INTRODUCTION
Hysterectomy, despite a decline in the rates of effective conservative management of benign uterine disease, is the most frequent gynecological surgery and overall, second to the cesarean section in many parts of the world [1] [2]. The choice of the approach depends on the surgeon’s preference, nature of the disease, the indication of the surgery, and patient characteristics [3]. Common medical indications of hysterectomy include gynecological ailments such as fibroids, dysfunctional uterine bleeding, uterine prolapse [4], endometriosis, or chronic pelvic pain. It may also be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment [5]. In the United States, among women aged 15 years and above who underwent hysterectomy during 2000–04, uterine leiomyoma was the most common hysterectomy indication accounting for nearly 41% of all hysterectomies [1].
Hysterectomy can be a part of staging laparotomy or radical hysterectomy. Rates of various complications with hysterectomy have been reported from 0.5% to 43% [6].
Tranexamic acid (TXA) is a synthetic lysine analog that competitively blocks the lysine-binding sites of plasminogen, plasmin, and tissue plasminogen activator, thereby retarding fibrinolysis and blood clot degradation. It may be administered orally, intravenously, or topically, with a rapid onset of action (tmax = appx 3 hours) and 11-hour half-life [7]. It is 6 to 10 times more potent than aminocaproic acid, another commonly used synthetic anti-fibrinolytic agent. Typical IV dosing is 10 mg/kg followed by infusion of 1mg/kg/hour [8]. A dosage of 10 to 15m/kg administered over 5 to 10 minutes before skin incision can also be given [9]. Intravenous TXA can cause hypotension (with rapid IV injection), dizziness, allergic dermatitis, diarrhea, nausea, vomiting, and blurred vision [10]. The CRASH-2 trial collaborators randomized 20,211 adult trauma patients with significant bleeding or at risk of significant bleeding within 8 hours of injury to IV tranexamic acid or placebo [11]. Mortality was significantly reduced with tranexamic acid (RR .91; p=.0035). Systematic reviews were done in 2011, and 2012, of patients undergoing elective surgery, showed that TXA administration reduced the risk of transfusion perioperatively(RR.61).12,13
The use of oral TXA in the management of acute and abnormal uterine bleeding has been reported and is FDA-approved for the treatment of menorrhagia [11] [12]. One randomized study of oral TXA in the treatment of ovulatory menorrhagia reported a 45% decrease in mean menstrual blood loss using TXA compared with placebo [14]. Oral administration of TXA in cases undergoing conization of the cervix with the open surgical technique has also been reported [15]. In patients undergoing primary debulking surgery for gynecologic cancers, the administration of IV TXA has been shown to decrease intraoperative blood loss by 30% and reduce the need for intraoperative blood transfusion [16,17]. However, the role of IV tranexamic acid has not been effectively evaluated in reducing blood loss during hysterectomies for benign gynecological conditions, hence the need for this study.