What is the most appropriate management for a woman in her 30s with severe anemia (hemoglobin level of 7 g/dL), heavy menstrual bleeding, and structural endometrial pathology, such as fibroids or polyps?

Management of Severe Anemia with Heavy Menstrual Bleeding and Structural Endometrial Pathology

The most appropriate management is hysteroscopic removal of the structural endometrial pathology (Option A), as this addresses the root cause of ongoing blood loss and prevents further anemia, with blood transfusion and iron replacement as adjunctive measures based on hemodynamic stability. 1

Immediate Stabilization Strategy

Blood Transfusion Decision

• Transfusion should be reserved for patients with severe symptomatic anemia or hemodynamic instability, not based solely on the hemoglobin threshold of 7 g/dL. 1
• A restrictive transfusion strategy targeting hemoglobin 7-8 g/dL is appropriate for stable patients without cardiac disease. 1
• Transfuse if the patient exhibits cardiac symptoms (chest pain, dyspnea, tachycardia), significant bleeding symptoms requiring rapid hemoglobin improvement, or hemodynamic compromise (hypotension, altered mental status). 1
• Use single-unit transfusion policy, reassessing after each unit rather than empiric multi-unit transfusion. 1

Iron Replacement Initiation

• All patients with iron deficiency anemia from heavy menstrual bleeding require iron supplementation to correct anemia and replenish body stores. 2, 1
• Intravenous iron should be considered first-line in patients with severe anemia (hemoglobin 7 g/dL) when rapid repletion is needed. 1
• Oral iron (ferrous sulphate 200 mg three times daily) is an alternative if the patient is stable and can tolerate oral therapy, though response is slower. 2
• Hemoglobin should rise by approximately 2 g/dL after 3-4 weeks of adequate iron replacement; failure suggests continued blood loss, malabsorption, or incorrect diagnosis. 2, 1

Definitive Management: Addressing the Root Cause

Hysteroscopic Removal as Priority

• Hysteroscopic removal of structural endometrial pathology is the priority intervention because it addresses the root cause of ongoing blood loss and allows hemoglobin recovery. 1, 3
• Structural endometrial pathology (fibroids, polyps) must be removed to stop ongoing blood loss; without this, anemia will persist or recur despite transfusion and iron therapy. 1
• Hysteroscopic resection is simple, safe, and effective for heavy menstrual bleeding associated with submucosal pathology and reduces the need for more major surgery like hysterectomy. 3
• In reproductive-age women in their 30s, hysteroscopic myomectomy is usually appropriate for pedunculated submucosal uterine fibroids causing heavy menstrual bleeding. 2

Why Not Hysterectomy

• Hysterectomy is usually appropriate for postmenopausal patients or those who have completed childbearing, not as first-line for a woman in her 30s with structural pathology amenable to hysteroscopic removal. 2
• For reproductive-age patients, fertility-preserving options should be prioritized unless the patient explicitly desires definitive surgical management. 2

Why Blood Transfusion Alone is Insufficient

• Blood transfusion addresses the symptom (low hemoglobin) but not the cause (ongoing blood loss from structural pathology). 1
• Without removing the structural pathology, the patient will continue to bleed and require repeated transfusions, creating a cycle of anemia. 1, 4

Post-Procedure Management

Iron Continuation

• Iron therapy should continue for three months after correction of anemia to replenish body stores. 2, 1
• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after a further year. 2
• Additional oral iron should be given if hemoglobin or MCV falls below normal. 2

Surveillance for Malignancy

• Heavy menstrual bleeding with structural pathology warrants investigation to exclude malignancy, though less common in the 30s age group. 1
• Rapid increase in fibroid size or failure to respond to appropriate treatment should prompt reevaluation for undiagnosed pathology including sarcoma. 2

Clinical Algorithm Summary

1. Assess hemodynamic stability and symptoms → Transfuse to hemoglobin 7-8 g/dL only if symptomatic or unstable 1
2. Initiate iron replacement → Preferably intravenous given severity of anemia 1
3. Perform hysteroscopic evaluation and removal → Stop ongoing blood loss from structural pathology 1, 3
4. Monitor hemoglobin response → Expect 2 g/dL increase within 3-4 weeks 2, 1
5. Continue iron therapy for 3 months → Replenish body stores after hemoglobin normalization 2, 1

Common Pitfalls

• Treating anemia without addressing the bleeding source leads to recurrent anemia and repeated interventions. 1, 4
• Delaying definitive management with medical therapy alone in the presence of structural pathology allows continued blood loss and worsening anemia. 1
• Multiple-dose treatments and appointment logistics can negatively impact adherence; single-dose intravenous iron is preferred when possible. 5
• Patients may lack disease awareness and refuse hospitalization despite life-threatening anemia; the most important risk factors are mental, social, and personal factors rather than organic abnormalities alone. 4