What is the diagnosis for a 47-year-old woman with anemia (low hemoglobin (Hgb)) due to chronic vaginal bleeding?

From the Guidelines

For a 47-year-old woman with anemia due to chronic vaginal bleeding, I strongly recommend a comprehensive approach that includes iron supplementation, hormonal therapy to control bleeding, and a thorough gynecologic evaluation to identify and treat the underlying cause of bleeding. This approach is crucial to address both the anemia and the underlying bleeding, prioritizing the patient's morbidity, mortality, and quality of life.

Key Components of the Approach

• Iron supplementation with ferrous sulfate 325 mg orally three times daily or ferrous gluconate 300 mg twice daily, taken with vitamin C to enhance absorption and between meals if tolerated, as suggested by general medical knowledge and practices.
• Hormonal therapy such as a combined oral contraceptive pill (e.g., ethinyl estradiol 35 mcg/norethindrone 1 mg daily) or a levonorgestrel IUD to control the bleeding, based on guidelines for managing heavy or prolonged bleeding 1.
• Prompt gynecologic evaluation to determine the cause of bleeding, which at her age could include fibroids, polyps, adenomyosis, or perimenopausal dysfunctional uterine bleeding, as indicated by the need to consider underlying gynecological problems in cases of irregular bleeding 1.

Considerations for Management

• If an underlying gynecologic problem is identified, treat the condition or refer for care, emphasizing the importance of addressing the root cause of the bleeding 1.
• If the patient's hemoglobin level drops below 7 g/dL or she becomes symptomatic (dizziness, shortness of breath, chest pain), blood transfusion may be necessary, highlighting the need for close monitoring of the patient's condition.
• Iron therapy should continue for 3-6 months even after bleeding resolves to replenish iron stores, ensuring that the patient's anemia is fully addressed.

From the Research

Diagnosis of Anemia due to Chronic Vaginal Bleeding

• The diagnosis for a 47-year-old woman with anemia due to chronic vaginal bleeding is likely iron deficiency anemia, as indicated by low hemoglobin (Hgb) levels 2, 3, 4, 5, 6.
• Iron deficiency anemia is a common finding in women of child-bearing age, and chronic vaginal bleeding is a significant cause of iron loss 2, 4.
• The diagnosis can be confirmed by measuring biomarkers of iron stores, such as serum ferritin, and hemoglobin levels 4, 6.

Treatment Options

• Oral iron supplementation is the first line of treatment for iron deficiency anemia, with ferrous sulfate being the most commonly prescribed drug 3, 4, 6.
• Other oral iron supplements, such as ferrous salts and ferric complexes, are also available and may have a better tolerability profile 3, 6.
• Intravenous iron therapy may be necessary in cases of moderate-to-severe iron deficiency anemia or when oral iron supplementation is contraindicated 5.

Management of Iron Deficiency Anemia

• The management of iron deficiency anemia involves correcting the underlying cause of iron loss, such as chronic vaginal bleeding, and replenishing iron stores 2, 4, 5, 6.
• Oral iron supplementation should be taken for a sufficient period, usually 6-8 weeks, to correct iron deficiency anemia 5.
• Patient compliance with oral iron supplementation can be improved by using formulations with a better tolerability profile, such as iron protein succinylate 6.