ROLE OF ANTIFIBRINOLYTIC THERAPY IN GYNECOLOGIC SURGERY: TRANEXAMIC ACID FOR REDUCING PERIOPERATIVE BLOOD LOSS

Abstract

Perioperative hemorrhage remains an important clinical concern in gynecologic surgery, including hysterectomy, myomectomy, cesarean delivery, and oncologic procedures, as excessive blood loss may contribute to postoperative anemia, transfusion requirements, reoperation, prolonged hospitalization, and increased perioperative morbidity. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that reversibly binds to plasminogen and inhibits its conversion to plasmin, thereby reducing fibrin degradation and stabilizing formed clots. This review evaluates current evidence regarding the pharmacological properties, dosing strategies, efficacy, and safety profile of TXA in gynecologic surgical practice. Available randomized controlled trials and meta-analyses indicate that prophylactic administration of TXA, most commonly as a 1 g intravenous dose before surgical incision, significantly reduces intraoperative and postoperative blood loss across several gynecologic procedures. In benign hysterectomy, a large randomized controlled trial involving 332 patients demonstrated that intravenous TXA significantly decreased mean blood loss compared with placebo and reduced the incidence of bleeding exceeding 500 mL, as well as the need for reoperation due to postoperative hemorrhage. Evidence from myomectomy studies similarly suggests a clinically relevant reduction in perioperative blood loss, with meta-analytic data showing an average decrease of approximately 213 mL. In cesarean delivery, pooled data from randomized trials have shown that prophylactic TXA reduces total blood loss, transfusion rates, hemoglobin decline, and the need for additional uterotonic agents in both low- and high-risk patients. Comparable benefits have also been reported in selected gynecologic oncology procedures and after cervical conization. Importantly, across available studies, standard perioperative doses of TXA have not been associated with a significant increase in thromboembolic complications, although careful patient selection remains necessary, particularly in individuals with active thromboembolic disease or severe renal impairment. Overall, current evidence supports TXA as an effective, safe, and cost-efficient adjunct for reducing perioperative bleeding and transfusion requirements in gynecologic surgery. Future research should focus on defining optimal dosing and timing protocols for specific surgical subgroups, including extensive oncologic debulking procedures and complex endometriosis surgery, as well as evaluating long-term safety outcomes.