What treatment is recommended for a ferritin level drop from 18 to 14 with one menstrual period?

Management of Declining Ferritin (18→14 μg/L) with Menstruation

You should immediately initiate oral iron supplementation to correct iron deficiency and prevent progression to iron deficiency anemia, as ferritin levels below 15 μg/L indicate depleted iron stores that require treatment. 1

Immediate Treatment Recommendation

Start oral iron supplementation with ferrous sulfate 200 mg three times daily (or equivalent ferrous gluconate/fumarate), as this is the most cost-effective first-line approach for correcting iron deficiency and replenishing body stores. 1

Specific Dosing Options

• Ferrous sulfate 200 mg three times daily is the standard regimen 1
• Alternative: 30-60 mg elemental iron daily or on alternate days if tolerability is a concern 1, 2
• Consider alternate-day dosing to improve absorption and reduce gastrointestinal side effects 2

Rationale for Treatment

Your ferritin drop from 18 to 14 μg/L with one menstrual period indicates:

• Active iron depletion - ferritin <15 μg/L confirms iron deficiency 1
• Menstrual blood loss is exceeding iron intake/absorption - menstruating women commonly develop iron deficiency, occurring in 5-10% of this population 1
• Risk of progression to anemia without intervention 1

Optimizing Absorption

Take iron supplements with 500 mg vitamin C on an empty stomach when possible to maximize absorption, though taking with meals is acceptable if better tolerated. 1, 2

What to avoid:

• Do not take iron with tea, coffee, or calcium-containing foods as these impair absorption 2
• Separate calcium-rich foods from iron supplementation 2

Monitoring Protocol

Measure ferritin and hemoglobin after 8-10 weeks of treatment to assess response. 2

• Target ferritin level: 50-100 μg/L 1, 2
• Continue iron supplementation for 3 months after correction of anemia to replenish iron stores 1
• Monitor ferritin every 6 months during treatment 2

When to Consider IV Iron

Consider intravenous iron if:

• Failure of oral therapy despite adequate compliance 2
• Intolerance to at least two oral iron preparations 1
• Malabsorption disorders present 2

Addressing Underlying Cause

Evaluate and address heavy menstrual bleeding as the likely etiology, since menstrual loss (especially menorrhagia) is the primary cause of iron deficiency in premenopausal women. 1, 2

• Consider gynecological evaluation if menstrual bleeding is excessive 2
• Pictorial blood loss assessment charts have 80% sensitivity/specificity for detecting menorrhagia 1

Common Pitfalls to Avoid

• Do not wait for anemia to develop - treat iron deficiency even without anemia 1
• Do not discontinue treatment once symptoms improve - continue until iron stores are adequately replenished 2
• Do not undertake extensive GI evaluation in premenopausal women unless there are GI symptoms or failure to respond to treatment, as menstruation is the likely cause 1

Expected Response

With appropriate supplementation:

• Hemoglobin recovery occurs within 30-32 days 3
• Ferritin recovery to baseline takes 21-76 days depending on initial levels 3
• Without supplementation, 67% of individuals do not recover iron stores by 168 days 3