Population surveys suggest that anaemia affects about 29 percent of women of reproductive age in Nigeria, making it a major public health problem. Studies among women in Lagos and Delta States report similar figures, indicating that anaemia remains common across different groups.
Many cases are only detected when they become severe because routine health check-ups are uncommon. A simple haemoglobin test can identify anaemia early, but many people only visit the hospital when symptoms become difficult to ignore. Cost is also a barrier, as healthcare is often paid for out of pocket. By the time women experience persistent tiredness, breathlessness or poor concentration, their anaemia is often already moderate or severe.
Many people describe anaemia as ‘low blood’ or ‘low PCV.’ What exactly is anaemia from a medical perspective?
People often refer to anaemia as ‘low blood,’ and while that explanation is easy to understand, it is not entirely accurate. Blood is made up of several components. There are red blood cells, which carry oxygen throughout the body; white blood cells, which fight infection; platelets, which help blood clot; and plasma, the liquid portion that carries these cells as well as proteins and other important substances.
Anaemia specifically refers to a reduction in the number of red blood cells or the amount of haemoglobin they contain. Your overall blood volume may remain normal, but if the proportion of red blood cells is too low, you are considered anaemic.
This matters because red blood cells transport oxygen to every organ and tissue in the body. When there are too few of them, less oxygen reaches vital organs such as the brain, heart, kidneys and muscles. That reduced oxygen supply explains why people with anaemia often feel tired, become easily breathless, struggle to concentrate and experience reduced physical and mental performance.
What are the most common causes of anaemia in Nigeria?
The leading causes are malaria and nutritional deficiencies, particularly iron deficiency. Malaria destroys red blood cells, while inadequate iron, folic acid and other nutrients reduce the body’s ability to produce new ones.
Other important causes include intestinal worm infections, inherited blood disorders such as sickle cell disease, and heavy menstrual bleeding. Many women may not realise that although their periods seem ‘normal’, they are losing more blood than their bodies can replace, especially if they already have low iron stores.
I’ve treated women with fibroids who had lived with heavy menstrual bleeding for years and did not come to the hospital until they collapsed from severe anaemia. One patient required four units of blood before she was fit enough for surgery. These cases show how easily chronic blood loss can go unnoticed.
As part of the WOMAN-3 Trial, we will also investigate the major causes of anaemia among participating women to better understand the problem in our own population.
What is the WOMAN-3 Trial and how is tranexamic acid different from iron tablets?
The WOMAN-3 Trial is designed to determine whether tranexamic acid (TXA) can help reduce anaemia in women of reproductive age who menstruate regularly. Tranexamic acid is not a new drug. It is already approved for use and is widely prescribed, including here in Nigeria. Its primary function is to reduce bleeding.
In gynaecology, we commonly use the injectable form during surgeries that involve significant blood loss, such as fibroid surgery. The tablet form, which we are using in this trial, is already prescribed for women who experience heavy menstrual bleeding. However, the focus of this study is different.
We are not recruiting women who already know they have heavy menstrual bleeding or who are already eligible for tranexamic acid for heavy menses. Instead, we are interested in women who may not realise they are losing more blood than their bodies can comfortably replace but who are found to be anaemic during screening.
These women will receive either tranexamic acid or a placebo during their menstrual periods. The medication will be taken for up to five days during each menstrual cycle over a six-month period. The aim is to determine whether women taking tranexamic acid maintain healthier blood levels than those receiving the placebo.
How exactly will the trial work?
Women aged 18 years and above will first be screened for anaemia using a simple finger-prick blood test. Those found to be anaemic will be invited to participate in the trial. The study is double-blinded, meaning neither the participants nor the researchers know who receives tranexamic acid and who receives the placebo. Only the team responsible for packaging the medication has that information, and it remains confidential until the study is completed.
