Workup and Management of Iron Deficiency Anemia with Associated Symptoms
For patients with iron deficiency anemia presenting with gastrointestinal symptoms, hair loss, and headaches, a comprehensive gastrointestinal evaluation is essential, along with iron supplementation preferably using ferrous sulfate once daily with vitamin C to enhance absorption. 1, 2
Diagnostic Workup
Laboratory Assessment
- Complete blood count with peripheral smear
- Iron studies: serum ferritin (<30 ng/mL), transferrin saturation (<20%), serum iron
- Additional tests: red cell distribution width (RDW)
Gastrointestinal Evaluation
Upper GI endoscopy with small bowel biopsy to evaluate for:
- Celiac disease (especially with GI symptoms)
- Atrophic gastritis
- Peptic ulcer disease
- Gastric cancer
- H. pylori infection 1
Colonoscopy or barium enema to evaluate for:
Additional Considerations
- For women: Evaluate menstrual blood loss (heavy menstrual bleeding is a common cause)
- For patients >45 years: Both upper and lower GI investigations are strongly recommended regardless of symptoms 1
- For patients <45 years: Upper GI endoscopy with small bowel biopsy if GI symptoms are present; anti-endomysial antibody testing for celiac disease 1
Management
Iron Replacement Therapy
First-Line: Oral Iron
- Ferrous sulfate 200 mg once daily (provides 65 mg elemental iron) 1, 2
- Consider every-other-day dosing if daily dosing causes side effects 1
- Add vitamin C (orange juice or supplement) with iron to enhance absorption 1, 2
- Continue treatment for 3 months after normalization of hemoglobin to replenish iron stores 2
- Monitor hemoglobin response: should rise by 2 g/dL after 3-4 weeks 1
When to Consider IV Iron
- Intolerance to at least two oral iron preparations
- Poor response to oral iron therapy
- Active inflammation (e.g., inflammatory bowel disease)
- Hemoglobin <10 g/dL requiring rapid correction
- Conditions with impaired absorption (e.g., celiac disease with severe villous atrophy) 1, 2
- Prefer IV iron formulations that can replace iron deficits with 1-2 infusions 1
Management of Specific Associated Symptoms
For Hair Loss
- Evidence suggests iron deficiency may contribute to hair loss, including telogen effluvium 4
- Iron replacement therapy may improve hair regrowth, though evidence is not definitive 4
- Monitor response of hair loss to iron repletion
For Headaches
- Iron replacement may improve headaches associated with anemia
- Consider other causes if headaches persist despite iron repletion
For Gastrointestinal Symptoms
- Treat underlying GI conditions identified during workup
- For celiac disease: Implement strict gluten-free diet along with iron supplementation 1
- For H. pylori infection: Eradication therapy may improve iron absorption 3
- For inflammatory bowel disease: Treat active inflammation to enhance iron absorption 1
Monitoring Response
- Check hemoglobin after 3-4 weeks of therapy
- Monitor iron studies every 3 months for one year, then after another year 2
- If no response to oral iron (hemoglobin increase <2 g/dL after 3-4 weeks):
- Assess compliance
- Consider alternative diagnoses
- Evaluate for continued blood loss
- Consider switching to IV iron 1
Common Pitfalls to Avoid
- Inadequate dosing of iron (underdosing)
- Failure to add vitamin C to enhance absorption
- Insufficient duration of treatment
- Taking iron with tea, coffee, calcium, or antacids (reduces absorption)
- Failure to identify and treat underlying cause
- Overlooking non-bleeding causes of iron deficiency (e.g., celiac disease, atrophic gastritis)
- Relying solely on hemoglobin without checking iron stores 2
By addressing both the underlying cause of iron deficiency and providing appropriate iron replacement therapy, most patients will show significant improvement in anemia and associated symptoms within 3-4 weeks.