What would you prescribe for a 46-year-old premenopausal woman with heavy menstrual bleeding and iron deficiency anemia?

Treatment for Heavy Menstrual Bleeding with Iron Deficiency Anemia

For a 46-year-old premenopausal woman with heavy menstrual bleeding and iron deficiency anemia, start oral ferrous sulfate 200 mg once daily with vitamin C 500 mg to treat the anemia, and initiate tranexamic acid as first-line therapy to reduce menstrual blood loss. 1, 2

Immediate Iron Replacement Therapy

Start oral ferrous sulfate 200 mg (65 mg elemental iron) once daily immediately without delaying for diagnostic workup 1. This is the most cost-effective first-line treatment for iron deficiency anemia 1.

• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption, which is particularly critical given the iron deficiency 3, 1
• Take 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 3, 1
• Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of treatment 3, 1

Alternative Oral Iron Options

If ferrous sulfate causes intolerable gastrointestinal side effects (constipation, diarrhea, nausea), switch to ferrous gluconate or ferrous fumarate, which are equally effective 3, 1.

When to Switch to Intravenous Iron

Consider IV iron if the patient meets any of these criteria 3, 1:

• Intolerance to at least two different oral iron preparations
• Failure of hemoglobin to rise by 2 g/dL after 4 weeks of compliant oral therapy
• Ongoing heavy menstrual bleeding exceeding oral replacement capacity

Preferred IV formulations include ferric carboxymaltose (1000 mg over 15 minutes) or iron dextran (total dose infusion), which can replace iron deficits in 1-2 infusions 3, 1.

First-Line Treatment for Heavy Menstrual Bleeding

Tranexamic acid is more effective than NSAIDs at reducing heavy menstrual bleeding and should be the first-line pharmacologic treatment 2, 4.

Alternative Medical Therapies

If tranexamic acid is contraindicated or not tolerated 2, 4:

• NSAIDs (mefenamic acid or naproxen) reduce menstrual blood loss more effectively than placebo and may help with dysmenorrhea 2, 4
• Combined oral contraceptive pill can be considered, though evidence is limited 5
• Levonorgestrel-releasing intrauterine system (LNG-IUS) is more effective than NSAIDs but requires procedural placement 2

Avoid NSAIDs if the patient has an underlying bleeding disorder, as they can worsen bleeding 6.

Investigation of Underlying Cause

At age 46, this patient requires evaluation beyond menstrual causes 3:

Essential Screening

• Screen for celiac disease with tissue transglutaminase (tTG) antibody and IgA level, as coeliac disease is present in up to 4% of premenopausal women with iron deficiency anemia 3
• Assess menstrual blood loss pattern (pictorial blood loss assessment charts have 80% sensitivity/specificity for menorrhagia) 3, 1

Gastrointestinal Investigation

For women aged 50 years or older with iron deficiency anemia, perform upper endoscopy and colonoscopy to exclude gastrointestinal malignancy 3. At age 46, GI investigation should be considered if 3:

• Upper GI symptoms are present
• Strong family history of colorectal cancer (two affected first-degree relatives or one before age 50)
• Persistent iron deficiency anemia after iron supplementation and correction of menstrual losses

Monitoring Protocol

• Recheck hemoglobin at 4 weeks - failure to rise by 2 g/dL indicates poor compliance, continued blood loss, or malabsorption 3, 1
• Monitor hemoglobin and red cell indices every 3 months for the first year, then again after another year 3, 1
• Provide additional iron supplementation if hemoglobin or MCV falls below normal 3

Critical Pitfalls to Avoid

• Do not prescribe multiple daily doses of oral iron - once-daily dosing improves tolerance while maintaining equal or better absorption due to hepcidin regulation 1
• Do not stop iron therapy when hemoglobin normalizes - continue for 3 months to replenish stores 3, 1
• Do not overlook vitamin C supplementation when oral iron response is suboptimal 3, 1
• Do not use danazol as first-line therapy despite its effectiveness, as adverse events are more severe 2, 4
• Do not delay iron replacement while awaiting diagnostic workup unless colonoscopy is scheduled within days 1

Failure to Respond

If anemia does not resolve within 6 months despite appropriate iron therapy 1:

• Reassess for ongoing blood loss (consider gynecology referral for menorrhagia management)
• Evaluate for malabsorption syndromes
• Consider further gastrointestinal investigation
• Verify patient adherence to therapy