What is the best course of treatment for a 36-year-old female patient with adenomyosis, iron deficiency anemia, neuropathic pain, and a positive Ureaplasma urealyticum test, who is trying to conceive?

Management of Complex Case: Adenomyosis, Iron Deficiency Anemia, Neuropathy, and Ureaplasma in Patient Desiring Conception

Immediate Priority: Treat Ureaplasma urealyticum Before Conception Attempts

You must treat the Ureaplasma urealyticum infection immediately with azithromycin 1g single dose, and ensure her partner receives treatment simultaneously, before any conception attempts. 1 This is critical because Ureaplasma urealyticum has been associated with spontaneous abortion, abruptio placentae, and interference with normal fetal development. 2 The European Association of Urology guidelines confirm that U. urealyticum (unlike U. parvum) is associated with male infertility and requires treatment of both partners. 1

• Administer azithromycin 1g as a single dose to the patient 1, 3
• Treat her partner simultaneously even if asymptomatic to prevent reinfection 1
• Advise abstinence until both partners complete treatment 1
• Note that single-dose azithromycin shows equivalent efficacy to 7-day doxycycline for U. urealyticum 3

Iron Deficiency Anemia Management

Continue ferrous sulfate 200mg daily (not three times daily as typically recommended) since she has inactive disease, and continue for 3 months after hemoglobin normalizes to rebuild iron stores. 1, 4

• Her ferritin of 13 ng/mL confirms iron deficiency (threshold <15 ng/mL) 4
• The elevated TIBC (451) and low MCH/MCHC support iron deficiency anemia 1
• Since she is 36 years old and has heavy menstrual bleeding with adenomyosis, menorrhagia is the likely cause 1, 4
• At age 36, she does NOT require routine GI investigation unless she develops upper GI symptoms 4
• Continue vitamin C 500mg with iron to enhance absorption 1, 4
• Target hemoglobin rise of 2 g/dL after 3-4 weeks 1, 4
• Continue iron for 3 months after anemia correction to replenish stores 1, 4
• Monitor hemoglobin and MCV every 3 months for one year 1

When to Consider IV Iron

Only use parenteral iron if she fails at least two different oral iron preparations or develops intolerance 1, 4

Neuropathic Pain Management

Continue gabapentin 300mg three times daily as prescribed, but recognize this does NOT need to be stopped for conception. The gabapentin is appropriately treating her mononeuropathy, which appears related to her adenomyosis causing nerve compression during menstrual periods (symptoms worsen with menses and improve when not menstruating).

• Gabapentin is not contraindicated in pregnancy planning, unlike methotrexate or JAK inhibitors which require 3-month washout 1
• Her symptom pattern (worsening with menses, improvement off menses) strongly suggests adenomyosis-related nerve compression
• The negative DVT ultrasound appropriately ruled out vascular causes

Adenomyosis and Fertility Planning

Optimize her adenomyosis control before conception, as uncontrolled disease increases adverse fetal outcomes. 1

• Adenomyosis originates from basalis endometrium invagination into myometrium and is estrogen-driven with progesterone resistance 5
• Her heavy menstrual bleeding (4-6 extra-large pads daily with clots) indicates active disease requiring management 5
• Ideally achieve a 3-month period of symptom control before conception 1
• Daily folic acid 400 mcg should be started immediately for pre-conception 1
• Daily vitamin D supplementation should be initiated 1
• Ensure cervical screening is current 1

Critical Timing Consideration

She previously discontinued birth control after adenomyosis diagnosis, but hormonal management may be necessary to control bleeding and optimize iron stores before conception. However, since she desires pregnancy soon, focus on:

1. Treating Ureaplasma infection first (both partners)
2. Correcting iron deficiency anemia
3. Achieving 3 months of stable hemoglobin/ferritin before conception
4. Continuing gabapentin (safe in pregnancy planning)

Von Willebrand Disease Screening

Await pending coagulation studies (PT/PTT, von Willebrand profile) given family history. If positive, this would explain her menorrhagia and require hematology consultation before pregnancy. 1

What NOT to Do

• Do NOT perform routine GI endoscopy or colonoscopy at age 36 with obvious menorrhagia as the cause 4
• Do NOT stop gabapentin for pregnancy planning (unlike methotrexate or JAK inhibitors) 1
• Do NOT allow conception attempts until Ureaplasma treatment is complete in both partners 2
• Do NOT use live vaccines if she requires immunosuppression for adenomyosis management 1