Objective: To investigate the cosmetic efficacy and impact on sex hormone levels of a combined treatment regimen of traditional Chinese acupuncture and tranexamic acid on female patients with melasma. Methods: A total of 122 female melasma patients admitted to the hospital from February 2023 to February 2025 were selected and randomly divided into two groups using a random number table method. Based on the use of vitamin medications, the control group (n=61) received tranexamic acid orally, while the observation group (n=61) additionally received traditional Chinese acupuncture therapy. Both groups underwent a treatment course of 6 months. Using the area and severity of melasma and skin lesion score as evaluation indicators for cosmetic effects, and comparing the differences in sex hormone levels between the two groups. Results: Before treatment, the MASI scores of both groups were relatively high and the difference was small (P>0.05). After 6 months of treatment, the MASI scores of the observation group were even lower than those of the control group (P<0.05); Before treatment, the skin lesion scores of the two groups were similar (P>0.05). After 6 months of treatment, the skin lesion scores of the observation group were even lower than those of the control group (P<0.05); The levels of two groups of sex hormones were comparable before treatment (P>0.05), and after treatment, the levels of FSH, LH, and E2 in the observation group were lower than those in the control group (P<0.05). Conclusion: Adopting a traditional Chinese medicine acupuncture combined with tranexamic acid treatment plan for female patients with melasma can significantly improve cosmetic effects and regulate hormone levels.