What is the recommended treatment for menstruation-related iron deficiency anemia?

Treatment of Menstruation-Related Iron Deficiency Anemia

Oral iron supplementation is the recommended first-line treatment for menstruation-related iron deficiency anemia, specifically with ferrous sulfate 200 mg three times daily for at least three months after correction of anemia to replenish iron stores. 1

Diagnosis and Assessment

Iron deficiency anemia in menstruating women is common, affecting 5-10% of this population 1. Key diagnostic criteria include:

• Hemoglobin below the lower limit of normal range for the laboratory
• Microcytosis (MCV < 76 fl)
• Serum ferritin < 15 μg/dl (most powerful test for iron deficiency)
• Transferrin saturation < 20% (particularly useful in inflammatory conditions)

Risk Assessment in Menstruating Women

Heavy menstrual bleeding is the primary cause of iron deficiency anemia in pre-menopausal women 1. Assessment should include:

• Evaluation of menstrual blood loss (pictorial blood loss assessment charts have ~80% sensitivity and specificity for detecting menorrhagia) 1
• Screening for underlying gynecological conditions
• Consideration of other contributing factors (pregnancy, breastfeeding)

Treatment Algorithm

First-Line Treatment

• Oral iron supplementation:
  • Ferrous sulfate 200 mg three times daily 1
  • Alternative options with similar efficacy: ferrous gluconate or ferrous fumarate 1
  • Continue for three months after correction of anemia to replenish iron stores 1

Enhancing Effectiveness

• Add ascorbic acid (vitamin C) to enhance iron absorption when response is poor 1
• Consider liquid preparations when tablets are not tolerated 1
• Monitor response: hemoglobin should rise by 2 g/dl after 3-4 weeks 1

Second-Line Treatment

Parenteral iron is indicated only when:

• Intolerance to at least two oral preparations
• Non-compliance with oral therapy
• Malabsorption issues 1

Monitoring and Follow-up

• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after a further year 1
• Provide additional oral iron if hemoglobin or MCV falls below normal 1
• Consider further investigation only if hemoglobin and MCV cannot be maintained with supplementation 1

Special Considerations

Treatment of Underlying Cause

• For menorrhagia, consider hormonal interventions or tranexamic acid 2
• For women with inherited bleeding disorders, a multidisciplinary approach is essential 2

Intermittent Dosing Option

While daily supplementation is the standard recommendation, intermittent iron supplementation (1-2 times weekly) may be considered in settings where daily supplementation is not feasible 3. However, be aware that:

• Intermittent dosing is less effective than daily dosing in preventing or controlling anemia 3
• Women receiving intermittent supplementation present with anemia more frequently than those on daily regimens 3

Common Pitfalls and Caveats

1. Failure to treat for sufficient duration: Iron therapy must continue for three months after normalization of hemoglobin to replenish iron stores 1

2. Inadequate investigation in older women: Women over 45 years with iron deficiency anemia require full gastrointestinal investigation due to increased risk of significant pathology 1

3. Poor adherence: Side effects like nausea and constipation often lead to non-compliance; consider:

   • Liquid preparations
   • Taking with food (though may reduce absorption)
   • Starting with lower doses and gradually increasing

4. Missed diagnosis of malabsorption: Consider testing for celiac disease with antiendomysial antibody determinations in non-responsive cases 1

5. Overlooking continued blood loss: Persistent heavy menstrual bleeding requires gynecological evaluation and management 2