Elevated MCV, MCH, and Ferritin in Heavy Menstrual Periods
No, elevated MCV, MCH, and ferritin levels are not typically related to heavy menstrual periods—in fact, heavy periods characteristically cause the opposite pattern: low ferritin with low or normal MCV and MCH due to iron deficiency anemia. 1
Expected Laboratory Pattern in Heavy Menstrual Bleeding
Heavy menstrual bleeding causes iron loss that leads to a predictable sequence of laboratory abnormalities:
- Low ferritin (<15-30 μg/L) develops first as iron stores become depleted 1
- Low MCV (microcytosis, typically <76 fL) occurs as iron deficiency progresses 1
- Low MCH (hypochromia) develops alongside microcytosis 1
- Iron deficiency anemia occurs in 5-10% of menstruating women, with menorrhagia being the primary cause 1
Why Elevated Indices Suggest Alternative Diagnoses
The combination you describe (elevated MCV, MCH, and ferritin) points away from heavy menstrual bleeding and toward other conditions:
Elevated MCV and MCH typically indicate:
- Vitamin B12 or folate deficiency (MCV often >100-120 fL) 2, 3
- Medication effects including hydroxyurea, azathioprine, 6-mercaptopurine, anticonvulsants, or methotrexate 2, 3
- Chronic alcohol use independent of nutritional deficiencies 3
- Hemolytic anemias or thalassemias with increased erythropoietic drive 2
Elevated ferritin suggests:
- Inflammation or chronic disease (ferritin is an acute-phase reactant) 1
- Hemochromatosis or iron overload 3
- Liver disease 1
- Ferritin >150 μg/L is unlikely to occur with absolute iron deficiency, even with inflammation 1
Critical Diagnostic Approach
Initial workup should include: 2, 3
- Complete blood count with red cell indices and RDW
- Peripheral blood smear examination
- Reticulocyte count to assess bone marrow response
- Serum vitamin B12 and folate levels (especially when MCV >100 fL)
- Transferrin saturation and iron studies
- C-reactive protein to assess for inflammation
For premenopausal women with true iron deficiency from heavy periods: 1
- Ferritin should be <15-30 μg/L (not elevated)
- MCV should be low or low-normal (not elevated)
- Coeliac disease screening is mandatory (present in 3-5% of IDA cases)
- GI investigation is generally not warranted in women <45-50 years unless there are GI symptoms, family history of colorectal cancer, or persistent anemia despite iron replacement
Common Pitfall to Avoid
Do not assume heavy menstrual bleeding is the cause when laboratory values show elevated indices. The pattern you describe requires investigation for macrocytic causes (B12/folate deficiency, medications, alcohol) and the reason for elevated ferritin (inflammation, liver disease, hemochromatosis). 1, 2, 3 Heavy menstrual bleeding may coexist but is not the explanation for these elevated values.
If a woman with heavy periods has these elevated indices, consider that she may have concurrent conditions masking expected iron deficiency 3, or the heavy bleeding may be unrelated to the laboratory abnormalities requiring separate evaluation.