What treatment is recommended for a patient with increased uterine bleeding during periods and severe iron deficiency (ferritin level of 5 ng/mL)?

Management of Heavy Menstrual Bleeding with Severe Iron Deficiency

Start oral ferrous sulfate 200 mg once daily immediately and add vitamin C 500 mg with each dose to maximize absorption, while simultaneously investigating the underlying cause of the bleeding. 1

Immediate Iron Replacement Strategy

Oral iron therapy is first-line treatment despite the severe ferritin level of 5 ng/mL. 1

• Ferrous sulfate 200 mg once daily is the preferred formulation due to effectiveness and low cost 1
• Add ascorbic acid (vitamin C) 500 mg with each iron dose to enhance absorption, which is particularly critical given the severely depleted iron stores 1
• Take iron on an empty stomach for optimal absorption, though taking with food is acceptable if gastrointestinal side effects occur 1
• Continue iron therapy for 3 months after hemoglobin normalizes to fully replenish iron stores 1
• Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of treatment 1

Alternative oral formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated. 1

Managing the Uterine Bleeding

First-line hormonal management for bleeding control:

• Levonorgestrel-releasing intrauterine device (20 μg/day) is the most effective medical approach, resulting in 71-95% reduction in menstrual blood loss 2
• This provides dual benefit: bleeding control and contraception 2
• Systemic progesterone absorption is minimal with primarily local endometrial effects 2

Alternative hormonal options:

• Estrogen-progestin oral contraceptive pills reduce bleeding symptoms 2
• Cyclic oral progestin reduces bleeding by 87%, though may cause irregular bleeding initially 2

Tranexamic acid is NOT recommended in this context despite being effective for heavy menstrual bleeding, as it should generally be avoided in women with cardiovascular risk factors given associations with MI and thrombosis 2. While the evidence specifically addresses SCAD patients, this caution applies more broadly.

NSAIDs are less effective than other options, reducing bleeding compared to placebo but inferior to tranexamic acid or hormonal therapies 3, 4

When to Switch to Intravenous Iron

Consider IV iron if:

• Intolerance to at least two different oral iron preparations 1
• No hemoglobin response (failure to rise by 2 g/dL) after 4 weeks of oral therapy 1
• Ongoing heavy bleeding exceeds oral replacement capacity 1
• Conditions affecting iron absorption are present (celiac disease, inflammatory bowel disease, post-bariatric surgery) 1

IV iron formulations:

• Ferric carboxymaltose (500-1000 mg single doses over 15 minutes) is preferred for rapid administration 1
• IV iron is more effective than oral iron in correcting anemia and replenishing stores in heavy uterine bleeding (82% vs 62% achieving ≥2 g/dL Hb increase) 5
• Avoid iron dextran due to higher anaphylaxis risk 1

Essential Investigations

Assess the bleeding source:

• Pictorial blood loss assessment charts have 80% sensitivity and specificity for detecting menorrhagia 1
• Screen for celiac disease with antiendomysial antibody and IgA measurement, as this is a common malabsorption cause in younger patients 1
• Consider pelvic ultrasound to evaluate for structural causes (fibroids, polyps, adenomyosis) 2
• Pregnancy test in all reproductive-age women 2

Monitor response:

• Check hemoglobin and ferritin at 4 weeks to assess response 1
• Monitor hemoglobin and red cell indices every 3 months for the first year 1
• Recheck ferritin after completing 3-month post-correction iron therapy 1

Critical Pitfalls to Avoid

• Do not stop iron therapy when hemoglobin normalizes - continue for 3 months to replenish stores 1
• Do not use multiple daily doses of oral iron - once-daily dosing improves tolerability with similar efficacy 1
• Do not overlook vitamin C supplementation when oral iron response is suboptimal 1
• Do not continue oral iron indefinitely without response - reassess after 4 weeks and switch to IV iron if hemoglobin fails to rise 1
• Do not fail to address the underlying bleeding cause while supplementing iron 1

Failure to Respond

If no improvement after 4 weeks:

• Assess for continued blood loss 1
• Evaluate for malabsorption syndromes 1
• Verify patient adherence to therapy 1
• Consider switching to IV iron 1

If anemia persists at 6 months:

• Reassess for ongoing blood loss 1
• Consider further gynecologic investigation 1
• Consider hematology consultation for complex cases 1