Can tranexamic acid (TXA) be used to treat uterine bleeds?

Tranexamic Acid for Uterine Bleeding

Yes, tranexamic acid (TXA) is effective for treating uterine bleeding, particularly for postpartum hemorrhage and heavy menstrual bleeding, with strong evidence supporting its use in reducing blood loss and improving patient outcomes.

Postpartum Hemorrhage

The World Health Organization (WHO) strongly recommends TXA for postpartum hemorrhage:

• Timing is critical: TXA should be administered within 3 hours of birth, as effectiveness decreases by 10% for every 15-minute delay, with no benefit after 3 hours 1
• Dosing regimen: 1g (100 mg/mL) intravenously at 1 mL/min (over 10 minutes), with a second 1g dose if bleeding continues after 30 minutes or restarts within 24 hours 1
• Indication: For clinically diagnosed postpartum hemorrhage (>500 mL after vaginal birth, >1000 mL after cesarean section, or any blood loss compromising hemodynamic stability) 1
• Broad application: Should be given regardless of bleeding cause (uterine atony, genital tract trauma, etc.) 1

TXA should be part of a comprehensive postpartum hemorrhage management protocol that includes uterotonics, fluid replacement, and escalating interventions as needed 1.

Heavy Menstrual Bleeding

TXA is also effective for heavy menstrual bleeding (menorrhagia):

• Effectiveness: Reduces menstrual blood loss by 26-60% 2
• Recommended dosage: 3.9-4 g/day for 4-5 days starting from the first day of menstruation 2
• Comparative efficacy: More effective than NSAIDs, oral progestins, and placebo, though less effective than levonorgestrel-releasing intrauterine systems 2, 3
• Lower dose option: Even at 2 g/day, TXA has shown 60.3% reduction in blood loss, comparable to medroxyprogesterone acetate (57.7%) but with fewer treatment failures 4
• Quality of life: Significantly improves quality of life parameters by 46-83% compared to 15-45% with norethisterone 3

For contraceptive-related bleeding, TXA has been identified as a potential treatment option for heavy bleeding associated with copper IUDs 1.

Safety Considerations

• Contraindications: Active thromboembolic disease, history of thrombosis/thromboembolism, or intrinsic risk for thrombosis 2
• Thrombotic risk: Generally no increased risk of thrombotic events in major bleeding scenarios, though there may be increased risk with gastrointestinal bleeding 5
• Timing: For postpartum hemorrhage, administration beyond 3 hours after birth may be potentially harmful 1
• Administration route: Current recommendations for postpartum hemorrhage apply to intravenous administration only 1

Clinical Algorithm for Uterine Bleeding Management with TXA

1. For postpartum hemorrhage:

   • Administer TXA within 3 hours of birth at first recognition of hemorrhage 1
   • Use alongside standard treatments (uterotonics, fluid replacement) 1
   • Monitor for continued bleeding and administer second dose if needed 1

2. For heavy menstrual bleeding:

   • Start with 3.9-4 g/day for 4-5 days from first day of menstruation 2
   • Consider lower dose of 2 g/day if concerned about side effects 4
   • Evaluate response after 3 months of treatment 4
   • Consider alternative treatments if inadequate response 1

3. For IUD-related bleeding:

   • TXA can significantly reduce blood loss compared to placebo 3
   • Consider as part of management before device removal 1

TXA represents an important tool in managing various forms of uterine bleeding, with strong evidence supporting its efficacy and safety when used appropriately and in a timely manner 5, 6.