What is the recommended treatment for excessive vaginal bleeding?

From the Guidelines

Tranexamic acid is recommended for the treatment of excessive vaginal bleeding, particularly in the context of post-partum haemorrhage, with a dosing regimen of 1 g intravenously, which can be repeated if bleeding continues or restarts within 24 hours. This recommendation is based on the most recent and highest quality study available, which is the updated WHO recommendation on intravenous tranexamic acid for the treatment of post-partum haemorrhage 1.

Key Considerations

• The use of tranexamic acid in excessive vaginal bleeding is supported by evidence from the WOMAN trial, which demonstrated its effectiveness in reducing mortality due to bleeding 1.
• The dosing regimen recommended by the WHO is 1 g intravenously, given over 10 minutes, with a second dose of 1 g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1.
• Tranexamic acid should be given in all cases of post-partum haemorrhage, regardless of whether the bleeding is thought to be due to genital tract trauma or for other reasons, including uterine atony 1.
• In addition to tranexamic acid, other treatment options for excessive vaginal bleeding may include hormonal treatments, such as combined hormonal contraceptives or progesterone-only options, as well as surgical options like endometrial ablation or hysterectomy 1.
• It is essential to identify and address underlying causes of excessive vaginal bleeding, such as fibroids, polyps, or bleeding disorders, as part of comprehensive management 1.

Treatment Options

• Tranexamic acid: 1 g intravenously, given over 10 minutes, with a second dose of 1 g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1.
• Hormonal treatments: combined hormonal contraceptives, progesterone-only options like the levonorgestrel IUD (Mirena), or oral progestins such as norethindrone acetate (5-10mg daily) 1.
• Surgical options: endometrial ablation or hysterectomy may be considered for persistent bleeding unresponsive to medical management 1.

From the FDA Drug Label

To control postpartum bleeding, 10 to 40 units of oxytocin may be added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony Intramuscular Administration – 1 mL (10 units) of oxytocin can be given after delivery of the placenta.

The role of tranexamic acid is not mentioned in the provided drug labels. However, oxytocin is mentioned as a treatment for postpartum bleeding.

• Oxytocin can be administered intravenously or intramuscularly to control postpartum bleeding.
• The dosage of oxytocin for postpartum bleeding is 10 to 40 units added to 1,000 mL of a nonhydrating diluent, administered at a rate necessary to control uterine atony, or 1 mL (10 units) given intramuscularly after delivery of the placenta 2. There is no information about tranexamic acid in the provided drug labels.

From the Research

Treatment for Excessive Vaginal Bleeding

The recommended treatment for excessive vaginal bleeding includes the use of tranexamic acid, which has been proven to be effective in reducing menstrual blood loss by 26%-60% 3.

Role of Tranexamic Acid

• Tranexamic acid is an antifibrinolytic agent that reduces bleeding by inhibiting the breakdown of blood clots 4.
• It is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth, improving the quality of life and reducing the risk of death from postpartum hemorrhage 5.
• The recommended oral dosage is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 3.
• For post-partum haemorrhage, the WHO recommends 1 g tranexamic acid intravenously as soon as possible after giving birth, followed by a second dose if bleeding continues after 30 min or restarts within 24 h since the first dose 4.

Barriers to Access and Myths Surrounding Tranexamic Acid Use

• Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health 5.
• Misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access are some of the barriers to tranexamic acid use 5.

Efficacy and Safety of Tranexamic Acid

• Clinical trials have shown that the efficacy and safety of tranexamic acid for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose 6.
• There is no evidence that tranexamic acid increases the risk of thrombotic events in patients with major bleeding overall, but there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding and seizures with the use of higher doses 6.
• Tranexamic acid is also used for the treatment or prevention of bleeding in other clinical settings, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding 7.