What is the best treatment approach for a patient with menorrhagia (very heavy periods) and iron deficiency anemia, with hormonal levels showing luteinizing hormone (LH) 0.5, follicle-stimulating hormone (FSH) 1.3, estradiol 102.0, and progesterone 11.4?

Management of Heavy Menstrual Bleeding with Iron Deficiency Anemia

Immediate Treatment Priorities

Start oral ferrous sulfate 200 mg once daily immediately, continue for 3 months after hemoglobin normalizes, and simultaneously address the underlying menorrhagia with tranexamic acid or levonorgestrel IUD as first-line therapy. 1, 2

The hormonal levels you've provided (low LH 0.5, low FSH 1.3, progesterone 11.4) suggest this patient is likely premenopausal with anovulatory cycles or is in the luteal phase, making menorrhagia the primary cause of iron deficiency in this population. 3

Iron Replacement Strategy

Oral Iron Therapy

• Prescribe ferrous sulfate 200 mg (65 mg elemental iron) once daily—never multiple times per day. 1, 2
• Once-daily dosing improves tolerance while maintaining equal or better iron absorption compared to multiple daily doses due to hepcidin regulation. 1
• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption. 1, 2
• Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated. 1, 2
• Continue oral iron for 3 months after hemoglobin normalizes to fully replenish iron stores. 3, 1, 2

Expected Response and Monitoring

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment. 1, 2
• Check hemoglobin at 4 weeks; failure to rise by 2 g/dL indicates poor compliance, continued blood loss, or malabsorption. 1
• Monitor hemoglobin and red cell indices every 3 months for the first year, then again after another year. 3, 1

When to Switch to Intravenous Iron

• Use IV iron if the patient cannot tolerate at least two different oral iron preparations, or if ferritin levels fail to improve after 4 weeks of compliant oral therapy. 1
• Recent evidence shows that patients with heavy menstrual bleeding and IDA experience substantial delays from symptom onset to IV treatment, and single-dose IV iron may improve adherence and quality of life when oral iron fails. 4
• Prefer IV iron formulations that can replace iron deficits with 1-2 infusions rather than multiple infusions. 1

Treating the Underlying Menorrhagia

Concurrent treatment of heavy menstrual bleeding itself is critical to prevent ongoing iron loss. 2

First-Line Medical Options (Ranked by Efficacy)

1. Levonorgestrel IUD - Most effective medical treatment, comparable to endometrial ablation. 5, 6
2. Tranexamic acid - Reduces menstrual blood loss by 20-60%, particularly indicated when hormone treatment is contraindicated or immediate pregnancy is desired. 5, 6
3. Oral contraceptives - Effective for reducing menstrual blood loss. 5
4. NSAIDs - Reduce menstrual blood loss by 20-60%. 5, 6

Treatment Selection Algorithm

• If pregnancy is desired soon: Use tranexamic acid as first-line treatment for menorrhagia. 5
• If no immediate pregnancy plans and no contraindications: Levonorgestrel IUD is the most effective option. 5, 6
• If hormonal contraindications exist: Tranexamic acid or NSAIDs are appropriate. 5

Age-Specific Considerations

Because this patient has menorrhagia with iron deficiency anemia, age determines the extent of investigation needed. 3

If Patient is Under 45 Years

• Pelvic ultrasound (both abdominal and transvaginal) is recommended as first-line procedure for etiological diagnosis. 5
• Screen for celiac disease with antiendomysial antibody and IgA measurement, as this is a common cause of malabsorption. 3
• Gastrointestinal investigation is only indicated if upper GI symptoms are present. 3

If Patient is Over 45 Years

• Full gastrointestinal evaluation is required even with documented menorrhagia, as the incidence of important GI pathology increases with age. 3, 2
• This includes upper endoscopy, small bowel biopsy, and consideration of colonoscopy. 3

Critical Pitfalls to Avoid

• Do not prescribe multiple daily doses of oral iron—this increases side effects without improving efficacy due to hepcidin-mediated absorption blockade. 1
• Do not stop iron therapy when hemoglobin normalizes—continue for 3 months to replenish stores. 3, 1, 2
• Do not treat iron deficiency alone without addressing the underlying menorrhagia—ongoing blood loss will prevent adequate iron repletion. 2
• Poor compliance is the most common cause of treatment failure—once-daily dosing and addressing side effects improves adherence. 1, 2
• Do not overlook vitamin C supplementation when oral iron response is suboptimal—this significantly enhances absorption. 1, 2
• Do not delay investigation in patients over 45 years—assume menorrhagia is the cause only after excluding GI pathology. 3, 2

Failure to Respond

If anemia does not improve after 4 weeks despite compliance: 1

• Reassess for continued blood loss exceeding replacement capacity
• Evaluate for malabsorption syndromes (celiac disease, inflammatory bowel disease)
• Verify patient adherence to therapy
• Consider switching to IV iron if oral iron has failed with two different preparations 1

If anemia persists at 6 months despite appropriate therapy: 1

• Further gastrointestinal investigation is warranted
• Consider hematology consultation for complex cases
• Re-evaluate the adequacy of menorrhagia treatment