What is the best course of action for a 25-year-old woman experiencing dyspnea (shortness of breath), fatigue, occasional palpitations, and menorrhagia (very heavy menstrual periods) for several months?

Immediate Diagnostic Workup for Iron Deficiency Anemia Secondary to Menorrhagia

This 25-year-old woman most likely has iron deficiency anemia from chronic menorrhagia, and the priority is to confirm anemia with complete blood count, assess iron stores with ferritin and iron studies, and initiate oral iron supplementation while evaluating the underlying cause of heavy menstrual bleeding. 1

Initial Laboratory Assessment

The diagnostic workup should immediately include:

• Complete blood count (CBC) with hemoglobin and hematocrit to confirm anemia and assess severity, as menorrhagia causing blood losses >80mL can result in anemia, fatigue, and syncope 1
• Serum ferritin and iron studies to confirm iron deficiency as the underlying cause of anemia 1
• Thyroid stimulating hormone (TSH) to evaluate thyroid dysfunction as a potential cause of both menorrhagia and fatigue 1
• Pregnancy test to rule out pregnancy-related complications 1

Clinical Correlation of Symptoms

The constellation of symptoms points directly to anemia:

• Dyspnea on exertion and fatigue are classic manifestations of reduced oxygen-carrying capacity from anemia 2
• Palpitations in a young woman with heavy menstrual periods are frequently benign and related to compensatory tachycardia from anemia, though cardiac arrhythmias must be excluded 3
• Heavy menstrual periods for several months provide the clear mechanism for chronic blood loss leading to iron deficiency 1

Immediate Management Strategy

Iron Replacement Therapy

• Initiate oral iron supplementation immediately once iron deficiency anemia is confirmed, as this is the primary treatment for anemia secondary to menorrhagia 1
• Monitor hemoglobin response at 4-6 weeks to assess adequacy of replacement

Menorrhagia Management

Medical therapy should be first-line for menorrhagia in this young woman:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce menstrual blood loss and are appropriate first-line therapy 1
• Hormonal therapy with oral contraceptives can regulate menstrual cycles and reduce blood loss 1
• Tranexamic acid is an antifibrinolytic agent that stabilizes fibrin and reduces menstrual bleeding, though it should be used cautiously with hormonal contraceptives due to increased thromboembolic risk 4

Additional Evaluation for Menorrhagia Etiology

The workup should identify underlying causes:

• Pelvic ultrasound to evaluate for structural abnormalities including uterine fibroids or adenomyosis 2
• Endocrine screening including FSH, prolactin, and cortisol if anovulation or polycystic ovary syndrome is suspected 1
• Liver and kidney function tests to exclude chronic diseases that can cause menorrhagia 1

Cardiac Evaluation Considerations

While cardiac causes are less likely in this young patient, certain findings warrant further investigation:

• Electrocardiogram (ECG) should be obtained if palpitations are frequent, associated with syncope, or inappropriately rapid 2
• Echocardiography is not indicated unless there are abnormal cardiac findings on physical examination (murmurs, extra heart sounds, edema) or ECG abnormalities 2
• The American College of Cardiology notes that palpitations in young women are frequently benign and related to hormonal fluctuations or anemia rather than structural heart disease 2, 3

Critical Pitfalls to Avoid

• Do not pursue extensive cardiac workup without first addressing the obvious cause of anemia from menorrhagia, as dyspnea and palpitations will likely resolve with iron replacement 2
• Do not delay iron supplementation while waiting for complete evaluation of menorrhagia etiology, as symptomatic anemia requires immediate treatment 1
• Avoid prescribing tranexamic acid with hormonal contraceptives due to increased thromboembolic risk; use effective non-hormonal contraception if tranexamic acid is chosen 4
• Do not assume palpitations are benign if they are associated with syncope, inappropriately rapid pulse, or occur at rest, as these require electrophysiological evaluation 2, 3

Expected Clinical Course

• Symptoms should improve within 2-4 weeks of initiating iron supplementation as hemoglobin levels rise 1
• Menstrual blood loss should decrease with appropriate medical management of menorrhagia 1
• Persistent symptoms despite adequate iron replacement warrant reassessment for alternative diagnoses including cardiac or pulmonary pathology 2