Management of Iron Deficiency Anemia in a 44-Year-Old Asymptomatic Female with Hemoglobin 7.8 g/dL
This patient requires immediate oral iron supplementation (ferrous sulfate 200 mg three times daily) AND comprehensive gastrointestinal investigation including upper endoscopy with small bowel biopsies and colonoscopy to identify the underlying cause of blood loss. 1
Immediate Iron Replacement Therapy
Start ferrous sulfate 200 mg three times daily (or ferrous gluconate/ferrous fumarate as equally effective alternatives) to correct anemia and replenish iron stores. 1
Continue iron supplementation for 3 months after hemoglobin normalizes to adequately replenish body iron stores. 1
Expect hemoglobin to rise by 2 g/dL after 3-4 weeks of treatment. 1
If oral iron is not tolerated after trying at least two different preparations, consider intravenous iron (though parenteral iron offers no faster hemoglobin rise than oral preparations). 1
Consider adding ascorbic acid to enhance iron absorption if response is suboptimal. 1
Mandatory Gastrointestinal Investigation
Despite being asymptomatic, this 44-year-old woman requires full GI evaluation because:
All patients over 45 years with iron deficiency anemia should undergo both upper endoscopy and colonoscopy regardless of symptoms, as the risk of serious pathology (particularly malignancy) increases significantly with age. 1
At age 44, she falls into a gray zone where investigation is strongly recommended given her severe anemia (Hgb 7.8 g/dL) - the lower the hemoglobin, the more likely serious underlying pathology exists. 1
Upper GI Evaluation
Perform upper endoscopy (esophagogastroduodenoscopy) with small bowel biopsies to screen for celiac disease, which accounts for 2-3% of iron deficiency anemia cases. 1
Upper endoscopy identifies a cause in 30-50% of patients with iron deficiency anemia. 1
Only advanced gastric cancer or confirmed celiac disease should deter subsequent lower GI investigation. 1
Lower GI Evaluation
Colonoscopy is preferred over CT colonography or barium enema, as it allows visualization of angiodysplasia and tissue biopsy. 1
Lower GI investigation is mandatory even if upper endoscopy reveals findings like esophagitis, erosions, or peptic ulcer, because dual pathology occurs in 10-15% of patients. 1
Additional Screening
Screen for celiac disease with tissue transglutaminase antibody (IgA type) and total IgA level (to exclude IgA deficiency which makes the test unreliable). 1, 2
Obtain detailed menstrual history - menorrhagia is responsible for iron deficiency anemia in 5-10% of menstruating women, though history alone is unreliable for quantifying blood loss. 1
Review use of NSAIDs and aspirin, which should be stopped whenever possible. 1
Assess dietary iron intake, though borderline deficient diets should not preclude full GI investigation. 1
Common Pitfalls to Avoid
Do not assume menstrual blood loss is the sole cause without investigation - at age 44 approaching menopause, GI pathology becomes increasingly likely. 1
Do not accept minor upper GI findings (esophagitis, gastric erosions, peptic ulcer) as the definitive cause without completing lower GI evaluation. 1
Do not perform fecal occult blood testing - it is insensitive, non-specific, and provides no diagnostic benefit in iron deficiency anemia. 1
Do not transfuse blood unless the patient develops cardiovascular instability - she is currently asymptomatic. 1
Monitoring and Follow-Up
Recheck hemoglobin after 4 weeks of iron therapy. 1
If anemia fails to respond (hemoglobin does not increase by 1 g/dL) despite compliance and absence of acute illness, perform additional testing including MCV, RDW, and serum ferritin. 1
Failure to respond suggests poor compliance, misdiagnosis, continued blood loss, or malabsorption. 1
Once hemoglobin normalizes, monitor every 3 months for one year, then annually. 1
Further investigation is only necessary if hemoglobin and MCV cannot be maintained with intermittent iron supplementation. 1