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

Treatment of Low Hemoglobin with Heavy Menstrual Bleeding

For reproductive-age women with heavy menstrual bleeding and anemia, initiate oral iron supplementation (ferrous sulfate 200 mg three times daily) immediately to correct anemia and replenish iron stores, while simultaneously starting the levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line treatment to reduce menstrual blood loss. 1, 2, 3

Immediate Iron Replacement Therapy

All patients with anemia from heavy menstrual bleeding require iron supplementation regardless of the bleeding treatment chosen. 1

• Start ferrous sulfate 200 mg three times daily as the most simple and cost-effective option 1
• Alternative oral preparations include ferrous gluconate or ferrous fumarate if ferrous sulfate is not tolerated 1
• Add ascorbic acid (vitamin C) to enhance iron absorption, particularly when response is poor 1
• Continue iron supplementation for three months after correction of anemia to replenish body iron stores 1
• Expect hemoglobin to rise by 2 g/dL after 3-4 weeks of treatment 1

When Oral Iron Fails

• Consider parenteral (intravenous) iron only when there is intolerance to at least two oral preparations or documented non-compliance 1
• Parenteral iron provides no faster hemoglobin rise than oral preparations but avoids gastrointestinal side effects 1
• Reserve intravenous iron for severe anemia, non-responders to oral therapy, or preoperative optimization 4

First-Line Treatment to Control Bleeding: LNG-IUS

The levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment for heavy menstrual bleeding and should be strongly considered as first-line therapy. 2, 5, 3

• LNG-IUS results in a large reduction of menstrual blood loss (mean reduction 105.71 mL/cycle) with the best ranking among first-line treatments 3
• Efficacy is comparable to endometrial ablation or hysterectomy while preserving the uterus 5
• Hemoglobin levels increase significantly after 1 year of LNG-IUS treatment 6
• Provides dual benefit of bleeding control and contraception for women who need both 2

Alternative First-Line Medical Treatments

If LNG-IUS is contraindicated or declined, consider these options in order of effectiveness:

Antifibrinolytics (Tranexamic Acid)

• Second most effective first-line treatment after LNG-IUS 3
• Reduces menstrual blood loss by 20-60% 5
• Best non-hormonal alternative, particularly useful for women with fibroids or those who cannot use hormonal therapy 5, 3
• Contraindicated in women with active thromboembolic disease or history of thrombosis 1

Combined Hormonal Contraceptives (CHCs)

• Effective for regulating menstrual cycles and reducing bleeding 2, 5
• Particularly appropriate for younger women who also desire contraception 5
• Can be used as combined oral contraceptives or combined vaginal ring 2

NSAIDs

• Provide modest reduction in menstrual blood loss (mean reduction 40.67 mL/cycle) 3
• Use for 5-7 days during menstruation 1, 2
• May improve endometrial blood flow 2
• Less effective than LNG-IUS, antifibrinolytics, or hormonal contraceptives but useful as adjunctive therapy 1, 3

Monitoring and Follow-Up

• Reassess at 3-6 months to evaluate treatment response, menstrual pattern normalization, hemoglobin levels, and patient satisfaction 2
• Check hemoglobin concentration; if normal, monitor at three-monthly intervals for one year, then annually 1
• If hemoglobin fails to rise by 2 g/dL after 3-4 weeks, consider poor compliance, continued blood loss, malabsorption, or misdiagnosis 1

When First-Line Treatment Fails

If medical management fails to control bleeding or the woman finds it unacceptable, counsel on second-line options including endometrial ablation or hysterectomy. 1, 5

Second-Line Surgical Options (in order of effectiveness):

1. Hysterectomy - provides definitive resolution of all bleeding symptoms and eliminates recurrence risk 5, 3

   • Choose the least invasive route: vaginal > laparoscopic/robotic > abdominal 5
   • Results in large increase in satisfaction 3

2. Non-resectoscopic endometrial ablation (NREA) - probably results in large reduction of menstrual blood loss and increases satisfaction 3

3. Resectoscopic endometrial ablation (REA) - results in large reduction of menstrual blood loss 3

Critical Pitfalls to Avoid

• Do not delay iron supplementation while waiting for bleeding control - anemia treatment must begin immediately 1
• Do not stop iron therapy when hemoglobin normalizes - continue for three additional months to replenish stores 1
• Do not use aspirin for bleeding control - it may actually increase menstrual blood loss 1
• Do not assume heavy menstrual bleeding is the only cause of anemia in women over 45 years - investigate for gastrointestinal pathology 1
• Do not normalize heavy bleeding or iron deficiency - both significantly impair quality of life and cognitive function 7

Special Considerations for Women Under 45 Years

• If no upper gastrointestinal symptoms are present, measure antiendomysial antibodies (and IgA levels) to exclude celiac disease as a cause of iron deficiency 1
• Colonic investigation only needed if specific indications are present 1
• Women over 45 years require full gastrointestinal evaluation regardless of menstrual bleeding 1