How should I evaluate and manage a premenopausal woman with mood swings, iron‑deficiency anemia, and irregular, prolonged menstrual bleeding?

Evaluation and Management of Premenopausal Woman with Mood Swings, Anemia, and Prolonged Irregular Bleeding

Start oral iron supplementation immediately and simultaneously initiate treatment for heavy menstrual bleeding with a levonorgestrel-releasing intrauterine device (LNG-IUD), which addresses both the ongoing blood loss and provides the most effective menstrual suppression. 1, 2

Initial Diagnostic Workup

Confirm Iron Deficiency Anemia

• Verify anemia with hemoglobin <12 g/dL in women and confirm iron deficiency with serum ferritin <45 ng/mL as the single most useful marker 3
• Obtain complete blood count with indices (MCV, MCH) and iron studies (ferritin, transferrin saturation, TIBC) 3
• Note that ferritin can be falsely elevated in inflammatory conditions 3

Identify Underlying Causes

• Screen for celiac disease with tissue transglutaminase antibody (IgA type) plus total IgA level, as celiac disease is found in 3-5% of iron deficiency anemia cases 3
• Test for H. pylori using non-invasive methods (stool antigen or urea breath test) 3
• Document comprehensive medication history, explicitly noting all NSAID use (including over-the-counter ibuprofen, naproxen, aspirin), anticoagulants, and antiplatelet agents 3
• Consider testing for bleeding disorders in adolescents and young women, as 46% of those with heavy menstrual bleeding may have an underlying bleeding disorder 2

Iron Replacement Strategy

Oral Iron Therapy

• Initiate oral iron supplements immediately with a target hemoglobin increase of 2 g/dL after 3-4 weeks of treatment 1
• Monitor hemoglobin after 3-4 weeks to verify response 1
• Continue iron supplements for three months after hemoglobin normalization to fully replenish body iron stores 1
• Monitor hemoglobin and erythrocyte indices every three months for one year, then annually 1

When to Switch to Intravenous Iron

• Consider intravenous iron if there is no response to oral iron, intolerance to at least two different oral preparations, or documented non-adherence 1
• Intravenous iron is also preferred when rapid iron repletion is required or when ongoing iron losses exceed absorptive capacity 4

Management of Heavy Menstrual Bleeding

The levonorgestrel-releasing intrauterine device is the most effective first-line treatment, achieving 89% menstrual suppression success and simultaneously treating both blood loss and associated pain. 1, 2

Treatment Options in Order of Effectiveness

• Levonorgestrel-releasing IUD: 89% success rate for menstrual suppression, treats both heavy bleeding and associated pain 1, 2
• Norethindrone acetate 5-10 mg daily: 83% success rate 2
• Transdermal contraceptive patch: 80% success rate 2
• Tranexamic acid combined with hormonal therapy: 100% achievement of menstrual suppression when used together 2
• Combined oral contraceptives are commonly used but were not found to be the most effective option 2

Critical Pitfall to Avoid

Do not assume primary care is managing the anemia while you only treat the bleeding—gynecologists must diagnose, manage, and initiate treatment for iron deficiency/anemia while simultaneously treating heavy menstrual bleeding, as this dual management significantly improves quality of life 4

Addressing Mood Swings

• Mood disturbances are directly related to iron deficiency itself, not just anemia, as iron deficiency adversely affects cognitive function and emotional well-being on a daily basis 5
• Expect improvement in mood symptoms with iron repletion, as iron deficiency has protean manifestations including fatigue and cognitive dysfunction 6, 7
• The combined burden of heavy menstrual bleeding during episodes and iron deficiency continuously affects quality of life, work performance, and school attendance 5

Follow-Up and Monitoring

• Recheck hemoglobin after 3-4 weeks expecting a 2 g/dL increase 1
• If no adequate response to treatment or bleeding persists despite gynecological management, consider further gastrointestinal evaluation, especially in patients over 45 years old 1
• Continue monitoring hemoglobin and erythrocyte indices every three months for one year after normalization, then annually 1

Special Considerations

• Iron deficiency in reproductive-aged women, even without severe anemia, adversely impacts cognitive function, work productivity, and quality of life 5, 7
• Women without bleeding disorders are more likely to present with severe iron deficiency anemia compared to those with bleeding disorders 2
• The interrelationship between heavy menstrual bleeding and iron deficiency is frequently normalized by society, healthcare providers, and affected women themselves, leading to underdiagnosis and undertreatment 5