What treatment is recommended for a patient with a fungal infection, gastroesophageal reflux disease (GERD) symptoms, vaginal discharge, and constipation, with a history of iron deficiency anemia and menorrhagia?

Treatment Recommendations for Multi-System Presentation

This patient requires treatment for vaginal candidiasis with fluconazole 150 mg as a single oral dose, gastroesophageal reflux with omeprazole 20 mg once daily before meals for up to 4 weeks, iron supplementation with ferrous sulfate 200 mg three times daily continued for 3 months after anemia correction, and management of menorrhagia-related iron loss. 1, 2, 3

Vaginal Fungal Infection Management

For vaginal candidiasis, administer fluconazole 150 mg as a single oral dose. 1 This is the FDA-approved standard treatment for uncomplicated vaginal candidiasis and provides definitive therapy with a single administration. 1

• The patient reports vaginal discharge without itchiness and is not sexually active, consistent with uncomplicated vaginal candidiasis. 1
• No additional doses are required for simple vaginal candidiasis in immunocompetent patients. 1

Gastroesophageal Reflux Disease Treatment

Initiate omeprazole 20 mg once daily taken before meals for symptomatic GERD treatment, with duration up to 4 weeks. 2

• The burning sensation and post-prandial burning pain are classic GERD symptoms requiring proton pump inhibitor therapy. 2
• Omeprazole should be taken before meals, and antacids may be used concomitantly if needed for breakthrough symptoms. 2
• If symptoms persist beyond 4 weeks, consider extending treatment to 8 weeks or performing upper endoscopy to evaluate for erosive esophagitis. 2

Important caveat: The reflux symptoms may be contributing to iron deficiency through occult blood loss from esophagitis, though this is an uncommon cause of chronic bleeding. 3 However, oesophagitis should not be accepted as the sole cause of iron deficiency without complete gastrointestinal evaluation. 3

Iron Deficiency Anemia Management

All patients with iron deficiency anemia should receive iron supplementation with ferrous sulfate 200 mg three times daily, continued for 3 months after anemia correction to replenish body stores. 3

Diagnostic Evaluation Required

• Confirm iron deficiency with serum ferritin <15 μg/dL (or <30 μg/dL in absence of inflammation). 3
• In premenopausal women with menorrhagia, this is the most likely cause of iron deficiency anemia, occurring in 5-10% of menstruating women. 3

Investigation Strategy for Iron Deficiency

Despite menorrhagia being present, gastrointestinal evaluation should still be considered unless there is documented significant non-GI blood loss. 3

• Upper GI endoscopy with small bowel biopsies should be performed, as 2-3% of patients with iron deficiency anemia have celiac disease. 3
• The reflux symptoms warrant upper endoscopy to exclude erosive esophagitis, peptic ulcer, or gastric pathology. 3
• Unless upper endoscopy reveals carcinoma or celiac disease, colonoscopy or barium enema should follow, as dual pathology occurs in 10-15% of patients. 3

Iron Supplementation Details

• Ferrous sulfate 200 mg three times daily is the most cost-effective first-line therapy. 3 Ferrous gluconate and ferrous fumarate are equally effective alternatives. 3
• Ascorbic acid (vitamin C) enhances iron absorption and should be considered if response is suboptimal. 3
• Iron is absorbed better on an empty stomach, but taking with meals improves tolerance in some patients. 3
• Taking iron with 500 mg vitamin C allows absorption even with calcium or fiber present. 3

Follow-up Protocol

• Monitor hemoglobin and red cell indices at 3-month intervals for one year, then annually. 3
• Continue iron supplementation for 3 months after hemoglobin normalization to replenish stores. 3
• If hemoglobin or MCV falls below normal during follow-up, check ferritin and resume iron supplementation. 3

Menorrhagia Management

The heavy periods with period pain require gynecological evaluation and management to prevent ongoing iron loss. 3

• Menorrhagia is a common cause of iron deficiency in premenopausal women and must be addressed to prevent recurrent anemia. 3
• Consider pictorial blood loss assessment charts, which have approximately 80% sensitivity and specificity for detecting menorrhagia. 3
• Coordinate with gynecology for hormonal management or other interventions to reduce menstrual blood loss. 3

Constipation Management

Address constipation through dietary modification, as this may worsen with iron supplementation. 3

• The patient's preference for junk food and prolonged toilet time suggest inadequate fiber intake. 3
• Increase dietary fiber, fluid intake, and physical activity. 3
• If constipation worsens with ferrous sulfate, consider switching to ferrous gluconate or using a liquid iron preparation, which may be better tolerated. 3
• Stool softeners or osmotic laxatives may be added if dietary measures are insufficient. 3

Critical Pitfalls to Avoid

• Do not assume menorrhagia is the sole cause of iron deficiency without GI evaluation, as dual pathology is common. 3
• Do not accept reflux esophagitis as the cause of iron deficiency without complete lower GI tract examination. 3
• Do not discontinue iron supplementation when hemoglobin normalizes—continue for 3 months to replenish stores. 3
• Do not use faecal occult blood testing, as it is insensitive and non-specific for evaluating iron deficiency. 3