What is the workup for a 35-year-old female with iron deficiency anemia, menorrhagia, fatigue, palpitations, and tachycardia?

From the Guidelines

For a 35-year-old female with iron deficiency anemia, menorrhagia, fatigue, palpitations, and tachycardia, the workup should include a comprehensive evaluation of her anemia and cardiac symptoms, with a focus on identifying and addressing the underlying cause of heavy menstrual bleeding and iron deficiency. The initial evaluation should include a complete blood count (CBC) to assess hemoglobin, hematocrit, red cell indices, and platelet count, as well as iron studies including serum iron, total iron binding capacity, ferritin, and transferrin saturation to confirm iron deficiency and monitor response to supplementation 1. A thorough menstrual history should document frequency, duration, and heaviness of periods, possibly using a pictorial blood assessment chart, and gynecological evaluation may include pelvic ultrasound to identify structural causes of heavy menstrual bleeding such as fibroids or polyps 1. Cardiac evaluation should include an electrocardiogram (ECG) during symptoms if possible, and consideration of 24-hour Holter monitoring to capture intermittent arrhythmias, as well as thyroid function tests (TSH, free T4) to rule out thyroid disorders that can cause both tachycardia and affect menstrual patterns 1. Basic metabolic panel and assessment of vitamin B12 and folate levels should be included to rule out other causes of anemia. If anemia persists despite adequate iron supplementation or if blood loss seems excessive, gastrointestinal evaluation with endoscopy may be warranted to rule out occult bleeding sources 1. Management should optimize iron supplementation, typically with ferrous sulfate 325mg daily between meals with vitamin C to enhance absorption, while addressing the underlying cause of heavy menstrual bleeding, which might include hormonal therapy such as combined oral contraceptives or a levonorgestrel intrauterine device to reduce menstrual flow 1. Key considerations in management include:

• Identifying and addressing the underlying cause of heavy menstrual bleeding and iron deficiency
• Optimizing iron supplementation to improve hemoglobin levels and reduce symptoms
• Monitoring for and managing potential complications of iron deficiency anemia, such as cardiac arrhythmias and decreased quality of life
• Considering alternative treatments, such as intravenous iron supplementation, in patients who do not respond to oral iron therapy or have severe iron deficiency anemia 1.

From the FDA Drug Label

Purpose Iron Supplement Therapy Ferrous Sulphate is an iron supplement for iron deficiency and iron deficiency anemia when the need for such therapy has been determined by a physician.

The FDA drug label does not answer the question.

From the Research

Diagnosis and Treatment

The workup for a 35-year-old female with iron deficiency anemia, menorrhagia, fatigue, palpitations, and tachycardia involves:

• Identifying and treating the underlying cause of iron deficiency, which in this case is menorrhagia 2
• Iron supplementation to control iron deficiency, with the most appropriate treatment being an oral ferrous salt in a prolonged-release tablet form, providing a dose of elemental iron equivalent to 60 mg per intake, in the range of 60 and 120 mg/day according to the severity of iron-deficiency anemia 2
• Treatment should continue for about 3 months to fill iron stores after haemoglobin levels have returned to normal 2

Iron Supplementation

• Oral iron supplementation is the first line of treatment for iron deficiency anemia, with ferrous sulfate being the simplest and most commonly prescribed drug 3
• The current recommended dosage for oral supplementation is 100 mg ferrous fumarate once a day for symptom-free patients with anemia, and 200 mg/day for patients with severe anemia or symptoms 4
• Parenteral supplementation should be chosen if oral therapy does not show effectiveness, the anemia is severe, or rapid increase of haemoglobin is indicated 4
• New formulations of oral iron supplements, such as ferric maltol or nanoparticle encapsulated sucrosomial iron, have been developed to improve efficacy and tolerability 3

Management of Menorrhagia

• Iron prophylaxis can be given to cover the increased losses due to menorrhagia, with one tablet containing 100 mg of iron given daily for 10 days in connection with the menstrual period 5
• The majority of patients with menorrhagia can absorb more iron from the tablets than is lost by the menstrual bleedings, making iron prophylaxis a sufficient treatment in most cases 5