Tranexamic Acid for Heavy Menstrual Bleeding Associated with Leiomyomas (AUB-L)
Key Points
General Considerations
For reproductive-aged girls and women with HMB in association with leiomyomas (AUB-L), orally administered tranexamic acid (TXA) is a viable option, regardless of whether or not the individual is trying to conceive.
TXA is a synthetic lysine-analogue antifibrinolytic that addresses the excess plasminogen activator-induced fibrinolytic activity typically found in individuals with AUB-E, one that may be shared by those with AUB-LSM (Ng, 2015). While there have been many robust randomized trials evaluating the impact of TXA in what we understand to be AUB-E, few have evaluated AUB-L and we are unaware of any that have evaluated the utility in specific leiomyoma phenotypes, in particular submucous tumore. In two clinical trials of women with AUB-L, TXA reduce menstrual volume in patients with leiomyomas by 30-40 percent, similar to the impact on women without fibroids (Eder et al., 2013). Unfortunately these results don’t allow for conclusions regarding the outcomes with submucous myomas. In patients with HMB secondary to primary endometrial disorders (HMB), robust evidence of 40 to 50% reduction in menstrual volume has been shown in the Cochrane review (Bryant-Smith et al., 2018). The investigators found that TXA appeared effective for treating HMB (AUB-E) compared to placebo, NSAIDs, oral luteal progestogens, ethamsylate, or herbal remedies, but is likely less effective than the 52 mg levonorgestrel-releasing intrauterine system .
While there is relatively widespread use, intravenous TXA has never been subjected to a clinical trial for treatment of acute HMB, associated or not associated with leiomyomas. This doesn't mean that the intervention cannot be tried, but it is important to understand that such an approach is not evidence based. There is evidence supporting the use of intravenous TXA as a surgical adjuvant in individuals undergoing abdominal (laparoscopic or laparotomic) myomectomy. A systematic review and meta-analysis of seven randomized trials, demonstrated that prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities(Baradwan et al., 2022).
Administration
A. Chronic AUB-L
B. Acute HMB (off label) or prophylaxis for abdominal myomectomy
Adverse Events
Note: There is no evidence of an increased risk of thromboembolic events associated with TXA use.
Contraindications
References
Baradwan S, Hafidh B, Latifah HM, Gari A, Sabban H, Abduljabbar HH, Tawfiq A, Hakeem GF, Alkaff A, AlSghan R et al. Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2022;276: 82-91.
Bryant-Smith AC, Lethaby A, Farquhar C, Hickey M. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev 2018;4: CD000249.
Eder S, Baker J, Gersten J, Mabey RG, Adomako TL. Efficacy and safety of oral tranexamic acid in women with heavy menstrual bleeding and fibroids. Womens Health (Lond) 2013;9: 397-403.
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