Participants will be randomly assigned to one of two groups. Half will receive tranexamic acid, while the other half will receive a placebo that looks exactly the same. Importantly, every participant will receive the standard treatment for anaemia-iron and folic acid supplements-during the first three months of the study.
This is an important ethical consideration. Once we identify that someone is anaemic, we cannot withhold the accepted standard treatment simply because they are participating in research. After the initial three months, participants will stop taking the iron and folic acid but will continue taking either tranexamic acid or the placebo during their menstrual periods for another three months.
By following everyone for a total of six months, we can determine whether tranexamic acid provides additional protection against anaemia after the initial iron deficiency has been corrected. If excessive menstrual blood loss is contributing to a woman’s anaemia, we expect to see better maintenance of healthy blood levels among those taking tranexamic acid compared with those receiving the placebo.
Many people are understandably cautious about clinical trials. How safe is this study? Can participants withdraw if they choose to?
Those are very important questions. First, I want to emphasise that tranexamic acid is not an experimental drug. It has been in medical use since the 1960s and is already approved by NAFDAC. It is routinely prescribed by gynaecologists for women with heavy menstrual bleeding and is widely available in pharmacies across Nigeria. Participants are therefore not being used as guinea pigs. We are studying a medicine whose safety and effectiveness are already well established. In fact, tranexamic acid has been evaluated in several very large international clinical trials.
The original WOMAN Trial enrolled about 20,000 women, while the WOMAN-2 Trial included approximately 15,000 participants. Other major studies, including CRASH-3 and HALT-IT, also evaluated tranexamic acid in different medical emergencies, such as traumatic injuries and severe gastrointestinal bleeding.
Across these and other studies, data from more than 50,000 participants have shown no major safety concerns associated with the drug. That said, participant safety remains our highest priority. Every participant will keep a study diary to record any symptoms or side effects they experience. The research team will monitor them closely throughout the study, paying particular attention to any known or plausible side effects associated with medicines that reduce bleeding.
And yes, participation is entirely voluntary. Anyone who chooses to withdraw from the study at any time is free to do so.
If the trial proves successful, what impact could it have? Could it improve fertility or women’s overall quality of life?
Anaemia is not a direct cause of infertility, although severe, long-standing anaemia can eventually affect fertility. When the body becomes extremely anaemic, it prioritises functions that are essential for survival. Processes that are not immediately necessary-such as reproduction-may begin to shut down. In very severe cases, menstruation may stop altogether, making pregnancy impossible. However, that represents an extreme situation and is not what most women experience. The more immediate benefits we hope to achieve are improvements in everyday quality of life.
Women with anaemia often experience chronic fatigue, reduced concentration and poorer cognitive performance. Some studies, including one conducted among university students in Ghana, have shown that anaemia becomes more common as the academic session progresses, possibly because students are under increased stress, eat poorly and neglect their nutrition.
Reducing anaemia could therefore improve energy levels, concentration, productivity and overall wellbeing. The long-term goal of the WOMAN-3 Trial, however, is to improve women’s health before pregnancy.
The idea for WOMAN-3 grew stronger from findings of the WOMAN-2 Trial, where we observed that women who had anaemia in pregnancy were much more likely to suffer severe complications if they experienced postpartum haemorrhage. That led us to ask an important question: What if we prevent anaemia before women become pregnant?
If more women begin pregnancy with healthy blood levels, they are better able to cope with the normal physiological changes that occur during pregnancy, including the natural dilution of the blood. This could ultimately improve maternal health and reduce pregnancy-related complications.
Could tranexamic acid also reduce pressure on Nigeria’s blood supply?
Yes, that’s certainly one of the outcomes we hope to see. In our previous WOMAN trials, we found that women who received tranexamic acid promptly after the onset of postpartum haemorrhage were less likely to require blood transfusions.
Beyond measuring survival, we also analysed outcomes such as the need for transfusions, and the findings consistently showed that timely use of tranexamic acid reduced the likelihood of needing donated blood. We hope to see a similar benefit in this trial. If women are able to maintain healthier blood levels before their anaemia becomes severe, fewer of them may require blood transfusions.
