lack of healthy red blood cells, affecting energy levels, breathing, heart rate, and a host of other bodily functions.
But many women feel that their anemia is not that serious or that their iron deficiency is completely ignored.
However, iron deficiency is a medical condition in itself and should be treated regardless of whether anemia is present or not.
Research shows that approximately 17 percent of adolescents and women between the ages of 14 and 50 are iron deficient, primarily due to heavy menstrual bleeding.
For girls and young women between the ages of 12 and 21, that figure is a staggering 40 percent.
Since heavier periods are more common during the menopausal transition, iron deficiency should also be on the radar of anyone over 40.
The symptoms of iron deficiency (see chart below) overlap so much with those experienced by many women in the menopause transition, that I think it is essential for women with any of the above symptoms to get tested.
If you’re not menstruating, for example due to a hysterectomy or hormonal IUD, the risk of iron deficiency is certainly lower, but it’s still worth checking.
There are a variety of therapies that can reduce menstrual blood loss, including transaminase.
Tranexamic acid is available over the counter and is taken three times a day.
These include hormones, such as the pill and the IUD (or Mirena intrauterine device), as well as nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen.
However, many women do not want to take hormones, and many people with certain underlying conditions cannot take NSAIDs.
Studies show that they are also not as effective as tranexamic acid.
Tranexamic acid is a synthetic form of the amino acid lysine and reduces bleeding by slowing the breakdown of blood clots in the body.
It is also used in other situations where bleeding is a concern, such as in some surgeries and as a treatment for postnatal hemorrhage.
Tranexamic acid is taken three times a day during menstruation (each dose is usually two 500 mg tablets).
In studies, it reduces menstrual blood loss by up to 50 percent compared to placebo.
Trial participants taking the drug have what is considered a “clinically significant reduction in bleeding,” which essentially means that most people find it very helpful.
There is a theoretical concern that tranexamic acid might increase the risk of dangerous blood clots in the lungs, but most studies have not shown this to be true.
Tranexamic acid has been sold over the counter in Sweden for more than 20 years, where only 1 percent of menstruating women use the drug, yet observational data have not identified an increased risk of blood clots.
Other safety data comes from the use of tranexamic acid for postpartum bleeding. In one study, more than 10,000 women received the drug and there was no increase in blood clots.
However, in Denmark, where researchers tracked records of women prescribed tranexamic acid, they found a very small increased risk of blood clots, meaning that for every 78,549 women taking the drug for five days, one might get a blood clot.
But because these are observational data, we don’t know whether this is a real effect or an artifact, and proving that this is a real effect will be nearly impossible given the number of people who would need to be enrolled in a clinical trial.
What does this mean for you? Most studies don’t show an increased risk, but if there is, it’s likely to be very low — at most, about one in almost 80,000, which is considered very rare.
What about combining tranexamic acid with estrogen-containing oral contraceptives, such as the combined pill?
Since estrogen-containing contraceptives increase the risks of blood clots and stroke, it’s a reasonable question.
According to the US package label, “Women using hormonal contraceptives should use tranexamic acid only if there is a strong medical need and the benefit of treatment will outweigh the possible increased risk of a blood clot.”
But it is important to remember that package labels are legal documents and do not always match evidence-based medicine for a variety of reasons. Also, the benefits of treatment must outweigh the risks of EACH medication.
In a survey of obstetricians and gynecologists in the United States, where the drug is available only by prescription, 64 percent had prescribed tranexamic acid along with estrogen-containing contraceptives during the past year.
Half of these doctors said that at least 50 percent of women who were treated this way had resolution of their symptoms and only one reported a blood clot.
Admittedly, this is not the most accurate way to get the data, but it is clear that many doctors are comfortable prescribing both drugs together.
The potential risks must be put into perspective because heavy bleeding can also have serious medical consequences.
Overall, most experts do not believe that combining tranexamic acid with hormonal contraceptives containing estrogen significantly increases the risk of blood clots.
However, if someone has other risk factors for blood clots in addition to taking an estrogen-containing contraceptive, that might require further discussions with a GP.
People with a history of blood clots or who are considered to be at high risk for blood clots should not take tranexamic acid.
I suspect that many people with heavy bleeding could benefit from the drug, but are missing out because no one has told them about it.
Meanwhile, a drug used to treat erectile dysfunction has become a household name.
Disparity is, well, the height of patriarchy.