What is the role of Tranexamic acid (TXA) in gynecology surgery?

Tranexamic Acid in Gynecologic Surgery

Tranexamic acid should be administered prophylactically at 1g IV over 10 minutes at the start of benign gynecologic surgery to reduce blood loss, transfusion requirements, and reoperations due to hemorrhage. 1, 2, 3

Standard Dosing Protocol for Gynecologic Surgery

• Administer 1g IV bolus over 10 minutes at the start of surgery, prior to incision 1, 2, 3
• For procedures expected to exceed 2-3 hours, consider maintenance infusion of 1g over 8 hours 2
• The loading dose of 15 mg/kg used in some myomectomy studies showed no benefit, suggesting the standard 1g fixed dose is preferable 4

Evidence-Based Benefits in Benign Gynecologic Surgery

Hysterectomy:

• Reduces intraoperative blood loss by approximately 36-40% (100 mL vs 166 mL objectively measured) 3
• Decreases incidence of blood loss ≥500 mL from 12.7% to 3.6% (absolute risk reduction 9.1%) 3
• Reduces reoperations for postoperative hemorrhage by 4.2% (number needed to treat = 24) 3
• Reduces need for rescue open-label TXA administration 3

Myomectomy:

• Evidence is mixed: one high-quality RCT showed no significant reduction in blood loss for laparoscopic/robotic myomectomy (200 mL vs 240 mL, p=0.88) 4
• However, other studies in abdominal myomectomy demonstrate benefit 5
• Consider using TXA for open myomectomy or cases with high bleeding risk (fibroids ≥10 cm, ≥5 total fibroids, intramural fibroids ≥6 cm) 4, 5

Critical Timing Considerations

• Administer at surgical start, not after bleeding begins - prophylactic use is the evidence-based approach for elective surgery 3
• For acute hemorrhage scenarios (e.g., postpartum hemorrhage), the 3-hour window applies: efficacy decreases 10% for every 15-minute delay 1, 2
• Administration beyond 3 hours in acute bleeding may paradoxically increase bleeding death risk 2

Safety Profile in Gynecologic Surgery

• No thromboembolic events or deaths occurred in the largest gynecologic surgery RCT (332 patients) 3
• Meta-analysis of over 125,550 patients across surgical specialties shows no increased risk of arterial or venous thrombotic events 2
• Well-tolerated with nausea and diarrhea as most common side effects 6
• Higher doses (>4g/24h) are associated with increased seizure risk, but standard gynecologic dosing (1g bolus) avoids this concern 2, 7

Contraindications Specific to Gynecologic Patients

Absolute contraindications:

• Active thromboembolic disease or history of thrombosis 7
• Active intravascular clotting or DIC 2
• Severe hypersensitivity to TXA 2

Relative contraindications requiring caution:

• Patients on oral contraceptive pills (increased baseline thrombotic risk) 2
• Atrial fibrillation or known thrombophilia 8
• Severe renal impairment (requires dose adjustment as TXA is renally excreted) 1, 2

Clinical Implementation Algorithm

1. Screen all patients scheduled for benign hysterectomy or open myomectomy for contraindications 3
2. Administer 1g IV TXA over 10 minutes, 20 minutes before incision 3
3. For laparoscopic/robotic myomectomy, consider TXA only in high-risk cases (large/multiple fibroids) given mixed evidence 4
4. Monitor for bleeding complications - TXA reduces but does not eliminate hemorrhage risk 3
5. Adjust dose in renal impairment (GFR <50 mL/min requires dose reduction) 8

Key Clinical Pitfalls to Avoid

• Do not wait for bleeding to occur - TXA is most effective when given prophylactically before surgical incision 3
• Do not use topical TXA as substitute for IV administration - systemic fibrinolysis requires systemic coverage 2
• Do not assume all minimally invasive procedures benefit equally - evidence for laparoscopic/robotic myomectomy is weaker than for open procedures 4
• Do not overlook thrombotic risk factors - screen for history of VTE, current oral contraceptives, and thrombophilia before administration 2, 7

Additional Gynecologic Applications

Heavy menstrual bleeding (non-surgical):

• TXA 1g orally 3-4 times daily during menstruation reduces menstrual blood loss by 34-58% 6
• Superior to placebo and oral progestins, equivalent to combined oral contraceptives 5
• Provides nonhormonal alternative for women who cannot or prefer not to use hormonal therapy 5