Management of Iron Deficiency Anemia in a 30-Year-Old Female
Start oral ferrous sulfate 200 mg three times daily immediately to correct the anemia and replenish iron stores, while simultaneously screening for coeliac disease and evaluating for menorrhagia as the likely source of iron loss. 1
Immediate Treatment
All patients with iron deficiency anemia require iron supplementation regardless of the underlying cause. 1
- Ferrous sulfate 200 mg three times daily is the first-line treatment due to its effectiveness and low cost 1
- Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if the patient cannot tolerate ferrous sulfate 1
- Continue iron therapy for three months after hemoglobin normalizes to fully replenish body iron stores 1, 2
- Consider adding ascorbic acid (vitamin C) if response is poor, as it enhances iron absorption 1
- Alternate-day dosing may improve tolerability while maintaining efficacy 2
Diagnostic Workup for a 30-Year-Old Female
Because this patient is under 45 years old and premenopausal, the diagnostic approach differs from older patients. 1
Essential Initial Screening
- Screen all patients for coeliac disease with anti-endomysial antibody testing (and measure IgA levels to exclude IgA deficiency, which makes the test unreliable) 1
- Assess menstrual history thoroughly for menorrhagia, as heavy menstrual bleeding causes iron deficiency in 5-10% of menstruating women 1, 2
- Pictorial blood loss assessment charts have 80% sensitivity and specificity for detecting menorrhagia 1
When to Pursue Gastrointestinal Investigation
For women under 45 years, extensive GI investigation is NOT routinely required unless specific indications are present: 1
- Perform upper endoscopy with small bowel biopsy only if upper GI symptoms are present 1
- Colonoscopy should be done only if there are specific colonic symptoms or significant family history of colorectal cancer 1
- Do NOT perform routine bidirectional endoscopy in premenopausal women under 40-45 years without GI symptoms 1
Monitoring Response to Treatment
Check hemoglobin after 3-4 weeks of iron therapy: 1, 2, 3
- Expect a rise of 2 g/dL over 3-4 weeks 1, 2, 3
- Failure to achieve this increase suggests poor compliance, continued blood loss, malabsorption, or misdiagnosis 1
Long-term monitoring schedule: 1, 2
- Monitor hemoglobin and red cell indices every 3 months for one year 1, 2
- Then recheck annually 1, 2
- Give additional oral iron if hemoglobin or MCV falls below normal 1
When to Escalate Investigation or Treatment
Further investigation is warranted if: 1
- Hemoglobin cannot be restored or maintained with oral iron therapy 1
- Patient develops symptoms suggestive of small bowel disease 1
- No response to oral iron after 3-4 weeks despite adequate compliance 1
Consider intravenous iron if: 3, 4
- Intolerance to at least two different oral iron preparations 1, 3
- Documented non-adherence to oral treatment 3
- Evidence of malabsorption 4
Management of Heavy Menstrual Bleeding
If menorrhagia is identified as the cause, treat the underlying gynecological condition to prevent ongoing iron loss: 3
- Levonorgestrel-releasing intrauterine device is highly effective 3
- Tranexamic acid is an alternative option 3
- Combined oral contraceptives can reduce menstrual blood loss 3
Common Pitfalls to Avoid
- Do not perform faecal occult blood testing - it provides no benefit in the diagnostic workup of iron deficiency anemia 1
- Do not use parenteral iron as first-line therapy - it is painful, expensive, carries risk of anaphylaxis, and provides no faster hemoglobin rise than oral preparations 1
- Do not stop iron supplementation when hemoglobin normalizes - continue for 3 additional months to replenish stores 1, 2
- Do not subject young menstruating women to invasive GI investigations without clear indications - menstrual loss is the most likely cause in this demographic 1