What is the appropriate diagnosis and treatment for a woman experiencing fatigue, shortness of breath, and palpitations, with a history of heavy menstrual periods?

Diagnosis: Iron Deficiency Anemia Secondary to Heavy Menstrual Bleeding

This 25-year-old woman most likely has iron deficiency anemia (IDA) caused by heavy menstrual bleeding (menorrhagia), and she requires immediate evaluation with complete blood count, ferritin level, and transvaginal ultrasound to assess for structural uterine pathology, followed by treatment with iron supplementation and menstrual suppression. 1, 2, 3

Clinical Presentation Analysis

The constellation of symptoms strongly suggests IDA:

• Fatigue, shortness of breath, and palpitations are classic manifestations of anemia, particularly when exercise intolerance develops over weeks to months 2, 4
• Heavy menstrual bleeding is the most common cause of iron deficiency in reproductive-aged women, affecting quality of life and causing progressive anemia 3
• The two-month timeline indicates chronic blood loss with progressive iron depletion 2, 3

Diagnostic Workup

Laboratory Assessment

• Complete blood count to confirm anemia and assess severity (hemoglobin, hematocrit) 2, 4
• Ferritin level to document iron deficiency (low ferritin inversely correlates with menstrual blood loss) 2, 5
• Serum iron and transferrin saturation provide additional confirmation of iron deficiency 5
• Thyroid-stimulating hormone to exclude thyroid dysfunction as a cause of menorrhagia 1
• Pregnancy test is mandatory to rule out pregnancy-related bleeding 1

Imaging Studies

• Transvaginal ultrasound with Doppler is the initial imaging study of choice to evaluate for structural causes (fibroids, polyps, adenomyosis) 1
• Combined transabdominal and transvaginal approach allows assessment of endometrial thickness and uterine pathology 1
• MRI may be needed if ultrasound is inconclusive or adenomyosis is suspected 1

Assessment of Bleeding Severity

• Pictorial blood assessment chart can objectively quantify menstrual blood loss (>80 mL defines menorrhagia) 6
• Clinical predictors of heavy bleeding include clots ≥1 inch diameter, "flooding" (changing pad/tampon more than hourly), and low ferritin 2

Underlying Etiology Considerations

Most Common Causes in Young Women

• Ovulatory dysfunction is the most common cause of heavy menstrual bleeding in adolescents and young women 4
• Structural abnormalities (fibroids, polyps) must be excluded with imaging 1, 6
• Bleeding disorders (von Willebrand disease) have higher prevalence in women with heavy menstrual bleeding and should be considered if there is personal or family bleeding history 2, 4

Treatment Approach

Iron Repletion

• Oral iron supplementation is essential to correct iron deficiency and restore iron stores 3
• Treatment must continue until ferritin normalizes, not just until hemoglobin improves 3

Menstrual Suppression

The 52-mg levonorgestrel intrauterine device (IUD) is the most effective treatment for heavy menstrual bleeding in young women, reducing menstrual blood loss by 71-95% 7, 4

• The levonorgestrel IUD works primarily at the endometrial level with minimal systemic absorption 7
• It is safe and effective in adolescents and young women, including those with bleeding disorders 4
• Superior efficacy compared to other hormonal options for controlling heavy menstrual bleeding 7, 4

Alternative Hormonal Options

• Combined oral contraceptives can reduce menstrual blood loss and are appropriate first-line therapy 7, 5
• Oral contraceptives can reduce anemia risk, particularly in young women 5
• Cyclic oral progestin reduces bleeding by 87% but may cause irregular bleeding 7

When to Refer

• Hematology referral if bleeding disorder suspected (flooding, prolonged menses, personal/family bleeding history) 2
• Gynecology referral if structural abnormalities identified on imaging or if medical management fails 1

Critical Pitfalls to Avoid

• Do not assume bleeding is "normal" for a young woman - both heavy menstrual bleeding and iron deficiency are frequently normalized by society and healthcare providers, leading to delayed diagnosis 3
• Do not stop iron supplementation when hemoglobin normalizes - iron stores must be fully repleted (normal ferritin) to prevent recurrence 3
• Do not overlook bleeding disorders - von Willebrand disease has high incidence in adolescents with heavy menstrual bleeding 4
• Do not delay treatment - prompt recognition and treatment can prevent transfusion, hospitalization, and long-term cognitive effects of iron deficiency 4, 3