Management of Severe Anemia with History of Heavy Periods and Prior H. pylori Treatment
Start oral iron supplementation immediately with ferrous sulfate 200 mg three times daily, continue for three months after hemoglobin normalizes, and consider age-based gastrointestinal investigation if the patient is over 45 years old. 1, 2, 3
Immediate Iron Supplementation Strategy
First-Line Oral Iron Therapy
- Ferrous sulfate 200 mg three times daily is the most cost-effective and evidence-based initial treatment 1, 2, 3
- Take iron at the start of meals to minimize gastrointestinal intolerance 4
- Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated 1, 3
- Add ascorbic acid (vitamin C) to enhance iron absorption if response is poor 1, 2, 3
- Liquid preparations may be better tolerated when tablets cause side effects 2, 3
Expected Response and Duration
- Hemoglobin should rise by 2 g/dL after 3-4 weeks of treatment 1, 3
- Continue iron supplementation for three months after hemoglobin normalizes to replenish body iron stores 1, 2, 3
- Premature discontinuation leads to rapid recurrence of anemia 2, 3
Age-Based Investigation Protocol
Critical Age Threshold at 45 Years
- Patients over 45 years require gastrointestinal evaluation (upper endoscopy and colonoscopy) even with documented heavy menstrual bleeding, as the incidence of GI pathology increases with age 1, 3
- Patients under 45 years with heavy menstrual bleeding as the clear cause may not require routine GI investigation 1
H. pylori Consideration
- While the patient was previously treated for H. pylori, H. pylori eradication has been shown to reverse iron deficiency anemia in patients with H. pylori-associated gastritis 5, 6
- In one study, 91.7% of patients recovered from anemia within 12 months after H. pylori eradication 6
- If anemia persists despite adequate iron supplementation and the patient is over 45, repeat H. pylori testing during upper endoscopy should be considered 7, 5
Monitoring Protocol
Structured Follow-Up Schedule
- Monitor hemoglobin concentration and red cell indices (MCV) every three months for one year, then annually 1, 2, 3
- Check ferritin levels if hemoglobin or MCV falls below normal during follow-up 1, 2
- Additional oral iron should be given if hemoglobin or MCV drops below normal 2, 3
When to Escalate to Intravenous Iron
Specific Indications for IV Iron
- Reserve intravenous iron for intolerance to at least two different oral iron preparations or documented non-compliance 1, 2, 3
- Consider IV iron if severe anemia requires rapid hemoglobin increase 8
- In patients with heavy uterine bleeding, IV ferric carboxymaltose (up to 1000 mg over 15 minutes, repeated weekly) is more effective than oral iron in correcting anemia (82% vs 62% achieving ≥2 g/dL Hb increase) 9
- Do not use parenteral iron as first-line therapy—it is painful, expensive, and carries risk of anaphylactic reactions 1, 3
Common Pitfalls to Avoid
Treatment Failures
- Poor compliance is the most common cause of treatment failure 1, 3
- Continued blood loss exceeding iron replacement will prevent response 1, 3
- Misdiagnosis or malabsorption can also cause poor response 1
- Failure to continue iron for three months after normalization leads to recurrence 2, 3
Monitoring Failures
- Not following hemoglobin and iron indices at appropriate three-month intervals 2
- Discontinuing monitoring too early (should continue for at least one year) 1, 2
Addressing the Underlying Cause
Concurrent Management of Heavy Menstrual Bleeding
- Treatment of the underlying heavy menstrual bleeding itself is critical to prevent ongoing iron loss 3
- Heavy menstrual bleeding affects 5-10% of menstruating women and is the primary cause of iron deficiency in this population 1, 3
- Gynecological evaluation and treatment should occur concurrently with iron supplementation 1