What is the best management for a patient with iron deficiency anemia, low ferritin, and heavy menstrual bleeding after copper IUD placement?

Management of Iron Deficiency Anemia with Heavy Menstrual Bleeding After Copper IUD Placement

Start oral ferrous sulfate 200 mg once daily immediately and address the menstrual bleeding with hormonal therapy, specifically a levonorgestrel intrauterine system (LNG-IUS), which treats both the bleeding source and the anemia simultaneously. 1

Immediate Iron Replacement

All patients with iron deficiency anemia require iron supplementation to correct anemia and replenish body stores, regardless of the underlying cause. 2

• Prescribe ferrous sulfate 200 mg once daily as first-line therapy—this is the most cost-effective and evidence-based approach 1
• Once-daily dosing improves tolerability while maintaining effectiveness compared to three-times-daily regimens 1
• Add vitamin C (ascorbic acid) 500 mg with the iron dose to enhance absorption, particularly important given the severely depleted ferritin of 6 2, 1
• Take on an empty stomach for optimal absorption, though taking with food is acceptable if gastrointestinal side effects occur 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
• If no response occurs within 4 weeks, assess for non-adherence, ongoing blood loss (likely in this case), or malabsorption 1
• Continue iron therapy for 3 months after hemoglobin normalizes 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

Address the Underlying Cause: Heavy Menstrual Bleeding

The copper IUD is likely causing or exacerbating the heavy menstrual bleeding, and this must be addressed to prevent ongoing iron loss. 2

Hormonal Management Options:

• Levonorgestrel intrauterine system (LNG-IUS) is the optimal choice—it can replace the copper IUD and dramatically reduces menstrual blood loss while providing contraception 3, 4
• The LNG-IUS improved hemoglobin levels and quality of life in women with heavy menstrual bleeding in randomized trials 4
• Alternative progestin-only options include etonogestrel subdermal implant or progestin-only pills 3
• Combined hormonal contraceptives are also effective for reducing menstrual blood loss 3

Copper IUD Considerations:

• Copper IUDs are known to increase menstrual blood loss and can cause or worsen iron deficiency anemia
• Removal or replacement with LNG-IUS should be strongly considered given the severe iron deficiency (ferritin 6) and symptomatic anemia

When to Consider Intravenous Iron

While oral iron is first-line, consider IV iron if:

• Patient cannot tolerate at least two different oral iron preparations 1
• Ongoing heavy menstrual bleeding exceeds oral replacement capacity (likely in this case initially) 1
• No hemoglobin rise after 4 weeks of adequate oral therapy 1
• Patient requires rapid correction due to severe symptoms 5

IV ferric carboxymaltose (up to 1000 mg over 15 minutes, repeated weekly to achieve total calculated replacement dose) is more effective than oral iron in women with heavy uterine bleeding, achieving faster hemoglobin correction and greater quality of life improvements 5

Common Pitfalls to Avoid

• Do not continue the copper IUD without addressing the bleeding—treating iron deficiency alone without stopping ongoing blood loss will result in treatment failure 2
• Do not prescribe multiple daily doses of oral iron—this increases side effects without improving 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 underestimate the severity—only 8% of anemic women with heavy menstrual bleeding were taking iron supplementation in one study, suggesting widespread undertreatment 4

Failure to Respond

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

• Reassess for ongoing blood loss (verify menstrual bleeding has decreased) 1
• Evaluate for malabsorption syndromes (celiac disease screening with antiendomysial antibody and IgA measurement) 1
• Verify patient adherence to therapy 1
• Consider hematology consultation for complex cases 1

Quality of Life Considerations

Correction of anemia significantly improves energy, physical functioning, social functioning, and reduces anxiety and depression in women with heavy menstrual bleeding. 4 Early aggressive treatment is justified not only for hematologic parameters but for substantial quality of life benefits.