Background <p>Cesarean scar–related abnormal uterine bleeding (AUB) is commonly associated with niche formation and is characterized by prolonged menstruation and postmenstrual spotting, which may significantly affect quality of life. Evidence comparing nonsurgical treatment options remains limited. This study aimed to evaluate and compare the effectiveness of tranexamic acid, combined oral contraceptive pills (OCP), their combination, and the levonorgestrel-releasing intrauterine system (LNG-IUS) in improving bleeding patterns among women with cesarean scar–related AUB.</p> Methods <p>This prospective, randomized, non-blinded comparative study was conducted at the Department of Obstetrics and Gynaecology, Saudi German Hospital, Madinah, Saudi Arabia, between March 2019 and October 2022. Participants were allocated into four groups: tranexamic acid (Group A), combined OCP (Group B), tranexamic acid plus combined OCP (Group C), and LNG-IUS (Group D). Changes in menstrual duration and postmenstrual spotting days were recorded using menstrual diaries at 3, 6, 9, and 12 months.</p> Results <p>All interventions were associated with significant reductions in menstrual duration and postmenstrual spotting compared with baseline (<i>P</i> &lt; 0.001 for all groups). The combination therapy group demonstrated greater improvement in both outcomes at all follow-up points compared with the other treatment groups (<i>P</i> &lt; 0.001).</p> Conclusion <p>Combined tranexamic acid and OCP therapy was associated with greater reduction in menstrual duration and postmenstrual spotting compared with single-modality treatments and LNG-IUS in women with cesarean scar–related AUB. These findings suggest that combination therapy may be a useful nonsurgical option, particularly in selected patients; however, further studies are warranted to confirm long-term effectiveness.</p>