Tranexamic acid for anemia in women of reproductive age: A systematic review of randomized trials

Objective The global target to halve the prevalence of anemia by 2025 has not been met. New strategies are needed. This systematic review examined the effect of tranexamic acid on anemia, menstrual health and wellbeing in women of reproductive age. Methods We searched six databases from inception to 30 August 2025 and reference lists of seven related reviews. We included randomized trials comparing the effects of tranexamic acid with placebo or standard care on uterine bleeding. Eligible participants had normal menstrual bleeding or any type of non-pregnant abnormal uterine bleeding. Outcomes included hemoglobin concentration and anemia prevalence as the primary outcome, estimated blood loss, quality of life, thromboembolic events, and other adverse events. We conducted meta-analyses and assessed risk of bias (Cochrane risk-of-bias tool for randomized trials) and the certainty of evidence. Results We included 17 trials in the review and 15 in the meta-analyses. None of the trials reported adequate data on hemoglobin concentration. For the anemia outcome, only one small trial contributed data (risk ratio 0.15, 95% confidence interval 0.01 to 2.74, very low certainty). Meta-analyses of secondary outcomes showed that tranexamic acid reduced objectively measured menstrual blood loss among women with heavy menstrual bleeding (6 trials, mean difference −47.0 milliliters, 95% confidence interval −56.6 to −37.4, I 2 = 13%, moderate certainty) and in women with intrauterine devices (3 trials, mean difference −41.6 milliliters, 95% confidence interval −52.2 to −30.9, I 2 = 64%, low certainty) and improved quality of life in women with heavy menstrual bleeding (2 trials, mean difference 0.5, 95% confidence interval 0.4 to 0.7, I 2 = 0%, moderate certainty). The risk of nausea or vomiting was similar between groups (4 trials, risk ratio 1.0, 95% confidence interval 0.6 to 1.8, I 2 = 0%, moderate certainty). Certainty of evidence for other outcomes ranged from very low to low, including for thromboembolic events, with only one event reported in the control arm of one trial. Conclusions Tranexamic acid appears to reduce menstrual blood loss, but its impact on anemia is unclear. High-quality randomized trials of TXA for menstruating women with anemia are needed.