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How does TXA Measure Up as a Treatment for Menorrhagia?


  • There are several treatments for heavy menstrual bleeding, with good evidence supporting levonorgestrel intrauterine system as a good management option  
    • Not all women will want an IUD  
    • Important to review safety of TXA due to concerns regarding thromboembolic disease  
  • Bryant-Smith et al. (Cochrane Reviews, 2018) assessed the effectiveness and safety of antifibrinolytic medications, specifically tranexamic acid (TXA), for the treatment of heavy menstrual bleeding (HMB) 


  • Database search of RCTs comparing TXA and precursor (antifibrinolytic) agents versus  
    • Placebo 
    • No treatment  
    • Other medical treatment 
  • Population: Women of reproductive age with menorrhagia  
  • Menstrual blood loss were measured by  
    • Objective assessment of mean blood loss in mL (using alkaline haematin method or similar) 
    • Subjective assessment of blood loss using continuous measures such as Pictorial Blood Assessment Chart (PBAC) scores, where over 100 correlates with heavy bleeding using objective methods  
  • TXA dose
    • Majority of studies used regular oral dose TXA (3 g/day to 4 g/day) while 4 studies used low-dose TXA (2 g/day to 2.4 g/day)
  • Primary outcomes  
    • Menstrual blood loss | Improvement in bleeding | Thromboembolic events 
  • Secondary outcomes 
    • Quality of life | Side effects  


  • 13 RCTs were included, totaling 1312 participants 
  • The evidence was very low to moderate quality 
  • When compared with a placebo, antifibrinolytics were associated with 
    • Reduced mean blood loss (Mean Difference (MD) -53.20 mL per cycle, 95% CI -62.70 to -43.70; moderate-quality evidence)  
    • Higher rates of improvement (RR 3.34, 95% CI 1.84 to 6.09; moderate-quality evidence) 
  • Compared to progestogens, antifibrinolytics were associated with 
    • No difference between the groups in mean blood loss (very low-quality evidence) 
    • Higher likelihood of improvement (RR 1.54, 95% CI 1.31 to 1.80; low-quality evidence) 
    • Fewer adverse events (RR 0.66, 95% CI 0.46 to 0.94; low-quality evidence) 
  • Compared to NSAIDs, TXA was associated with 
    • Reduced mean blood loss (MD -73.00 mL per cycle, 95% CI -123.35 to -22.65; low-quality evidence)  
    • Higher likelihood of improvement (RR 1.43, 95% CI 1.18 to 1.74; low-quality evidence) 
  • Compared to herbal medicine (Safoof Habis and Punica granatum), TXA was associated with 
    • Reduced mean PBAC score after three months’ treatment (MD -23.90 pts per cycle, 95% CI -31.92 to -15.88; low-quality evidence) 
    • Inconclusive rates of improvement 
  • Compared to levonorgestrel intrauterine system, TXA was associated with 
    • Higher median PBAC score (median difference 125.5 points; very low quality evidence)  
    • Lower likelihood of improvement (RR 0.43, 95% CI 0.24 to 0.77; very low quality evidence) 


  • Antifibrinolytic treatment appears effective for treating menorrhagia compared to placebo, NSAIDs, oral progestogens or herbal remedies 
  • However, they appeared less effective compared to levonorgestrel IUD 
    • The authors suggest that if 85% of women improve with levonorgestrel IUD, 20% to 65% of women will do so with TXA 
  • Adverse outcomes were hard to quantify due to inadequate amount of data 

Learn More – Primary Sources: 

Antifibrinolytics for heavy menstrual bleeding.