What is the role of TXA in dysfunctional uterine bleeding?
Bottom line up top: Tranexamic acid (TXA) is a safe and effective treatment for dysfunctional uterine bleeding (DUB).
Clinical scenario
A 23-year-old woman presents with heavy vaginal bleeding for 2 weeks and lightheadedness today. She has a history of heavy, prolonged periods and has needed blood transfusions several times. Vitals: HR 74, BP 105/65, SpO₂ 100% on room air, afebrile. Her pregnancy test is negative and her hemoglobin is 6.2 g/dL. You transfuse one unit of PRBCs. As you prepare to discharge her, she asks whether anything can prevent this from happening again.
What your gut says: There is not much more to do from the ED besides referring her to gynecology.
What the evidence says
Accepted treatments for DUB include surgical options (endometrial ablation, hysterectomy) and medical therapy (hormonal therapy, NSAIDs, and TXA). ACOG recommends TXA for both acute and chronic DUB in non-pregnant, reproductive-aged women.
Acute DUB
First-line therapy is hormonal, given orally or intravenously depending on the case. Hormonal treatments are highly effective (DeVore 1982; Munro 2006) and are typically started with gynecology.
TXA is an adjunct: 1.3 g PO, or 10 mg/kg IV (max 600 mg/dose), every 8 hours (ACOG 2013).
If these treatments fail, operative or interventional management is often needed. In the ED, bleeding can be temporized with a balloon tamponade device (for example, Bakri balloon) or a vacuum-induced hemorrhage control device (for example, JADA).
Chronic DUB
Hormonal therapy is also first-line and can be started in the ED after assessing thrombotic risk. Options include oral contraceptives (most commonly used from the ED), IUDs, and IM progestin.
TXA can be used with hormonal therapy, or alone when hormones are contraindicated or not tolerated.
TXA reduces bleeding in chronic DUB by 30–55% (Lethaby 2000; Lukes 2010).
Typical dosing: 1–1.5 g PO three times daily for 5 days during menstruation.
Safety data at this dose are reassuring: minimal increase in minor adverse events and no reported increase in thromboembolic disease (Bryant-Smith 2018).
Clinical bottom line
TXA is safe and effective. Consider prescribing TXA 1–1.5 g PO TID for 5 days during menstruation for patients with DUB. It can be combined with oral contraceptives.
Clinical pearls
Stabilize first: transfuse as needed and start hormonal therapy for acute bleeding, in conjunction with gynecology.
TXA is an ED-prescribable option that can cut menstrual blood loss by about a third to a half.
Screen for thrombotic risk before starting estrogen-containing therapy.
References
DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding: a double-blind randomized control study. Obstet Gynecol. 1982;59:285–291. PMID: 6281704
Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2006;108:924–929. PMID: 17012455
Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. ACOG Committee Opinion. Obstet Gynecol. 2013;121(4):891–896. PMID: 23635706
Lethaby A, et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4). PMID: 11034679
Lukes AS, et al. Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:865–875. PMID: 20859150
Bryant-Smith AC, et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018. PMID: 29656433
