What is the best course of treatment for a patient with severe anemia (Hemoglobin 8.6 g/dL) and prolonged heavy menstrual bleeding (menorrhagia) for 2 weeks, with a history of heavy periods for 2 years, and no evidence of gastrointestinal (GI) bleeding?

Management of Severe Anemia with Prolonged Menorrhagia

This patient requires immediate gynecologic consultation for bleeding control, initiation of intravenous iron therapy given the severity of anemia (Hb 8.6 g/dL) with ongoing bleeding for 2 weeks, and hormonal therapy to stop the current bleeding episode. 1

Immediate Assessment and Stabilization

Critical first steps:

• Confirm hemodynamic stability - check orthostatic vital signs, as patients with Hb <7 g/dL or ongoing heavy bleeding may require blood transfusion to maintain Hb ≥7 g/dL 1
• Obtain complete blood count to quantify current anemia severity and compare to the previous ED value of 11.2 g/dL from August 2024 1
• Rule out pregnancy - mandatory in all reproductive-age women with abnormal bleeding regardless of contraceptive use or sexual history 1

The drop from 11.2 g/dL to 8.6 g/dL over several months with 2 weeks of continuous bleeding indicates significant ongoing blood loss requiring urgent intervention 1.

Acute Bleeding Control

For the current 2-week bleeding episode:

• High-dose progestin therapy (medroxyprogesterone acetate 20 mg three times daily or norethindrone acetate 5-10 mg three times daily) should be initiated immediately for acute bleeding control 1
• Tranexamic acid 1300 mg three times daily (or 1000 mg four times daily) can be added as adjunctive therapy to reduce menstrual blood loss by 40-50% 2, 3
  • Start at 500 mg twice daily and gradually increase to minimize gastrointestinal side effects 2
  • Contraindications include recent thrombosis; relative contraindications include atrial fibrillation or known thrombophilia 2, 3

Gynecologic consultation is essential for consideration of additional interventions if medical therapy fails, including endometrial ablation or surgical options 1.

Iron Repletion Strategy

Given Hb 8.6 g/dL with ongoing bleeding, intravenous iron is strongly preferred over oral iron:

Why IV Iron is Superior in This Case:

• Ongoing blood loss exceeds oral replacement capacity - the patient has been bleeding for 2 weeks continuously 4
• Faster hemoglobin recovery - IV iron produces more rapid improvement than oral iron when bleeding continues 2, 4
• Better tolerance - no gastrointestinal side effects that could limit compliance 4

Recommended IV Iron Protocol:

• Ferric carboxymaltose 500-1000 mg can be administered in a single 15-minute infusion 4, 5
• Total dose can replace iron deficit in 1-2 infusions rather than multiple visits 4
• Expected response: Hb should rise by approximately 2 g/dL after 3-4 weeks 4, 5

If IV Iron is Not Immediately Available:

• Start ferrous sulfate 200 mg once daily (65 mg elemental iron) 4
• Add vitamin C 500 mg with each iron dose to enhance absorption 4
• Take on empty stomach for optimal absorption, though taking with food is acceptable if GI side effects occur 4

Long-Term Menorrhagia Management

Once acute bleeding is controlled, implement definitive therapy:

Hormonal Options:

• Levonorgestrel intrauterine system (LNG-IUS) - reduces menstrual blood loss by 90% and is the most effective medical therapy 2, 6
• Combined oral contraceptives - continuous or cyclic dosing reduces menstrual blood loss by 40-50% 1

Continued Antifibrinolytic Therapy:

• Tranexamic acid can be continued long-term during menses (1300 mg three times daily for 5 days per cycle) 2, 7

Diagnostic Workup

While treating, investigate the underlying cause:

Essential Evaluations:

• Pelvic ultrasound to assess for structural abnormalities (fibroids, polyps, adenomyosis) 1
• Thyroid function tests - hypothyroidism commonly causes menorrhagia 7
• Coagulation screening if history suggests bleeding disorder:
  • Von Willebrand disease screening (VWF antigen, VWF activity, Factor VIII) 7
  • Platelet function assessment if family history of bleeding 7
  • Consider hematology referral if flooding, clots ≥1 inch, or family history of bleeding 7

Age-Appropriate Considerations:

• Endometrial sampling is NOT routinely needed in women under 45 years without risk factors for endometrial hyperplasia/cancer 2
• Risk factors requiring endometrial biopsy include: obesity, PCOS, unopposed estrogen exposure, tamoxifen use 1

Monitoring Protocol

After initiating therapy:

• Recheck hemoglobin at 4 weeks - failure to rise by 2 g/dL indicates continued blood loss, poor compliance, or malabsorption 4
• Continue iron therapy for 3 months after hemoglobin normalizes to fully replenish iron stores 2, 4
• Monitor hemoglobin every 3 months for the first year, then annually 2

Critical Pitfalls to Avoid

• Never delay pregnancy testing - ectopic pregnancy or miscarriage can present with prolonged bleeding and anemia 1
• Do not perform invasive procedures (D&C, endometrial biopsy) before confirming pregnancy status and stabilizing anemia 1
• Do not rely on oral iron alone when ongoing bleeding exceeds replacement capacity - this patient needs IV iron 2, 4
• Do not stop iron therapy when Hb normalizes - continue for 3 months to replenish stores 2, 4
• Do not overlook bleeding disorders - 13% of women with menorrhagia have von Willebrand disease 7
• Do not use multiple daily doses of oral iron if oral therapy is chosen - once-daily dosing is equally effective with better tolerance 4

When to Escalate Care

Consider hospitalization if:

• Hemoglobin drops below 7 g/dL 1
• Hemodynamic instability develops (orthostatic hypotension, tachycardia) 1
• Bleeding does not respond to medical therapy within 24-48 hours 1
• Patient develops symptoms of severe anemia (syncope, chest pain, severe dyspnea) 1

Surgical intervention may be necessary if:

• Medical therapy fails to control bleeding after 3-6 months 1
• Patient has completed childbearing and prefers definitive treatment 8
• Structural abnormalities require surgical correction 1