How can iron deficiency be managed during menstruation?

Management of Iron Deficiency During Menstruation

Women with menstruation should take oral iron supplementation with ferrous sulfate 200 mg once daily (65 mg elemental iron) to prevent and treat iron deficiency, particularly those with heavy menstrual bleeding. 1

Risk Factors for Iron Deficiency During Menstruation

Iron deficiency is a significant concern for menstruating women due to:

• Heavy menstrual blood loss (≥80 mL/month), affecting approximately 10% of women 2
• Use of intrauterine devices (associated with increased menstrual blood loss) 2
• Previous diagnosis of iron deficiency anemia 2
• Low dietary iron intake 2

Studies show that only about one-fourth of adolescent girls and women of childbearing age (12-49 years) meet the recommended dietary allowance for iron through diet alone 2.

Diagnostic Approach

Iron deficiency should be diagnosed through:

• Hemoglobin concentration (low in anemia)
• Serum ferritin (<30 μg/L without inflammation, up to 100 μg/L with inflammation) 1
• Transferrin saturation (<20%) 1
• Additional tests as needed: erythrocyte zinc protoporphyrin, transferrin concentration, serum iron, MCH, MCHC 1

Treatment Algorithm

First-Line Treatment

• Oral iron supplementation: Ferrous sulfate 200 mg once daily (65 mg elemental iron) 1, 3
  • Take in the fasting state (morning) to maximize absorption 1
  • Once-daily dosing is preferred over divided doses 1

Alternative Formulations (if ferrous sulfate not tolerated)

• Ferrous gluconate or ferrous fumarate 2, 1
• Liquid preparations if tablets are not tolerated 2, 1

Enhancing Iron Absorption

• Add ascorbic acid (vitamin C) to enhance iron absorption 2, 1
• Avoid taking with tea, coffee, calcium, or antacids which reduce absorption

For Heavy Menstrual Bleeding

• Consider prophylactic iron supplementation during menstrual periods 4
• Research shows that taking 100 mg iron daily for 10 days during menstruation can effectively replace iron lost through menstrual bleeding 4

When to Consider Intravenous Iron

• Intolerance to at least two oral preparations 2
• Non-compliance with oral therapy 2
• Conditions affecting iron absorption 1
• Failure to respond to oral therapy despite adjustments 1

Monitoring Response

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of therapy 2, 1
• If no response after 2-4 weeks, consider:
  • Poor compliance
  • Ongoing blood loss
  • Malabsorption
  • Incorrect diagnosis 2, 1
• Absence of hemoglobin rise of at least 10 g/L after 2 weeks strongly predicts treatment failure 1
• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1

Special Considerations

• Oral contraceptives may reduce risk of iron deficiency by decreasing menstrual blood loss 2
• Recent research shows that taking iron supplements during menstruation does not increase menstrual bleeding volume 5
• Iron deficiency, even without anemia, can impact cognitive function, work performance, and quality of life 6
• For women with persistent heavy menstrual bleeding, addressing the underlying gynecological cause is essential for long-term management 6

Common Pitfalls to Avoid

• Normalizing symptoms: Heavy menstrual bleeding and iron deficiency are often normalized by society and healthcare providers 6
• Inadequate treatment duration: Iron therapy should continue for 3 months after hemoglobin normalization to replenish stores 1
• Missing underlying causes: In women over 45 years with iron deficiency, investigate for gastrointestinal causes 2
• Ignoring iron deficiency without anemia: Even without anemia, iron deficiency can cause fatigue and cognitive impairment 7
• Excessive supplementation: Avoid excessive iron supplementation which can cause iron overload 7

By following this approach, iron deficiency during menstruation can be effectively managed, improving quality of life and preventing complications associated with chronic iron deficiency.