Dr. Chapa’s OBGYN Clinical Pearls

Episode Summary: TXA for ENG Implant Bleeding?

Air Date: January 16, 2026
Host: Dr. Chapa
Focus: Evaluating tranexamic acid (TXA) for breakthrough bleeding in etonogestrel implant users

Overview of the Episode

This episode dissects the challenges of breakthrough bleeding among users of the etonogestrel (ENG) contraceptive implant and examines a new randomized controlled trial (RCT) testing the effectiveness of tranexamic acid (TXA) as a treatment. Dr. Chapa explores the pathophysiology behind bleeding with implants, reviews previous management strategies, and critiques the latest research, always keeping it lively, evidence-based, and practical for healthcare professionals.

Key Discussion Points & Insights

1. Breaking the Taboo: “Cute” Period Terminology and Clinical Realities

• The episode opens with a comedic reflection on euphemisms for menstruation, segueing into the seriousness of managing menstrual disorders.

  • “All the names for periods suck…You know what you call a period? A period should be called bloody tissue falling out of a hole.” [A, 00:10]

• Dr. Chapa acknowledges the challenges women face:

  • “The ability for women to go through life, work, take care of children, take care of their job, go to school, whatever, with bloody tissue coming out of a hole is just mind blowing to me. So much respect to the fair sex because women, you really do have a superpower.” [B, 01:54]

2. ENG Implant Bleeding: The #1 Reason for Discontinuation

• ENG Implant as contraception:
  • Praised as the “most failure resistant” reversible birth control method, with a failure rate of only 0.05%. [B, 02:52]
• Breakthrough Bleeding (BTB) is the main drawback:
  • BTB, or “contraceptive induced menstrual changes” (CIMC), most often leads to early discontinuation.
  • Bleeding typically improves after the first 3-6 months, often leading to amenorrhea, but heavy or unpredictable bleeding drives patient dissatisfaction. [B, 04:23]
• Clarifying terminology:
  • BTB is preferred over CIMC as it more accurately reflects episodes outside the physiologic menstrual cycle.

3. Current and Investigational Treatments for ENG Implant Bleeding

• Common interventions (with varying evidence):
  • Doxycycline: Mild anti-inflammatory, “shown a little bit of promise”
  • Estrogen supplementation (alone or with a progestin): Restores hormonal balance, often clinically effective
  • Ponstel® (mefenamic acid): NSAID, some data for efficacy
  • Short-term tamoxifen: Used in research settings; concerns about safety
  • Norethindrone: Some conversion to estrogen, can “patch up” the endometrium ([B, 07:00]).
• Ulipristal acetate (Ella): Lower doses over 5 days may help by moderately reducing progestin, allowing endometrial recovery ([B, 07:59]).
• Mechanistic focus:
  • “You’re trying to restore the balance if something is progestin rich.”
• Dr. Chapa teases deeper discussion of the mechanistic rationale (“We’re going to get into the mechanism of action here of progestin-related breakthrough bleed in just a minute” [B, 09:15]).

4. Pathophysiology: Why Might (or Mightn’t) TXA Work?

• How TXA works for normal cycles:
  • TXA is an oral antifibrinolytic approved for regular, heavy, cyclic bleeding (“Listida oral TXA…is FDA approved for regular, heavy cyclic bleeding…typically ovulatory bleeding.” [B, 16:58])
  • Mechanism: It reduces endometrial fibrinolysis occurring during a typical menstrual cycle, preventing excess breakdown of clots as tissue sheds after progesterone withdrawal.
• Why implant-related bleeding is different:
  • BTB in ENG implant users is due to chronic progestin exposure, which causes exposed, fragile blood vessels rather than increased fibrinolysis ([B, 19:20]).
  • “With acute or chronic progestin administration…what happens is…as that endometrium becomes decidualized and thin, you get an exposed basalis layer of vasculature that becomes very friable, very, very porous. Okay. Very weepy…In other words, the reason why there’s breakthrough bleeding on progestin isn’t because there’s an increase in fibrinolysis, it’s because it’s vascular exposure, which makes them more leaky and fragile and therefore they bleed.” [B, 20:50]
• Bottom line—TXA should not intuitively work for this indication.

5. NEW STUDY: TXA RCT out of Oregon Health and Science University ([20:50-31:40])

• Study details:
  • RCT, double-blind, placebo-controlled
  • Population: Established ENG implant users (not just new insertions) with defined irregular or prolonged bleeding
    • “Patients came in saying, ‘Hey, I’m having weird bleeding’…two or more independent bleeding episodes or spotting or prolonged bleeding of seven days…within a 30 day interval.” [B, 24:22]
  • TXA dosing: Standard 1300 mg TID x 5 days vs placebo
  • Patients tracked bleeding via e-diary; results analyzed “intent to treat”
• Study findings:
  • “A five day treatment course of TXA did not improve bleeding in contraceptive etonogestrel implant users experiencing frequent or prolonged bleeding patterns.” [B, 27:52]
  • Longer courses weren’t tested due to lack of safety data for TXA beyond five days
  • Clinical takeaway: TXA is not effective for implant-related BTB—the pathophysiology matches the lack of benefit.

6. Teaching Moments & Notable Quotes

• On language with patients:
  • “Be careful what we say. If we tell a patient, ‘Oh, breakthrough bleeding is normal,’ well, is not having breakthrough bleeding abnormal then? … The preferred way… is, ‘Breakthrough bleeding on birth control, especially hormonal, is understandable as an expected and anticipated side effect.’” [B, 29:13]
• “Tweetable statement” of study:
  • “Tranexamic acid did not improve bleeding patterns in contraceptive implant users experiencing unfavorable bleeding.” [B, 27:52]

Recommendations and Takeaways

• ENG implant remains the most effective reversible contraceptive, but unpredictable bleeding remains a challenge.
• Many interventions have shown some benefit (e.g., estrogen, combined pills, norethindrone, ultralow-dose ulipristal, NSAIDs).
• TXA should not be used for ENG implant-related BTB, as per latest evidence and mechanistic rationale.
• Always frame BTB as an “expected and anticipated side effect,” not “normal.”
• Other options remain viable; personalize management using evidence and patient-specific factors.

Timestamps for Key Segments

| Segment | Timestamp | |----------------------------------------------------|---------------| | Comedic take on period terminology | 00:10–00:49 | | Praise for women’s ability to handle menstruation | 01:54–02:40 | | Efficacy and side effects of ENG implant | 02:52–04:23 | | Review of other management options for BTB | 06:40–09:15 | | Pathophysiology: TXA for cyclic bleeding | 16:58–19:20 | | Pathophysiology: BTB in ENG implant users | 20:50–22:34 | | Language: How to address BTB with patients | 29:13–30:10 | | RCT summary: OHSU TXA trial results | 24:22–28:00 | | Final clinical pearls and wrap-up | 31:40–33:00 |

Memorable Moments & Quotes

• “Women, you really do have a superpower.” – Dr. Chapa [01:54]
• “Breakthrough bleeding…is understandable as an expected and anticipated side effect, especially with chronic progestin use.” [29:13]
• “Tranexamic acid did not improve bleeding patterns… in implant users” (study’s tweetable statement) [27:52]
• “The pathophysiology is a little bit different. Anyway, I thought this was interesting.” [32:36]

Final Thoughts

Dr. Chapa combines humor, practical advice, and timely clinical evidence in this deep dive, providing clear guidance: while many options exist for managing ENG implant bleeding, TXA is not effective and should not be used for this purpose. Listeners are encouraged to use this latest data when counseling patients and personalizing care, always remembering the unique mechanisms at work in contraceptive-induced bleeding patterns.