That would allow our limited blood supply to be reserved for genuine emergencies-life-threatening situations and surgeries where transfusions are truly unavoidable.
What about people living with sickle cell disease? Could this treatment also benefit them?
We certainly hope so, and this study will help answer that question. Initially, we considered excluding people living with sickle cell disease because not all of them require iron supplements. Since sickle cell disease causes red blood cells to break down more rapidly, some patients actually accumulate excess iron in their bodies. However, after consulting haematologists, we decided they should not be excluded from the study.
One of the laboratory tests we will perform is a ferritin test, which measures the body’s iron stores. That allows us to determine whether a participant would benefit from iron supplementation. If someone has adequate or high iron stores, they may receive folic acid without additional iron.
By including people living with sickle cell disease, we hope to gather evidence on whether reducing menstrual blood loss with tranexamic acid can also help improve anaemia in this group.
Should routine haemoglobin screening become standard for adolescent girls and young women?
Absolutely. This is not a new recommendation. Measuring haemoglobin is already considered one of the most basic investigations during a routine health check anywhere in the world. If annual wellness checks became part of our healthcare culture, haemoglobin testing would naturally be included. In fact, it is often performed before investigations such as cholesterol or blood sugar, particularly in younger people.
The challenge is that many people only visit a hospital when they are already ill. We rarely present for preventive health checks. Routine haemoglobin screening would help detect anaemia early, allowing treatment before symptoms become severe.
What is the biggest misconception about anaemia that you would like young women to stop believing?
Interestingly, I haven’t encountered many widespread myths about anaemia among the women I have worked with. I’ve spent many years supervising female students and caring for women in clinical practice, and I haven’t found misconceptions about anaemia itself to be a major barrier.
One concern raised by our collaborators in another country is that some women worry medications that reduce menstrual bleeding might prevent the body from ‘flushing out’ unwanted substances during menstruation. However, that is not a belief I commonly encounter among Nigerian women.
In my experience, the greater challenge is not myths but a lack of awareness. Many women simply do not realise they are anaemic until the condition has become serious enough to interfere with their daily lives.
If a mother notices that her teenage daughter is constantly tired, pale or dizzy, what should she do first?
The first step is to take her to a healthcare provider for proper evaluation. Two important conditions should be considered-anaemia and diabetes. Although diabetes is often associated with older adults, it can also occur in young people. Simple tests for haemoglobin and blood sugar can help identify the cause of these symptoms. If anaemia is confirmed, treatment should go beyond medication. Iron tablets can correct the immediate deficiency, but if the underlying causes remain, the anaemia is likely to return.
Nutrition is especially important. Diets that is high in carbohydrates but low in iron-rich foods, leafy vegetables and other essential nutrients increase the risk of anaemia. Even the way iron tablets are taken matters. Taking iron supplements together with milk can reduce iron absorption because calcium interferes with the body’s ability to absorb iron effectively.
So, while medication is important, long-term prevention also requires good nutrition and appropriate medical guidance.
Can good nutrition alone prevent anaemia, or do women still need to address conditions such as malaria and worm infections?
Nutrition is only one part of the solution. Tranexamic acid addresses one specific contributor to anaemia-it reduces menstrual blood loss. If a woman’s anaemia is caused by something else, such as recurrent malaria or intestinal worm infections, the medication alone will not solve the problem.
Anaemia has many possible causes, and each must be managed appropriately. That means ensuring adequate nutrition, preventing and treating malaria, managing intestinal worm infections where necessary, and adopting other preventive measures such as sleeping under insecticide-treated nets, eliminating mosquito breeding sites and using preventive medication in high-risk groups, including pregnant women and people living with sickle cell disease or HIV.
Our study focuses on one important aspect of anaemia prevention, but it does not replace these other essential interventions.