Tranexamic Acid (Bleeding Symptoms Only)

Tranexamic Acid for Heavy Menstrual Bleeding Associated with Leiomyomas (AUB-L)

Key Points

  • Orally administered tranexamic acid (TXA) has been shown to be effective at managing the symptom of HMB in individuals with and without leiomyomas, reducing menstrual blood loss by about 50%.
  • There are no available data on the efficacy of TXA on HMB in women with submucous leiomyomas (AUB-LSM)
  • Administration need only occur during the menstrual period.
  • TXA has no impact on leiomyoma volume or mass-related symptoms.
  • Depending on the specific formulation, the total daily dose ranges from 2 to 4 grams administrated three to four times per day for up to 5 days (example, 500 mg four times per day)
  • There is no evidence that TXA increases the risk of thromboembolic phenomena
  • Intraoperative intravenous TXA has also been shown to reduce intraoperative blood loss associated with abdominal myomectomy (laparoscopic or laparotomic).

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

  • Tranexamic Acid 650 mg tablets (®Lysteda) typically prescribed at a dose of 1,300 mg daily for up to 5 days, the duration depending on response.
  • Tranexamic Acid 500 mg tablets (®Cyclokapron) typically prescribed 1,000 to 1,500 mg three to three times daily for up to 5 days, the duration depending on response.


B.    Acute HMB (off label) or prophylaxis for abdominal myomectomy

  • Intravenous Bolus: one gram (1,000 mg) in 100 mL of normal saline infused as a bolus over 10 minutes (slow intravenous push). Rapid infusion may cause hypotension. May repeat in 8 hours, but do not exceed a total of 2 grams.
  • Intravenous Bolus plus infusion: 10 mg/kg as a bolus followed by  an infusion of 1 mg/kg per hour.

Adverse Events


  • Gastrointestinal symptoms
  • abdominal discomfort;
  • headaches; dizziness;
  • breast tenderness
  • weight changes
  • mood swings


Note: There is no evidence of an increased risk of thromboembolic events associated with TXA use.

Contraindications


  • Known allergy to TXA
  • Intracranial bleeding
  • Known defective color vision
  • History of venous or arterial thromboembolism
  • Active thromboembolic disease 

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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