Clinical Conundrum: What Is the Role of TXA in Dysfunctional Uterine Bleeding?

There are a number of accepted treatments for dysfunctional uterine bleeding (DUB) endometrial ablation and hysterectomy as well as medical treatments like hormonal therapy, NSAIDs and tranexamic acid (TXA). The American College of Obstetrics and Gynecology (ACOG) recommends the use of TXA in both acute and chronic DUB in non-pregnant, reproductive aged women. 

Acute DUB:

First-line treatment focuses on hormonal therapies which can be given either orally or intravenously depending on the individual case. Hormonal treatments have been found to be highly effective (Devore 1982, Munro 2006). This is typically done in conjunction with gynecology. TXA acts as an adjunct therapy and can be administered by mouth (1.3 g) or IV (10 mg/kg up to a max of 600 mg/dose) every 8 hours (ACOG 2013). Failure of these treatments to control bleeding often results in operative or interventional management though temporization in the ED with a balloon tamponade device (eg Bakri Balloon) may be necessary.

Chronic DUB:

Hormone therapy represents first-line management here as well and can be started in the Emergency Department after assessment for clotting risks. There are numerous options including oral contraceptives (most commonly used from the ED), IUDs and IM progestin. TXA can be used in conjunction with hormonal therapies or as solo treatment in patients where these medications are contraindicated or not tolerated. TXA can reduce bleeding in chronic cases by 30-55%  (Lethaby 2000, Lukes 2010). Typical dosing is 1-1.5 g by mouth TID for 5 days during menstruation. Safety data at this dosing is reassuring with minimal increase in minor adverse events and no reported increases in thromboembolic disease (Bryant-Smith 2018).