Would you consider anti-fibrinolytics for heavy menses in patients with a history of VTE?

A recent review article provided reassuring evidence about the combined use of antifibrinolytics and estrogen in women with heavy menstrual bleeding (Meschino et al., PMID 40680937); however, it did not specifically provide data in women with a prior history of VTE. In this case, I would first ensure there isn't an underlying bleeding disorder (like VWD) that could be managed with specific treatments. I would then gather more information about the prior VTE history. If the VTE was clearly provoked and there are no other risk factors for thrombophilia, I would not hesitate to prescribe tranexamic acid for heavy menses. On the other hand, if the VTE was triggered by a weak provoking factor (like travel) or was unprovoked, or if there are risk...