What interventions are recommended for a patient with severe iron deficiency anemia and heavy menstrual bleeding due to uterine fibroids?

Management of Severe Iron Deficiency Anemia Secondary to Uterine Fibroids

Start oral ferrous sulfate 200 mg once daily immediately with vitamin C 500 mg to enhance absorption, continue for 3 months after hemoglobin normalizes, and simultaneously address the underlying menorrhagia through gynecologic intervention. 1, 2

Immediate Iron Replacement

• Prescribe ferrous sulfate 200 mg (65 mg elemental iron) once daily on an empty stomach as the most cost-effective first-line treatment for this severe iron deficiency 1, 3
• Add vitamin C (ascorbic acid) 500 mg with each iron dose to enhance absorption—this is particularly critical given the severely depleted iron stores (ferritin 4.9 ng/mL, iron saturation 3.8%) 4, 1, 2
• 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, 2
• Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate causes intolerable side effects 4, 1, 3

Expected Response and Monitoring

• Check hemoglobin at 4 weeks—expect a rise of approximately 2 g/dL from the current 9.0 g/dL 4, 1, 3
• If hemoglobin fails to rise by 2 g/dL after 4 weeks, verify adherence, assess for continued menstrual blood loss, and consider switching to intravenous iron 1, 2
• Continue oral iron for 3 months after hemoglobin normalizes to fully replenish body iron stores (total treatment duration typically 6-7 months) 4, 1, 2, 3
• Monitor hemoglobin and red cell indices every 3 months for the first year, then again after another year 4, 1, 2

When to Switch to Intravenous Iron

• Consider IV iron if the patient cannot tolerate at least two different oral iron preparations (ferrous sulfate, ferrous gluconate, ferrous fumarate) 1, 2, 3
• Switch to IV iron if ferritin levels fail to improve after 4 weeks of compliant oral therapy 1, 2
• Prefer IV iron formulations that replace iron deficits in 1-2 infusions (such as ferric carboxymaltose 500-1000 mg) rather than multiple infusions to minimize risk 1
• All IV iron formulations have similar safety profiles, with true anaphylaxis being rare (0.6-0.7%) 1, 2

Addressing the Underlying Menorrhagia

• Concurrent treatment of heavy menstrual bleeding is essential to prevent ongoing iron loss and recurrence of anemia 2, 3
• Heavy menstrual bleeding from fibroids affects 5-10% of menstruating women and is the primary cause of iron deficiency in this population 4, 3
• Gynecologic interventions may include medical management (tranexamic acid, hormonal therapy) or surgical options (myomectomy, hysterectomy) depending on the patient's age, fertility desires, and fibroid characteristics 5, 6, 7
• Pictorial blood loss assessment charts have 80% sensitivity and specificity for quantifying menorrhagia if clinical assessment is uncertain 4, 2

Age-Specific Gastrointestinal Evaluation

• For women under 45 years with documented menorrhagia from fibroids, gastrointestinal investigation is only needed if upper GI symptoms are present (dyspepsia, reflux, dysphagia) 4, 1
• Screen for celiac disease with antiendomysial antibody and IgA measurement in women under 45 without upper GI symptoms 4, 1
• For women over 45 years, perform full gastrointestinal evaluation (upper endoscopy with small bowel biopsy and colonoscopy) even if menorrhagia is present, due to increasing incidence of GI pathology with age 4, 3

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, 2
• Do not stop iron therapy when hemoglobin normalizes—premature discontinuation leads to rapid recurrence of anemia 1, 2, 3
• Do not overlook vitamin C supplementation when iron stores are severely depleted, as absorption enhancement is critical 4, 1, 2
• Do not use parenteral iron as first-line unless there is documented intolerance to at least two oral preparations 4, 2, 3
• Do not fail to address the underlying menorrhagia while treating anemia—ongoing blood loss will prevent adequate response to iron supplementation 2, 3

Failure to Respond Algorithm

• If hemoglobin fails to rise by 2 g/dL after 4 weeks: verify patient adherence, assess for continued heavy menstrual bleeding, and evaluate for malabsorption 1, 2
• If anemia does not resolve within 6 months despite appropriate iron therapy and menorrhagia control: reassess for occult gastrointestinal blood loss and consider further investigation with upper endoscopy and colonoscopy 1, 2
• Consider hematology consultation if anemia persists despite addressing iron deficiency and controlling menstrual blood loss 1