What is the most appropriate management for a woman with severe anemia (low hemoglobin), heavy menstrual bleeding, and structural endometrial pathology?

Management of Severe Anemia with Heavy Menstrual Bleeding and Structural Endometrial Pathology

The most appropriate initial management is hysteroscopic removal of the structural endometrial pathology combined with iron replacement therapy, reserving blood transfusion for symptomatic severe anemia or hemodynamic instability. 1

Immediate Assessment and Stabilization

• Evaluate for symptoms of severe anemia including dyspnea, chest pain, altered mental status, or hemodynamic instability (tachycardia, hypotension). 2
• Blood transfusion should be reserved for patients with severe symptomatic anemia or those who are hemodynamically unstable, not based solely on hemoglobin threshold. 1, 2
• With hemoglobin of 7 g/dL, transfusion is indicated if the patient has cardiac symptoms, significant bleeding symptoms requiring rapid hemoglobin improvement, or hemodynamic compromise. 1
• A restrictive transfusion strategy targeting hemoglobin 7-8 g/dL is appropriate for stable patients without cardiac disease. 1, 2

Definitive Management of the Underlying Cause

Hysteroscopic removal is the priority intervention because treating the structural endometrial pathology addresses the root cause of ongoing blood loss and prevents further anemia. 1

Why Hysteroscopic Removal Over Other Options:

• Structural endometrial pathology (polyps, fibroids, or other lesions) must be removed to stop ongoing blood loss and allow hemoglobin recovery. 1
• Blood transfusion alone does not address the underlying bleeding source and will result in recurrent anemia. 1
• Hysterectomy is overly aggressive for a woman in her 30s who may desire future fertility and should be reserved for refractory cases after medical and conservative surgical therapies have failed. 3

Iron Replacement Strategy

All patients with iron deficiency anemia from heavy menstrual bleeding require iron supplementation to correct anemia and replenish body stores. 1

Iron Therapy Approach:

• Intravenous iron should be considered first-line in patients with severe anemia (hemoglobin <7 g/dL) or when rapid repletion is needed. 1, 2
• Oral iron (ferrous sulfate 200 mg three times daily) can be used if the patient is stable and can tolerate it, though absorption may be inadequate with ongoing bleeding. 1
• Iron therapy should continue for three months after correction of anemia to replenish body stores. 1
• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of adequate iron replacement. 1

Clinical Algorithm

1. Assess hemodynamic stability and symptoms: If unstable or severely symptomatic → transfuse to hemoglobin 7-8 g/dL 1, 2
2. Initiate iron replacement: IV iron preferred given severity of anemia 1, 2
3. Perform hysteroscopic evaluation and removal of structural pathology to stop ongoing blood loss 1
4. Monitor hemoglobin response: Should increase 2 g/dL within 3-4 weeks 1
5. Continue iron for 3 months after hemoglobin normalization 1

Important Caveats

• Heavy menstrual bleeding with structural pathology in a woman this age warrants investigation to exclude malignancy, though less common in the 30s age group. 1
• Up to 20% of women with heavy menstrual bleeding have an underlying bleeding disorder, so consider coagulation assessment if bleeding persists after structural correction. 4, 3
• Failure to respond to iron therapy (inadequate hemoglobin rise) suggests continued blood loss, malabsorption, or incorrect diagnosis requiring further evaluation. 1
• Transfusion should use single-unit policy when needed, reassessing after each unit rather than empiric multi-unit transfusion. 1