Management of Menorrhagia Associated With Chemotherapy-Induced Thrombocytopenia in Women With Hematologic Malignancy

Jill S. Bates, Pharm.D., M.S.; Larry W. Buie, Pharm.D.; C. Brock Woodis, Pharm.D.


Pharmacotherapy. 2011;31(11):1092-1110. 

In This Article

Recommendations for Treatment Options

Many women undergoing chemotherapy may not have effective or timely prophylaxis against menorrhagia for a variety of reasons and may experience heavy menstrual bleeding. For many years, the mainstay of therapy to control menstrual bleeding has been hormonal therapies, specifically high-dose oral contraceptive pills or progestins. However, the data for use of these agents are sparse. The most robust data available for the treatment of menorrhagia are for tranexamic acid. Most women receiving the treatment in randomized trials experienced meaningful reductions in menstrual bleeding, and this translated into improved quality of life. Although there is some concern of increased risk of thrombosis with use of tranexamic acid, the risk was not observed in clinical trials. Again, it should be pointed out that these trials were not conducted in patients with cancer or women who had abnormal uterine bleeding due to thrombocytopenia. However, the data are relevant because of the meaningful reductions in blood loss and very few adverse events associated with the therapy.

Table 6 provides a management strategy for the prophylaxis and treatment of menorrhagia in patients with hematologic malignancies. For women receiving hormonal therapy, the estrogen components can be escalated to high doses (ethinyl estradiol ≥ 50 μg/day). Likewise, extended courses of progestin therapy can be given until cessation of menses occurs, then maintenance therapy can be started. For those who are nonresponsive to higher doses of oral estrogen, progestin, or antifibrinolytic therapy, a short course of intravenous conjugated estrogens is indicated to stop bleeding. Once bleeding has stopped, another means for suppressing menses that should be started is a GnRH analog with progestin overlap. Intravaginal danazol, desmopressin, and rFVIIa should be reserved for patients who are refractory to more conventional therapies. Because of the risk of thrombosis, rFVIIa should not be used without careful consideration in patients at risk.


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