What is the best course of treatment for a patient with iron deficiency anemia, adenomyosis, and a family history of Von Willebrand disease?

Management of Iron Deficiency Anemia in a Premenopausal Woman with Adenomyosis

Start oral ferrous sulfate 200 mg once daily immediately to correct the iron deficiency anemia and replenish iron stores, continuing for 3 months after hemoglobin normalizes. 1

Immediate Iron Replacement Therapy

All patients with iron deficiency anemia require iron supplementation regardless of the underlying cause. 2

• Ferrous sulfate 200 mg (containing 65 mg elemental iron) once daily is the preferred first-line treatment due to its effectiveness and low cost 1, 3
• Once-daily dosing improves tolerability while maintaining effectiveness compared to multiple daily doses 1
• Take on an empty stomach for optimal absorption, though taking with food is acceptable if gastrointestinal side effects occur 1
• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption, particularly important given your low ferritin of 13 ng/mL 2, 1
• Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated 2, 1

Expected Response and Monitoring

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment 2, 1
• Continue iron therapy for 3 months after anemia correction to fully replenish iron stores 2, 1
• Monitor hemoglobin and red cell indices every 3 months for the first year, then again after another year 2, 1
• If no response occurs within 4 weeks, assess for non-adherence, malabsorption, or ongoing blood loss 1

Addressing the Underlying Cause: Adenomyosis-Related Menorrhagia

The adenomyosis is the likely source of chronic blood loss causing iron deficiency in this premenopausal woman. 2 The British Society of Gastroenterology guidelines note that menstrual loss, especially menorrhagia, is usually responsible for iron deficiency anemia in 5-10% of menstruating women. 2

Treatment Options for Adenomyosis-Related Bleeding:

• Tranexamic acid is highly effective for reducing menstrual blood loss and should be considered as first-line therapy for menorrhagia 4, 5
• Standard dosing is 1-3 grams daily in divided doses for the first 5 days of the menstrual cycle 4
• Combined oral contraceptives are also effective first-line options for reducing menstrual blood loss 5
• Hormonal therapies (levonorgestrel IUD, progestins) can reduce menstrual bleeding and prevent recurrent iron deficiency 5

Special Consideration: Family History of Von Willebrand Disease

Clotting disorder workup is reasonable given the family history, but should not delay iron replacement therapy. 2

• Von Willebrand disease is the most common congenital bleeding disorder and frequently presents with menorrhagia in women 5
• Women with VWD and menorrhagia commonly develop iron deficiency anemia 4, 5
• If VWD is confirmed, tranexamic acid at higher doses (3 grams daily) has been shown to effectively control menorrhagia in VWD patients 4
• Von Willebrand factor replacement therapy is typically reserved as third-line therapy when hormonal and antifibrinolytic treatments fail 5

When to Consider Gastrointestinal Investigation

For premenopausal women under age 45 with a clear gynecologic source of bleeding, extensive GI investigation is not routinely indicated. 2

• The British Society of Gastroenterology recommends that women under 45 years should only have upper GI endoscopy if they have upper GI symptoms 2
• Celiac disease screening with antiendomysial antibody (and IgA measurement) should be considered 2, 1
• Women over 45 years should undergo full bidirectional endoscopy (upper endoscopy with small bowel biopsy and colonoscopy) regardless of gynecologic bleeding 2

When to Switch to Intravenous Iron

Intravenous iron is indicated if: 1

• Intolerance to at least two different oral iron preparations
• Inadequate response to oral iron after 4 weeks despite good adherence
• Ongoing blood loss exceeds oral replacement capacity
• Conditions affecting iron absorption (inflammatory bowel disease, celiac disease, post-bariatric surgery)

Common Pitfalls to Avoid

• Do not use multiple daily doses of iron - once-daily dosing is better tolerated with similar efficacy 1
• Do not stop iron therapy when hemoglobin normalizes - continue for 3 months to replenish stores 2, 1
• Do not overlook vitamin C supplementation when oral iron response is suboptimal 2, 1
• Do not fail to address the underlying menorrhagia - iron replacement alone without controlling bleeding will lead to recurrent deficiency 2
• Do not continue oral iron indefinitely without response - reassess after 4 weeks and switch to IV iron if hemoglobin fails to rise 1

Failure to Respond

If anemia does not resolve within 6 months despite appropriate iron therapy: 1

• Reassess for ongoing blood loss from adenomyosis
• Evaluate for malabsorption syndromes (celiac disease screening)
• Verify patient adherence to therapy
• Consider hematology consultation for complex cases