Incidence of venous thromboembolism with intraoperative tranexamic acid use in breast surgery patients on estrogen-containing medications: a case series

Consideration of perioperative bleeding and venous thromboembolism (VTE) are important thrombotic complications for surgeons. Tranexamic acid (TXA) is an antifibrinolytic agent that is often used perioperatively to control bleeding. Product monographs caution its use in patients using estrogen-containing medications due to theoretical increased risk of VTE. However, no studies have explored this relationship in breast surgery. This retrospective case series aimed to determine the incidence of VTE with intraoperative TXA use in breast surgery patients using estrogen-containing medication at our institution. Demographics, estrogen medications, surgical characteristics and incidence of VTE were recorded and summarized narratively. Between 2018–2025, 188 breast surgeries with intraoperative TXA administration were performed. Twelve patients used estrogen-containing medications at the time of surgery. Eight patients used an estrogen-containing combined hormonal contraceptive. Four patients used estrogen hormone therapy. TXA was administered intravenously (N=7) or topical irrigation (N=5). No patients had incidence of VTE. This is the first study to describe the relationship of TXA and estrogen-containing medications in breast surgery patients. These results provide preliminary clinical data regarding a patient population for which TXA use is cautioned against. Future prospective studies are warranted to better define the risk-benefit profile of TXA in this population.