What is the best treatment approach for a female patient of reproductive age with heavy menstrual bleeding causing iron deficiency anemia?

Treatment for Heavy Menstrual Bleeding Causing Anemia

Start with oral ferrous sulfate 200 mg once daily plus vitamin C 500 mg, and simultaneously address the heavy menstrual bleeding with either a levonorgestrel-releasing intrauterine system (LNG-IUS) or tranexamic acid, as treating the bleeding source is essential to prevent recurrent anemia. 1, 2

Immediate Iron Replacement Strategy

• Begin ferrous sulfate 200 mg (65 mg elemental iron) once daily on an empty stomach—this is the most cost-effective first-line treatment with no therapeutic advantage of other oral formulations 1, 3

• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption, which is particularly critical given the ongoing blood loss 1, 3

• Women of reproductive age with heavy menstrual bleeding require 50-100 mg elemental iron daily for maintenance, which may necessitate two 200-mg ferrous sulfate tablets daily 4, 3

• Continue iron therapy for 3 months after hemoglobin normalizes to fully replenish iron stores 4, 1, 3

• Expect hemoglobin to rise by approximately 2 g/dL after 3-4 weeks of treatment 1, 3

Treating the Underlying Heavy Menstrual Bleeding

You must simultaneously treat the heavy bleeding, or the anemia will recur regardless of iron supplementation. 1, 5

First-Line Medical Options for Heavy Menstrual Bleeding

• LNG-IUS results in the largest reduction of menstrual blood loss (mean reduction 105.71 mL/cycle) and ranks as the best first-line treatment 2

• Tranexamic acid is probably the second-best option, reducing menstrual blood loss by approximately 80 mL/cycle 2

• NSAIDs (such as mefenamic acid or naproxen) reduce menstrual blood loss by approximately 40 mL/cycle and are more effective than placebo, though less effective than tranexamic acid or LNG-IUS 2, 6, 7

• Combined oral contraceptives can be considered but have less robust evidence for heavy menstrual bleeding reduction compared to LNG-IUS or tranexamic acid 2

When to Switch to Intravenous Iron

• Use IV iron if the patient cannot tolerate at least two different oral iron preparations 1, 3

• Consider IV iron if hemoglobin fails to rise by 2 g/dL after 4 weeks of compliant oral therapy, suggesting ongoing blood loss exceeds oral replacement capacity 1, 3

• For severe anemia (hemoglobin <8.0 g/dL), IV iron is preferred for more rapid correction 8

• Prefer IV iron formulations that replace iron deficits in 1-2 infusions rather than multiple sessions 1, 8

Monitoring Protocol

• Recheck hemoglobin at 4 weeks to confirm response—failure to rise by 2 g/dL indicates poor compliance, continued blood loss, or malabsorption 1, 3

• Once hemoglobin normalizes, monitor hemoglobin and red cell indices every 3 months for the first year, then annually 1, 3

• Screen for anemia annually in women with risk factors including extensive menstrual blood loss, low iron intake, or previous iron deficiency anemia 4

Critical Pitfalls to Avoid

• Do not treat iron deficiency without simultaneously addressing the heavy menstrual bleeding—the anemia will recur 1, 5

• Do not prescribe multiple daily doses of oral iron, as once-daily dosing improves tolerance while maintaining equal or better absorption due to hepcidin regulation 1, 3

• Do not stop iron therapy when hemoglobin normalizes—continue for 3 months to replenish stores 4, 1, 3

• Do not overlook vitamin C supplementation, which significantly enhances iron absorption especially with ongoing blood loss 1, 3

• Do not normalize heavy menstrual bleeding as acceptable—it adversely impacts quality of life and cognitive function on a daily basis, and iron deficiency in early pregnancy may adversely impact fetal neurodevelopment 5, 9

Special Considerations

• Heavy menstrual bleeding affects 20-50% of women and is the major contributor to iron deficiency anemia in reproductive-aged women 5

• Only 8% of anemic women with heavy menstrual bleeding take iron supplementation, representing a significant treatment gap 9

• Improved quality of life after treatment is strongly associated with correction of anemia, with significant improvements in energy, physical functioning, social functioning, and reductions in anxiety and depression 9

• Intrauterine devices (non-hormonal) are associated with increased menstrual blood loss and higher risk of iron deficiency, while oral contraceptives decrease this risk 4