Diagnostic Workup and Treatment for Recurrent Canker Sores with Heavy Menstrual Bleeding
This 17-year-old requires immediate laboratory testing for iron deficiency anemia and nutritional deficiencies, as heavy periods commonly cause iron depletion that directly contributes to recurrent aphthous ulcers.
Initial Laboratory Testing
First-Line Blood Work (Order Immediately)
- Complete blood count (CBC) with ferritin levels to screen for anemia and iron deficiency 1
- Serum iron, folate, and vitamin B12 levels as nutritional deficiencies are common causes of recurrent aphthous stomatitis 1, 2
- Fasting blood glucose to exclude hyperglycemia predisposing to infections 1
The combination of heavy periods and recurrent oral ulcers strongly suggests iron deficiency anemia, which affects young menstruating women and is a well-established cause of recurrent aphthous ulcers 3, 2. Iron deficiency does not cause acute hepatic porphyrias but commonly causes chronic symptoms in young women and should be treated 3.
Additional Testing Based on Clinical Context
- HIV antibody testing if risk factors present 1
- Syphilis serology to exclude syphilitic ulcers 1
- Autoimmune markers only if clinical features suggest systemic autoimmune disease 1
When to Perform Biopsy
Biopsy is NOT indicated initially for typical recurrent aphthous ulcers that resolve within 2 weeks 1, 4. However:
- Biopsy any ulcer persisting >2 weeks despite treatment to rule out malignancy or other serious pathology 1, 4
- Multiple biopsies may be needed if ulcers have different morphological characteristics 1
- Direct immunofluorescence should be performed if bullous diseases are suspected 1
Treatment Approach
For the Oral Ulcers
First-line topical therapy:
- Topical corticosteroids (betamethasone sodium phosphate, fluticasone propionate, or clobetasol 0.05% ointment) are the mainstay of treatment 4, 2, 5, 6
- Topical anesthetics (lidocaine) for pain relief 2, 6
- Antiseptic agents (triclosan) can be tried first before escalating to corticosteroids 6
- Barrier preparations (Gengigel mouth rinse/gel or Gelclair) for pain control 4
Lifestyle modifications:
- Avoid hard, acidic, salty foods, alcohol, and carbonated drinks 6
- Avoid toothpastes containing sodium lauryl sulfate 6
- Eliminate sources of trauma and maintain effective oral hygiene 4
For the Heavy Periods
Address the underlying menorrhagia with appropriate gynecologic management, as treating iron deficiency without controlling blood loss will result in recurrent deficiency.
Systemic Therapy (If Topical Treatment Fails)
- Colchicine is suitable for most cases of recurrent aphthous stomatitis when topical treatments are insufficient 2
- Pentoxifylline or prednisolone can be combined with local measures in severe cases 6
- More aggressive immunosuppression should only be used for refractory cases or Behçet's disease 6
Common Pitfalls to Avoid
- Do not rely solely on clinical appearance without laboratory testing for persistent or recurrent ulcers 1
- Do not treat symptoms without establishing iron/nutritional status in a young woman with heavy periods 3, 1
- Do not overlook the connection between menorrhagia and oral ulcers through iron deficiency 3, 2
- Do not biopsy typical aphthous ulcers that resolve within 2 weeks unless there are atypical features 1, 4
Specialist Referral Indications
- Refer to oral medicine specialist if ulcers persist >2 weeks or do not respond to 1-2 weeks of treatment 1, 4
- Refer to hematology if blood count suggests leukemia or other blood disorders 1, 4
- Refer to gastroenterology if inflammatory bowel disease is suspected 4, 2