What is the role of Tranexamic Acid (TXA) in managing vaginal bleeding?

From the Guidelines

Tranexamic acid (TXA) should be used to manage vaginal bleeding, particularly in the context of post-partum haemorrhage, as it has been shown to reduce maternal death due to bleeding when administered early, within 3 hours of birth, at a dose of 1 g intravenously, with a potential second dose if bleeding continues or restarts 1.

Key Points

• TXA works by inhibiting fibrinolysis, thereby stabilizing clots and reducing blood loss, making it particularly useful in cases of excessive bleeding caused by increased fibrinolytic activity.
• The WOMAN trial, a large randomised, double-blind, placebo-controlled trial, demonstrated the efficacy of early intravenous TXA in reducing maternal death due to bleeding in women with clinically diagnosed post-partum haemorrhage 1.
• The World Health Organization (WHO) strongly recommends the early use of intravenous TXA, in addition to standard care, for women with clinically diagnosed post-partum haemorrhage following vaginal birth or caesarean section, with a fixed dose of 1 g intravenously, and a second dose of 1 g if necessary 1.

Administration and Dosage

• The recommended dose is 1 g intravenously, given over 10 minutes, with a potential second dose if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of completing the first dose.
• It is essential to administer TXA early, within 3 hours of birth, to optimize benefits in the context of post-partum haemorrhage.

Considerations

• TXA is generally well-tolerated, but caution should be exercised in patients with a history of thromboembolism, renal impairment, or those taking hormonal contraceptives.
• Side effects may include nausea, diarrhea, and headache.
• TXA should not replace investigation of underlying causes of abnormal vaginal bleeding, which may include fibroids, endometriosis, polyps, or malignancy.

From the Research

Role of Tranexamic Acid (TXA) in Managing Vaginal Bleeding

• Tranexamic acid is an effective treatment for heavy menstrual bleeding (HMB), reducing menstrual blood loss by 26%-60% 2.
• It is also used to manage postpartum hemorrhage, reducing deaths due to bleeding with no increase in thromboembolic events 3.
• The recommended oral dosage for HMB is 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle 2.
• For postpartum hemorrhage, the WHO recommends 1 g tranexamic acid intravenously as soon as possible after giving birth, followed by a second dose if bleeding continues or restarts 3.

Efficacy and Safety of TXA

• TXA has been shown to improve the quality of life of women treated for HMB 2.
• It is generally well-tolerated, with few and mainly mild adverse effects 2.
• There is no evidence of an increase in the incidence of thrombotic events associated with its use in most clinical contexts 2, 3, 4.
• However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding and seizures with higher doses 4.

Barriers to Access and Myths Surrounding TXA Use

• Despite its benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health 5.
• Barriers include structural sexism, period poverty, misinformation, stigmatization of vaginal blood loss, and drug access 5.
• Education and awareness are necessary to address these barriers and ensure that TXA is used effectively to manage vaginal bleeding 5.