How to manage menorrhagia and iron deficiency anemia in a patient on Erin (birth control) with a desire for future fertility?

Management of Menorrhagia and Iron Deficiency Anemia in a Patient with Desire for Future Fertility

Tranexamic acid is the most effective first-line treatment for managing your heavy menstrual bleeding while addressing your iron deficiency anemia and preserving future fertility.

Assessment of Current Situation

Your clinical presentation shows:

• Continuous heavy bleeding following polyp removal
• Recent ultrasound showing polyps and fibroids (removed)
• Current birth control (Erin) initially effective but bleeding has resumed
• Previous birth control (Hailey) discontinued due to hypertension
• Laboratory evidence of iron deficiency: iron 47, ferritin 24
• Desire for future fertility (hysterectomy not an option)

Management Plan

1. Control Heavy Bleeding

• First-line: Tranexamic acid 1.3g three times daily for 4-5 days starting from first day of menstruation 1, 2

  • Reduces menstrual blood loss by 26-60%
  • Non-hormonal option that preserves fertility
  • More effective than NSAIDs and does not affect future conception

• Alternative option: High-dose ibuprofen (600-800mg three times daily during menstruation)

  • Less effective than tranexamic acid but can reduce bleeding by 20-40%
  • Can be used in combination with tranexamic acid if needed

2. Address Iron Deficiency

• Oral iron supplementation: 60-120mg elemental iron daily 3, 4

  • Take with vitamin C (500mg) to enhance absorption
  • Take on empty stomach if tolerated, or with meals if GI side effects occur
  • Continue for at least 3 months after normalization of hemoglobin to replenish iron stores

• Dietary recommendations:

  • Increase intake of iron-rich foods (red meat, poultry, fish)
  • Pair non-heme iron sources with vitamin C-rich foods
  • Avoid tea, coffee, and calcium supplements within 2 hours of iron intake

3. Hormonal Management

• Continue current birth control (Erin) for at least 3 cycles to allow for adjustment
• Consider switching to continuous birth control regimen (skipping placebo pills) to prevent withdrawal bleeding 3
• If bleeding persists after 3 cycles, consider alternative options:
  • Progestin-containing IUD (significant reduction in menstrual bleeding while preserving fertility)
  • Different formulation of combined hormonal contraceptive with better bleeding profile

Follow-up Plan

1. Return in 4-6 weeks to assess:

   • Response to tranexamic acid therapy
   • Tolerance of iron supplementation
   • Any side effects from current birth control

2. Laboratory monitoring:

   • Repeat iron studies in 3 months (target ferritin >30 μg/L)
   • Complete blood count to monitor hemoglobin response

Special Considerations

• Avoid iron deficiency during reproductive years - Iron deficiency, even without anemia, can impact quality of life and cognitive function 5, 6
• Beware of thrombotic risk - Tranexamic acid is contraindicated in patients with active thromboembolic disease or high risk for thrombosis
• Common pitfalls to avoid:
  • Stopping iron supplementation too early (continue for 3 months after hemoglobin normalizes)
  • Inadequate dosing of tranexamic acid
  • Failure to address underlying cause of bleeding (fibroids/polyps)

This comprehensive approach addresses both the immediate concern of heavy bleeding and the underlying iron deficiency while preserving your fertility options for the future.