What is the best approach to treat anemia due to menorrhagia in a female patient of reproductive age?

Treatment of Anemia in Menorrhagia

Immediate Iron Replacement Strategy

Start oral ferrous sulfate 200 mg once daily immediately to treat the anemia, as this is the most cost-effective first-line treatment for iron deficiency anemia secondary to menorrhagia. 1

• Once-daily dosing is superior to multiple daily doses because it improves gastrointestinal tolerance while maintaining equal or better iron absorption due to hepcidin regulation. 1
• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption, particularly important when iron stores are severely depleted. 2, 1
• Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated. 2, 1
• Continue iron therapy for 3 months after hemoglobin normalizes to fully replenish body iron stores—this is critical to prevent recurrence. 3

Expected Response and Monitoring Protocol

• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of treatment. 2, 1
• Monitor hemoglobin and red cell indices at 3-month intervals for the first year, then again after another year. 3
• If hemoglobin or MCV falls below normal during follow-up, restart iron supplementation (check ferritin in doubtful cases). 3

When to Switch to Intravenous Iron

Consider IV iron if the patient cannot tolerate at least two different oral iron preparations, or if oral iron fails to improve ferritin levels after 4 weeks of compliant therapy. 1

• Ferric carboxymaltose (500-1500 mg) can be administered in 1-2 infusions and is highly effective for severe anemia in menorrhagia, avoiding blood transfusion. 4
• IV iron is particularly indicated when hemoglobin is severely low (below 7-8 g/dL) and rapid correction is needed before definitive treatment of menorrhagia. 4
• All IV iron formulations have similar safety profiles; true anaphylaxis is rare (0.6-0.7%). 1

Addressing the Underlying Menorrhagia

While treating anemia, simultaneously address the menstrual blood loss to prevent recurrence of iron deficiency. 2, 5

Initial Evaluation

• Quantify menstrual blood loss using pictorial blood loss assessment charts (80% sensitivity and specificity for detecting menorrhagia). 2
• Check thyroid stimulating hormone (TSH) to rule out hypothyroidism as a cause of menorrhagia. 5, 6
• Perform pregnancy test to exclude incomplete abortion. 5
• Consider screening for coagulation disorders in younger women with severe menorrhagia. 5

Medical Management of Menorrhagia

• Tranexamic acid is an antifibrinolytic agent that reduces menstrual blood loss by stabilizing fibrin and preventing its dissolution by plasmin. 7
• Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce menstrual blood loss through prostaglandin inhibition. 5
• Hormonal therapy with oral contraceptives or progestins (including levonorgestrel-releasing intrauterine system) can effectively control menorrhagia. 5, 8

Critical Pitfalls to Avoid

• Do not prescribe multiple daily doses of oral iron—this increases gastrointestinal 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, as premature discontinuation leads to recurrence. 3
• Do not delay investigation of menorrhagia cause while treating anemia—both must be addressed simultaneously. 2, 5
• Do not use parenteral iron as first-line unless there is documented intolerance to at least two oral preparations. 2, 3
• Do not overlook vitamin C supplementation when oral iron response is suboptimal. 2, 1

Failure to Respond Algorithm

If hemoglobin fails to rise by 2 g/dL after 4 weeks despite compliant oral iron therapy: 1

1. Verify patient adherence to therapy. 2
2. Assess for continued menstrual blood loss exceeding replacement capacity. 2
3. Evaluate for malabsorption (consider celiac disease screening with antiendomysial antibody and IgA measurement). 2, 1
4. Switch to intravenous iron if oral therapy has failed. 1

If anemia does not resolve within 6 months despite appropriate iron therapy and menorrhagia control: 3

• Reassess for ongoing occult blood loss from gastrointestinal sources. 2
• Consider further investigation with upper endoscopy and colonoscopy if patient is over 45 years or has gastrointestinal symptoms. 2
• Refer to hematology for evaluation of other causes of anemia. 1

Age-Specific Considerations

• For women under 45 years with menorrhagia-related anemia: Focus on treating menorrhagia and iron deficiency; gastrointestinal investigation is only needed if upper GI symptoms are present. 2
• For women over 45 years with iron deficiency anemia: Perform full gastrointestinal evaluation (upper endoscopy with small bowel biopsy and colonoscopy) even if menorrhagia is present, due to increasing incidence of gastrointestinal pathology with age. 2