Is tranexamic acid appropriate for treating acute uterine bleeding, and what are its dosing and contraindications?

Tranexamic Acid for Uterine Bleeding

Yes, tranexamic acid is highly effective and recommended for specific types of uterine bleeding, particularly postpartum hemorrhage and heavy menstrual bleeding, but the indication, timing, and contraindications differ significantly between these conditions.

Postpartum Hemorrhage (Primary Indication)

Tranexamic acid is strongly recommended by WHO for postpartum hemorrhage and should be administered within 3 hours of birth as a life-saving intervention. 1

Dosing Protocol

• First dose: 1 g IV over 10 minutes (at 1 mL/min) 1, 2
• Second dose: 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• Administer as soon as possible after diagnosis of PPH (blood loss >500 mL vaginal birth or >1000 mL cesarean section) 3

Critical Timing Considerations

• Efficacy decreases by 10% for every 15-minute delay in administration 1
• No benefit after 3 hours post-birth 1
• Potentially harmful if given beyond 3 hours after delivery 1

Scope of Use in PPH

• Give for all causes of PPH, including uterine atony and genital tract trauma 1, 3
• This represents a broader indication than previous recommendations that limited use to cases where uterotonics failed 1
• Should be part of comprehensive PPH management alongside fluid replacement, uterotonics, and escalating interventions 1, 3

Heavy Menstrual Bleeding (Non-Pregnancy)

Tranexamic acid is effective for heavy menstrual bleeding, reducing blood loss by 26-60% and significantly improving quality of life. 4, 5

Dosing for Menorrhagia

• 3.9-4 g/day orally for 4-5 days starting from the first day of menstruation 4
• Reduces menstrual blood loss by 34-54% in idiopathic menorrhagia 5
• Improves quality-of-life parameters by 46-83% 5

Efficacy Evidence

• More effective than placebo, NSAIDs, oral progestins, and etamsylate 4
• Reduces blood loss by 70% in menorrhagia secondary to intrauterine devices 5
• Limited but potentially beneficial data for fibroid-related menorrhagia 5

Absolute Contraindications

Do not use tranexamic acid in patients with:

• Active thromboembolic disease 1, 4
• Known thromboembolic event during pregnancy 1, 2
• History of thrombosis or thromboembolism (US labeling) 4
• Intrinsic risk for thrombosis or thromboembolism (US labeling) 4

Critical Exclusions

Tranexamic acid is NOT indicated for:

• First or second trimester miscarriage 6
• Incomplete abortion or bleeding from retained products of conception 6
• Any pregnancy loss before viable delivery 6

The WHO recommendation and WOMAN trial established efficacy specifically for postpartum hemorrhage, not for pregnancy loss 6. There is no evidence supporting its use in early pregnancy bleeding, and the 3-hour window applies only to post-delivery hemorrhage 6.

Safety Profile

Thrombotic Risk

• No increased thromboembolic events reported in multiple studies of menorrhagia 4, 5
• One case-control study suggested 3-fold higher risk of deep vein thrombosis in women taking tranexamic acid for menorrhagia, but with wide confidence intervals (0.7-15.8) 7
• Trials in severe hemorrhage have not shown increased thrombosis risk 7
• The thrombotic risk appears acceptable in life-threatening bleeding but is less well-documented for non-severe bleeding 7

Administration Route

• IV route only for postpartum hemorrhage 1, 2
• Oral route appropriate for heavy menstrual bleeding 4
• Benefits and harms of non-IV routes in PPH remain a research priority 1, 2

Common Pitfalls to Avoid

• Do not delay administration in postpartum hemorrhage—every 15 minutes matters 1
• Do not give beyond 3 hours after birth in PPH cases 1
• Do not use for early pregnancy bleeding or miscarriage 6
• Do not withhold in PPH regardless of bleeding etiology (trauma vs. atony) 1, 3
• Do not use IM route for postpartum hemorrhage—IV only 2