Ms. H, a 36-year-old G0 arrives at the clinic for a focus visit complaining of heavy menstrual bleeding. Her periods are “regular,” occurring monthly, but have become increasingly heavy. She complains that she now “soaks through” her sanitary protection and often passes clots.

Ms. H reached menarche at age 11. Her menses have been regular beginning around age 16. She has taken oral contraceptives in the past for contraception, but these were discontinued as it was discovered that she had a history of migraine with aura. She is not currently in a sexual relationship and does not want hormonal contraception “of any kind.”

Ms. H is well groomed and conversant. She appears frustrated. On physical examination, she is 5’5” tall and weighs 175lbs. Vital signs are good: BP 130/78mm Hg; pulse rate 82bpm.

   Vulva: Normal
   Vagina: Moderate, clear discharge
   Cervix: Clear
   Uterus: Upper limits of normal size, non-tender
   Adnexa: Ovaries palpable, normal size

Ms. H is diagnosed with menorrhagia. A transvaginal ultrasound is scheduled to evaluate her for potential causes (e.g., fibroids, polyps, adenomyosis). A prescription is written for tranexamic acid to manage the heavy bleeding. Based on her CrCl, Mrs. H does not need a dose adjustment and is prescribed 1,300mg three times daily for five days during menses. She is instructed to return to the clinic for follow-up.