From the Guidelines
Heavy menstruation in a 17-year-old with a ferritin level of 5 requires immediate attention for both the bleeding and the severe iron deficiency, and management should include hormonal therapy to control bleeding and iron supplementation to address the iron deficiency. The most common cause in adolescents is anovulatory cycles due to immature hypothalamic-pituitary-ovarian axis, though bleeding disorders, polycystic ovary syndrome, thyroid dysfunction, or structural abnormalities should also be considered 1.
Causes of Heavy Menstruation
- Anovulatory cycles due to immature hypothalamic-pituitary-ovarian axis
- Bleeding disorders
- Polycystic ovary syndrome
- Thyroid dysfunction
- Structural abnormalities
Management of Heavy Menstruation and Iron Deficiency
- Hormonal therapy to control bleeding, such as combined oral contraceptives (e.g., ethinyl estradiol 30-35 mcg with levonorgestrel or norethindrone) taken continuously for 3-6 months, or a levonorgestrel IUD if appropriate
- Iron supplementation is crucial, with oral ferrous sulfate 60-65 mg elemental iron 2-3 times daily between meals with vitamin C to enhance absorption, as iron from meat (heme iron) is better absorbed than plant-based iron (non-heme) 1
- For severe anemia, intravenous iron (such as iron sucrose or ferric carboxymaltose) may be necessary
- A comprehensive workup should include complete blood count, coagulation studies, thyroid function tests, and pelvic ultrasound
- Lifestyle modifications including regular exercise and maintaining healthy weight can help regulate cycles
- The patient should be monitored every 1-3 months until ferritin normalizes (>50 ng/mL) and menstrual cycles stabilize, with long-term management focusing on preventing recurrence of heavy bleeding and maintaining adequate iron stores 1.
From the Research
Causes of Heavy Menstruation
- Heavy menstrual bleeding (HMB) is the most common cause of iron deficiency anemia (IDA) in women 2, 3, 4
- Iron deficiency is one of the most common causes of anemia, with the 2 main etiologies being blood loss due to menstrual periods and blood loss due to gastrointestinal bleeding 5
Management of Heavy Menstruation
- Tranexamic acid (TA) has been shown to increase hemoglobin and ferritin levels in women with HMB 2
- Oral iron therapy is commonly prescribed for iron deficiency anemia, with ferrous sulfate being a common choice 6
- Intravenous iron therapy may be used in patients who are not responsive to oral iron therapy or have contraindications to oral iron 5, 6
- Combined oral contraceptives may be prescribed for abnormal uterine bleeding, but evaluation for underlying bleeding disorders is often inconsistent 6
Iron Deficiency Anemia in Adolescents
- Iron deficiency anemia is a common problem in adolescent girls with HMB, with severe anemia often requiring urgent medical care, including hospitalization and blood transfusion 6
- The median initial hemoglobin concentration for adolescents with HMB and IDA is often low, with most patients presenting to the emergency department or via inpatient transfer 6
Importance of Addressing Iron Deficiency
- Iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders 3, 4
- Addressing iron deficiency and HMB is critical to improving the quality of life for reproductive-aged girls and women, and to preventing long-term effects on cognitive function and daily life 3, 4